Sleep Disorders and Health Conditions: Focus on Insomnia - Episode 12
Drs C. Michael Gibson, Ashgan A. Elshinawy, and Nathaniel F. Watson examine setting treatment expectations with patients and treatment adherence for sleep disorders.
C. Michael Gibson, MD: One of the problems that we have in cardiology is adherence. Although we have drugs that save lives and improve the quality of life, we've done some studies that show 30% of the time people don't fill the prescription. Some of this is because it's a silent killer. Obviously, sleep disorders and insomnia impact people directly, but do you have problems with adherence in this field? Do some of the new drugs, like daridorexant, have less of that hangover effect? Are they better tolerated, are people more adherent, and does that factor into your treatment decisions?
Ashgan A. Elshinawy, DO: It goes back to communication and education with the patient. They're so vital. You have to set the expectations at the beginning. Before I ever prescribe a medication, I want complete ownership by the patient. I want them to be a team player in making this decision. I almost want them to come to the decision even before I do because that will enhance the adherence and the commitment to the therapy. I also educate them about the pluses, minuses, and the alternatives of this therapy. We have a conversation about how it's not a prescription “on-your-way-out” type of thing. That's where you'll see the low adherence especially with cardiology, since there's a lot of frequent dosing during the day, and that makes it definitely more difficult to adhere to therapy. With sleep, fortunately, it's a 1 time a day drug, and they usually remember it because they're obsessing already about sleep and they know to take that drug. Specifically with the DORAs, it may be a little bit more challenging because it's not a “knock you out” medication, and it would be very hard for them to adhere to it, if they are not educated beforehand that this is not going to necessarily knock you out the first night, second night, or ever. It's going to enhance these parameters, and these are the parameters that we're going to follow together. I say, “That's why I see you in a couple of weeks,” or 3 weeks, and we'll talk about it so I can hold your hand going through the therapy. They have to know that you're partnering with them and that you're not just giving them a prescription and seeing them in 6 months.
Nathaniel F. Watson, MD: This is another role for the consumer sleep technologies that we talked about before. Not only identifying sleep problems, but also providing objective evidence to the individual that the treatment plan that they're enacting is actually working the way it's intended. Unfortunately, in regard to sleep, people aren't always able to subjectively assess the quality of their sleep, or duration as well as we would hope because you're unconscious while you're sleeping, so how would you really know how well your sleep was. With these technologies longitudinally over time, people could compare what their numbers look like after starting a treatment compared to previously and that can be a powerful motivator for somebody to stick with a medication in the long term, but sleep medicine is certainly not immune to the problems with treatment adherence. We must continue conversations with people to explore what their challenges are, and then, help them overcome those hurdles. Last thing, in regard to daridorexant, is that subjective total sleep time was one of the secondary outcomes, and there was a 60 minute or so improvement in that in regard to that medication, despite the challenges of being able to successfully assess your sleep quality or duration. The patients that were taking that did notice a substantial increase in the duration of their sleep at night.
C. Michael Gibson, MD: It sounds like less of a hangover in the morning. What do you do about people who have memory problems, such as those who may not even remember to take their sleeping agent at night? Are there apps out there that you can use to help remind the person to take their medicine, or to engage family members in improving adherence?
Ashgan A. Elshinawy, DO: In general, that can apply to any medication, or any therapy. I often will involve family members usually if somebody's memory is impacted, or if there's any element of dementia. They're typically not living alone. In the rare situation that they are, we use audio reminders, setting an alarm to go off. Especially for my older patients, their older children will actually call them at a certain time and say, “Mom it's time to take this medicine,” or we'll do a Facetime discussion until they get the hang of it on their own. I have done that with both respiratory and sleep treatment, and that's usually very effective, but they need a support system and someone involved to help them.
C. Michael Gibson, MD: Let's talk a little bit about unmet needs. Obviously, people need to wake up to sleep disorders. We think of sleep as something not exciting, but what are some of the big unmet needs? What do we need to do?
Nathaniel F. Watson, MD: Sleep deprivation is the most common cause of sleepiness in our society, and we have to find ways to encourage people to prioritize sleep in their life when there are so many competing interests for their time, and what I do is I try to get the patient to focus on the quality of their wakefulness experience. As opposed to the quantity of their wakefulness experience, that seems to resonate with patients when I discuss that with them. We have a sleep medicine physician shortage in this country, so we need to grow the specialty and I know that the American Academy of Sleep Medicine and other organizations are working to grow fellowship programs, bring more trainees into sleep medicine, and to improve access to care across the board. We live in a time where 80 to 85% of patients with sleep disorder breathing never cross the threshold of a sleep disorder center to get the problem diagnosed and treated. That's a real problem when we know how much of a positive impact we can have on the quality of life for these individuals. It's such a missed opportunity, and we have to figure out a way to tackle and solve that problem, which has been somewhat recalcitrant to our efforts to engage other specialties in the care of sleep medicine. On the bright side, cardiologists such as yourselves are embracing the notion of paying attention to sleep disorders and sleep problems. I know that there [are] currently some entities developing products that could be a cross between a Holter monitor and a sleep monitor, for instance. Hopefully, we'll have technologies that can be used by other specialties like cardiology and sleep medicine in order to bring these groups together to have discussions and to make sure that appropriate referrals are landing on our desk. It is a challenging time in many ways. We have to continue to convince anyone who listens to us that healthy sleep is the way to a healthy, happy life.
Transcript edited for clarity