‘Take sleep seriously’: Tips and treatment for insomnia
Although many primary care physicians view sleep health as an important aspect of patient care, recent survey data show that they often feel uncomfortable diagnosing and treating sleep disorders.
Anecdotal evidence suggests that sleep issues have increased since the start of the COVID-19 pandemic, according to Russell Rosenberg, PhD, D.ABSM, sleep specialist and former chair of the Board of the National Sleep Foundation.
“It’s important for physicians to focus on sleep as a problem,” he said in an interview. “They often have short periods of time to address this, but I want every health care provider and individual to take sleep seriously. Sleep — while its primary function is widely recognized to resolve sleepiness — is important for good health.”
Healio Primary Care spoke with Rosenberg to learn more about the impact of COVID-19 on sleep, behavioral changes that PCPs can recommend to patients with sleep disorders, pharmacological treatment for those with insomnia, and when to refer patients to a sleep specialist.
What impact has the COVID-19 pandemic had on sleep in the United States?
We don’t have much published literature in this area. There seems to be an increase in prescriptions for sleep medications, which gives us an indication that the rate of insomnia could be linked to changes related to COVID-19.
The pandemic has derailed our daily routine, which is really important for sleep. In addition, there is anxiety about issues related to COVID-19 — everything from getting the disease to work-related issues. It’s not surprising that people are having more difficulty with their insomnia or sleep due to this threat, and it is a real threat. People are having trouble turning off their thoughts, frustrations and anxieties.
What behavioral and environmental changes should PCPs recommend to patients with insomnia?
With everything being derailed because of COVID-19, I want everyone to get on track with their sleep and to take this seriously. That means maintain a fairly regular bedtime and wake-up time. Bedtime will probably set itself if patients keep a regular wake-up time.
Simple behaviors, which we group into sleep hygiene, help set the stage for sleep to occur. These include winding down, having very little screen time before bed and avoiding alcohol. There has been a reported increase in the consumption of alcoholic beverages during the pandemic. Drinking near bedtime can be really disruptive to sleep continuity. If alcohol intake is an issue at bedtime, we usually recommend the 3-hour rule, which is don’t drink any alcoholic beverages within 3 hours of bedtime.
Avoid watching the news within 3 hours of bedtime. The news can be very activating and stimulating and can emotionally affect people in a way that is not conducive to falling asleep. I’m not saying all news is bad, but it’s not very relaxing.
People who are having trouble sleeping can also use sound machines to mask ambient noise and ensure the light is not being intrusive to the sleep environment. They should also avoid excessive use of caffeine, especially in the afternoon.
If a patient has developed sleep problems during this pandemic, I think it’s worth starting with these sorts of behavioral changes. Unfortunately, a lot of people might improve but are unable to resolve the problem. That’s when it is time to find out what else can be done.
What pharmacological treatments are available for insomnia?
We know that there are people who are not sleeping well because of COVID-19, but there are many people who have symptoms of insomnia — about 30% of adults in the United States — and probably close to 10% could be diagnosed with insomnia disorder. So, this is a very common problem in our society.
One of the drugs that I have worked on for the last 3 years that was recently released this summer is a sleep agent called Dayvigo (lemborexant; Eisai Inc). It represents a new option for physicians to treat adults with insomnia. Our research showed that individuals who took this a once-per-night sleep medication fell asleep faster and stayed asleep longer than those who took placebo.
About 2,000 adult patients with insomnia were enrolled in the clinical trials, SUNRISE 1 and SUNRISE 2, that were sent to the FDA for the approval of Dayvigo.
Dayvigo is dosed at 5 mg or 10 mg. The mechanism of action is believed to be through antagonism of orexin neurons that are involved in wake-up signaling. It’s not like some of the other sleeping pills that we’ve used in the past, which are more sleep-promoting agents. Dayvigo clamps down the wake signaling, allowing sleep to occur.
The most common adverse events that were reported in 5% or more of patients treated with Dayvigo and at least twice the rate of placebo was somnolence, which was 10% with the 10-mg dose and 7% with the 5-mg dose. From a safety perspective, one of the things that we are concerned about is rebound insomnia, which can occur when patients are withdrawn from a sleep drug. There was no evidence of rebound insomnia with Dayvigo.
In the label, there are warnings about sleep paralysis, which is a short period of an inability to move upon awakening, as well as complex sleep-related behaviors. One of the more important adverse events for primary care physicians to look out for is the potential impact on respiratory functioning in patients with compromised breathing like sleep apnea or COPD. Those patients need to be examined a little more carefully.
When should PCPs refer patients with insomnia to a sleep specialist?
Any primary care physician who suspects that a patient has sleep apnea should refer the patient to a sleep medicine specialist. When insomnia is persistent and unresponsive or not fully responsive to a medication, then the patient also should go to a sleep specialist. If the patient doesn’t improve within 7 to 10 days after the exam, there may be other comorbidities at play that might not be evident. Some patients often tell their physician that they are not sleeping well but don’t provide all the background information. Insomnia may just be the tip of the iceberg for some patients. Other reasons to refer a patient to a sleep specialist is if the patient is sleepwalking, sleep talking or acting out their dreams.