The Management of Patients With Insomnia
In this multidisciplinary roundtable discussion, Jaspal Singh, MD, MHA, MHS, interviews Douglas Kirsch, MD, and Seema Khosla, MD, about the management of patients with insomnia, including the definition, prevalence, considerations for patients and clinicians, and preparing for sleep. This is part one of a three-part series on insomnia.
For more insomnia content, visit the Resource Center.
Watch episode two of this three-part series here.
Watch episode three of this three-part series here.
TRANSCRIPTION:
Jaspal Singh, MD, MHA, MHS:
Welcome everybody to Consultant 360. I'm your host, Jaspal Singh. On behalf of Consultant 360, I wanted to welcome you all. And we have two very distinguished guests today with us. First of all, I'd like to introduce Dr. Seema Khosla. Seema, tell us about yourself a little bit.
Seema Khosla, MD:
So I am a pulmonologist practicing in Fargo, North Dakota. I am not an academic. I am just a straight-up private practice person.
Jaspal Singh, MD, MHA, MHS:
That's way too humble because you do a lot of work with guidelines and a lot of work for the academy. And so we're very grateful for all that you've done for the field. Next, I have Dr. Doug Kirsch. Doug, introduce yourself, please.
Douglas Kirsch, MD:
I'm Doug Kirsch. I'm a neurologist by training, but 100% sleep medicine. I am the medical director of sleep medicine for Atrium Health, which is a large health system in the southeast. I am a clinical professor at Wake Forest University School of Medicine and I'm a past president of the American Academy of Sleep Medicine.
Jaspal Singh, MD, MHA, MHS:
Well, thank you both for those awesome introductions. And well, first of all, let's take it away. So today's episode, we want to talk about insomnia. A lot of our members actually have a lot of perceptions of what is insomnia. Some may be managing patients with insomnia or at least attending or directing where those patients go. And some of them may be, as you know, in healthcare. Some of our healthcare workers may be suffering from insomnia and so have to deal with it themselves or their family or friends and such a very common problem. So, Doug, I'll ask you first. When you see a patient with insomnia, walk us through your first initial thoughts and what considerations most patients should be thinking about or practitioners, or clinicians would be thinking about at that point.
Douglas Kirsch, MD:
So insomnia is incredibly common. You brought this up, but somewhere around 10% of the United States population probably has some amount of chronic insomnia. And so this is a big problem. Lots of people see it and it is a reasonably sized piece of my clinical practice. We see insomnia patients every day. I saw at least two this morning. So the first thing to prepare yourself is to understand a little bit about their sleep and this is something that takes a little bit of time. And I think this is the challenge for non-sleep doctors, is taking the time to talk to people about their sleep and understanding that on a broader level because it's not something that you can flash through in 30 seconds and have a good understanding of how somebody sleeps.
Jaspal Singh, MD, MHA, MHS:
That's great. Seema, what else would you add to that?
Seema Khosla, MD:
So I think part of it, too, is helping people better understand what is normal and not normal about sleep. So for example, we all know those people that can fall asleep the second their head hits the pillow. And I think there is this assumption that that is good, that that is a good sleeper when in reality we know that normal sleep onset latency is 15 to 30 minutes. And so if somebody is falling asleep that quickly, that may suggest that they have chronic sleep deprivation, either duration or quality of sleep. And so I think part of the conversation that we have is really establishing what is normal, what is abnormal, and what they mean when they say I have insomnia. Is it difficult to fall asleep? Is it difficult to stay asleep? Are you waking up too early? Are you waking up a lot? Sometimes people will assume they have insomnia, even though they sleep throughout the night, but they just don't feel rested in the morning.
Therefore, they may use it as maybe an umbrella term, that they're somehow dissatisfied with their sleep. And so it's important to get a little bit more granularity about what exactly you mean by that. Help me understand that.
Jaspal Singh, MD, MHA, MHS:
That's great. I mean, I think that's a great way of looking at it. So if I hear you both correctly, you're kind of thinking through. The first thing you're thinking about is understanding where they're coming from, and what they mean by that definition. And when they say they have insomnia, what are their sleep habits? What's happening both in the home and in the bedroom as well as what's happening around? What kind of personalities they are, kind of understanding more about, and then kind of going into how their sleep habits or their sleep whatever patterns are affecting their daytime functioning. Is that pretty accurate?
Douglas Kirsch, MD:
I think that that's true. I think one of the things that people often don't have the time to explore is their sleep patterns. At some basic level, talking to them about when they go to bed and get up on weekdays versus weekends versus vacations versus what their internal body clock is telling them to do, shift work, not shift work, all those patterns matter when it's trying to help somebody sleep better. And once you understand what the problem is, which I think Seema eloquently laid out, it's trying to understand how those processes fit together. Is there a problem with the patterns themselves or is there something else that's going on that is being disrupted to their sleep?
Jaspal Singh, MD, MHA, MHS:
Got it. So you look at patterns, look at what their sleep-wake cycle looks like, maybe at least mentally, if not physically, draw it out a little bit. And then I assume you're thinking about other issues, like environmental issues. Maybe caffeine, maybe stress, maybe work, maybe home life. It sounds pretty time-consuming.
Seema Khosla, MD:
So I would absolutely agree. And I think Doug would probably agree, too, that it is a time-consuming conversation. And I don't know, maybe is this a function of the ads for pharmaceuticals that promise to have you fall asleep pretty quickly? Is there the assumption that treating insomnia is all about just whipping out your prescription pad? Therefore, it should be easy and not time intensive, but I know for me personally, for somebody with insomnia, I feel like that is a more time-intensive visit than maybe somebody with restless leg syndrome or obstructive sleep apnea or narcolepsy. I don't know if, Doug, you feel the same way.
Douglas Kirsch, MD:
I agree. As I, I think, tried to say in the beginning, it's a longer conversation to have and it's hard to do in a primary care setting sometimes because they don't take a lot of time or don't have a lot of time. It's not that they don't take it. They don't have a lot of time to have that conversation. And to the point where even when you're whipping out the prescription pad and a prescription has been written for that patient, patients will come to see me saying this medicine didn't work. Well, the reason it didn't work was they weren't taking it at the right time. So it's not even just writing the prescription. It's actually talking to patients about how they use that prescription, what time of evening they take that prescription, and what their shifts look like for sleeping.
Seema Khosla, MD:
And even what we expect that medication to do. We don't expect it to club you over the head. It's not anesthesia. It is a sleep aid and so there's that component of your brain has to be ready for sleep. It's not realistic to go 90 miles an hour during the day and then turn it off for sleep. And there's no magic pill that will do that.
Douglas Kirsch, MD:
Particularly if you're not ready for sleep.
Seema Khosla, MD:
There you go. Yep, you're exactly right.
Douglas Kirsch, MD:
We talk to people about being ready. A sleep aid will help you go from being ready to sleep to sleep, but it's not going to make you ready for sleep. And I think that that is an important fact when you're talking to somebody about using a medication. And a lot of the time when they come in, they talk about this. This happened today. They were taking their medication three, or four hours before they were going to go to bed and said, "Well, that's when I need to take it to make it work." And I said, "Actually, by the time you actually get to sleep, that medication's actually worn off. So you're not even getting the benefit. You're just taking a medication three hours too early." So that piece of this really matters.
It's that level of detail with each of these steps that makes a difference in getting somebody to go from not sleeping well to going to sleep well. And I think, Seema, to your point earlier, I think comparison matters, too. I feel like a lot of the people who have insomnia are married to the people whose heads hit the pillow and go to sleep. They're constantly comparing themselves to their spouse, or bed partner, who is such a good sleeper that they feel like they are failing in comparison.
Seema Khosla, MD:
Well, and I think you've hit on something really important. I think there are certain expectations and sometimes we put so much pressure on ourselves. Now, I know sleep is really important. And hang on, I've got to get seven to nine hours. How am I going to do that? And, oh, my gosh, I'm killing myself if I don't get enough sleep and my heart is going to stop. And we put so much pressure on ourselves and sometimes we just have to give ourselves grace. Tomorrow's another night to get it right and we just have to understand that we want to make these changes over time because we want you to be successful. And those numbers that are put out there are meant broadly for the population and they may not apply to you. I personally am a long sleeper. Jaspal is not.
So I think we all have our normal for ... And then really trying to put it back in the patient's power when they say, "Well, gosh, how do I know if I'm getting enough sleep?" And what I'll usually ask them is, "Well, do you wake up on your own? How do you feel during the day?" Most people don't just pop out of bed and feel terrific, but how do you feel maybe two hours after you wake up? And so let's make this a little bit more achievable, more attainable, and less scary so that we can empower them to really get the most out of their sleep.
Jaspal Singh, MD, MHA, MHS:
That's great. I mean, it's interesting that you're thinking about what is normal, trying to define that. Kind of comes back to what we started at the beginning, the deeper dive history as Doug mentioned, sleep normality as defined by whatever metrics we're supposed to have and the expectations that come with that. And the idea of trying to be healthier, trying to get more sleep, and that's created this fuel, this anxiety related to that. And I think that's important that we think about. Now, that said, there's a whole industry emerging about defining normal. Both of you have been heavily involved in the idea of device information, and wearables. These are defining norms and apps that are out there that are telling you not just how you're sleeping, but how effectively you're sleeping. And are there other things happening to you at night that you should be aware of? And this sort of aspect of do you all use wearables in your clinics at all? And what do you tell your patients who are interested or thinking about using wearables to help track their sleep? Seema?
Seema Khosla, MD:
So yeah, these come up a lot and I actually really kind of get a kick out of it. A, I always ask them, "Well, why do you have this device? Was it intended to track your sleep, or did you get it for Christmas, or for steps, or something like that?" It happens to also tell you about your sleep. And so we kind of get it. Well, what is the intent behind this? Is it because your sleep has really bothered you forever and now this is your way of taking that first step? My youngest daughter and I were at a sleep conference earlier this year and it was at Disney. And so of course we're on the bus to Animal Kingdom and there are these four middle-aged women sitting near us and they are all talking about their sleep and their wearables. And one lady said, "I don't need a watch to tell me that I don't sleep well. I just don't sleep well."
But then that was it. She wasn't going to do anything about it because she felt like it was just hopeless. And so I feel like there are so many different levels of why people utilize devices and then how much faith they put in them. Some people hang their hat on every single thing that that sleep score says. Well, gosh, my sleep score is 75 tonight, and the night before it was 85. And what am I doing wrong? Whereas other people may look at it over the course of a month and then recognize that this is when I had a cold. And so I think sometimes some people are dismissive of the information. And I usually will say, "Well, let's look at trends. Let's look at what we think is realistic." We know that these are not based on brainwaves and so that's normally how we stage sleep.
So you have to take a little grain of salt, but is there useful information? Can we look at the time that it thinks that you are sleeping? Can we look at the regularity of your sleep-wake cycle? Can we sort of focus on the things that we think are more accurate rather than the nebulous maybe sleep score, where we're not really sure how things are weighted? Is it regularity? Is it duration? Is it interruptions? I don't really know. And then to allow them, I usually will ask them, "Well, when you wake up in the morning and you try to figure out how well you slept, base it on how you feel rather than what your wearable tells you." I feel like I slept great, not Fitbit tells me that I had X interruptions. And just sort of change that conversation a little bit.
Jaspal Singh, MD, MHA, MHS:
Doug, anything to add?
Douglas Kirsch, MD:
I mean, I think there are a couple of things. Seema put it really well. I think that we don't want to rely too heavily on wearable data, but it's not to say that none of it's important either. I had a woman who came in using CPAP for sleep apnea and she could show me that her oxygen levels looked pretty good I was going to do an overnight oximetry and I felt like maybe I don't need to do this. Her device is giving me a pretty good signal. I think the same is true around sleep. I think what I talk to people about is around the patterns in which they are using it, meaning, okay, well, you're going to bed around here and you're getting up around here and we can kind of see the ranges of those, but not to focus too much on deep sleep.
I get a lot of people come in, they're worried that they're not getting enough deep sleep. Well, you're 84, and actually, if we measured you in a laboratory, you probably wouldn't be getting a lot of deep sleep. That's actually normal for your age, but it's not normal according to what your wearable is telling you or your REM sleep amount. I think that because there's so much differing between wearable devices themselves and between wearables and the way we measure things in a laboratory, I tend to not let people get too distressed by those levels of numbers and to really try and focus on, okay, let's see if we can try and get your patterns to look good.
And as Seema says, see what we can do about getting you up, and feeling a little bit better. Recognizing that sometimes treating insomnia doesn't actually lead to somebody feeling any better. They may feel relieved that they're not having insomnia anymore, but the concept of fatigue is not always treated by insomnia. And I often try and make sure that people are taking those two things apart. My job is to try and make your sleep better. If your fatigue gets better, that's great, but your fatigue may or may not represent a symptom of your insomnia. And I think that that's an important discussion to have with patients as well.
Jaspal Singh, MD, MHA, MHS:
That's great. So they feel like, again, we're coming back to define the problem, really getting deep at defining the problems, setting expectations. Maybe the wearables may be helpful in certain situations. Generally speaking, they'll really understand their intent and understand their value, but trying to get patients not necessarily be perfect and fully relieved, but get them on the journey towards better health and better sleep health. Actually, start with that and then see where that lands. Is that about right? Okay.
Seema Khosla, MD:
Yeah, and you're exactly right. There's sleep health as it contributes to overall health. And I think we're getting more messaging about the importance of sleep as it fits into part of our overall health and well-being.
Douglas Kirsch, MD:
And unfortunately, that message then creates that feedback loop to insomniacs that they're not being healthy. And I think that that's a challenge, too, because I think we want to make their sleep better, but it's also recognizing that even people who have insomnia get sleep. They may not sleep as much as they want or feel that their sleep is as good as it could be, but they are sleeping. And so I often will try and feedback to them the importance of recognizing that sleep and rest is important for our health and our well-being. And so even if it's not 100% at that metric that this amount of sleep is considered really great for everybody, I think it's important to recognize sleep is good for you. And trying to attain an appropriate amount of sleep for you is actually the really important thing.
Seema Khosla, MD:
I love that you are giving them permission to rest. I think that that's something that's really undervalued in our society and you either feel like you need to be productive and sleeping or you need to be working or playing. But then that rest, I think it's so overlooked. And I'm hoping that we are better at recognizing the importance of rest and making it more acceptable to do that.
Douglas Kirsch, MD:
How many patients, Seema, do you have who, when they're not sleeping well, the first thing they do is get up and start doing chores? They'll do the laundry, they'll clean the kitchen, do the dishes. I get that a lot and my comment to them is just because you're not sleeping doesn't mean you then have to do all these other things. Assuming that there are sleep windows and you kind of set things up for them to be appropriate sleepers, which may not be the case if they're up at three o'clock in the morning, but part of it is giving them not just the permission, but the directive to say, "Hey, three o'clock in the morning isn't time to be productive." And it's time to really say, "Okay, all that other stuff is going to wait for 7:00 AM or 8:00 AM," or whatever time their natural wait time is going to be, and try and leave the to-do list for another time.
Seema Khosla, MD:
And that's really hard for a lot of people. And I feel like once we acknowledge that and start to untangle that, to me, it seems like that's a ripple effect throughout their lives then, where they recognize that it is okay to be kind to themselves. It is okay to not be productive all the time. It's okay to let the laundry wait a day. It's okay to let go of that.
Douglas Kirsch, MD:
Or five hours for that matter.
Jaspal Singh, MD, MHA, MHS:
I'm going to tell my wife that next time. But anyway, this was very helpful. I'm just trying to think back. I'm just going to recap, actually, for this first episode. We kind of talked about taking a deep dive, patients with insomnia really defining the problem, focusing on solutions, focusing on steps. It's almost like a therapy type of endeavor, kind of moving from one to the next, one step to the next, and starting to understand expectations, some of the data, some of the tools that we can use to really move them towards better sleep health, then better overall health. And how all that journey plays out for every individual is somewhat unique, which makes insomnia management a little bit sometimes daunting for some people, for clinicians, but also sounds like from both of you pretty rewarding, if it's done well. Am I right?
Seema Khosla, MD:
Yeah, it can definitely be life-changing for people.
Jaspal Singh, MD, MHA, MHS:
Yeah. Well, I just wanted to say thanks very much for this episode. This is very insightful. Again, this is Jaspal Singh. On behalf of Consultant 360, I wanted to thank our guests today, Dr. Doug Kirsch and Dr. Seema Khosla.