Transcript: Treating Patients with Insomnia

Liz Rohr:
Well, hey there, it's Liz Rohr from Real World NP and you are watching the Real World NP YouTube channel. We make weekly episodes to help save you time, frustration, and help you take the best care of your patients.

Liz Rohr:
In this week's episode, we're going to be talking about insomnia, both the approach to assessment and diagnosis, as well as management principles. So, I just want to validate that this can be a tricky chief complaint to address in primary care for a few reasons. So, the first reason that I find in primary care is that a lot of patients who come in for a chief complaint of insomnia and that's their primary reason for their visit, is because they're frustrated. They've been dealing with this for a while and they've already tried medications to help them. And so, they're coming in and they're like, "You know what, just fix me, give me this medication, and let me go home."

Liz Rohr:
That's a lot of the attitude that I see, and so it can be tricky because it's our job to assess what's going on and not just hand out medications. Right? And I think that sometimes, people who are not in healthcare forget that, that there's more to our job than simply writing a prescription. Right? So, we just have to be careful with the assessment of insomnia.

Liz Rohr:
So first, I just want to say that most of my visits with patients who have insomnia, I start by connecting with them. I do this with all patients, but especially for this chief complaint. Connecting with how they're feeling and really validating what's going on for them. Because until I meet patients where they're at, they may or may not be interested in hearing what my assessment and my management suggestions are. This applies for everything, but I think especially with this chief complaint.

Liz Rohr:
So, I do validate that. "It sounds like it's been very frustrating for you. I'm here to help you. You know what, I have some questions I need to ask you first and then we can get into what the treatment options are." And so, I usually start with something along those lines and just kind of validate what's going on with them, and then I get into the history.

Liz Rohr:
So, let's start with the history questions. So, when it comes to any chief complaint, symptom-based chief complaint, we always start with some sort of framework, right? I use OLD CART which you've heard of before, if you've been following for a while. So, starting with OLD CART for any chief complaint.

Liz Rohr:
But what are the questions to ask in addition? So, for insomnia, we want to ask about a couple of different things. One centers around sleep hygiene. So, let me just start by describing sleep hygiene and then you can kind of... we'll work backwards what the questions are. So, sleep hygiene is kind of like this thing that I think maybe providers and patients alike are kind of like, "Oh my goodness, why are you talking to me about this?" But in fact, they really do make a difference. So, it's really important to stress that with patients, assessing those things before we're like, "Oh, hey. Just go do these things." Because like I said, they've probably done all the things already and they're coming to see you to help them. Right?

Liz Rohr:
So, let's talk about you and I, let's talk about sleep hygiene. And then we'll translate that into the patient question. So, sleep hygiene is going to bed at the same time and waking up at the same time every day, no matter it's a weekday or a weekend. It also includes having a cool, dark place to sleep, low noise or silent preferably would be great. The other thing is that we want to avoid screens two hours before bed, at least. And so, we know that the blue lights that come out of televisions or phones or tablets or anything like that can reduce the melatonin production in the brain, which leads to difficulty with sleep.

Liz Rohr:
So the other pieces we want to think about with sleep hygiene are caffeine use, tobacco, and alcohol use. So caffeine use, we really want to limit the amounts that we have, especially keeping them earlier, like way before anywhere near they're going to bed. If a person goes to bed, for example, at 10:00 PM and wakes up at seven or 8:00 AM, we want to avoid caffeine after say about noon time. I should probably be taking notes myself.

Liz Rohr:
And then with alcohol and caffeine, alcohol and tobacco rather, tobacco, I mean, anytime, but especially if they're consuming it right before bed. Alcohol, the same thing. So, one of the metabolites of alcohol is actually a stimulant and that can wake them up in the middle of the night and be disruptive.

Liz Rohr:
The last thing about sleep hygiene is naps. And so what we try to do is, avoid naps during the day. If we must nap for adults, we're talking about less than 30 minutes of sleep, again, well before it's time for bed, whatever bedtime they have, if possible.

Liz Rohr:
So yeah, those are the main components of sleep hygiene. And so if we understand those components, our history questions are just eliciting those pieces of information. Again, one of the pitfalls is that we kind of launch into, "Here's all the things you should do.", instead of, "Okay, when are you going to bed? When are you waking up? Is it the same every day? Does it vary? Do you do shift work? Do you work all night and sleep during the day? Does it switch back and forth? Do you keep that schedule all the time?"

Liz Rohr:
And then we get into those questions of, "How much caffeine are you using? What types?" When I was a new grad, I'd be like, "Oh, you have caffeine. That's great." Moving on to the next question. But let's pull it back for a second. "Are we talking about Venti Starbucks multiple times a day, right before bed, I can have caffeine at any time. It doesn't affect me, kind of thing?" Yeah. And then just asking about all those other things. Do they have a cool, dark room at night? Is it noisy? Is it hot? Are there other people? Things like that. Right? So that's one of the history places that I start, is about eliciting those sleep hygiene questions initially, before we launch into the management counseling around that.

Liz Rohr:
The next piece is though, there's a couple other pieces we want to assess when it comes to insomnia. We want to start, in addition to assessing those questions about sleep hygiene, we want to ask about if it's acute or if it's chronic. Is this the last couple of days, maybe weeks or has this been for like 30 years? Right? What other medications have they tried? What other supplements are they trying? Things like that. That's the next part.

Liz Rohr:
Another kind of diagnostic tool question is, asking about, what does it look like for them? And so, there are three questions. Is it difficult to fall asleep, stay asleep, or is it just that you feel tired when you wake up in the morning? Or, is it all three? So those three things are three different categories. One is sleep latency and that's difficulty falling asleep. One is sleep maintenance, which is staying asleep. And then the third one is sleep quality. They just feel like garbage, even though they slept all the hours that they should have. Right? And that is important for the management principles as well.

Liz Rohr:
The last pieces are getting into what I alluded to at the beginning of this episode, is that our job is to really make sure what else is going on here, and be skeptics. Right? Is this primary insomnia, meaning it's only insomnia, nothing else is going on with this person? Or is there some underlying medical condition that is contributing to this insomnia, difficulty falling asleep, staying asleep, or they just feel like garbage in the mornings? So some of the things to think about, so we want to think about psychiatric mental health illnesses, anxiety, depression, PTSD, et cetera, acute grief. What else is going on with the context, especially if it's more acute?

Liz Rohr:
Another thing we want to think about is, why are they... Again, if it's a sleep maintenance issue, they're waking up in the middle of the night, why is that happening? Is it they're having a difficult time catching their breath? Are we looking at paroxysmal nocturnal dyspnea, is actually the diagnosis, not insomnia? Or is it nocturia, they're avoiding multiple times a night? Or, they're snoring.

Liz Rohr:
So, that's another big one I really want to touch on is, I think this is really underdiagnosed. I don't have any stats in front of me, but generally speaking, anecdotally speaking, every time I assess for sleep apnea I feel like I find it. So, we really want to assess for snoring as well as, do they have restless movements at night? So, do they know if they snore? Is somebody else in the house or where they live can verify if they're snoring? Are they waking up gasping in the middle of the night? Those are usually the questions that I'm asking. And then the restlessness, pretty much people can tell you that, right? Is there underlying, a restless leg syndrome or something like that?

Liz Rohr:
And then the last piece as it relates to those kind of underlying comorbidities is, what medications are they taking? Not just for treatment so far, but what are they taking overall? And can we do some digging into those medications and see if those could potentially be contributing? I don't necessarily have a list for that right now, but that's my general approach, is when I'm talking with patients, I look at their med list. And then I'm kind of like, "Okay, is this a potential contributor?" Looking up whatever resources that you use to verify that.

Liz Rohr:
So, management. The management depends on what you found in your history, right? There's no real other diagnostic thing involved with insomnia, aside from the history that you've gathered from this person. And you are sleuthing for underlying medical conditions. Right? So, everything is really individualized. We want to again, just as a recap, we want to talk about... we want to assess their sleep hygiene behaviors at baseline. We want to assess for underlying medical conditions, medications they're taking, especially psychiatric mental health concerns. We want to ask about things like sleep apnea and restless leg, potentially some restless leg syndrome there.

Liz Rohr:
And once we've gotten there, we can do our management, right? So pretty much everybody, unless they have clearly like, "Well you actually have heart failure, and so let's deal with that.", pretty much everybody can use sleep hygiene counseling, right? And I kind of already went over that. And so reinforcing that with patients, going slow, going through the things, brainstorming with them, really encouraging them, that these things do make a difference. And I know it's not a medication, but they really do make an impact. So, it's important to try.

Liz Rohr:
Another part of that is, obtaining a sleep diary. I think, especially if it's not really clear if this is a primary insomnia thing versus related to an underlying condition, keeping a sleep diary of when they go to sleep, what time, what time they wake up, when they woke up. What was the context around what was going on? Similar to headache diaries. Right? If we can keep a sleep diary for the next week or two weeks, that would be really helpful for us understanding what potentially could be going on.

Liz Rohr:
Okay, let's talk about if it is primary insomnia, what are those management principles? So fortunately or unfortunately, the research supports that CBT for insomnia, cognitive behavioral therapy, specific to insomnia CBT-I is widely studied and is very effective for primary insomnia. That is first line, not medication, so a lot of patients don't really want to hear that. But we do have conversations about what they can do, empower them in their own lives, with sleep hygiene. Plus if they have access to that mental health resource, pursuing that. That is really effective. Those are the most effective options that we have for insomnia.

Liz Rohr:
Next step, though, if we don't have access to cognitive behavioral therapy for insomnia, someone is not willing to do that. We can consider pharmacologic management. So when it comes to pharmacologic management, the choices that we make are dependent on whether somebody has sleep latency challenges, meaning it's difficult to fall asleep, versus if they have sleep maintenance challenges, which is staying asleep, or if it's both. It's a combination of mixed.

Liz Rohr:
Because the principles of management are, that we try to avoid pharmacologic pharmacology in the first place. But if we do, we want to choose this lowest dose for the shortest period of time, at the shortest half-life. Right? And so if we have a sleep latency problem, we're going to succeed more often with the lower half-life options, because it doesn't have to last the whole night. We just have to help people stay asleep. And we try to do it short term, because the most effective treatment, especially for chronic insomnia is CBT for insomnia.

Liz Rohr:
So, what are those options? I'm going to give a general approach to pharmacology here because things change so much. And this is the most kind of up-to-date thought as of May, 2022, is when I'm recording this. So when it comes to the first line options, PS, I'm really good at reading things and I'm not great at pronouncing them. So, apologies if I'm butchering these words, but Ramelteon is the generic version of the melatonin receptor agonists. You may know by another name, but I don't want to use brand names on this channel.

Liz Rohr:
So, that is the first line, in terms of on label. All of these are basically the same in terms of first line, there isn't like 1, 2, 3, 4 in the same way that diabetes medications are. There's not a ton of evidence for any of it. But in terms of it being on label for insomnia, that is a kind of quote, unquote first line option because it's on label. Most of the other options are off label. And so, it doesn't mean you have to choose the on label versus off label first. But this just for your knowledge sake. Any of these options are appropriate.

Liz Rohr:
The next one is melatonin. And again, it doesn't have to go 1, 2, 3, 4. These are all options. Melatonin is a supplement over the counter. And the thing with supplements versus medications, which you probably learned in pharmacology, but just as a refresher, they are not regulated in the same way. So, one of the recommendations when we're having any patients take supplements is that there is a label called, USP Verified, where those are just more monitored to make sure that they actually are what they say they are. And you can have patients ask a pharmacist for help for those over the counter medication options. Because melatonin is over the counter.

Liz Rohr:
Other ones that are off label, but they're as well, first line, they're off label for insomnia, but their first line options are sedating antidepressants. So, those in those categories are things like amitriptyline, Trazodone, Mirtazapine, those are all potential options. And the choice to use one over the other is dependent on what else is going on with the patient. Do they also have comorbid depression? Then you can choose a sedating medication for depression to take at night to help with the insomnia. Right?

Liz Rohr:
So, the next kind of category is sleep maintenance. So basically, it's all the same options, except we have another additional option of those orexin receptor antagonists. I'm reading them on my notes, so I don't butcher the names. Lemborexant and Suvorexant, I typically, in my regular life, refer to them by the brand names, but on this channel I prefer to use generics. So, those are the generic names. Those have a longer half-life, they're safer to use than the sedative hypnotics, those Z medications like zolpidem, et cetera, as well as benzodiazepines. Those are not really recommended anymore. It's a little bit of a contentious thing because some people are still prescribing them. It's not officially contraindicated, but it's really wise to avoid sedative hypnotics as well as benzodiazepines.

Liz Rohr:
But those DORA, that orexin receptor antagonists, those other newer agents, those have a much safer profile than those other options. And so, you can use those, especially for those sleep maintenance people where they're having trouble staying asleep or it's mixed, staying asleep and falling asleep. The problem is the cost. Most patients have a cost issue for those.

Liz Rohr:
So, what are some of the other options? Low dose doxepin specifically can be used for sleep maintenance. Those are kind of neck and neck when it comes to like those DORA medications, as well as that. And then we try to avoid the sedative hypnotics as well as the benzodiazepines. You can also use all the other medications that I mentioned already, so the sedating antidepressants, Amitriptyline, Trazodone, Mirtazapine, as well as if the sleep maintenance issue you're hypothesizing is related to restless legs, you can consider off-label use of Gabapentin for insomnia. It's also off-label for restless legs, but that's a potential option.

Liz Rohr:
Those are majority of the management principles. And I definitely recommend you utilize the resources that you have in terms of the dosing options and the choices that you make, keeping in mind, the comorbidities and what you've assessed already for that patient. I think one thing I just want to be extra mind... If you can take one thing away from this, two things, one is that cognitive behavioral therapy is first line and sleep and sleep hygiene. So, the non-pharmacologic options are first line. And the second thing I want you to take away from this episode is that, we really just have to do our due diligence to make sure we're not missing anything medically. So sleep apnea, do we need a sleep study for this patient? Do they have underlying urologic concerns, cardiology concerns, et cetera, et cetera?

Liz Rohr:
And I don't have a full list of all the differentials in there for medical reasons, because it's very broad, but you just have to do kind of your due diligence and digging and sleuthing when it comes to that history taking. So hopefully this episode was helpful for you. If you haven't grabbed the ultimate resource guide for the new NP, head over to realworldnp.com/guide. You'll get these episodes sent straight to inbox every week with notes from me, patient stories, and bonuses I really don't share anywhere else. Thank you so much for tuning in. Talk to you soon.