Looking Ahead to the Future of Sleep Disorder Care

Karl Doghramji, MD, FAASM, DFAPA

Karl Doghramji, MD, FAASM, DFAPA

This is the second of a 2-part interview. For part 2, click here.

The COVID-19 pandemic has pushed the clinical community into a position where it has, overall, needed to reevaluate the importance of a variety of aspects of care. One such area of focus has been sleep, which has been broadly affected in a negative way for many individuals.

In parallel, research has continued and provided information on the role of sleep in the pathological processes of diseases such as dementia, and revealed the impact of poor sleep on overall health and wellness. Although these advances have pushed the field forward, many challenges remain, including the need to improve sleep measurements in a clinical setting and the identification of sleep disorders. Despite this, the future of the field remains bright.

In an exclusive conversation with NeurologyLive^®, Karl Doghramji, MD, FAASM, DFAPA, professor of psychiatry and human behavior; professor of neurology; and medical director, Jefferson Sleep Disorders Center, at the Vickie and Jack Farber Institute for Neuroscience of Jefferson Health, offered his insight into the possible advances that sleep medicine may experience in the coming year.

NeurologyLive^®: Outside of insomnia, are there any areas that are not getting enough attention when it comes to therapeutic development?

Karl Doghramji, MD, FAASM, DFAPA: Well, certainly the disorders characterized by central nervous system hypersomnia, such as narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, etc. Sleepiness, in general, is a very common problem in our society as well. And although narcolepsy is a very small contributor to that prevalence, it actually represents a model disorder, if you will, of sleepiness where the therapeutics in narcolepsy can help us understand potential therapeutic agents for other areas of daytime sleepiness.

The pharmacotherapy of narcolepsy has always been a challenge, for many decades, because all we've had available to us have been the scheduled stimulants, which have an array of side effects. Wake-promoting agents such as modafinil and armodafinil have been around for a few decades as wake-promoting agents, and more recently introduced has been solriamfetol, which has not only dopamine but also norepinephrine properties, and pitolisant, which is a histamine agent. These agents have really been very, very helpful in treating narcolepsy and hypersomnias, and most recently, we've seen the introduction of sodium oxybate, as well as its low-sodium cousin—if you will—low-sodium oxybate, for the treatment of idiopathic hypersomnia, a cousin of narcolepsy characterized by the lack of REM symptoms or REM types of clinical findings such as cataplexy, sleep paralysis, and hypnagogic hallucinations. They're representing a large portion of the central nervous system hypersomnias. There are now a number of agents available to us for the treatment of these disorders of central hypersomnia, which in the past, have been very difficult to treat.

Are there still challenges in properly diagnosing patients with certain disorders or differentiating one from another?

We do see this, unfortunately, still, on the primary care level. Simply identification of patients who have sleep disturbances is still a challenge in the regular history and physical intake history and in follow-up settings. Incorporating questions about sleeplessness or daytime sleepiness is still a challenge and not done in a wide variety of clinical settings. Even in the arena of specialists such as neurologists and psychiatrists. The data, unfortunately, show that those sorts of questions are not being routinely asked, and it's so important to do so. But even after doctors and clinicians of various kinds ask the question and get a positive finding along the lines of many of these symptoms, we're finding that the methodologically sound way of addressing these, the evaluation process of arriving at a definitive diagnosis and arriving at a workup strategy, is still lacking in many clinical contexts. We have a lot of work to do.

In the arena of the specialists such as medical practitioners, we, of course, have sophisticated diagnostic techniques and practitioners who are educated in diagnosis. The challenge is one of the availability of services. We see that practitioners are so inundated with patients that, in many cases, patients are having access difficulties to these specialized settings. Interestingly, even in these very specialized settings and sleep medicine settings, the focus seems to be in many areas on sleep-related breathing disturbances. Asking questions that elicit things like narcolepsy or idiopathic hypersomnia is still a bit of a challenge because of various factors, including the fact that it does take some time to delve into the diagnosis of narcolepsy and idiopathic hypersomnia. We have challenges across the board, as you can see, in many of these areas.

Do you find that sleep specialists are being incorporated in the comprehensive care model as often as they should be?

Not at all. I think it's safe to say that there are significant challenges there. This model of comprehensive care which incorporates multiple disciplines including sleep neurology and psychiatry into one setting is still something that many centers are working on developing, but we're still not there. We've developed something like this at my host institution, Jefferson Health, along the lines of primary care and sleep medicine for the management of sleep apnea. There is, within the context of primary care, heightened awareness for sleep apnea by implementing some screening models, including what's called the STOP inventory. A positive or highly positive screen that triggers a sleep medicine evaluation, which could include a sleep medicine physician consult as well as sleep testing, at home or in laboratory testing. We're just beginning to have some data emerge from this, showing us how well we've captured patients in this population. But these types of coordinated models are far and few between, and we still need to do a lot more work in developing these models.

One of the interesting things that have been happening over the past few years is that the training programs in sleep medicine are beginning to incorporate specialists from multiple disciplines. It used to be that sleep medicine fellowship programs admitted primarily neurologists, pulmonologists, and psychiatrists. Now we're seeing the influx of family physicians and primary care, and individuals in internal medicine. These physicians are emerging into primary care practices, where we're now, as sleep specialists, beginning to incorporate sleep medicine into their everyday work, which is an exciting development for me because now we can see the incorporation of sleep medicine right into the arena where we see sleep disorders—most that is in the arena of primary care.

Do you believe that some sort of certification for primary care providers would be helpful in giving them a baseline of knowledge in sleep care?

That's a fascinating thought, just to underline what you said. The average time that we devote to education and sleep medicine at the medical school level was assessed a few years ago—it's around 35 minutes. For a process where we spend one-third of our lives. A certificate program or a specialized training program would be great. We can also think along the lines of incentives being provided from third-party payers for improvement of sleep, or for improvement of metrics relative to sleep, on a primary care level or even in the neurologic and psychiatric setting. Absolutely. In all fairness, we still have some work to do in terms of convincing all of us as a medical profession about the role and importance of sleep and its impact in terms of human functioning. There are so many other competing processes in clinical medicine for specific types of type of awareness that I think for sleep, our educational processes are just sort of beginning to emerge. Absolutely education on a medical school level, on a residency level, and a certificate or other program on a graduate level, I think would be very highly helpful.

Regarding the glymphatic system’s role in sleep, what are the key things of which the clinical community should be aware?

It is a fascinating area. The glymphatic system, we're now beginning to recognize, is so important in maintaining brain integrity on some on a cellular level, and that system is most active during sleep. There is a very important connection between sleep and the maintenance of proper brain function on a cellular level. This is a key area of awareness for us now, and there are a number of diseases that we now know are more likely to occur in patients who are sleep-deprived. The area of Alzheimer disease and the dementia processes is one. Now we do have long-term data clearly showing us that low levels of sleep or poor sleep is associated with higher levels of development of Alzheimer and various dementing processes. We have the data. Interestingly, we also have data showing us that enhancing sleep with medications, even benzodiazepines, is helpful in diminishing the levels of these poisonous compounds like beta-amyloid from building up in the central nervous system, and even have a positive impact in terms of some clinical parameters. We have the data. The future is exciting. There’re so many laboratories now working on developing compounds that promote this system, the glymphatic system. And by developing these compounds, we can see where we're headed to a point in time where possibly, by improving sleep, we can at the same time be able to enhance a number of areas of neurocognitive function.

Looking forward to 2022, what are you excited about?

I think the most important aspect of sleep that we become aware of is how important it is for our emotional and physical lives. By virtue of the COVID-19 pandemic, the number of complaints relative to sleep have increased dramatically, and not only being sleepy but also not sleeping well at night. Also, in correlation with this, diminished mood and diminished productivity on an individual level. We've also seen how improving one's sleep-wake environment can be so helpful in restoring some of that function. We've always talked about this, but I think the COVID pandemic—it's not anything positive, but it pointed out to us how important sleep can be. That has increased our level of attention to sleep and has made our patients much more not only aware of it but has given them the armamentarium to help themselves in the future. We can only build on this in the future and I'm seeing next year as being possibly an important one for us to emerge from COVID-19 and begin to sleep better.

Transcript edited for clarity.