State of Insomnia Care and Overcoming Inconsistencies in the Traditional Care Strategies

Ashgan Elshinawy, DO

Insomnia, a common sleep disorder characterized by frequent arousals during the night and earlier awakening, can be caused by environmental, physiological, and psychosocial factors, as well as from other neurological disorders. There are no specific tests to diagnose insomnia, so individuals may opt for a blood test to rule out other medical conditions, keep a sleep diary, or complete a sleep study. Over time, lack of sleep or poor-quality sleep can negatively affect a patient’s physical and mental health, as well as contribute to diabetes, driving accidents, high blood pressure, mood disorders, and weight gain.

Certain lifestyle changes and improvements such as increased physical activity, reduced caffeine intake, quitting smoking, and elimination of blue lights and screens before bed, can all contribute to improving nighttime sleep and preventing insomnia. Insomnia occurs more often in women than men, as pregnancy and hormonal shifts can also play a factor into sleep. Additionally, insomnia becomes more common over the age of 60 years, mainly because of bodily changes related to aging, and/or other contributing medical conditions.

To learn more about the current assessment of insomnia care, and the available treatments to treat this condition, NeurologyLive® sat down with Ashgan Elshinawy, DO, a pulmonologist at Penn Medicine, and pulmonologist and sleep medicine physician at Cardio Metabolic Institute. Elshinawy provided insight on treatments such as cognitive behavioral therapy, the need for patience when managing the condition, and the potential to overhaul care going forward.

NeurologyLive^®: How would you describe the current care for insomnia right now?

Asghan Elshinawy, DO: It’s suboptimal, partly because a lot of people are not well versed on the standard of care therapy, which includes cognitive behavioral therapy. A lot of people will tend to push sleep hygiene on people and give them medications that they may or may not be familiar with. I also don't feel like it's tailored to the patient's needs, and things are not considered in terms of what other medications they're on. I don't think it's the best of care that we have, right now for patients with insomnia. The other thing is I don't think a lot of physicians, especially primary care physicians, who know the definition of insomnia. Hopefully, sleep physicians are aware that it's not just a nighttime disease, and that it carries over into the daytime. It’s a 24-hour problem.

Has there been any sort of therapeutic approaches that stand apart from the rest or have shown even more favorable results in caring for these patients?

From my personal experience—and I've been doing this for about 17 years—if you take the time to do the cognitive behavioral therapy, it's almost always effective. It just, it requires a lot of time on the practitioners. It also requires having the knowledge of how to do it and requires the patient to meet you halfway and do the homework that you instruct them to do. But if they do follow the instructions, their sleep does improve, even without medications. It just takes a little bit more effort, it's always easier to pull out your prescription pad. I definitely prescribe medications, mainly because of the limitations of cognitive behavioral therapy, because a lot of people are not on board, they don't just want a quick fix, or that their quality of life is so poor that they need something quickly. If they do need pharmacologic therapy, I treat it with multiple different medications. I base my choice based on people's comorbidities and other medical problems, their age, how much sleep they're looking to get, and safety issues, of course.

What are the most difficult aspects of insomnia management currently?

It's patience, some impatience with the process. A lot of people will call you back 2-3 days after you say prescribe something, or start a cognitive behavioral therapy, and they'll say, “I'm not sleeping, I'm still not sleeping.” You try to explain to them that you've had insomnia for 22 years, and it's not going to get better in three days. It's a process more than a quick fix. Some medications that we give have to be built up in the system and don't work the first night. I feel like everybody wants like a hammer to the head and just knock me out. I spend a lot of time setting expectations in the office so that I don't get that call 48 hours later saying I'm still not sleeping. I tell them, It's not a miracle thing. This drug, even though it works for so many of my patients, it may not work for you, so don't get frustrated, there are other medications that we can try. I think it's their impatience, their eagerness, their anxiety—because a lot of people who have insomnia, also have anxiety. You have to assess the other challenges that you have, and to not only treat the insomnia, but treat the anxiety, because if you ignore one, the other one is not going to get better.

What is the biggest priority for improving the care paradigm for insomnia?

My biggest goal with these patients is not necessarily to just increase their number of hours of sleep from 4 to 7 hours. I mean, that would be lovely. But a lot of people think that’s the goal, “just get me more sleep.” I always try to tell them that you may not need 7 hours of sleep to be functional during the day, so don't look at it as like that. If you don't get that you have failed, or we have failed. I tell them, it's the amount of sleep that you need in order to function well during the day. If you're able to complete your tasks, do your work, go to school, attend classes, attend meetings without falling asleep, then I think we're successful. If your mood, your memory, your concentration, those type of markers, are good during the day, then that’s good. I usually focus more than “how many hours of sleep are you getting now compared to before,” because maybe you're getting the same exact amount of hours asleep, but maybe you're getting quality sleep now as opposed to before, where you were getting arousals every five minutes. I tried to move them away from that, "you have to have the perfect seven and a half hours of sleep in order to have normal sleep."

Transcript edited for clarity.