Assessing Response to Insomnia Treatment

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: We’ve talked, and we’ve given our colleagues a lot of different options for medicines. We’ve talked about the benefits of all the different medicines and some of the adverse effects, etc. But here’s my question to you as we’re wrapping up our discussion today, how do you determine efficacy in insomnia? What do you use to determine efficacy, if anything?

Debra Davis, CRNP: What a good question, and the honest truth is, and I probably should be a little embarrassed about this, is the patient report. I don’t have an IDSIQ [Insomnia Daytime Symptoms and Impacts Questionnaire]; I don’t have a scoring system. Now, I do that on hormones, because so many times when you bring someone to normalcy, they say, “I’m no better.” I say, “Oh really, you’re still having hot flashes and night sweats?” “No, I haven’t had that since you put me on medicine.” “Really, you’re not sleeping at night?” “No, I sleep just fine.” When somebody feels normal, they’re like, “I’m no better,” and so in my world a lot of times I really do rely on that, “How are you feeling? Are you feeling better? Are you sleeping better?” When really, it probably should be a bit more of a scoring system, of pointing out to them, “Remember, you were only sleeping 4 to 6 hours, and now you’re sleeping 7 to 8 hours.” Because so many times when people feel normal, they’re like, “Well, I don’t know. I don’t think I’m better,” when really, you’re a lot better.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Absolutely. I don’t use a real scoring tool either, I just ask, “Do you feel like it’s helped you? In what way? How long is it taking you to fall asleep? How much longer are you asleep in the middle of the night?” But what I also have asked people to do is, I’ll say to them, “If 10 was the worst you’ve ever thought your sleep was, and you had to rate your sleep today, where are you? With 0 being the best sleep you envision.” And that gives me a sense of, if they say, “I was a 10, and I’m a 5 now,” I say to them, “That sounds like a 50% improvement. Let’s see what we can do tweak that.” Which brings us to our next question, when would you change treatments? What would provoke you? What would be the instigator for you to change a treatment?

Debra Davis, CRNP: Often with the DORAs [dual orexin receptor antagonists] especially, they are supposed to take them every night. If someone says, like when the suvorexant first came out and people were like, “This did not work for me at all.” Then, I’m going to have to make some changes. But if they’re 50% better, I often will pull up a scale and show them that this really improves over time, to stay with it, keep doing the same things. And we always do talk about, “What are you doing before you go to bed at night? Are you watching TV? Are you looking at your phone?” Because remember, the light shuts off melatonin, you need to have a time before bed where you’re not engaging in being on your phone, having that light in your eyes, you really do need a dark room. “What are you doing to prepare for sleep?”

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I agree with you, and I would add that for me, what would cause me to change my treatment would be some of those complex sleep behaviors, right? Or if they were reporting sleep paralysis, where they feel like they can’t move when they wake up, or hypnopompic, hypnagogic hallucinations, if they’re seeing things as they’re falling asleep or as they’re waking. Some adverse event, or if they say to me, “I slept through my baby crying.” Those are all reasons that I would switch, and obviously, if they’re not working, then I would move to a different agent.

I want to talk for a moment about adherence to our treatment regimen, and you just mentioned something, Debbie, where you said we really want people taking the DORAs every night. Now, you said that, but historically, we’ve said, “Oh, we don’t want people on sleep medications every night.” So, I think as we’re getting newer options that are safer, our philosophy on how we treat sleep is evolving. Would you agree?

Debra Davis, CRNP: I would agree completely because you would never take your antihypertensive medication every 3 days, or just when you felt like you needed it. You need to take this drug as it’s prescribed, and it’s prescribed for nightly use, because it shows that it really does get better over time. And if you stick with it, and you want to take it properly, take it every night, and I think you’ll find that it gets better and better. You were saying that sometimes people have really adverse events. At what moment, or time, do you say, “Hey, it’s time for you to see a sleep specialist,” and how does that happen?

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: Certainly, once we’ve diagnosed them with sleep apnea, we will get them in to see a nurse practitioner specializing in sleep so she can titrate up their CPAP [continuous positive airway pressure] machine. If I’m concerned regarding narcolepsy, if I’ve tried the standard of care and these folks are not getting better. If the sleep study was inconclusive, and maybe they need an in-house sleep study. Those are some of the reasons that I send people over for sleep medicine. Does that seem similar to what you’re doing for sleep medicine?

Debra Davis, CRNP: Yes, it is, especially I like what you said about the inconclusive studies, because sometimes it’s, is this mild, or is this moderate, or was it done properly because it was done in the home? Then referring them out I think is a much better idea at that juncture.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: As we talk about adherence to the regimen, and you talked about the fact that it’s important people take this once a night, there are different kinds of tools out there. I wanted to share with you a couple of tools we have in our clinic. We now have a bidirectional interface with a patient’s pharmacy. So I click on this cute little button, it’s called “fill history” in our EHR [electronic health record], and I can see any drug the patient has filled at a pharmacy. And if it hasn’t been prescribed by my clinic, it’s in a bold category, so I know someone else is prescribing it. What that helps me to do is drug-to-drug interactions checks, but I can also say, “Look, I’m seeing here that you last filled this drug 6 months ago. Are you still taking it? What’s going on?” Are there other tools that you have for tracking adherence?

Debra Davis, CRNP: We have the same option in our EMR [electronic medical record] system, which is great, because you can, like you said, see drug-to-drug interactions and find out what else they’re taking. Because so many times, patients will say, “No, I haven’t had it filled, but I have plenty.” I can say, “You should not have plenty; how is that you have plenty?” And so, that is a way to bring up the conversation of, “You really should.” I hate to should people, but “I would really like it if you tried taking this every night because it would work better, you would sleep better, and you would feel better.”

Transcript edited for clarity