Peter L. Salgo, MD: If we assume that we have to treat insomnia, or we’d like to treat insomnia if we can, are there guidelines out there to tell us when to treat and what to treat? What about cognitive behavioral therapy? Where does all this fit?
Karl Doghramji, MD: I think CBT, or cognitive behavioral therapy, especially in the context of the elderly, is really the place to start, right? Adjusting one’s behavior to make sure that their bedtimes are regular. They’re not going to bed late, not napping too much through the course of the day, exposure to light is only during the day and not close to bedtime when it can harm sleep, that they don’t have a lot of biological substances like caffeine. To clean up their life behavior, if you will, a lot of times that can improve sleep in and of itself.
Gary L. Johnson, MD, MS, MBA: Don’t we call that sleep hygiene?
Karl Doghramji, MD: Absolutely. That’s the concept.
Peter L. Salgo, MD: Are there actual guidelines? Can I go to a book somewhere and find 10 bullet points that say these are the guidelines from this society?
Karl Doghramji, MD: You can and I wrote that book. I’ll be very happy to send it to you, yes, absolutely.
Peter L. Salgo, MD: I don’t want to read it and they can’t see it. What is this thing?
Karl Doghramji, MD: A number of textbooks have been written, including one that I wrote, a primer on insomnia, which describes some of these sleep hygiene alterations and what to do about them behaviorally, absolutely. But I should also say that other more focused things are helpful in the elderly also, in terms of behavioral control. For example, something called sleep restriction. The elderly tend to fragment their sleep by waking up and sleeping, waking up and sleeping, throughout the day. And what we found is that if we restrict the time that they spend in bed, their sleep at night becomes more efficient and more productive, as opposed to having more insomnia. So some behavioral changes in the way they sleep can really help them sleep better.
Peter L. Salgo, MD: What about now, because people are focused on medications, they’ve heard all this: restrict your sleep, go to bed at the right time, don’t stay in bed too long, try not to nap, don’t take too much coffee. And they go, “Poppycock, I want a pill. So I want to go to the drugstore and I want to take an over-the-counter sleeping pill.” What’s out there and are they safe? We’ve got melatonin. There’s tryptophan, that’s a big one, right? Hydroxytryptophan. What do we do with all this?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Well, I think the first thing, especially when we’re working with older adults, is it’s really important to look at, as was mentioned, their existing medications first. But if they want a pill to address the sleep and they’re going to start self-treating, we always recommend they talk with their providers first to make sure there’s nothing medically going on. But if they say, “I really want something,” I think it’s really important to look at the risk versus benefit. Some people like teas, some people like pills. So let’s start with agents like valerian root or chamomile, which you can get in different formulations, not just at your local drugstore.
Peter L. Salgo, MD: We’ll call that herbals.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: We’ll call those herbals that are available readily over the counter. And so that might be a first step approach because they’re something that might calm you down and make you relax before you go to bed. It might be safer than using something like diphenhydramine. We find those preparations that have more of those anticholinergic properties can make you potentially more confused. So you’ve got this vicious cycle of getting something that might make you confused on top of being at risk for being confused. A lot of these agents, diphenhydramine, doxylamine, or some of the other preparations that are out there, again, we have to watch those.
We have families and patients asking about melatonin. There are lots of different doses of melatonin. So, if you’re going to try melatonin, be warned that it’s not a quick fix. So sometimes there’s misperceptions and misunderstandings about the value of over-the-counter medications because some of them might make you sleepy right away. Some of them you need to take on a regular basis to really get the full benefit.
Gary L. Johnson, MD, MS, MBA: I’m going to go back to the sleep hygiene, and I’ll put in a plug for primary care medicine. I think the job here of the primary care provider is to steer people away from pills, like you say, if somebody asks for a pill. The analogy is asking for antibiotics. I don’t know how many conversations I’ve had with patients about why they don’t need an antibiotic. And it’s the same thing with insomnia.
Peter L. Salgo, MD: OK. It occurs to me that at least part of your life was lived in a part of the country, north in Alaska, where sometimes, the day was 24 hours, and the day/night cycle that we come to associate with sleep is disrupted. How do you deal with all of that as the days grow longer/shorter? Does that affect sleep?
Gary L. Johnson, MD, MS, MBA: It can in some people. For me personally, it did not. We did not have shades on our window, and I slept when it was daylight.
Peter L. Salgo, MD: We didn’t really touch on the tryptophans, by the way. I don’t want to leave without talking about that.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: We’re just hitting the tip of the iceberg of the various things that could be out there. But tryptophan, we think of our turkey dinner, right, and Thanksgiving coming up, and potentially the role of that agent in terms of helping us to feel more sleepy and improve our sleepiness, and maybe our amount of sleep at night. But I caution because with many over the counters, especially herbals, they may not be standardized. And we don’t always know what we’re getting in terms of the dose and consistency.
Peter L. Salgo, MD: If you go into the drugstore, you go to the health food store, you buy something in a bottle and it says this is this drug, it’s not standardized?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: The herbal products are not necessarily standardized. They’re not going through the FDA. Some of them may be checked in terms of some USP [United States Pharmacopeia] standards but not all the products. And I deal with various socioeconomic statuses that we watch. And they go to the dollar stores, and there’s been consumer reports coming out on what actually are in some of these preparations. In some of them they’ve even found prescription-like substances within these preparations like valerian root. There definitely is a safety concern, and so I treat any medication, whether it’s prescribed or over the counter, especially in older adults, you need to look at it. And to Gary’s point, is we’re trying to minimize the self-treatment without that discussion with the providers.
Karl Doghramji, MD: I’m sorry to interrupt.
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: No, please.
Karl Doghramji, MD: We think of these agents as being innocuous in nature, but that may not be the case, correct, Nicole?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: Yes.
Karl Doghramji, MD: There were some data suggesting that even melatonin, for example, could increase blood sugar levels and increase insulin resistance in some patients. Some of these so-called innocuous agents, like hops, for example, or valerian, may actually produce hepatotoxic effects. So just because it’s natural doesn’t mean it’s completely safe.
Peter L. Salgo, MD: Not only that, if they’re not really being monitored the way I thought they were and the way you tell me they’re not, there could be adulterants of all sorts of these things.
Karl Doghramji, MD: Absolutely.
Peter L. Salgo, MD: And you have no idea what’s in them.
Karl Doghramji, MD: Absolutely.
Peter L. Salgo, MD: Which brings up the question.
Sanford H. Auerbach, MD: Which has happened in the past.
Peter L. Salgo, MD: Which has happened.
Sanford H. Auerbach, MD: Adulterants with tryptophan was used many years ago.
Peter L. Salgo, MD: Is that right?
Sanford H. Auerbach, MD: There were adulterants that wound up there and caused a lot of problems, and were taken off the market for a long period of time.
Karl Doghramji, MD: Eosinophilia-myalgia syndrome.
Peter L. Salgo, MD: You know, I do remember that.