Let's go ahead and get started. Welcome to Improving Patient Outcomes with Sleep Psychology sponsored by the American Academy of Sleep Medicine. I'm Emerson Wickwire, Chair of the Sleep Psychologist Assembly. Deirdre Conroy is Vice Chair, and together she and I will moderate the session. The genesis of this webinar was to have as big a clinical impact as possible throughout the AASM membership in as little time as possible. So we've adopted a clinical pearls format with a truly outstanding faculty. There are many thanks to go around, thanks to the AASM staff, thanks to the many faculty who have agreed to participate, and thanks especially to you for being here to learn to take better care of your patients. All the faculty have volunteered to share some of what sleep psychology has to offer about hot topics in the field, shift work, comorbid insomnia and OSA, pediatric sleep medicine, telehealth, and sleep in older adults. Before we get started, Dr. Conroy will present a few housekeeping items. Hi everyone, I'm Deirdre Conroy, and thank you so much for being with us today. I wanna just make sure that your audio is muted and that your video is off, and please turn off any cell phone or pagers that you have. We'd love this session to be as interactive as possible. So please include your questions in the Q&A. The AASM is accredited by ACCME to offer CME to physicians. AASM has implemented mechanisms to identify and mitigate conflicts of interest for all individuals in a position to control content prior to the planning and implementation of the CME activity. Course chairs, including myself, reviewed the COI declarations and are satisfied that no commercial bias exists. All conflict of interest disclosures are provided to participants prior to the start of this activity. I have no financial interests or relationships with any ineligible companies to disclose. And I also have, and thanks very much, Dr. Conroy, and I also have no relevant COI for this panel. Now, I wanna make sure that I'm controlling the screen here. Super. Now, allow me please to introduce our speakers. Dr. Philip Chang is an Associate Scientist at the Henry Ford Health System. Dr. Rachel Manber is Professor at the Stanford University School of Medicine. Dr. Dami Lewin is a Senior Sleep Research Scientist at SleepMed. Dr. Ana Bartolucci is CEO of Atlanta Insomnia and Behavioral Health Services. And Dr. Jennifer Martin is Professor at UCLA School of Medicine and also President-Elect of the American Academy of Sleep Medicine. Thank you incredibly much. So that all of the participants and attendees are aware, we've had two run-throughs as a group. And I think what you'll find is that you're going to learn an incredible amount in the next 55 minutes. We also need to realize that all of the technology transitions and speaker swap overs and loading of slides that normally takes place in a half day workshop is gonna take place in the next 55 minutes. So please be patient and we very much appreciate your patience. Here's how this is gonna work. Each presenter will speak for five minutes and answer two questions. Dr. Conroy and I will moderate those questions. As she mentioned, please post those in the chat. Each speaker will then receive control of the slides during that transition period. And after Dr. Martin concludes her presentation, we will assume a gallery view and have a discussion as a panel, again, including moderated questions. So be sure to post those in the chat. Okay, terrific. First up is Dr. Phil Cheng. All right, let me make sure I have control, fantastic. Okay, so thank you for the invitation. I'm very excited to be here to talk to you all about some of the new thinking around treatment of Schiffler disorder. And I have no conflict of interest to disclose. Start with the problem. First of all, Schiff workers are essential and in demand. So for example, if our loved ones or ourselves have a medical emergency in the middle of the night, it is Schiff workers who enable us to receive critical care. Of course, we also think it's important that we have first responders who can address emergencies around the clock. As consumers, we also want things fast and cheap and Schiff workers allow our deliveries to happen quickly. All this to say is that we need Schiff workers, but Schiff workers also need us. But sometimes when someone with Schiff work disorder comes to us, the best thing we can offer feels like it's a letter, a certified letter that says they should stop doing Schiff work. And I really think that we should and can do better than that. Now, one of the core things we think about when we think about Schiff work disorder is circadian misalignment, some major contributing factor. And we also know that we can reduce circadian misalignment with timed bright lights. But without clinically feasible assessments of circadian timing, we're really left to make some sweeping assumptions. One of those assumptions is that people with Schiff work disorder have melatonin rhythms like day workers. So they have this melatonin secretion between 10 and midnight, for example. And if we give light in the evening, we can shift that and reduce that circadian misalignment. However, if you look at the data, Schiff workers are actually all around the clock in terms of their circadian phase. And so that calls into question when we should be giving lights. Because if we don't know when their phases, we could accidentally phase advance them when we're trying to phase delay them. So really what we need is a better proxy of circadian phase. And sometimes we think about using sleep time because, hey, in day workers, it works really well. Well, we also have data to show that sleep time, even when we look at sleep after the night shift or on their off days, really doesn't do a very good job. Another way we can do this is to use actigraphy data that includes light and activity to measure their activity levels and light input into their SCN and run that through a model. And our evidence seems to suggest that that does a much better job. So one thing that we can use is an open source tool that's available now. It is a website that is almost like a phase calculator. It's www.predictdailmode.com. You can upload your CSV files with your actigraphy data and it'll output your predicted dailmodes into the window. And that can help you make some decisions about light therapy, for example. Now, of course, as psychologists, we also appreciate that physiology is not the end all be all. It's really only one dimension of health and we ought to push beyond circadian misalignment as the only or the only important mechanism in shift work disorder. And so one of the things we ought to think about is what other mechanisms there are. And in fact, if you look at the data, our data suggests that circadian misalignment alone predicts less than 10% of symptom severity and thus is likely not the only mechanism. If we look at things like sleep activity and stress, we see that these mechanisms are at least equal contributors to symptom severity. And this is research that we will be following up. So in summary, I want to say that we need shift workers and shift workers need us. And with this just stop it therapy approach is not quite going to cut it anymore. There are clinically feasible tools that are emerging. The website is one of them. There are others that are also in development and that clinical approaches to shift work disorder will need to expand to consider other intervention targets such as sleep activity or stress. So with that, I will happily take any questions. Thank you, Dr. Chen. We are monitoring the Q&A. I do not see any questions just yet, but I did have one, I'll get us started. So this patient population is very difficult to work with and the tools aren't the best. If we don't have access to actigraphy, do you recommend other tools or websites instead of this predictdilmo.com? Yeah, so right now the tool is made specifically for actigraphy, but one of the things we're pushing towards is being able to use wearable technology like Apple Watch and Fitbit data. Of course, you don't have as much or if any light input, but our data seems to suggest that activity itself does actually a pretty decent job. So keep your eyes peeled. This should be coming out shortly. In addition to that, there are of course other ways of predicting melatonin or phase, things like blood draws are coming out of various groups, one of which is the Northwestern group as well as their markers of the microbiome and genetic analyses. I do see that another question has come through the Q&A, I'm gonna read that out. Phil, thanks so much for a really wonderful presentation. And we'll take the Q&A, which says, what solutions or output does the model provide? And Phil, I wonder if you could build upon your answer to what solutions or output does the model provide to just in a sentence or a couple sentences, how should sleep medicine physicians tailor treatment based on DILMO? In other words, if I really knew a given patient's current hardwired circadian phase, how would I treat the patient differently? Yeah, so one of the things that you can do with a more precise estimate is you can time light to be more effective because we know that time, depending on the timing of the light exposure, you can either be advancing or delaying someone or maybe even having very little impact if they're sort of in the quote unquote dead zone. And so really thinking about the phase response curve, you can be more deliberate and intentional and get a bigger bang for your buck for the unit of light exposure. Thank you very much for a wonderful presentation. Next, Dr. Manber. Hi, I'm Rachel Manber. And my topic today, sorry about that. My topic today is the challenges, the diagnostic and treatment challenges that comorbid insomnia and sleep apnea presents to us. And I have no conflict of interest to disclose. So in terms of the diagnostic challenges, one is that the ICSD, one of the criteria is that the symptoms are not better explained by another sleep disorder. This is a very difficult criterion to ascertain and the picture is rather complicated. Sleep apnea may predispose individuals to developing insomnia or sleep apnea may be a precipitating factor that causes sleep disturbances. However, what happens is two things happen over time. First, what could happen is that with repeated exposure to being frustrated in bed and not sleeping, the person then develops an association so that the bed becomes a cure for arousers, which creates a longer term insomnia. And the second is that the person may end up adapting coping strategies that over time become maladaptive and become factors that maintain the problem or perpetuate the problem long after the sleep apnea, for example, has been addressed. So for example, if you look at this black, at that figure and the black threshold for insomnia disorder, initially the sleep apnea is what causes it, but over time it's the green that becomes the perpetuating factor. So this is suggesting that the best way is to think about it as two comorbid disorders. Indeed, the data suggests that insomnia symptoms are very common. The majority of patients with sleep apnea have some complaints of initiating or maintaining sleep. And the data also says that initiating PAP therapy alone, although it reduces the frequency of sleep maintenance difficulties, it does not fully do so. And it also does not reduce the frequency of difficulty falling asleep. So overall, the diagnostic challenge solution to it is to really think about the two disorders of comorbid. So now let's move on to treatment. Insomnia, so there are two directions. Insomnia is a challenge for PAP therapy. And indeed, research is showing that a presence of coma with insomnia hinders adherence to PAP therapy. Fortunately, research is also, and RCT also shows us that starting CPTI before initiating PAP therapy can actually enhance adherence in subsequent introduction of PAP therapy by an average of 61 million people. So we can start CPTI before initiating PAP therapy by an average of 61 minutes compared to not having CPTI before initiating. The picture is not as clear. I mean, this is a very clear message, but the timing seems to be important. Another study by Jason Ong showed that if you initiate CPTI along with PAP therapy at the same time then that you don't seem to have a similar benefit and so I would say it is also pragmatically very difficult to really initiate two disorders by two different clinicians at the same time in the clinical setting. So on the other direction, if you look at sleep apnea as a challenge to cognitive behavioral therapy, before you look at the challenge, please know that CPTI is affecting for comorbid insomnia and sleep apnea and it is effective in published literature when delivered by a therapist, but our work currently that we are finishing with Jack Edinger shows that digital CPTI is similarly effective in this population. But in terms of clinically in the clinic, what the challenges are is that some adaptation need to be made when treating patients with sleep apnea and insomnia. The first is we typically recommend short naps. We do that both to promote safety and to prevent inadvertent or unintentional dosing and sleeping later in the evening that could be even more detrimental to subsequent nocturnal sleep. And for therefore, we recommend to do take a nap, but do it early enough in the day and keep it short enough to get the best of both worlds. The other adaptation that we make is we typically are careful to introduce sleep restriction or what I call time in bed restriction with a more generous time in bed initially, for example, using different variants of sleep compression therapy depending on the patient presentation. So I think COMISA patients are best served when both insomnia and sleep apnea are considered target for intervention and initiating a CPTI before initiating PAP may help promote adherence to PAP therapy and it might also apply to promoting reinitiation of PAP therapy among those who gave it up. So for instance, in the clinic, I oftentimes get patients who've been diagnosed with sleep apnea who are presenting for treatment and insomnia, and we integrate into the CPTI elements to support and to promote or to encourage adherence to PAP therapy. In summary, I would say most patients with sleep apnea report insomnia symptoms, PAP therapy alone does not fully address the symptoms, CPTI is effective and it can help with PAP adherence. Thank you, Dr. Manber, that was great. Open up to questions now. Did have one question that can get us started off with. So what are the challenges with full courses of CPTI is the access to a provider and also the frequency with which we can deliver the CPTI. Is there a sort of a couple of ingredients of CPTI that you think are most critical to treating a patient with co-MESA? I wouldn't distill it to certain elements because I am a strong advocate of tailoring the treatment to the patient and patient with comorbid sleep apnea and insomnia come in many shades of colors, the same way that patients with insomnia come in across either comorbidities or even without comorbidities. So I'm sorry, I'm not giving you, what reporters oftentimes ask me and I often resist to give like tidbits of what to do. I have a question as well. And Rachel, thanks very much for another great presentation. Before I ask that question, I'll mention that there are over 120 individuals on this call and we had approximately 340 registered. There are a mix of psychologists and physicians and other health professionals on the call and it really speaks to the interest within the AASM of patient-centered care and really taking great care of our patients and also thanks to our really outstanding panel highlighting the value that sleep psychology approaches can bring to the field. Rachel, my question is you've been very involved in ICSD4 updates and how has the comorbidity of insomnia and obstructive sleep apnea been considered at that level? Thank you for that question. Yes, so I am leading the work group for the text revision of the ICSD and we have expanded that criteria that I started with first of all to include other disorders not only sleep disorders similar to bring it more in line with the DSM and I would say we're even more careful in our language to state that it is not solely explained by to really open up the mind of people in the trenches who all of us who are treating people with insomnia and sleep apnea that it really doesn't matter because at the end what we want to do is to treat both and I would say that the soon to come within probably a matter of weeks is a version that will be open to for public comment so I'm hoping that people can go and look at the revision and comment on it. Thank you very much. It looks like your topic has generated a few other questions. Thanks Dr. Conroy. One from Steve Carstensen and one from Erin Morse so we'll be sure to circle around to those when the panel has a discussion. Next up is Dr. Danny Lewin. Greetings all. I'm just trying to get control of my slides here. There we go. All right. So I'll be presenting on pediatric sleep medicine, mysterious nighttime awakenings. And so I have no conflicts to disclose related to my presentation today. So this is a vexing problem in pediatric sleep medicine, not only vexing for parents but also often vexing for clinicians. So sample case, four-year-old child wakes one to three times a night even when there is a rich positive bedtime routine and the child is falling asleep independently. So why do some children still wake in the middle of the night when their parents follow all the recommendations? So we want a differential diagnosis here of a few different disorders. I'll briefly review sleep onset association disorder is defined as an early childhood insomnia where the child becomes attached to an association, apparent parental presence at bedtime, nursing, sound in the room, et cetera. And then when they have one of many normal awakenings in the middle of the night, they need that cue present in order to reinitiate sleep. The other is a limit setting sleep disorder, which occurs also in young children, but slightly older children. And that's where there's a repetitive interaction between child and parent. The child often engages in curtain calls, engaging the parent multiple times and the bedtime becomes extended. And finally, parasomnias or confusional arouses, sometimes night terrors can also be involved with some of these nighttime awakenings. So on a nightly basis, this four-year-old was in charge. He had created a complex bedtime routine that lasted 1.5 hours involving parental engagement, more stories, more water and a sequence that he often changed up. His parents were both charmed by their child's creativity, but also exhausted by the length and intensity and variability in routine. So his parents described these nightly awakenings on three nights a week. They involved kind of a demanding engagement, but he didn't really fully appear his usual self. On two nights, he called his parents into the room. And once they came in, he was able to settle. They left and he was quiet for the rest of the night. So in terms of approach, his sleep onset association was his over control of bedtimes and the bedtime routine. So in this case, it wasn't specifically parental presence, but this child needed control or felt the need to control these bedtimes. So that, in this case, was conceptualized as the association. So the approach was to modify bedtime routines so that they lasted no more than 15 minutes. And also to differentiate the positive routines, which is closeness, reading a story, positive chat from evening routines. So you can have a long evening routine leading up to bedtime, but the bedtime routine itself should be very short. Finally, a careful description of the quality of the nighttime awakenings can help to add to the differential diagnosis. And educating parents about parasomnias is very, very important, particularly when it's very difficult to differentiate whether or not a child is fully awake or not. So a few clinical pearls. Sleep onset problems can be associated with a complex sequence of behavioral, not just the moment at sleep onset, behavioral changes or complex routines as was the case here. Parents can be enabled to take control of their child's bedtime routines, which in reality can reduce the child's anxiety. Children like to feel in control, but feel more secure when adults are in control and helping them feel comfortable. And finally, parasomnias can look like full awakenings, and most parents don't understand the difference. Often what I'll recommend the parents do is drop some kind of cue during the parasomnia, such as saying something about an elephant and then asking the child in the morning if they recall something about an elephant discussed in the middle of the night. So in summary, almost all sleep mysteries can be solved with careful questioning and analysis, and giving parents the permission to be in control is a powerful intervention. Thank you. Thank you, Dr. Lewin. That was excellent. Could you say just a little bit more about the role of the parents during the parasomnia and what the interaction should look like? Sure. So typically we instruct parents to not attempt to wake the child, but to calm the child, certainly keep them safe. For children who are sleepwalkers, we certainly, they need to be observed always. So we caution parents that if the child does get out of bed, in particular, if the child leaves the bedroom, they must get up with a child and observe them, but not wake them, perhaps calm them. I find that sometimes kind of some other sensory stimuli, pat on the back, maybe a sip of water can help a child transition back to sleep smoothly. I agree, Dr. Lewin. That was an excellent presentation. And as I often do, I'll confess to our colleagues and audience that I owe Dr. Lewin a testimonial. We had a 45-minute speakerphone intervention when our son was a little tyke. For any sleep disorder specialist whose children are given bedtime resistance, there's a certain degree of angst or shame in that, particularly if you're a sleep psychologist and should have all the answers. So Danny, you're the go-to guy here. My question is a little bit broader. It's related to partially public health and partially implementation. I think that like sleep psychology, broadly speaking, pediatric sleep medicine is really underserved. There aren't enough pediatric sleep medicine specialists, and there are a lot of kids who have trouble sleeping. So what are one or two things that AASM sleep medicine centers that are member colleagues who are really making their living being full-time clinical providers, how can they do more than they are now? What tools might be available to them or educational materials? How can we get this kind of information in the hands of the broader sleep medicine community? Yeah, I think it's a great question. And out beyond that community to pediatricians and to other health care providers, and perhaps most importantly, the parents, and I'd say even extended down to children. If we started sleep health education in pre-K even, in kindergarten, with good materials so that children can actually know a little bit more about their own sleep, and then they have a dialogue with parents and they bring the questions to pediatricians. I've always found that the more you engage the child, even a very young child, the further you get quickly with the intervention. So I would say education in medical schools and psychology programs and nursing programs, social work programs, and educating teachers to really help the broad community understand more about what the basics of sleep health are and what basic sleep health behavior is. Thank you for those thoughts. It's interesting because the AASM and other organizations have sponsored increasingly efforts to engage. There's the high school video contest and so on and so forth. But really, if we're engaging younger and younger people, we don't want to be educating eight-year-olds about sleep in older adults, right? We want to be educating them about sleep in kids first. So thanks very much. Dr. Ana Bartolucci, please, you're next. Thank you so much, and thank you for allowing me to be here. So my name is Ana Bartolucci, and I'm going to talk about the burning question that has been on a lot of people's minds over the past couple of years, which is, does telehealth work for CBT-I? I have no conflicts to disclose. And so our problem, as a couple of our speakers have mentioned so far, is that cognitive behavioral treatment for insomnia is very effective, and it is very highly in demand. And as we as a society continue to process the trauma and stressors over the past two years and the ones that continue to come up, it's only going to get more and more in demand. And it's been interesting because at first we were all on lockdown, so we couldn't do in-person sessions. And now that patients have gotten used to doing telehealth, this is a lot of their preferred modality. So they might not be comfortable with in-person sessions, and honestly, they might not want to drive to come see their provider. As you probably saw from my practice name, I'm in Atlanta, Georgia. We are notorious for our bad traffic. And so even patients who are coming from across town have been requesting telehealth. We were actually fortunate that at the beginning of all of this, we had already been doing telehealth with patients in outlying and rural areas, so it was not a complete surprise. And we'd already started increasing accessibility. So let's talk about what telehealth is. It's basically what we're doing here. It's use of video or audio channels to communicate with patients rather than being in a face-to-face session. It's very important that we are on HIPAA compliant platforms because we want, of course, everything to be confidential. I assure my patients that we're not recording their sessions. The major advantages I've already discussed is that it makes it more accessible for patients, both in terms of distance and also some patients with mobility issues find it a lot easier to use this modality. The major disadvantage basically comes down to logistics. It's a little bit harder for us. Sometimes there's technology issues. We have to figure out how to get handouts to the patients. We have to figure out how to get their sleep diaries back to us. And honestly, it can be a bit more physically and mentally demanding because we are trying to infer the same amount of information from probably about only half the nonverbal cues that we used to get. What does the data show? So I can tell you from experience that it works and that it's effective. And the data backs that up as well. And that telehealth for CBT-I has been shown to be non-inferior and they have both the objective measures of the insomnia severity index and then also subjective daytime functioning. And let's be honest, patients are coming to us because they want to feel better during the day and they've tied that to how they're sleeping at night. And yep, that can definitely be connected. And the data also shows that it is possible to make a satisfactory therapeutic alliance. You know, we've had a lot of complaints about Zoom fatigue and how people don't really feel like they're connecting as well, but you know, honestly, it's good enough and we can still connect with our patients. Honestly, I've had a couple of patients who I felt like I wasn't connecting really well with. And then my cat jumped into the frame or onto my desk and suddenly they warmed up and it was like magic. So, you know, maybe telehealth can help us in ways we hadn't expected. So our clinical pearl is that telehealth can be effective. And if you're already doing it, this might be a good checklist to use to see how your current provider is working. And if you're looking into it, this is a good checklist to ask them about. So first again, HIPAA compliance, super important. Is it secure? And you might already have an option that's integrated into your electronic health record system. I know they've all been scrambling to make this a part of it. Are there training options? Will it show you how to use it? Will somebody from the company give your staff a class? Is it easy to use? Keep in mind that the more things patients or you have to click through, the less easy it is to use and the less likely they'll be to want to do it. You do need to make sure that you can securely transfer documents. It's also helpful to have a secure way for them to sign and read the initial paperwork. And finally, if something goes wrong, is there somebody on the other end to support you and help walk you through it? So in summary, as you guys have probably already figured out, telehealth is likely to become the new normal for many segments of health care, especially mental health care, where we don't necessarily need to touch or physically examine our patients. And as the demand for CBTI has grown, we got to be flexible and keep up with it. So it does require a bit of a learning curve, but it's not as complicated as a lot of people think it might be. Yes, I admit it can be very overwhelming at first to try to figure this all out, but as with everything, take it one step at a time and be patient with yourself for mistakes and have a backup. And finally, CBTI can be delivered via telehealth without loss of effectiveness. We know it works and we know that we can still connect with our patients. And let's be honest, cats make everything better. So thank you, guys. Thank you, Dr. Bartolucci. I would agree with that last statement. Excellent presentation. I know that on my mind is that the insurance coverage for telehealth post-pandemic, whenever that may be, do you have any information on this continued insurance coverage for telemedicine? As far as I know, they are, well, I know that they have extended the emergency authorization or whatever it was, and they keep extending it. And of course, we all look to Medicare to see what's going to happen with insurance. And so far Medicare does seem to be supporting it. And recently they even have supported payment for phone sessions. So without even video, but I can say from experience, like we do take some insurance in my practice and we haven't had any trouble getting it paid for. Ana, thank you so much. It's interesting listening to you speak. I was so struck by how different some of our professional environments are from community-based care where you're really on the front lines and in the business of helping patients and clinical operations, if you will, as opposed to working, for example, like I do in an academic medical center or even in a large health system. Folks on the call might not know that you're a go-to resource for a major AASM accredited center at Emory University in Atlanta. And the question that I have for you is similar to what I asked Dr. Luman a moment ago about increasing access to care. Can you just tell us a little bit about what it's like to be a telemedicine resource or a remotely located resource for an AASM accredited center? And can you speculate about whether other AASM accredited centers would like to have someone like you for their patients a phone call away? Well, to answer your second one, I don't necessarily know that it would even be a speculation. I'm almost certain that most AASM accredited centers would love to have somebody like me if not on staff, then nearby and with compatible insurance coverage. As for what it's been like, I have to say that although the pandemic has really disrupted a lot of businesses, it's been very good for mine because as I mentioned, I have patients who formerly probably would not have come to see me because it would be an hour's drive across town in terrible traffic and now it's like okay you know what we'll just do this via video and you know they're welcome to come in if they meet certain criteria for safety but you know generally even if they do most patients have opted to be telehealth and so we haven't really done a whole lot of marketing because we haven't needed to but I also wanted to mention the PSYPACT I don't know if it's a credential but basically some of us are PSYPACT providers where we can practice across state lines in other PSYPACT states and so I think that's also going to help to increase access. Thank you so much and last is Dr. Jennifer Martin. Well thanks everybody I've really learned a lot actually from my co-panelists here today and I appreciate that. Let me see here so I'm going to be talking about some common sense recommendations to help our older patients. I always like to say that every year I give this talk the definition of an older patient gets older but I work a lot in geriatric settings and so when I think about older patients I don't think about just age I think about function as well so a lot of times a healthy patient just because they're over 65 we treat them just like a patient who's under 65 but we do see some changes in health and in geriatrics that might impact how we approach and treat sleep disorders. I don't have any relevant financial relationships to disclose regarding this presentation. So age-related declines in physical and cognitive function can make implementation of evidence-based treatments for sleep disorders especially challenging. This is something that I think we have to keep in mind when we're working with patients is even things as simple as reduced visual acuity can make it hard for patients to use some of the materials that we might provide. Hearing impairment might present challenges to use of technology so you know even at a very basic level this is something that we should always keep in mind. So one approach is to think through feasible changes that can improve sleep and quality of life for older patients. So some of the things that might be perfectly appropriate for a younger patient for example who drives and I really appreciated Dr. Bartolucci's comment because I think one of the advantages of telehealth modalities is that some of our older patients for example start stop driving at night and so they may not want treatment in the winter if it means they're going to have to drive home after dark but if we can make telehealth available that might be an option for adapting. We do know that we can adapt evidence-based recommendations to address comorbid conditions when we're working on sleep concerns. Something that comes up often in CBTI is the recommendation to get out of bed at night if you can't sleep. Well if we have an older adult who's at high risk for falls who physically can't get out of bed on their own we might need to adapt that recommendation to fit their individual needs. Which leads me to the last point which is oftentimes eliciting support from the patient's social network and caregivers can be really essential. So if you know a patient is having a hard time putting on their CPAP mask because of severe arthritis they may need help from a family member or other person in their social network to do that. So I'll just highlight a you know a couple of studies. One is a meta-analysis of cognitive behavioral therapy for insomnia that was done by Mike Irwin and his colleagues that really showed that older adults benefit just as much as younger adults from behavioral and cognitive behavioral interventions. The second piece of data that I'll highlight is a recent study that showed that PAP therapy improved a range of cognitive domains after six months of use in older adults. You know sustained use of CPAP can be challenging but I think for a lot of our older patients the idea that they can sustain their cognitive functioning longer would be an important motivating factor. So some clinical pearls. Very importantly we generally avoid use of prescription sleep aids in older adults in particular those with cognitive or functional impairments. So the American Geriatric Society specifically recommends against the use of sleeping pills in older adults. Instead we should focus our clinical attention on feasible behavior changes. A couple that are top of mind increasing evening activities and light exposure to help older adults maintain alertness later in the evening and avoiding recommendations to get out of bed among our older patients who are at increased risk of falls and instead focus on other aspects of behavioral strategies that might help them to achieve a better night's sleep. So in summary older adults often struggle with sleep problems. Studies show that older adults benefit from therapies just as much as younger adults and because of that evidence-based treatment should be offered to our patients regardless of their age. Thank you Dr. Martin. That was great. A quick question about medications. I know that you had said that medications are not preferable to start them on but what about your patients that come in on medications? Do you work to get them off before CBTI or do you just start it? It depends on the patient. I mean I think Dr. Manber very eloquently stated you know that every person who walks in is different. So I have some patients who come in and getting off of their sleeping pills is a high priority. They're very concerned about it. Maybe their doctor has indicated that it has risks that as they've gotten older or a problem and then I have other patients who are not interested at all. So I really try to meet them where they are and I always offer them CBTI whether they want to change their medication regimen or not. Sometimes what I find is that people are my older patients are afraid to stop taking a medication they've been taking for a very long time but once they're sleeping better after we do CBTI they're more receptive if not to discontinuation at least to a dose reduction or in some instances changing to a medication with a more favorable risk profile. So that that's kind of been my experience. Uh Jen thank thank you very much um for for an excellent presentation uh with the aging population in addition to um to we aging panelists uh it's important to be able to take care of of the bookends if you will uh uh sort of Danny's group and your group in terms of our panel today. I'm going to read a question they're actually two for you that have popped into the chat so why don't we um uh Jaton you can go ahead please and switch us to gallery view there are 10 or so questions and I'm very curious to hear if panelists have uh thought of questions for for their their colleagues and co-panelists. Um Jen first how effective is CBT in patients with comorbid psychiatric disorders? I really appreciate that question when we updated the clinical practice guidelines for behavioral and psychological treatments for insomnia one of the things that we found is that um CBTI is still very effective in patients with comorbid uh physical and mental health conditions. Um I in my own research um we actually are looking at the benefits to mental health symptoms when we just treat insomnia and I know Rachel Manber has done a lot of work in the area of depression um that not only is uh is treatment effective it benefits the comorbid mental health condition in a lot of patients as well. Um so uh it does not appear that the effectiveness is compromised which I think is a concern a lot of people have that we still can deliver effective insomnia treatments in people with comorbid mental health conditions. Thanks so much for that why don't we go ahead and and sort of open up now um encourage the panelists there are 10 questions we'll get through as many as we can in addition to whatever other um just discussions uh and and Q&A among the panelists emerge organically um but please uh chime in with your questions if you haven't already uh there are um 130 folks on the call there's been absolutely zero drop off and that uh of course speaks to uh really the quality of wonderful information that's being shared by this group of sleep disorder specialists. Um Ana I'm very curious if your experience in a very applied private practice setting in terms of CBTI in the context of comorbid uh psychiatric disorders and comorbid stress and mental health problems is that also your experience in the real world? Oh yeah definitely and I think it's one of the beauty of being a psychologist who's doing this is that we've all gotten this great grounding in cognitive behavioral treatment generally a lot of us before we specialized in insomnia and so yes I'm I love being able to tell patients you know you don't have to go out and find another therapist we can handle everything here we're basically one stop shopping. Um on the other hand if they already have a therapist that they like we can still work with that situation as well but yeah it's been it's been nice to be that flexible. Thank you very much um Rachel you are obviously an expert in this area um from a research perspective do you have anything to add on that question regarding CBTI in comorbid psychiatric conditions? Not really I think Jen did a fantastic um a fantastic uh job the question is there is a meta-analysis I would say that looked at the effect of CBTI on other symptoms uh and depression the effect size that is observed is typically relatively small. Excellent thanks and Phil I see you have your hand up. Yeah I just wanted to add that um there's a question about these self-driven uh app-based interventions and that there's now uh more and more evidence coming out that even the self-driven app-based interventions can be very helpful for coma co-morbid depression um and there's evidence uh from multiple labs now including ours that it can even prevent future incidents of depression which is uh pretty powerful. Fantastic yeah I think that you you you published that paper right that folks who go through an online CBTI platform it reduces the incidence of subsequent major depressive episodes. Yeah and we also followed up to see how they were doing during COVID-19 and we found that folks were more resilient which is very exciting. Wow very cool thank you um uh Deirdre should we alternate questions here would you like to to to take the next question? Sure I'm going to loop back to the beginning to some of them that we that came through very early on and I'm going to read this question this one looks like it might be for Dr. Manber and the question is some patients with low arousal threshold endotype don't do well with PAP and are given oral appliances do you have any experience with patients on oral appliance therapy and CBTI? I do um and I must say I don't see any difference between patients on oral appliances and any patients with insomnia whatsoever so there are no specific challenges that came up my way when treating that um that population. That mirrors my experience I see a number of patients with oral appliances I think that as a field we underutilize oral appliance therapy in terms we want to create as many evidence-based options as possible for patients and interestingly there was a paper published this is of course to the individual who asked the question there was a paper published maybe in 2005 out of Brazil Makado is the first author and of individuals who had a suboptimal response to oral appliance therapy insomnia comorbid insomnia was the only significant predictor of poor response to oral appliance therapy so I that's why we were so lucky to have Dr. Manber speak on comorbid insomnia and obstructive sleep apnea and I think that's just a great question. Deirdre you can run with it if you'd like or we can alternate either way. Can I ask a follow-up question? Please Jen oh I'm sorry I missed your question. No it's okay uh I'm curious I mean one of the experiences that I've had is that patients who are using oral appliance therapy and have comorbid insomnia seem to be equally non-adherent um and I found that I do have to spend a fair amount of um effort working with them on adherence to therapy just like I would with a patient on CPAP and I'm curious if others have this and I my approach is usually to address both at the same time treat the insomnia and work on whatever adherence challenges are present but for me my experience has been it's it's equally challenging to use CPAP and oral appliances when you have comorbid insomnia. I see a lot of nodding but just curious if anybody has anything to add. I agree and I've also adopted the CPAP desensitization protocol for oral appliances basically teach them to ignore it. I think Rachel could you say that again please? I said learning to ignore it I mean yeah yeah exactly I Jen I don't know if your intention was to highlight how sleep psychology really does impact everything that we do as a field but it's true the kinds of education and support and adherence interventions I mean sleep apnea is a sleep apnea treatments involve lifestyle change period right and so um that's exactly yeah that's why we as a collegial community of psychologists as part of this broader field of of sleep medicine are here today so I really appreciated that question. Danny here's a great question um for you um it says uh from my personal experience I have a four this is questions from Amy Bender thank you very much Amy from personal experience here I have a four-year-old who would pull similar stunts and as soon as I moved his bedtime one hour earlier most of these um association uh disorder kinds of questions went away it seemed that he was catching a second wind do you find this in your pediatric patients? Yeah great question and so I'll answer it in a couple of different ways one is there certainly what we call the first zone or forbidden zone which is a burst of activation or a second wind that occurs usually we think theoretically about 15 to 20 minutes before our optimal fall asleep time so this happens in kids and they can get wild and dysregulated and what often happens is that there's a synergy between parents and kids but the child gets a little wild parent gets frustrated so you get a mounting of activation there's also a subtle answer to your question and I think that's that how do we find the right bedtime for a young children for a young child so a child who's four um sometimes children are a little bit shifted or they can shift to a little bit more of an evening schedule but it may be that you did two things one is that you um you kind of um you address the burst zone by putting your child to bed earlier it could also be that the earlier bedtime was appropriate for your child and that there was a combination of the burst zone plus a little bit of increased need for sleep that was occurring in the evening can I add something please of course so my my experience and I work with pediatrics as well is that children when they are sleepy are not we're sleep deprived don't behave like adults when they're sleep deprived in the sense that we adults experience the world the sleepy more lethargic and the child who's insufficiently sleeping um is hyperactive and so it is possible that by going to bed earlier you reduce the sleep deprivation which reduces the hyperactivation as well it's an added to to Dan's excellent insights these are I remember um and thanks all these are just such excellent points um when when uh Dr. Lewin uh came and and spoke to us at the Maryland Sleep Society about the danger zone right where we've got this circadian alerting signal at its peak right before bedtime that it's sort of hardwired that kids are are bouncing off the walls even independent of sleep loss or circadian dysregulation um what I'd like to do is check in with panelists because we're down to about a minute um one if we can't get to all the questions today um perhaps we can generate just really brief written responses there are a dozen questions or so that we haven't gotten to um two uh if folks have just a couple minutes we can do one or two more questions but otherwise we're at the end of our time and so uh the extension of of gratitude uh first is to the panelists we couldn't have done this without you thank you very much um it's uh been a little bit more work and trial and error than uh most of the guest presentations that we make of course thank you um I think it was well worth it uh second to the AASM staff and most important to the 130 uh attendees um uh who made time to be here for the betterment of your patients on a busy Monday afternoon so based on some of the texts that I'm getting right now we'll go ahead and wind down but we will do uh written responses uh and to the panelists I just want to say thank you again and look forward to continuing our discussion.

sleep psychology

patient outcomes

shift work

comorbid insomnia

obstructive sleep apnea

pediatric sleep medicine

telehealth

sleep in older adults

CBTI