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Insomnia. We’ve all had it. Lying in bed at 2 am staring at the ceiling, getting anxious every hour that you’re not falling asleep as you have a busy day coming up. Insomnia sucks.  Chronic insomnia sucks even more.

For those with serious illness, sleep problems and insomnia are all too common.  Instead of reflexively jumping to melatonin or ambien, on today’s podcast we talk with two sleep experts, Cathy Alessi and Brienne Miner, about a better approach to sleep problems and insomnia.

We will go over epidemiology of insomnia, how these experts think about work up including which medications to avoid or discontinue, non-pharmacological treatment such as cognitive behavioral therapy for insomnia (CBT-I), and what if any is the role of pharmacological therapy in including newer agents like melatonin receptor agonists (ramelteon) and dual orexin receptor antagonists (like suvorexant).

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: [… silence …] I’m sorry, I was just falling asleep there. [laughter]

Eric: Ba dum bum.

Alex: Ba dum bum. We have Brienne Miner who is a geriatrician and sleep specialist and assistant professor at Yale in geriatrics. Welcome to the GeriPal podcast, Brienne.

Brienne: Thank you for having me.

Alex: And we have Cathy Alessi, who is a geriatrician, Director of the Geriatrics Research Education and Clinical Care Center at the VA, greater Los Angeles and Professor of Medicine at UCLA. Cathy, welcome to the GeriPal podcast.

Cathy: Thank you. Hello.

Eric: We’re going to be talking about sleep problems, insomnia, in older adults. But before we do, I believe Brienne, you have a song request for Alex.

Brienne: I do. My song request is Dreams, by Fleetwood Mac.

Alex: Terrific choice.

Eric: Should I ask, why did you choose Dreams?

Brienne: Well, I have always loved this song. But of course we’re going to talk about sleep today. So I thought this was topical and I actually went back and looked at the lyrics to say, is it really about sleep? And I think it’s about the way that those things that happen to you, that disturb you during the day that you try to avoid or tuck under the rug, they come back while you’re sleeping. And it also links to why sleep is so important to people.

Alex: That’s good-

Brienne: We all want to have that sort of sleep that washes us clean and we wake up with a clean slate and some of us don’t. And that’s a very miserable place to be.

Alex: Here, I thought it was just like a relationship tension and breakup song. But okay, that’s better. I love it. Here’s a little bit, just a little bit.


Eric: Wonderful. Thank you, Alex.

Alex: Thank you.

Eric: Cathy, I’m going to start off with you. Sleep is a focus of your academic and clinical career. How did you get interested in this?

Cathy: Actually, many years ago, I did some research on delirium and then I was doing some research on nursing home residents and we were doing work looking at, I was interested in how sleep problems and nighttime events might lead to delirium, and then I just became very, very interested in sleep. And so pursued, in addition to geriatric certification. So it was like a path, it was a fortuitous route.

Eric: Was it the same thing for you, Brienne?

Brienne: So for me, I was working as a postdoctoral fellow in our geriatric clinic, our geriatric assessment clinic. And there were just so many people with sleep problems and I didn’t know how to help them. I think at the same time I was getting very interested in studying symptoms in my research because symptoms matter to lots of people. So it just happened that the research and clinical worlds met and it seemed to make a lot of sense for that reason to get clinical training in sleep, but also to start to study it.

Eric: And we say you noticed it was really common. Especially in older adults, topic is going to be sleep problems, insomnia in older adults, how common is this in the older adult population? More or less than the general population?

Brienne: More. I would say pretty easily 50%, maybe more with older people, have some sort of sleep complaint. Cathy, what would you say?

Cathy: Yeah, it’s very, very common. And very common symptom or coexists commonly with other health conditions and in medications that are used, impacted. It’s just extremely common.

Eric: Yeah. What are the common comorbidities that it’s associated with? What are the ones that come up to your mind right away when you hear that?

Cathy: Actually, basically, anytime I have a patient or their caregiver talk about a nighttime problem or problem with their sleep, I’m thinking about primary sleep disorders, insomnia, sleep apnea, et cetera. But I’m also thinking about other health conditions and other medications that might be causing them trouble. So I’m sort of trying to parse out, okay, so they’re talking about their sleep, but this is a symptom of some other medical problem going on. And often they’re coexisting. So often patients or their caregivers, to be honest with you, are asking for a simple solution. Sometimes that’s medications. But I don’t know how you are, Brienne, but in my mind I’m thinking, okay, so what else is going on that I should be thinking about?

Brienne: Yeah. Yeah. I think it’s often the case that there has been a sort of, or I see a lot of patients where there’s been a bandaid and that’s kind of like what a sleep medication is to me. And so when I see them, I’m really sort of getting this very detailed history and really finding out more about the sleep. And so instead of thinking about a bandaid, really trying to get at the underlying causes.

Eric: So what does that look like? So somebody comes into your office, Brienne, what kind of detailed history, what are you looking for? What are some of the questions that you ask?

Brienne: So usually, the place that I start when I’m thinking specifically about their sleep and taking a history. And I tell the trainees that I work with all the time to get very specific about what people mean when they say they have a sleep problem. Is it a problem falling asleep? Is it a problem maintaining sleep? Is it early morning awakenings? Is it daytime sleepiness? And then also getting very specific sleep schedule. So what time are they going to bed? When are they getting out of bed for good? How long are they in bed? What happens? Are they waking up? How long are they awake for? And if they are, during the day, are they napping? And if so, how much are they napping? So I tell people to get very specific about the schedule.

Eric: And how often when you ask those questions, are you getting reliable answers? Because often when I ask those questions, “Oh, I’m just not sleeping enough.” How many hours are you sleeping when you fall asleep? It’s often vague, but it’s this feeling that I’m not getting enough sleep or I can’t fall asleep quickly enough. Are you asking them to do sleep logs, things like that?

Brienne: So yeah, the sleep logs, let’s put that aside for a second. But I do think people can give you pretty specific information.

Eric: I guess you got to ask it very specifically, then.

Brienne: Yeah. Right, you sort of take it piece by piece. All right, so what time you usually go to bed?

Cathy: You know what Brienne? Even what I do is I’ll say if they’re like you’re describing Eric, I’ll say, “Okay, what about last night? What time did you go to bed last night or the night before? How long did it take you to fall asleep? What time did you get up out of bed? How many times did you get up during the night?” So I think a lot of conditions in older people, if their answers are vague, then asking a very specific timeline, like last night or a night before, that might maybe able to help with that.

And also I think Brienne, I don’t know if you agree, but when I’m asking those questions, I’m also trying to figure out are there problematic behaviors, sleep related behaviors that they’ve gotten themselves into that are actually contributing to the insomnia? Are they going to bed really, really early and lying awake in bed and not getting up out of bed because they think they need to stay in bed longer so they can sleep better? And that’s actually contributing to their poor sleep because of…

Brienne: And that’s why getting the schedule is so important. It’s like, well, when did you wake up? But when did you get out of bed for good? If there’s a big difference there, they’re spending too much time in bed. If you ask the schedule in that very specific way, you can start to find out things like that. You might also get a… you made me think, Eric, sometimes people say, “I just don’t sleep. I just don’t sleep.” Or their sleep is so irregular that they can’t tell you a schedule. And I think that is a problem. That is a person who then needs a schedule. If they’re really sort of saying, “My sleep is all over the place and I can’t tell you what time I usually go to bed.” Well, then they need to fix that.

Eric: Are you also talking to their significant others, getting other information about how things are going at night?

Brienne: 100%. And I think that it’s interesting, this is a place where sleep and geriatrics overlap really nicely. I think it comes very naturally to a sleep physician to get collateral history from the bed partner because there are just certain things that you’re not going to know unless you talk to a bed partner. So are they snoring? Are they acting out dreams? What are they doing when they’re sleep that you can observe that they don’t know about?

And I’m sure Cathy, you’ll agree that you’ll have these people come in who say, “I’m here because my wife made me come. I don’t think I have a problem, but my wife does.” That actually happens a lot in the sleep clinic. So I think in both geriatrics and sleep, we’re very often trying to get collateral. And so for my clinic, where I see a lot of patients with cognitive impairment, I also have to do that to sort of say he tells me his sleep is just fine, and then the partner says no that it’s not. He says he doesn’t have any sleep problems and he’s up all night long and he sleeps all day, or something like that.

Eric: Yeah. Well, I’m going to go back to I noticed you had a reaction when I used the phrase sleep log.

Brienne: I did.

Eric: What was that about?

Brienne: We should use them.

Eric: Okay. It wasn’t a don’t ever.

Brienne: It’s just that the reliability of getting the information back, that’s the problem. But I think that we shouldn’t give up on it and just say, “Oh, we just can’t get this information.” But I would say I have a 50% return rate on the sleep logs that I send out.

Cathy: Granted, it’s difficult to hit someone with, “I want you to fill out a two week sleep log,” the first time they tell you that they’re having trouble with their sleep. But if to the point where you want to actually treat them behaviorally, if they have insomnia, you’re going to have to get a sleep log, really, because whoever’s helping them work through their cognitive behavioral therapy for insomnia or a similar type of treatment, don’t you think Brienne, they’re going to need a sleep log in order to work them through that treatment.

Brienne: Part of it, you might set a schedule for them and you’re not even going to know if they’re sticking to the schedule.

Eric: Or if things are improving, right? I guess you could tell based on if they’re feeling any different. Do you ever use the new techie stuff, like if somebody has a Apple Watch.

Brienne: So I use that stuff a lot in my research. In the clinical setting, not so much. How about you, Cathy? Do you?

Cathy: No. My clinic is very old and so I don’t have a lot of Apple Watch users in my clinic. But yeah, in a younger population. The problem is the validity of the device. Knowing for sure how well the device is reflecting reality is not quite as clear as far as I know as the research grade actigraphy that we use in our research projects.

Brienne: Yeah. So I think that the best thing these devices do is give you a sense of the total sleep time at night. And so that’s probably something that you could track from night to night, as people are going through therapy. But I think most of the time when we see these devices, they’re causing more problems because we see people who they’re obsessing about their sleep and they’re saying, “Well, the watch gave me this score for my sleep last night.” And so oftentimes, we are telling people with insomnia, we’re saying, “All right, stop. No more watch. Okay?”

Eric: I actually noticed my Apple Watch gave me anxiety. I had to stop using it.

Cathy: That’s a good point.

Brienne: And we’re trying to get people to have less anxiety about their sleep, when we’re treating them for insomnia. So it can be counterproductive.

Eric: And when we think about sleep problems, insomnia, older adults, they’re in your clinic, especially around insomnia, are there meds that they may be on that are… like a lot of meds can cause sleep problems, right? Are there ones that are your high yield, man that’s a bad, bad drug for you?

Brienne: I have some thoughts about this.

Eric: Yes.

Brienne: So number one is when they say I’m taking Tylenol and then I can sleep, that’s Tylenol PM until proven otherwise, which for those people listening who don’t know means it has Benadryl in it, or diphenhydramine, which we really don’t like for treating sleep problems and also for people who might have cognitive concerns. So that’s one pearl.

And then the other thing that I tell my trainees that I always look for when people have trouble initiating sleep or trouble sleep, staying asleep is I look, are they on an SSRI? Because we know that those can exacerbate underlying sleep disorders. So those are two that come to my mind. How about you, Cathy?

Eric: All SSRIs, SNRIs, are they part of that too or just any antidepressant?

Alex: All of them.

Brienne: Yeah. So any SSRI or any SNRI and Tricyclics can do it as well.

Eric: Okay. Cathy, anything else come to your mind?

Cathy: Sometimes it’s obvious things like the patient who’s on a diuretic and they’re taking it late in the day because they have things they want to do during the daytime and they don’t want to have to be going to the bathroom during the daytime, so they’re taking it in the afternoon or evening. So sometimes it’s things pretty obvious. There are some medicines that are reliably sedating, some that are reliably stimulating. But there’s a little bit of idiosyncrasy there among people. So sometimes I find it helpful to ask the patient or their caregiver, “What do you think is causing this person trouble with their sleep?”

Brienne: And just sort of related to that, I would say I get a lot of bang for my buck by just finding out are they on something that’s just sedating them during the day so that they’re not able to sleep at night. That happens a lot and especially people who might be on behavioral medications. I think the classic example is somebody who just came out of the hospital, they’re put on these new medications because they were having problems in the hospital and now they’re home and they don’t need those anymore. And then you get the call from the family, they can’t sleep at night. And if you ask, you get that history from the care partner, you may find out, oh, actually yeah, he’s sleeping a lot in the middle of the day. Well then, let’s decrease the sedating meds during the day.

Eric: And anything else from the history or the physical that’s going to help you around the differential of the sleep problem?

Cathy: Well, yeah. So there are certain sleep disorders, certain sleep problems, which are either very common or very important in older people. And I know our focus right now today is on insomnia, but I don’t think you can consider insomnia in an older person without considering all the other sleep problems that are more common in older people. Because primary insomnia, quote, unquote, simply insomnia and not a comorbidity or not another sleep disorder I think is pretty rare in older people, at least the older people that I see in geriatric clinic. So I’m always going through my differential in my head. Okay, so do they have any symptoms of restless legs? Are they snoring? Do they have excessive daytime sleepiness? Do I have to worry that this person is one of the many, many people that have unrecognized sleep apnea? Are they having a movement disorder?

Brienne, I think we talked earlier about acting out their dreams. Are they having vivid dreaming and shouting out or moving around at night? So I have to worry about REM sleep behavior disorder. So I assume Brienne is the same, when it’s an older person, I’m always running through my head of the simple items which will help me know if I need to veer towards one of these other sleep problems, or one of the geriatric syndromes. Is this actually a symptom of depression? Are they depressed? And so I jump into my quick couple of items screeners for depression. Do they have anxiety? So I think the key here-

Brienne: That’s a great point. We were talking about comorbidities before and we didn’t mention those psychiatric comorbidities and sleep and psychiatric comorbidity, they go hand in hand. So actually, I use a depression screen and I also use an anxiety screen. And so I find those to be very useful and I think treating those I have seen can really help sleep problems a lot.

Eric: I’m guessing also substance use, alcohol use disorder probably high up there too on your list of things to think about.

Cathy: Yep. Yeah.

Brienne: Yeah. I think that people know that alcohol can help them fall asleep, but they don’t realize that it may wake them up in the middle of the night or that they might not metabolize alcohol to the same extent in their older age that they did in their middle age. And that’s just a start. That’s just dipping our toe in the substance use and how that might affect sleep.

Alex: … That depression can both cause sleep disorders and the treatment for depression can cause sleep disorders.

Brienne: We’re used to complex medical situations, right?

Cathy: Yeah. That’s why we’re in geriatrics. We like to sort that through. But also people who have sleep problems that are not being addressed are more likely to become depressed too.

Alex: Yeah.

Cathy: Both ways.

Alex: Right.

Eric: Yeah.

Brienne: And then a huge reason that I think Cathy and I are both here is that this link between sleep and dementia.

Eric: Well, what do we know about sleep and dementia?

Brienne: That’s probably a topic for a whole nother podcast. But I think what’s really interesting that we’re learning more about all the time is glymphatic function. So the glymphatics are sort of the lymphatics of the brain that are clearing neurotoxins, things like beta amyloid. And we think that this glymphatic function is taking place while we sleep. So we’re learning more about how we measure it, what it actually is, what it’s doing in the brain, which I think is allowing us to understand more about why is it that sleep problems seem to increase risk of dementia.

Alex: I know in the interest of time, we should just cut to chase here. So is that when you prescribed the benzodiazepine?

Eric: With a melatonin shooter?

Cathy: Yeah.

Brienne: It’s funny, I’m a sleep doctor and I will tell you I prescribe very few hypnotics because what I generally find is there’s a lot that needs to be done in these patients in terms of finding a history and taking a history, doing some evaluation that may or may not include getting a sleep study, de-prescribing certain medications from the medication list, thinking about behavioral interventions. There’s a lot to do before you have to go to a hypnotic.

Cathy: And I find too, that very helpful for me to at least keep in my mind that the majority of patients, older patients that you see that have a sleep problem, that have insomnia, they’ve had it for years. So I don’t have to fix it that day and I certainly don’t have to fix it by giving them a medication that’s going to increase their risk of falls and fractures and stuff like that.

So I think it helpful to remember that for the vast majority of these patients, they’ve had their insomnia for some time and so they have time to think it through and work it out. And I agree with Brienne, we’re laughing when you say do you prescribe the benzodiazepine? But I think at least for me, never. Really, at least for insomnia. I can’t remember prescribing a benzo or non benzo for an older person with insomnia. If they’re on it, they came to me on it. And then I’m trying to get them behavioral treatment to help them work through CBTI and medication tapering. And I’ll say things like, “Well, when did you start this medicine?” And they say, “When I was 60.” And, “Well, you know you’re 80 now. And so the effects of this medicine are different and more problematic in you now.”

Eric: So when I was in med school-

Brienne: … Quite receptive to you sort of explaining why it is that you don’t want to use those medications.

Cathy: Yeah.

Eric: Let’s talk about non-pharm treatment because when I was in med school they taught us about sleep hygiene and the importance of sleep hygiene. And in preparation for this, I’m seeing that sleep hygiene by itself really doesn’t do anything, education around sleep hygiene. Is that right? Have we moved on beyond just recommending sleep hygiene?

Brienne: I think that what you’re bringing up is that if you look at somebody who’s a behavioral sleep specialist and who specializes in treating insomnia and they hear that the way you treat insomnia is through sleep hygiene, then they groan, right? Because it’s not enough. You can’t just say, “Here’s a sheet, here’s 30 things that you need to do and that’ll treat your insomnia.” So I think that’s the problem. For people without an insomnia disorder, sleep hygiene can be very helpful. But if you’re really thinking about somebody who’s got insomnia disorder, then it’s not enough.

Eric: Is that chronic insomnia versus… and do you separate that from the acute insomnia?

Brienne: Yes. We’re saying this to somebody who’s had insomnia for, there’s criteria out there. But essentially, it’s sleep problems at night that are causing impairments in daytime function/ and there is a chronicity to it. So it’s not an acute thing. And usually, like Cathy said, when we see these people, they’ve had it for years.

Cathy: So the sleep hygiene, it does as Brienne, I’m hoping that you’re picking the nuance of what she’s saying I think is that sleep hygiene can be very helpful in people who have sort of your run-of-the-mill mild symptoms. Yeah, it can be very helpful to have them learn some tips. Don’t lie awake in bed while you… get up out of bed. Do something soothing and quiet and then go back to bed later. Get up at the same time every morning. Set a sleep structure to your bedtime and wake time, especially your wake time. So all these kind of tips can be very helpful. And they are part of the behavioral treatment, like cognitive behavioral therapy for insomnia. They’re a part of it, but they’re not adequate effective alone.

Eric: Incorporating these things like CBTI.

Cathy: Yeah. I personally think there is no excuse for us not to be providing in getting CBTI for our patients. And I think that’s particularly true in an older adult where the risks of medications are so much higher. And the evidence is clear, this is a very potent treatment. There are multiple ways that you can get it for your patients.

Eric: It’s on your phone now too, right? You can use apps for that and on the internet.

Brienne: And this is also a place where we have really good studies in older people to show that CBTI or BBTI we often call it, the brief behavioral therapy intervention, that they’re very effective for treatment of insomnia.

Alex: Who do you refer patients to or what resources do you give them in order to connect them with CBTI or brief therapy?

Cathy: Well, where I work, CBTI is readily available. Actually, much of the research that we’re doing in the research group that I’m involved in involves some form of CBTI or CBTI with another condition, CBTI in patients who also have sleep apnea, whatever. But in the clinic, through mental health, I’m able to get CBTI pretty readily for my patients. That may not be the same everywhere, but I don’t know, Brienne, what your experience is?

Brienne: Same for us. In our sleep clinic, we have a couple different behavioral sleep medicine providers that can do CBTI. So that’s probably a good resource for anybody out there who’s thinking, how do I get this for my patient? Think about sending them to a sleep clinic.

Alex: And is there another key component of CBTI? You mentioned that good sleep hygiene might be a part of it and a structured approach to sleep. But what else do they do in CBTI?

Cathy: Yeah, and intervene, Brienne. So it’s generally a combination. Getting into the details of it, it’s a combination of some very specific treatments. And I’m not a mental health professional, but this is not psychoanalysis. This is very specific structured process in order to help people change behavior, which they generally have developed over time, which is perpetuating their sleep problem.

And so it’s typically sleep restriction. So you limit the amount of time. I’m going to do it as a non-mental health professional. But sleep restriction, we’re limiting the amount of time that they’re in bed to more closely resemble the amount of time that they actually sleep. So having them not spend lots of time awake in bed so that they can more properly train their time in bed to either intimacy or sleep. Stimulus control is a part of that sort of training them to not do things in bed, which will train their brain to think that bedtime is for something other than sleep.

Cognitive therapy, where you’re fixing these false beliefs that people develop like, “I didn’t sleep well last night so I need to spend more time in bed tonight so I can have enough opportunity to sleep.” But actually that’s perpetuating the problem. And there are other things too, but it’s really, I think key to understand is it’s really quite structured.

Alex: Yeah.

Eric: Do you ever do things like bright light therapy? Is that a thing anymore?

Cathy: Sure.

Brienne: Yeah. I think then you’re sort of thinking more about people’s circadian rhythm and whether you are trying to shift that.

Eric: Okay.

Brienne: If somebody has a delayed sleep phase, so they want to go to bed at two o’clock in the morning instead of what’s a more sort of societally normal time, then you could could use bright light in that situation. Or somebody who is in early phase, they go to bed too early, you could use bright light and you could also use melatonin in those situations. So those are sort of-

Eric: Ah, we had a drop finally.

Brienne: Yep, the M word.

Alex: Hey, what about melatonin? I think every patient I see in the hospital’s on melatonin.

Eric: Yeah.

Alex: Is that the right approach or is that an issue?

Eric: Somewhere between 0.5 and 10 milligrams? Never know. It’s always a surprise what they’re on.

Brienne: So my feelings about melatonin, it’s generally not harmful, especially if you make sure people don’t just keep going up and up and up on the dose. If we’re talking about REM sleep behavior disorder, that’s a place where it’s actually very helpful.

Eric: Just one sentence, what is REM sleep behavior disorder?

Brienne: This is acting out your dreams because you still have muscle tone during your dream sleep, or REM sleep. So that’s a place where we actually do use it in higher doses, so six to 12 milligrams. Otherwise, for insomnia disorder, it doesn’t help. So I think we’re using it a lot because we feel like we can give the person something to help them sleep that’s not harmful. But it’s probably not helpful.

Alex: And do you agree Cathy, it’s not harmful? I see patients who are delirious, well I’m sure you do too. And all the time in the hospital. And I wonder is that melatonin contributing, that six milligrams or eight milligrams of melatonin or whatever they’re on, or you think that it’s something else, probably?

Cathy: Yeah. I’m not usually real concerned about discontinuing their melatonin, right or wrong. So kind of the same approach Brienne has is that for most people, it’s relatively harmless and it’s probably not causing them a problem. But the other thing also I think, particularly in clinic is Brienne mentioned the RBD, the REM sleep behavior disorder, which is increasingly being recognized and people are more and more aware of it. I also want to be sure that I’m not stopping melatonin that is treating something that I haven’t gotten the information about yet. But I do see more and more use of melatonin in the hospital setting. And I’m not sure the evidence is really strong for that, but it is probably pretty benign in terms of-

Eric: And if you were going to use it, how much and when do you actually give it, if hypothetically you’re going to believe it does something? Do you have to give it right around the time they fall asleep? Do you have to give it an hour before? Do you have to give it…

Brienne: So if you’re giving it because you want to help them fall asleep, it does have some weak hypnotic effect with, so some weak ability to help people fall asleep. And so then you probably want to give it about an hour before sleep.

Eric: Okay. One to three milligrams sound about right?

Brienne: Yeah., Our release of melatonin from our pineal gland is on the order of micrograms. So in theory one milligram is a super therapeutic dose and it’s plenty. I think the problems we run into is, this is not FDA, it’s not controlled. So you don’t actually know that you’re getting a milligram though.

Eric: But there is, right? We got Ramelteon. Is it Ramelteon ? Did I pronounce that one right? I struggle with all of these pronunciations. So you got a melatonin receptor agonist, right? Should we use that? Do you think there’s a role there? No. Cathy?

Cathy: Yeah, we have it on our formulary and maybe there are some patients where it’s helpful. And it’s pretty benign, so it’s probably not causing a lot of trouble. As far as I know, it’s not been compared head to head with melatonin. So I’m not really sure if it has a benefit over using melatonin if you know that tablet actually has melatonin in it.

Eric: Well, the other one we see a lot in the hospital is Trazodone. Everybody’s on Trazodone 25, maybe Trazodone 50 if they’re having a lot of problems. Thoughts on Trazodone?

Cathy: You want to do that one, Brienne?

Brienne: So Trazodone is… every medication has risks, but some medications are riskier than others. So I think we use a lot of Trazodone to avoid using riskier medications. And I think the evidence of it is out there that it’s not helpful for people with insomnia disorder. But for people with more mild symptoms, I think I will use it in that case.

Eric: Okay. Now, the one that I’m know a lot about, but I see it and I think there’s some studies in patients with mild moderate dementia was the dual orexin receptor antagonists. What the heck are those, and do you ever use them?

Brienne: So I will say quickly that I don’t use them. It’s because recently they’ve been so expensive. And I know this study you’re talking about, they have used this medication in people with Alzheimer’s disease and it was a randomized controlled trial and they used the gold standard to measure sleep. But people had pretty mild disease, not a lot of other comorbidities and they didn’t use the medication for very long. So I don’t think we have really strong evidence. And I think it just tends to be the case that in our patients with a lot of medical problems and a lot of other medications that using this one, adding this onto everything, in my mind, isn’t necessarily going to be that much less harmful than using any of the other medications that you might. So I sort of think of it, or I was saying before, I have a lot of people who come to my clinic with bad insomnia and it’s just another medication in the mix that they’ve tried that hasn’t worked. But I will say I don’t use it a lot. So Cathy, I’m really interested to hear your thoughts here.

Cathy: Yeah. So short answer is that I have not been using it in my dementia patients yet. No.

Eric: Okay. And real quick, because I don’t know too much about these drugs. Was it Suvorexant?

Brienne: Suvorexant, Lemborexant.

Eric: Are there a lot of side effects like you see with the benzo receptor?

Brienne: Yeah, so it’s working through a different mechanism. So it’s not acting on the benzo, the GABA receptor. It’s blocking the effect of orexin, which is a wake promoting neurotransmitter. It’s working through a different mechanism. But I do think that there’s, even if you look in that study and people with Alzheimer’s disease where they only took it for four weeks or something, there was still daytime sedation there and there were still falls. So I think what Cathy is trying to say is, we need more data.

Eric: And then last thing, I know at the top of the hour and we got to let you go, maybe one thing you both are… I know both of you are working around this space, one thing that you’re doing that you’re excited about right now, kind of moving forward as far as next steps. Brienne, how about for you?

Brienne: So my work is all really related to how we measure sleep in older people. So I am doing stuff to say we need to assess sleep more globally, thinking about people’s quality, people’s duration, and also the timing of sleep. So bringing in that circadian component, and then really starting to use these measures in people with cognitive impairment in Alzheimer’s disease. So that’s what I’m working on right now.

Eric: That’s great. Cathy?

Cathy: So we’re working on a study to help middle-aged and older adults who have sleep apnea and have, quote, failed PAP therapy who are not using their PAP and we use behavioral treatment to treat improve their use of PAP. That’s what I like to do.

Eric: Great. Well, be mindful of the time, maybe we can get a little bit more back to our Dreams. Alex?

Alex: (singing)

Eric: You’re a little soft, Alex.

Alex: Yeah, we’re going to stop it there. For those who are listening to the podcast, you get my recorded version. So live, sorry, we’re out of time.

Eric: Well, Cathy, Brienne, thank you for joining us on this podcast. It was fabulous. And for all of our listeners, you can go to our show notes, we’ll have more information on there. And with that, I want to thank everybody for joining on this podcast. Thank you Brienne and Cathy.

Brienne: Thank you so much for having us and talking about this topic. It’s my favorite topic.

Cathy: Thank you.

Eric: All right, thanks everybody.

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