32 HOW TO TREAT : DIGITAL HEALTH INTERVENTIONS IN SLEEP DISORDERS
32 HOW TO TREAT : DIGITAL HEALTH INTERVENTIONS IN SLEEP DISORDERS
4 AUGUST 2023 ausdoc . com . au
On examination , her blood pressure is mildly elevated ( 145 / 86 mmHg ). There is nothing else of note on examination .
Priya completes the insomnia severity index , revealing a score of 18 / 28 , indicating clinical insomnia . She scores particularly high in the severity of insomnia problems ‘ difficulty falling asleep ’ and ‘ difficulty staying asleep ’, both 4 / 4 . The Flinders Fatigue Scale reveals elevated fatigue scores of 16 / 31 .
Priya does not snore or have excessive daytime sleepiness .
The GP identifies symptoms indicative of insomnia disorder with increasing anxiety and explains the treatment options .
Because Priya is reluctant to take medication , the GP suggests CBT-I . This could be delivered face to face or digitally , and Priya can self-pace through the therapy . Both modalities have several potential components , including sleep education , behavioural therapies ( involving sleep restriction , stimulus control and relaxation ), cognitive components ( mainly associated with the management of sleep-related worries and dysfunctional beliefs about sleep ), and relapse prevention .
There is a large body of evidence supporting the use of CBT-I in insomnia and , importantly , in association with mental health disorders . Priya says she would like to try digital CBT- I . Her GP recommends either This Way Up , a free internet-delivered program , or CBT-i COACH , a free mHealth app developed by the US Department of Veterans Affairs . The GP
- worn by the individual
Wearables
- often estimate movement , heart rate , oxygen saturation , and other signals to infer sleep
- include fitness trackers , face masks , and headbands
Web-based programs
- include self-guided treatment programs and software to monitor treatment adherence
- may include clinician dashboards for physicians to monitor patient progress
Figure 6 . Categories of digital health interventions used in sleep health .
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- placed near the individual
Nearables
- often estimate breathing disturbances
- include devices that measure the environment , such as light and sound
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Phone apps
- may estimate breathing disturbances from phone microphone
- also include treatment and relaxation apps
- a massive consumer market , with empirical evidence available for only a few apps
Table 1 . Overview of classification rules for software-based medical devices ( SaMDs )
Diagnosing and / or recommending treatment of intervention for a disease or condition
Provides information to an individual
Provides information to a health professional
Death / severe deterioration / high public health risk
Serious disease or condition / otherwise harmful / moderate public health risk
Class III
Class IIb
Class IIb
Class IIa
Any other case Class IIa Class I
Screening and / or specifying a treatment or intervention for a disease or condition
Death / severe deterioration / high public health risk
Serious disease or condition / otherwise harmful / moderate health risk
Class III
Class IIb
Screening
Suspected OSA
Administer ESS and either > OSA50 > Stop-Bang > Berlin Questionnaire
Suspected Insomnia
Administer Insomnia Severity Index
Assess for short-term , versus chronic insomnia
Consider presence of other sleep disorders , lifestyle factors , occupation , sleepiness-related accident risk , treatment preference , chronic conditions
Any other case
Class IIa Monitoring the state / progression of a disease or condition
Immediate danger to a person / high public health risk
Other danger to a person or another / moderate public health risk
Any other case
Class IIb
Class IIa
Class I For providing therapy through provision of information May result in death / severe deterioration May cause serious harm May cause harm Any other case
Class III Class IIb Class IIa Class I
Further assessment and treatment options
If criteria met , refer for home or laboratory sleep study
If criteria not met , consider sleep specialist referral
> Provide reassurance for short-term insomnia
> Consider referral to a psychologist for CBT-I with a Mental Health Treatment Plan
> Refer for digital CBT-I > Consider short-term medicine prescription and taper plan
Adapted from TGA 2021 44 Key : Class I Class IIa Class IIb Class III
Increasing levels of regulatory scrutiny
Figure 7 . Potential digital sleep health pathway for general practice .
These questionnaires , and further information about the assessment and management of insomnia and sleep apnoea , are available through the online Sleep Health Primary Care Resource : www . sleepprimarycareresources . org . au