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HOW TO TREAT 33 recommends that Priya come back in four weeks for follow-up .
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HOW TO TREAT 33 recommends that Priya come back in four weeks for follow-up .
At follow-up , Priya has been working through the This Way Up program , and her insomnia severity index score has dropped to 12 / 28 , indicating subthreshold insomnia . Her sleep is better , but she has some nights where she wakes during the night and cannot get back to sleep despite feeling exhausted . The GP reassures Priya that an occasional night of poor sleep is common , that improvements will occur gradually and the latter will persist even after CBT-I is complete .
Priya reports that sleep restriction therapy has led to a short-term increase in her daytime sleepiness . The GP reassures her that this is a sign that treatment is working , and that this sleepiness will subside after time in bed is gradually extended from week to week .
Her fatigue has improved , although she reports still feeling some tiredness during the day . Her anxiety levels are better , and she feels that her “ head is clearer ” and she has time to think .
Evidence shows that patients with insomnia and anxiety can benefit greatly from CBT-I , as it treats both conditions . However , full face-to-face CBT-I is challenging to provide in primary care , and digital approaches can be both cost-effective and allow the patient to self-pace through the therapy with follow-up visits to the GP to monitor progress .
The GP recommends that Priya continue with the digital program to completion and ensure that the behavioural and cognitive
1 . Which TWO statements regarding sleep disorders are correct ? a At least four in 10 Australian adults regularly experience sleep disturbance . b There is no evidence for bi-directional relationships between sleep problems and chronic disease . c All patients with sleep problems are managed in the primary care setting . d Sleep , alongside diet and exercise , are central to good health .
2 . For which TWO are sleep disorders a risk factor ? a Mental health conditions . b Physical health conditions . c Genetic conditions . d None of the above .
3 . What THREE sleep disorders are most commonly seen in general practice ? a Circadian rhythm disorders . b Insomnia c Restless legs syndrome . d OSA .
4 . Which TWO statements regarding sleep disorders are correct ? a The prevalence of sleep disorders generally decreases with age .
Figure 8 . Australasian Sleep Association ’ s sleep health primary care resources webpage .
components are completed to improve her fatigue and anxiety .
Case study two
Bruce , 59 , presents to the GP with daytime sleepiness . He also feels that his memory is not as good as it was . He says his wife sleeps in another room because he snores loudly and keeps her awake at night . She has told him he might have sleep apnoea after she saw a story about it on television .
He is obese and has struggled with his weight for decades . Bruce has a sedentary desk job and has little time for exercise during the day . His wife gave him a fitness tracker / smart watch for Christmas to help him increase his daily step count , but he is struggling to raise it . He has been wearing the fitness tracker for the past two weeks and using the sleep tracking feature , as he thought this
How to Treat Quiz .
b Insomnia is characterised by self-reported sleep difficulty . c Sleep apnoea is more common in women . d OSA can cause excessive daytime sleepiness , fatigue and cardiovascular sequalae .
5 . Which THREE statements are correct ? a The symptoms of restless legs syndrome ( RLS ) are worse on movement and can be relieved by rest . b An estimated 10 % of the population may experience some form of circadian rhythm disorder . c RLS is more common in older adults and has a higher prevalence in women . d Between 30 % and 50 % of people with OSA have comorbid insomnia symptoms .
6 . Which THREE are barriers to the management of sleep disorders in primary care ? a Patients likely under-report might help the GP with a diagnosis , especially if it relates to his sleep . On examination , his BMI is 31kg / m 2 and his BP is elevated at 158 / 88mmHg . This is the second time in the past year that it has been high . Bruce did not want to start antihypertensive medication at the last visit . There are no other abnormalities noted on examination and no arrythmias .
Bruce shows the GP his sleepwake recordings from the fitness tracker . They show that he goes to bed late ( around midnight ) most nights , but the ‘ light ’ and ‘ deep ’ sleep values do not appear correct . The GP tells Bruce that while these consumer wearable devices claim to measure sleep precisely , they only reliably estimate time in bed and the sleep metrics do not accurately reflect those of an overnight sleep study . The latter includes monitoring
DIGITAL HEALTH INTERVENTIONS IN SLEEP DISORDERS
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sleep problems to GPs . b Time constraints and workload in general practice . c Funding structure of general practice . d Detailed coverage of sleep health education within medical curricula .
7 . Which ONE is not a differential diagnosis of daytime sleepiness ? a Depression . b Narcolepsy . c Hyperthyroidism . d Excess alcohol intake .
8 . Which TWO statements regarding digital technology are correct ? a Patients are increasingly using consumer technology devices to track their general health . b There is robust evidence supporting the efficacy of sleep mHealth apps . c There is clear regulatory oversight governing the use of sleep mHealth apps . d Clinical support models
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The GP suspects OSA based on the symptom profile and examination . He uses the Australasian Sleep Association online sleep health primary care resources to identify important areas of assessment for OSA , including nocturnal , daytime and physical symptoms , and fitness to drive .
The GP administers an online version of the OSA50 and Epworth Sleepiness Scale ( ESS ). Bruce ’ s OSA50 is 8 / 10 and ESS is 12 / 24 , which is suggestive of a high risk of OSA . The GP can either order a home-based or laboratory diagnostic polysomnography sleep study to confirm OSA severity .
The GP prescribes enalapril 5mg daily for blood pressure control , and orders 12-lead ECG , fasting biochemistry , FBC , lipid profile , glucose , and urea and creatinine for a full cardiovascular workup . He advises Bruce
integrating mHealth apps with direct clinical care have yet to be established in Australia .
9 . Which THREE statements regarding digital sleep health approaches are correct ? a The common features of all interventions are that their purpose is to monitor , assess / diagnose , treat , manage , and / or prevent sleep disorders . b Wearable fitness trackers that incidentally monitor sleep are classed as ‘ software as medical devices ’ ( SaMDs ). c Sleep data collected from wearable consumer devices is not always accurate . d Limited knowledge of devices / mHealth apps may affect GPs ’ decision-making ability .
10 . In which THREE ways can GPs use digital tools for managing sleep disorders ? a Confirm a diagnosis of a sleep disorder . b Access interventions such as digital cognitive behavioural therapy for insomnia . c Communicate tailored sleep health information to patients via email or text messages . d Access on-demand information about sleep disorders . about exercise and dietary measures to aid weight control .
Two weeks later , Bruce has completed a home-based sleep study that confirms OSA with an apnoea-hypopnoea index of 22 , indicating moderate sleep apnoea .
Bruce and the GP discuss treatment options . Bruce wants to see a sleep physician for possible CPAP treatment .
Bruce sees the sleep physician , who diagnoses moderate / severe OSA and prescribes a CPAP machine and mask . The GP will continue to monitor Bruce ’ s CPAP therapy use using a nightly download of adherence data ( how many hours of use each night ) and monitor ongoing symptoms , CPAP side-effects , and provide adherence support .
Data from a connected mobile app indicates that Bruce has used his CPAP equipment for an average of six hours / night over the past two weeks .
CONCLUSION
SLEEP disturbance and sleep disorders are highly prevalent in the Australian community and commonly present to primary care . Crucially , poor sleep health and sleep disorders are strongly associated with increased risk of chronic physical and mental health disorders and therefore should be investigated , diagnosed and treated to improve overall health .
Evidence suggests there is an increase in sleep disorders , and primary care will need to be equipped to manage and treat these patients , especially because of the complexity and bi-directional nature of many chronic conditions .
Digital sleep health interventions are likely to offer a scalable solution to address sleep disorders , but models of care need to be developed . With an increase in digital health technology , including sleep trackers and mobile health apps , digital sleep health interventions are increasingly part of the health ecosystem , and the challenge for primary care is the medical integration of these tools into clinical practice .
RESOURCES
• Australasian Sleep Association bit . ly / 3NpPEIW — Obstructive Sleep Apnoea
Assessment – History bit . ly / 44fCkwU
— Insomnia Severity Index ( ISI ) bit . ly / 3HiiWFK
— Flinders Fatigue Scale bit . ly / 3Vq6idP
— OSA50 bit . ly / 449TRGv
— Epworth Sleepiness Scale bit . ly / 42tPJzZ
• This Way Up insomnia program bit . ly / 3nhAAmg
• US Department of Veterans Affairs , National Center for PTSD : CBT-i COACH ( free app ) bit . ly / 3LFcXfJ
• RACGP mHealth in general practice : a toolkit for effective and secure use of mobile technology bit . ly / 44pHnLa
• Australian Government Department of Health and Ageing , Head to Health digital resources bit . ly / 3BrzXdp
References Available on request from howtotreat @ adg . com . au