But if people are trying all these over the counters and they're not having the result, they want and they tell you you know I really kind of cleaned up my act and I don't use my iPhone in bed or my my other kind of phone in bed. Let'S not, let's not demonize iPhones per se, and and I don't take naps and I don't have coffee and I don't drink alcohol and I've tried these over-the-counter meds and they're not working. When do you move from there to more prescription medications in the elderly? You know one of the things that we've left out of this equation here is the distress of the patient, and you know a lot of the things that we do.
You know sleep, Hygiene is wonderful, but you have to measure it against the distress of the patient At that moment in time as to what you're gon na do, and I think that that temper are some things take longer to do and that all has to go Into the equation - and so I think that's the first step and we've talked about all these various Options and there's a time factor involved. There'S the acceptance of the patient
You know part of the leaves these herbals is also a little placebo effect built into it and that you can't discount, which in which is probably good, and we have to keep all of that in mind when you've, exhausted and now you're. Confronted with a situation where, in the judgment to the clinician, you need to sort of do something else to help this patient out, because they're not going to believe you that just make all these changes in your life, then that's when you would start considering other medications. Okay, I've always been kind of a therapeutic nihilist myself if we don't have to use medication at all. Let'S not it sounds to me. The key core of what you were saying is the distress of the patient well, and acceptance of the patient. I have patients who come to see me and they say I'm just want a pill.
I'M not gon na Listen to anything else. I have other patients come to me like the therapeutic nihilist here who say, no pills, no medications, never nothing, there's a middle ground, and so - and there are people in the middle people who do both. People may start off with some medication and do the other things as well. So so and to me it's a matter of judging and dealing with the patient. You know. The other thing I hear from all of you is that this can be terribly distressing and that patients are who have almost by definition if they have insomnia, they're unhappy and it's affecting them in some deleterious way. So the question is: what is the urgency of treating this? I mean it takes time if you're gon na do sleep hygiene clean up your hat stay in bed. Try this now you're talking days and weeks. Maybe try over-the-counter now, it's weeks and months and still the patient's not doing well. Is there a point where you say: let's do something else! This is an urgent situation. Does it ever get there urgent, urgent? Well again, that's dictated by the patients.
I don't know necessarily has to do anything with the time you know there are some people who may be having insomnia for a few weeks and they're, desperate and other people, and it's commonly people come in and say. Well you know. I'Ve always took me two hours to fall asleep and so to get by and but now it's starting to get a little worse and it's been going on for years. So this time is not the issue here. I think it again. It'S it's the matter of dealing with the patient at hand. Okay, that's what dictates concerns one thing sandy of it. Don'T you think? Also, it's a matter of also how impaired the patient is during the day, in other words, when the Insomnia's gotten to the point where the patient's not functioning well or as functioning less
Well, I think you and with behavioral therapy. I think you need to do something to help them function get back quickly. One of the advantages of pharmacologic therapy is that it works rapidly, whereas kind of behavioral therapy takes a while. That'S what I was saying. So if you need to rapid improvement patients, symptoms are significant enough. I had a patient the other day. He had insomnia for a year and a half horrible debilitating sleep. The man could not work. He needed to get back to work right away.
He was in lose his job. Wouldn'T you do something very rapidly to get him there. Cbt would have taken weeks, maybe months to work. So I think it's a matter also how impaired the patient is, how quickly you'd like to to text, but I therapy. Quite frankly, one of the other issues is available in some parts of the country. There are no cognitive, behavioral therapists available, so pharmacology is the only going thing, so those practical issues are also problem and there's one other thing that I think that there's a socio-economic factor here Hospital I deal with there's a safety net Hospital. So we see large lot of people who come to us who are illiterate.
We'Re with this kind of cognitive, behavioral therapy is a very foreign concept to them, and it's and assuming that you can get somebody who can do it in their native language and and so you know, you sort of it's it's nice to go through these things and To have these ideals of how to manage patients, but there you have to be practical all right. You know before we launch into a discussion of some of the prescription drugs I caught something that you said earlier, which is you kind of watch it in older patients that what may be safe and a 20 year old has some consequences in older folks that we Might not like what what, for example, well, I've had
You know, as we think about We'Ve talked about Falls, but I'll put it, for instance, with the anticholinergic such as diphenhydramine, where an older gentleman has an underlying prostate disorder in large, prostate and that antek just interject. When I hear this yeah the tipping point for urinary retention that led to urosepsis and really the tipping point was the use of the diphenhydramine at higher doses for sleep. So really looking at that. It'S that interaction between their coexisting, medical conditions and how those medications might be the tipping point, and so for them to have an exacerbation of that problem. So I I think the threshold and our ability to readjust, especially if we have a fall - and I think these medications are not without the implications on Falls and it might be because of those sleepiness, but also because of the blurred vision or other