Staying up to date with consumer sleep technology

With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?

As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.

One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.

Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).

Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.

There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).

Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.

Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.

This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.

Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).

Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.

There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.

Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.

Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).

CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
 

Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.

With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?

As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.

One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.

Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).

Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.

There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).

Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.

Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.

This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.

Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).

Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.

There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.

Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.

Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).

CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
 

Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.

With Siri and Alexa sitting at our kitchen tables and listening to our conversations, we have all but forgotten about the before times – when we had to use the Yellow Pages to look up a number or address and when we had no idea how many steps we took in a given day. Wearable technology has become ubiquitous and has us watching not only our step count but also our sleep. Did I get enough deep sleep? What does my sleep score of 82 mean? Should I be worried?

As clinicians, we must also navigate how this information impacts our clinical decision-making and consider how our patients are interpreting these data on a daily basis. There is an inherent assumption that we, as sleep clinicians, will understand the nuances of each consumer-facing sleep technology (CST) whether it is a wearable, a nearable (a device that sits near the body but not on the body), or an app. Very little validation data exist, as most of these technologies are marketed as wellness devices and are not intended to render a diagnosis. It therefore falls to us to determine how to utilize this information in an already busy clinic.

One strategy is to use these technologies as patient engagement tools – a way to increase public awareness of the importance of sleep. While this certainly should be beneficial, oftentimes, the data are confusing and can lead to misunderstandings about what normal sleep should look like. Approaching these data as partners to our patients allows us to set expectations around normal sleep cycles and sleep duration. It also allows us to discuss appropriate sleep timing and sleep hygiene.

Many wearable devices have incorporated oximetry into their metrics, and some claim to have accuracy that is better than hospital-grade oximeters. Many of these companies are no longer in business. Others specify higher accuracy in dark-skinned individuals (“CIRCUL Ring Pulse Oximeter in Dark-Pigmented Individuals: Clinical Study Validates Efficacy and Reliability,” Medical Device News Magazine, Feb. 26, 2021).

Despite these claims, they are registered as wellness devices with the FDA and are not diagnostic devices. Logically, if one of these devices demonstrates worrisome data, then it can prompt further clinical queries and, potentially, objective testing for obstructive sleep apnea (OSA). The reverse, however, cannot be claimed. A normal reading by CST does not obviate the need for objective testing if the clinical symptoms warrant it.

There are CSTs that have been created around very specific needs - such as jet lag- and provide guidance for how to quickly acclimate to the destination time zone by providing nudges for light exposure and timed melatonin or dark glasses (https://www.timeshifter.com/).

Others analyze the sleep space for extrinsic sounds (https://www.sleepcycle.com/), while a plethora of apps provides advice for how to optimize your sleep environment and wind-down routine. There is even a sleep robot designed to facilitate sleep onset (https://somnox.com/). This bean-shaped device is designed to “breathe” as you hold it, and the user is meant to emulate those same breathing patterns. It is a take on the 4-7-8 breathing pattern long endorsed by yogis.

Although validation data are lacking for the vast majority of CST, a recent study (www.ncbi.nlm.nih.gov/pmc/articles/PMC8120339/pdf/zsaa291.pdf).demonstrated that CST had high performance when compared with actigraphy in assessing sleep and wakefulness and, as such, may improve the evaluation of sleep and wake opportunities prior to MSLT or improve identification of circadian sleep-wake disorders. Many practices do not currently utilize actigraphy due to its expense and very limited potential for reimbursement. Using a patient’s sleep-tracking device may allow access to these data without financial outlay. While these data demonstrate the ability of CST to potentially differentiate sleep from wakefulness, it is notable that this study also found that the determination of individual sleep stages is less robust. In general, CST cannot identify an underlying sleep disorder, however, may raise awareness that a disorder might be present.

This leads to more reflection on the role of CST in a typical sleep clinic. Many years ago, discussion around this technology was primarily patient-initiated and often times met with skepticism on the part of the clinician. As technology has improved and has become more accessible, there appears to be more acceptance among our colleagues – not, perhaps, in terms of absolute actionable data, but rather as an opportunity to discuss sleep with our patients and to support their own efforts at improving their sleep. Trends in the data in response to CBT-I or medications can be observed. Abnormalities identified via CST often serve as the initial prompt for a clinical visit and, as such, should not be eschewed. Rather, reframing the use of this information while also addressing other sleep issues is likely to be the more appropriate path forward.

Assessing this information can be time-consuming, and best practice suggests establishing expectations around this process (J Clin Sleep Med 2018 May 15. doi: 10.5664/jcsm.7128).

Agreements can be made with patients that the data are reviewed in the context of a clinical visit rather than longitudinally as data are uploaded and then sent via messaging unless such an understanding has already been agreed upon. RPM billing codes may ultimately allow for reimbursement and recognition of this workload. At the present time, RPM billing is limited to FDA-cleared, prescription devices, and CST does not yet qualify.

There also needs to be recognition of potential harm from CST. Inevitably, some patients will develop orthosomnia, a term coined by Dr. Kelly Baron, where patients become so fixated on achieving perfect sleep scores that it contributes to insomnia. In this case, identification of orthosomnia is made via the clinical visit and patients are advised to stop tracking their sleep for a set period of time. This allows the anxiety around achieving “perfect sleep” to dissipate.

Google and the AASM recently announced a partnership. Essentially, the Google Nest Hub will serve to detect sleep concerns (such as timing of sleep, snoring, insufficient sleep, etc.) and will direct the user to educational resources such as www.sleepeducation.org. The idea behind this is that people are often unaware of an underlying sleep disorder such as OSA and don’t know what to search for. The Nest Hub uses information it collects and directs users to appropriate resources, thus obviating the need to know what to Google.

Clearly, big tech has invested heavily in our field. Between the copious wearables, nearables, and apps that are sleep-focused, these industry giants obviously believe that sleep is worthy of such a significant allocation of resources. This has improved the overall awareness of the importance of sleep and of identifying and treating sleep disorders. While these technologies are no replacement for a clinical evaluation, they can serve as patient engagement tools, as well as potentially large-scale OSA screening tools and may help us improve the percentage of patients with undiagnosed OSA, estimated to be 80% (Frost and Sullivan, “Hidden Health Crisis Costing America Billions,” American Academy of Sleep Medicine, 2016).

CST may allow us to better identify circadian sleep-wake disorders and evaluate sleep satiation prior to MLST that no longer requires investment in expensive actigraphy devices. They also allow us to partner with our patients by meeting them where they are and recognizing the efforts they have already made to improve their sleep before we even meet them.
 

Dr. Khosla is Medical Director, North Dakota Center for Sleep, Fargo, North Dakota.