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Differentiating Insomnia Subtypes


Peter L. Salgo, MD: Hello and thank you for joining this AJMC® Peer Exchange titled “Managing Challenges of Insomnia in the Elderly.”

Elderly patients are likely to be more sensitive to the adverse effects of medications. These medications can cause confusion and memory problems, which could increase the risks for falls and fractures. However, inconsistent sleep can cause agitation and depression in elderly patients, especially with neurologic comorbidities.

Our panel of experts is going to discuss some safe and effective treatment options for elderly patients who experience insomnia.

I am Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University Vagelos College of Physicians and Surgeons and associate director of surgical intensive care at NewYork-Presbyterian Hospital in New York, New York.

Participating today on our distinguished panel are:

Dr Sanford Auerbach, director of the Sleep Disorders Center and Sleep Medicine Fellowship Training Program, and associate professor of neurology, psychiatry, and behavioral neurosciences at Boston University School of Medicine in Boston, Massachusetts;

Dr Nicole Brandt, executive director of drug therapy and aging, and professor of pharmacy practice and science at the Peter Lamy Center on Drug Therapy and Aging at University of Maryland School of Pharmacy in Baltimore, Maryland;

Dr Karl Doghramji, medical director of Jefferson Sleep Disorders Center and program director of Fellowship in Sleep Medicine at Thomas Jefferson University in Philadelphia, Pennsylvania;

And Dr Gary Johnson, medical director at a large national insurer who works from his home in Northern Michigan.

I want to thank all of you so much for being here. This is going to be terrific. Why don’t we start with the obvious question. What are we talking about? What is insomnia here? Who wants to jump in?

Karl Doghramji, MD: I’ll take that, Peter.

Peter L. Salgo, MD: I thought you might.

Karl Doghramji, MD: I’d be happy to. Peter, the most widely accepted nosologic understanding of insomnia is in DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth edition], which says that insomnia disorder is basically a subjective dissatisfaction with sleep where people have difficulty with sleep quality or quantity, either not falling asleep quickly enough or not staying asleep, and that there’s some consequence associated with it, some disturbance.

Peter L. Salgo, MD: But wait, you said it’s subjective.

Karl Doghramji, MD: Highly subjective.

Peter L. Salgo, MD: I would bet out in our audience, most folks are looking for a far more definitive answer than that. It’s less than 3 hours sleep, 5 hours sleep, 8 hours sleep, you wake a lot. None of this matters as long as you feel good.

Karl Doghramji, MD: If you have the problem more than 3 nights per week and if it lasts at least a few weeks or longer, then it’s defined as insomnia disorder. And of course, it has to cause some consequences for it to be insomnia disorder.

Peter L. Salgo, MD: And what are the consequences?

Sanford H. Auerbach, MD: That’s the biggest point about this is that it’s not just having difficulties with sleep at night. It’s not an issue of not being able to fall asleep, stay asleep. It really hinges on the second part of that definition, which it has to have an impact on daytime function.

Peter L. Salgo, MD: OK. So somebody who says, “I get 6 hours of sleep at night, I don’t think it’s enough, but, gee, I’m top notch during the day. I feel great.”

Sanford H. Auerbach, MD: That’s not insomnia.

Peter L. Salgo, MD: What is it?

Sanford H. Auerbach, MD: It’s just short sleep.

Peter L. Salgo, MD: I get by with less sleep.

Sanford H. Auerbach, MD: Yes, that’s what it means. You don’t need as much sleep as everybody else. You’re a short sleeper perhaps.

Peter L. Salgo, MD: That’s another thing I want to bring up to the panel. There are people who say, “I get by, I don’t need sleep. I can work till 3 in the morning and I’m great in the morning.” Are there people like that?

Sanford H. Auerbach, MD: Most of them are lying. I knew an orthopedic surgeon who told me that. He said, oh, he never needs more than 4 hours of sleep. He said, “But you know what, it’s a funny thing, like every 2 weeks I spend a weekend in bed sleeping.”

Peter L. Salgo, MD: He catches up.

Sanford H. Auerbach, MD: Yeah, he catches up. I think that there are some people like that who don’t need as much. But I think there are a lot of people who really do need more sleep.

Gary L. Johnson, MD, MS, MBA: But does it matter if a person has difficulty getting to sleep or maintaining sleep? Is there something that distinguishes those two?

Karl Doghramji, MD: Insomnia is characterized by one or the other or both, as you well know. What’s interesting is that over time these 2 symptoms can vary from one to the other, so they’re really not stable symptoms. People with sleep initiation problems can become maintenance problems and vice versa. But the differences really are more with diagnosis and treatment implication rather than have to do with the phenomenology of the person themselves. So people who have difficulty primarily falling asleep may have circadian rhythm abnormalities, for example, or may have substances that they take before sleep that may cause problems with sleep initiation. Whereas, people who have problems with sleep maintenance may have underlying disorders like sleep apnea or depression. So it’s important to look at these things from a diagnostic standpoint, I think.

Peter L. Salgo, MD: Is there chronic versus acute insomnia? Is there such a thing?

Sanford H. Auerbach, MD: Sure. There are people who have this problem for only a short period of time. It’s interesting. As sleep specialists, we only see the ones with chronic insomnia. The shorter acting ones, if they do go to a physician, they may go to a primary care physician, and usually there’s something very specific that’s come up to trigger that insomnia.

Peter L. Salgo, MD: A call from the IRS [Internal Revenue Service].

Sanford H. Auerbach, MD: Call from the IRS, back pain, grief, some sort of loss. It can be a whole variety of different things that come up.

Peter L. Salgo, MD: And is there primary versus secondary insomnia? What does that mean?

Karl Doghramji, MD: We used to make a lot of that, right? We used to make a lot of the primary and secondary, primary being something that is caused by itself or secondary being caused by something else. But those distinctions don’t seem to be as relevant or important clinically anymore, we think. Well, we now say, it’s comorbid or not comorbid. So insomnia that exists with something else is said to be comorbid or coexistent with something else. Here’s the issue. If insomnia exists with something else, we’re never quite sure whether that something else is causing the insomnia, whether the insomnia is causing that something else, or whether they’re unrelated. So I think it’s important to know if there’s another disorder coexisting with insomnia. But the causality type of thing we have difficulty establishing. We’ve eliminated this primary/secondary understanding.

Sanford H. Auerbach, MD: I think this whole notion of insomnia standing by itself is a pretty rare phenomenon in my experience, that sometimes patients may have what’s called primary insomnia, and maybe they have some anxiety, for instance. But maybe the anxiety doesn’t quite meet research-grade definition for calling it insomnia, and so it gets fluffed off. People who do research on drug trials and so forth, they look for people with primary insomnia. Those people are hard to find, so I think it’s all an issue of dealing with this phenomenon of which comes first because they usually have both.

Peter L. Salgo, MD: And then they have the final common pathway, is it making a difference to you? Does it bother you? Is it having consequences?

Sanford H. Auerbach, MD: Right, exactly. And it’s really the impact. And there was always this interesting interaction between these things like pain and insomnia. People who have insomnia maybe change their pain threshold, so it’s more difficult to treat their pain. On the other hand, people with pain will have more trouble sleeping. So which do you address first, people who have anxiety and insomnia? Which comes first? And I think that oftentimes you have to take the patient as a whole.

Peter L. Salgo, MD: This is why you can do this job and I don’t have to worry about it. That sounds much too complicated for me.

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