Peter L. Salgo, MD: We’re going to focus a bit on insomnia in the elderly. How common is it? What’s the prevalence?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: I think when we look at prevalence, I’ve seen studies up to 70% with chronic insomnia in older adults. I think to Sandy and Karl’s point, the problem is there are so many co-conditions. And I find some of the medications that we use might be aggravating their sleep cycle, which is important to look at in addition to their underlying medical conditions. You mentioned depression, you mentioned anxiety, you mentioned pain. But there are certain lifestyle things, too, and as we get older, some of those comorbidities—I think later we’ll be talking about Alzheimer disease—they may not be as active throughout the day, so they might be having different changes in their sleep/wake cycle because they’re napping. I work with a lot of older adults with Alzheimer disease or dementias, and unfortunately, they’re not as active during the day so they’re sleeping a lot throughout the day. I think there are things that we have to look at.
Gary L. Johnson, MD, MS, MBA: I was going to say from the perspective of a large insurer, we really don’t know because there’s such an overlap between the comorbid conditions. We can track the pharmaceuticals that are used, but we don’t know what they’re being prescribed for.
Peter L. Salgo, MD: Let’s take the broadest definition we can, which is whatever is wrong with your sleep, it’s OK unless it’s bothering you, and that makes it insomnia when it does. If that’s the definition.
Karl Doghramji, MD: Or causing consequences, right?
Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: That’s really important.
Peter L. Salgo, MD: It’s a very broad definition. Can you get a handle at all on the economic burden of this problem?
Gary L. Johnson, MD, MS, MBA: Depends on whose perspective you’re looking at.
Peter L. Salgo, MD: Yours.
Gary L. Johnson, MD, MS, MBA: Our perspective, insomnia per se has very little economic impact. We pay for pharmaceuticals, but the pharmaceuticals are generally generic drugs. So there’s very little economic impact. If somebody can be found to have a comorbid condition—a fall, a fracture, etcetera, caused by insomnia, although the attribution there is very difficult to ascertain—then there would be a greater economic impact from the insurer’s perspective. But in general, it’s more of a—I hate to use the word—but a “lifestyle” type of problem.
Peter L. Salgo, MD: But I don’t want to minimize that because if there are consequences to insomnia, and we’re not talking about the expense of drugs to combat sleeplessness, but the impact on society. People who don’t get enough sleep, people who don’t feel sharp at work, people whose productivity is diminished, can we get a handle on that? What is the cost to society?
Gary L. Johnson, MD, MS, MBA: That’s where the perspective comes in. If you’re taking a societal perspective, it’s probably huge, but most of us don’t have a way of tracking that.
Peter L. Salgo, MD: It’s sort of like in the early days where presenteeism was being tracked. People who wanted to go to work, and they did go to work, with the flu, didn’t do anything and infected everybody else. So that wasn’t a cost per se, but it was a societal cost.
Sanford H. Auerbach, MD: I think the problem here is that you don’t want to trivialize something. I think even in the 1980s there was a big symposium to address this issue, and that’s when it was declared that insomnia is a symptom, and you don’t bother with a symptom. You get to the disease. So forget about the insomnia, just treat the pain, just treat the other comorbid issues. And then about 10 years ago, it was re-examined, and the decision was to think of it as a comorbid disorder, which gives it much more credence. There’s much more importance to treating the insomnia by itself. It helps manage these other problems, and so it’s too easy to trivialize it to just a lifestyle issue.
Peter L. Salgo, MD: I’ll tell you, from a personal perspective I think probably everybody’s had this experience. Something’s bothering you, you can’t get to sleep, you’re awake at 3 in the morning, and the next day you feel like, fill in the blank, which we can’t say on television. That happens a lot. Now you’ve got an issue, right? Whether it’s primary, secondary, a symptom, or it’s a real problem, that’s a problem, isn’t it?
Karl Doghramji, MD: Very much so. I think even though we have not been able, to Gary’s point, to identify these problems in a very concrete fashion with insomnia, we have not been able to identify how we improve these, the concrete problems or consequences are with treatment. I think the data are emerging to show us that when we treat insomnia, we begin to see some benefit in some of the other comorbid areas. Now, we don’t have a lot of great data on this. But for example, with depression, we begin to see greater well-being with people in depression when we treat their insomnia versus when we don’t treat their insomnia.