Diagnosing Insomnia in Older Individuals

Peter L. Salgo, MD: Who out there is managing insomnia? They don’t go all the time to sleep specialists. Is it the general practitioners? Is it the family physicians, the gynecologists? Who’s taking care of this for this most part?

Gary L. Johnson, MD, MS, MBA: All of the above.

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: All the above.

Peter L. Salgo, MD: All of the above.

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: And the patients themselves, because oftentimes they’re self-treating with over-the-counter medications, and they may not be getting properly evaluated for the underlying causes.

Peter L. Salgo, MD: Do you think that healthcare workers actually recognize this? Do people go in complaining of insomnia? Are healthcare workers trained to ask about it?

Karl Doghramji, MD: Well, the data show that most do not. Most healthcare professionals don’t ask about sleep, period. And even in the context of the patient who comes in complaining of sleeplessness, most don’t actually manage it at all, which is an interesting thing. In fact, when you ask physicians, most of them don’t want to know that the patient can’t sleep because there’s a problem with it in that, first of all, it complicates the visit. It makes it longer. Secondly, you have to ask more questions to identify the problem, which makes things problematic. So insomnia is poorly identified and often not treated in any setting, any medical setting.

Sanford H. Auerbach, MD: It’s usually a thing where the primary care doctor has his 17 minutes, whatever, with the patient.

Peter L. Salgo, MD: Seven, by the way.

Sanford H. Auerbach, MD: I was being generous. As the patient is starting to leave the room, he says, “Oh, by the way, I forgot to tell you about my sleep,” and that sends shivers through the body of that physician.

Peter L. Salgo, MD: Because here we go.

Sanford H. Auerbach, MD: Because it’s just, as we’ve already hinted, a very complex issue to tackle.

Peter L. Salgo, MD: You were going to chime in.

Nicole Brandt, PharmD, MBA, BCPP, CGP, FASCP: I was going to say I think it’s not a simple conversation, especially when you’re working with older adults. And as we alluded to, whether it’s grief, whether it’s the coexisting medical conditions, it’s the multiple medications they’re taking, there tends to be more of an impact, especially when there might be already a lower functional threshold. And so getting back to the point, they may not be coming in saying, “I’m not as productive at work,” where we might be screening a little bit more easily in a younger patient population. So I think some of the cues to work it up further, or their lack of productivity, isn’t seen as easily.

Peter L. Salgo, MD: Somebody comes in. Let’s just say that it’s their primary complaint. It’s not one of these things at the door, “Oh, by the way….” But instead it’s, “I’ve come to see you specifically because I’m having trouble with sleep.” How do you work it up? What’s your diagnostic work-up like?

Sanford H. Auerbach, MD: Well, I think the first thing, like anything else in medicine, it’s a matter of getting a good history, identifying what is going on with the sleep, both their nighttime sleep patterns and their daytime function, and knowing full well that patients are not always very good observers about how well they sleep at night. We see that all the time and in both directions, people underestimating or overestimating the amount of sleep that they get.

Peter L. Salgo, MD: Is it as simple as a good history? That’s what it sounds like.

Sanford H. Auerbach, MD: I think that, like everything else in medicine, it starts with a good history and that’s a big part of it—getting a good detailed history, finding out what medications the patient is on, finding out what kind of medical issues there are, finding out the timing of this, when did it start in relationship to their other life stressors.

Peter L. Salgo, MD: Now, that sounds like you’re making a distinction, in terms of the history at least, in primary versus secondary. Do you have conditions that are causing you to lose sleep, or is your loss of sleep primary? Is that what you’re doing?

Sanford H. Auerbach, MD: No, because I think that sometimes it’s hard to make that distinction. I think that a lot of these things go hand in hand; as already alluded to, the issue of depression and sleep difficulties, pain and sleep difficulties. They go hand in hand, anxiety and sleep problems. And to address these problems, oftentimes you’re much more efficient in treating them both.

Peter L. Salgo, MD: It sounds like there would be a blood test. Let’s get the insomnia test and see if it comes up positive, but there’s nothing like that. I think the closest most doctors think of in dealing with insomnia is the sleep study. Where does that enter in in terms of work-up?

Karl Doghramji, MD: There are a number of comorbidities that are important to identify, and one of them is sleep apnea, of course. And sleep apnea is only identified through a polysomnography or a sleep study. But there are some others, like periodic limb movements in sleep, which a sleep study is useful for. But I think there are also other tests that can and should be done, for example, a comprehensive set of blood tests including TSH [thyroid stimulating hormone] to make sure we’re not forgetting any endocrine possibilities, metabolic disturbances. And also it’s very relevant to look at one’s sleep log. Look at the pattern of sleep over time by an objectively filled out sleep log or something on a PDA [personal digital assistant] that shows us the pattern of sleep. Some of these tests can be helpful.

Peter L. Salgo, MD: Now, I was told that the single best diagnostic test is to ask the bed partner.

Karl Doghramji, MD: That’s a good idea, it’s a great idea. Bed partner is often more aware of what’s going on than the patient in terms of the nighttime snoring.

Peter L. Salgo, MD: Well, the patient may be asleep, right?

Karl Doghramji, MD: Of course, sure. Snoring, movements during sleep, limb movements, and so on, absolutely.

Peter L. Salgo, MD: I get this interview: “Doctor, I’m sleeping.” Great. And the bed partner is going, “Are you kidding? You stop breathing and then start again.”

Karl Doghramji, MD: Also, some patients are so sleepy that they’re falling asleep during the day but do not acknowledge it or are not aware of it. And bed partners, or spouses or whatever, life partners, are more able to identify that.

Sanford H. Auerbach, MD: In the opposite direction, patients will come in saying, “I don’t sleep at all.” And in fact, they may not sleep perfectly normally, but may sleep 5 or 6 hours. I’ve had this experience in the sleep laboratory where people go and say, “Oh, you’re going to have to repeat the study,” and I say, “What do you mean?” They say, “Well, I never slept, oh maybe 5 minutes.” And then you look at the study and it may not perfect, but it’s 5, 6 hours of sleep.

Peter L. Salgo, MD: So a bed partner might help you there, too.

Sanford H. Auerbach, MD: Sure. Now, from a perspective of an old ICU [intensive care unit] physician, I’m interested in what the bicarb [bicarbonate level] shows. Do people have elevated bicarbs when they start having real sleep apnea and sleep problems or not?

Karl Doghramji, MD: Well, not so much when they have sleep apnea, but if they have hypoventilation or something along those lines. But I don’t think a bicarb is very useful for identification of sleep apnea, per se.

Peter L. Salgo, MD: I knew you were going to say that. All my hopes are dashed again. I’m looking for the apnea test, I’m looking for the one blood test that’s going to fix all this.

Karl Doghramji, MD: Well, that’s not to say that the day won’t come where we will have that technology available, that we can simply identify these things in, for example, a watch or something, but the day’s not here yet.

Peter L. Salgo, MD: Right. So we have the fog of war over here trying to figure out what’s going on. And you have to parse that all out and pay for it.