The High-Risk Patient Populations

Peter L. Salgo, MD: What about the high-risk medication list, what is that?

Gary L. Johnson, MD, MS, MBA: Well, whose list? Who’s high risk?

Peter L. Salgo, MD: Your list. Well, whom you define as high risk in older individuals.

Gary L. Johnson, MD, MS, MBA: There are many conditions, many classes of pharmaceuticals that are considered high risk, one of which is treating insomnia, sedative-hypnotics, but there are many others, and again, that’s a list defined by the Beers Criteria. That’s what we look at, and we try to do what we can by alerting the physicians with whom we contract if we see from our pharmacy claims data a patient receiving high-risk medications.

Peter L. Salgo, MD: You know, one of the things that occurs to me is that, as patients grow older and not as an individual necessarily but an aging population, the incidence of primary neurologic disorders simply goes up, whether you get Alzheimer disease, you get Parkinson symptoms. What are the challenges of insomnia in patients with preexisting and perhaps progressing neurologic disease?

Sanford H. Auerbach, MD: You’re upping the ante here.

Peter L. Salgo, MD: I just did.

Sanford H. Auerbach, MD: Right, because now you’re not only dealing with the patient, their level of function, how well they do during the day, but now, you’re dealing with the caregivers. One of the things that will push families to institutionalize a family member is that they can’t sleep at night. And so a lot of times, getting the patient to sleep at night becomes a crisis for the family because the patients will wake up in the middle of the night, they may wander around, and they’re very unsafe. And they can wander out. It creates a whole different set of dynamics of the family. And the imperative of treating it—and these patients are not going to respond very well to cognitive behavioral therapy, obviously—is pushing to treat them medically.

Peter L. Salgo, MD: Do some of these other techniques work even with neurologic impairment? For example, sleep hygiene, getting to bed at a regular time, trying to get them to bed, all of that.

Sanford H. Auerbach, MD: Sure. Some of the things that Karl mentioned—addressing caffeine, regular bedtimes, minimizing fluids perhaps before they go to bed so they don’t have to get up to go to urinate.

Peter L. Salgo, MD: Do you see, even with these neurologic impairments, an improvement in the overall patient well-being if you can regularize or normalize their sleep cycle?

Sanford H. Auerbach, MD: That’s much harder because you’re dealing with a disease that’s progressing anyway. No matter how good you are at treating their sleep, they’re going to progress. You may just make them function a little bit better during the day, and you improve the quality of the life of the caregivers, so you just improve the whole mix. It’s hard to tell. Is it going to alter the course of the disease? It’s very hard to tell.

Peter L. Salgo, MD: It would seem to me that whatever would make you more neurologically functional if you have no impairment, it would certainly make you more functional with some impairment, and perhaps it’s even more important.

Sanford H. Auerbach, MD: Oftentimes I have patients who come to me and talk about somebody who has late stages of Alzheimer disease, and they may have been one of these patients who just stop sleeping. They’re convinced if I got them to sleep at night, they would be much better during the day. The problem with that is with that particular patient population, to get them to sleep at night, you almost have to overmedicate them. And so their function during the day and your ability to judge that is sort of distorted.

Peter L. Salgo, MD: Are there limitations on the therapy for insomnia that you can use in patients with preexisting neurologic disease?

Sanford H. Auerbach, MD: Well, just that you have to be more cautious. You have to be more cautious about the benzodiazepines that Nicole mentioned, for instance, that you’re going to increase the level of confusion, you’re going to increase the level of their gait disorder, their balance difficulties, that a lot of them may already have. And you have to balance that. You have to balance that against the risk. And they’re difficult cases to deal with. We may even deal with a class of medications that we haven’t even mentioned, depending upon the stage of the patient and so forth, and may even use things like antipsychotic medications that we really haven’t addressed here, that don’t necessarily target their sleep as it is to target their overall level of agitation. Yes, you have to worry much more so about the [adverse] effects, but the whole equation changes.