Sleep Initiation and Maintenance Disorders: Bramley TJ

Navarro R, Mitrzyk BM, Bramley TJ. · Xcenda, 1528 Preston St, Salt Lake City, UT 84108, USA. · Am J Manag Care. · Pubmed #18041872 No free full text.

Abstract: The elderly population is of particular concern with regard to insomnia and managed care. Early intervention and management of insomnia as a chronic disease are recommended. Increased awareness of the negative clinical and economic consequences associated with not treating insomnia may serve to raise the perceived importance of having effective formulary options for this disease area. Because the elderly population is now covered by Medicare Part D, health plans previously without a Medicare drug benefit must now select and reimburse for sedative-hypnotics for the elderly. A review of the major Medicare Part D plans' formularies reveals they offer a limited number of sedative-hypnotic alternatives, but not all are available. Due to variable response, variation in comorbidities, drug and disease interactions, and individual patient needs, managed care organizations should cover a reasonable array of drugs. This is essential to optimally manage patients with chronic insomnia to reduce the long-term clinical morbidity and economic consequences.

Roth T, Franklin M, Bramley TJ. · Xcenda, 1528 Preston St, Salt Lake City, UT 84108, USA. · Am J Manag Care. · Pubmed #18041871 links to  free full text

Abstract: Recent research into the pathophysiology of insomnia has brought a shift in the approach to treatment. Insomnia rarely occurs in isolation and is typically comorbid with other conditions. Rather than simply treating the primary disorder, whereby symptoms of insomnia may go unaddressed, now there is a push to acknowledge the existence of chronic insomnia as a disorder that itself merits treatment. This recognition is due to the identification of pathophysiologic changes and associated morbidity, which can be substantial. Insomnia patients have increased risk for psychiatric disorders, especially depression, anxiety, decreased quality of life, increased healthcare utilization and costs, drug/alcohol abuse, decreased occupational performance, and increased falls/accidents. Current management patterns explore non-nightly or discontinuous hypnotic treatment - non-nightly flexible, non-nightly semiflexible, non-nightly fixed, and flexible timing - which deviates from past trends of continuous dosing with hypnotics. These trends reflect a change from considering insomnia a symptom to treating insomnia as a disorder.

Reeder CE, Franklin M, Bramley TJ. · Xcenda, 1528 Preston St, Salt Lake City, UT 84108, USA. · Am J Manag Care. · Pubmed #18041870 links to  free full text

Abstract: Insomnia affects a large percentage of the population, particularly the elderly. Literature reports varying estimates of prevalence, a variation that relates to the lack of definition and consistency in diagnostic criteria. Primary insomnia (not caused by known physical/mental conditions) responds to pharmacologic therapy, while secondary insomnia(resulting from other illnesses, medications, or sleep disorders) responds to pharmacologic and psychologic treatments (cognitive therapy, relaxation techniques, stimulus control). Use of certain agents in the elderly and patients with abuse/addiction potential is a concern. Medicare Part D does not cover benzodiazepines (classified as controlled substances). Nonprescription agents are affordable but have sedation and anticholinergic side effects. Medication use should be considered a possible contributing factor. Insomnia patients experience significantly more limited activity and higher total health services than those without insomnia. Annual costs are between $92.5 billion and $107.5 billion. A standard definition and better pathways to recognize and treat insomnia are needed.