Pharmaceutical Update
Helping Our Patients Sleep Well
by Gary Snodgrass, Pharm.D.| Geriatric Times |  |
July/August 2000 | |
Vol. I | |
Issue 2 |
How did you sleep last night? If you answered "poorly," you are not alone. Reports estimate that 20% to 30% of adults in the United States complain of insomnia (Hatoum et al., 1998). The continuing education program "Treatment of Insomnia in a Long-Term Care Facility" estimates that as many as 33% of all people in the United States are plagued by a sleep disorder (Scharf and Grosso, 1995). According to the National Institutes of Health, the prevalence of sleep disorders rises to 50% of adults over 65 years of age who live at home and approximately two-thirds of all residents living in nursing homes. Simply stated, most of us don't sleep well.
The salient point here is that we all know that trouble sleeping-especially for more than one night-interferes with our work productivity and enjoyment of leisure activities. This same attitudinal mind-set should be applied to our patients. When asked to consult on drug therapy for a resident, do we approach the problem with an overview of how insomnia is interfering with the resident's activities of daily living (ADLs)? Do we first inquire whether the insomnia is diminishing the resident's ability to participate in facility recreational programs? If we do, we are less likely to immediately recommend a drug therapy option.
Assessment Before Treatment
Returning to our own lives, what do we usually do after we acknowledge we are sleeping poorly? On a very informal basis we do a differential diagnosis and an abbreviated sleep history. Our approach is usually disguised in the form of thoughts such as, "When the stress of meeting the deadline for this article is over, I'll sleep better." It may present in the form of a mental checklist of questions, e.g., Coffee late in the day? Exercise close to bedtime? Noisy hotel room? If we are honest and introspective, it may involve assessing alcohol intake, admitting we should have kept that dental appointment or exploring the possibility of depression. What we do not do is immediately place ourselves on routine dosing of long-acting benzodiazepines. Therefore, any temptation to shortcut the data-gathering process in responding to a consult request for our residents should be avoided.
A good sleep history should include a review of the resident's problems in initiating or maintaining sleep and determining if they experience daytime sleepiness. Documentation of the onset, duration, periodicity and intensity of sleep, as well as any changes in sleep patterns, is essential. How is the sleep disturbance impacting the resident's social life, medical condition, behavioral status and nutrition? A thorough review of sleep history methodology is beyond the scope of this column. For further reading, Geriatric Psychopathology: Sleep Disorders in Old Age by Katherine M. Slama, Ph.D., and David A. Smith, available from Manisses Communications Group Inc., gives a detailed discussion of assessment and of the electrophysiology and neurochemistry of sleep.
Think Horses, Not Zebras
After a thorough sleep history is obtained, we should be able to recognize potential etiologies of insomnia. The causes of insomnia can be as esoteric as desynchronization of circadian rhythm. More often, however, they are straightforward, such as excess noise or light; and we can do something to control them. Etiologies of sleeplessness generally fall into major categories such as situational factors, medical illnesses and contributing medications. As clinicians, we are guided by some excellent recent articles in the literature such as "Evaluation of Sleep Disorders in Nursing Facilities" by Gena W. Cramer, Pharm.D., et al., in The Consultant Pharmacist and "Insomnia Pharmacotherapy: Selecting a Hypnotic Agent" by Tracy L. Skaer, B.Pharm., Pharm.D., in Pharmacy & Therapeutics.
Despite the availability of knowledge on sleep disorders, there is a tremendous gap in applying this knowledge for our patients' benefit. For example, we would be quick to act in our personal lives if a teen-age daughter was promoting our insomnia with a 120-decibel concert of hip-hop music at 2 a.m. Are we as quick to investigate resident complaints about noise on the night shift?
One of my clients was surprised to find staff yelling down the hall to the nursing station at night. Another found staff turning on the bright fluorescent light directly over the resident's bed whenever they entered the resident's room. For me this would be like trying to sleep in a motel directly facing a working lighthouse. How much flurazepam (Dalmane) would it take to keep you asleep in this environment? Since this discovery, staff try to use a penlight whenever possible to perform nighttime procedures in a resident's room.
Sedative Hypnotics? Maybe.
Once an educated guess (diagnosis) is made regarding the cause(s) of a resident's insomnia, we can proceed to therapy. Consensus is that therapy should include nonpharmacologic approaches. Key components are sleep hygiene, sleep restrictions, relaxation training and cognitive therapy. Sedative hypnotics may play an important role as an adjunct to nonpharmacologic approaches; however, all clinicians, especially consultant pharmacists, should discourage the use of sedative hypnotics as the sole approach to insomnia. In fact, each resident taking sedative hypnotics should have their care plan reviewed to ensure that good sleep hygiene is actively promoted.
Returning to our personal lives: we would never nap all day, go to bed at a different time every night and-10 minutes before retiring-eat a lobster dinner, finish a bottle of wine, smoke a cigarette, drink a cup of coffee, exercise heavily, turn the thermostat up to 90 degrees or turn the television volume up, and wonder why we were having trouble sleeping.
Finally we come to the part of this article where you would ask, "What drug do you recommend?" This question was distilled by the American Society of Consultant Pharmacists in a handout entitled "Sleep Disorders in the Elderly" (Anconi-Israel and Clark, 1999). Their answers were zaleplon (Sonata), zolpidem (Ambien) and temazepam (Restoril), depending upon the onset and duration of action best suited to your resident's particular sleep disorder. The America's Senior Care Pharmacists (ASCP) handout also does a great job of providing a capsule summary of drugs that are "acceptable" versus "preferred," as well as sedative hypnotics that should not be used.
If the answer to "What drug do you recommend?" is that short and simple, then why all the literature on insomnia? Despite the well-referenced articles on insomnia and therapeutic alternatives; despite ASCP and pharmaceutical manufacturers doing a good job of developing treatment guidelines and continuing education programs; despite very specific regulations in the 1987 Omnibus Budget Reconciliation Act to restrict sedative-hypnotic use, in practice, we still see remarkably inappropriate approaches to assessing and treating sleep disorders. An example would be a physician who routinely places a newly admitted resident on a long-acting benzodiazepine without any record of medical necessity prior to admission. We encounter reluctance to consider options such as prn versus routine dosing. We see resistance to considering a 15 mg dose with a "may repeat times one" protection versus automatically prescribing the 30 mg dose.
In one extreme case of prescriber intransigence, it took me four months to convince a physician to consider an alternative to "Phenobarbital 60 mg q. hs for insomnia." Take my word for it, there wasn't any medical necessity such as seizure disorder, or "allergic to all rational alternatives." We tried diplomacy, working through the medical director and so on. After months of progress notes documenting persistent insomnia, sleeping most of the day, weight loss and ataxia, we were finally able to overcome good old-fashioned prescriber stubbornness. Fortunately, this happened before the resident broke a hip and the facility was cited out of existence by licensing inspectors.
In addition, impediments to effectively dealing with insomnia are not restricted to the prescriber. There is a need for better nursing assessment and documentation of signs and symptoms of sleep disorders. As a consultant, I can't make a recommendation when there are no progress notes on safety or efficacy for weeks after a medication change. All facility staff, including social services and activities, need to make a concerted effort to document the resident's response to both behavioral and pharmacologic interventions.
Consultant pharmacists are not immune to contributing to the problem. We need to actively advocate for enough time to implement the systematic approach to treating insomnia espoused in the literature.
I was asked by an administrator colleague to help at a facility that was in trouble with licensing inspectors. Not only did I find overuse of sedative hypnotics, but instances of early morning lethargy due to q. hs doses being given at 3 a.m. to 5 a.m. In addition, I found one resident who was treatment resistant to polypharmacy with two different sedatives. Coincidentally, a discussion with the nursing staff, which was corroborated by the medication administration record, revealed a pattern of the resident waking up in pain every night and requesting hydrocodone bitartrate (Vicodin). Did anyone think he might sleep better if he wasn't screaming in pain? He might even help his roommate who was starting to develop an insomnia problem.
Whatever other problems this facility had, and it did have some interesting ones, it was obvious that the previous consultant pharmacist was "asleep at the wheel" (sorry, I couldn't resist). It turns out that he was being pressured by his employer to work full-time filling orders, as well as consulting for a gigazillion residents.
Most of us have been in this conflict of interest squeeze. Hold out. Don't let market pressure raise your malpractice. If you really are going to help the interdisciplinary team treat insomnia, it's going to take more effort than just knowing which drug has the shorter T one-half. Good luck!
Dr. Snodgrass is an independent consultant and president of Triad Management Group. His firm assists health care managers in pharmacy systems analysis, vendor evaluation, medication utilization and quality assurance in long-term care, residential care and psychiatric facilities.
References
Anconi-Israel A, Clark TR (1999), Sleep Disorders in the Elderly. Alexandria, Va.: American Society of Consultant Pharmacists.
Cramer GW, Chaponis RJ, Bauwens S, Chamberlain T (1999), Evaluation of sleep disorders in nursing facilities. The Consultant Pharmacist 14(5):545-560.
Hatoum HK, Kania CM, Kong SX et al. (1998), Prevalence of insomnia: a survey of the enrollees at five managed care organizations. American Journal of Managed Care 4(1):79-86.
Scharf M, Grosso J Jr. (1995), Treatment of Insomnia in a Long-Term Care Facility-Role of the Consultant Pharmacist. Hackensack, N.J.: Bimark Inc. Healthcare Education.
Skaer TL (2000), Insomnia pharmacotherapy: selecting a hypnotic agent. Pharmacy & Therapeutics 25(2):93-101.
Slama KM, Smith DA (1995), Geriatric Psychopathology: Sleep Disorders in Old Age. Providence, R.I.: Manisses Communications Group Inc.