Managed Care Considerations

Managed care issues arising from excessive daytime sleepiness (EDS), which impacts as many as 37% of adults, are widespread. In the United States, insomnia is among the 3 most common complaints. Often it is younger people who have difficulty falling asleep, whereas their elders report more difficulty remaining asleep. Currently, people in the United States sleep 25% fewer hours than they did 100 years ago. Chronic sleep deprivation may be a choice driven by economic or social factors. Industrialized countries engage about 20% of the work force in shifts, and people working night shifts are thought to average 8 fewer hours of sleep each week than day workers. Falling asleep behind the wheel is the single most imminent risk associated with excessive sleepiness.

Nonpharmacologic treatments for EDS include light variations, positive-airway pressure, dental and oral devices, and cognitive-behavioral therapy. When used, any pharmacologic treatment must carefully balance the amount of wakeful stimulation with bedtime drowsiness.

(Am J Manag Care. 2007;13:S148-S153)

In the United States, the 3 most common complaints in patients with sleep disorders are headache, symptoms of the common cold, and sleep dysfunction or insomnia, respectively.⁷ Insomnia affects more than 60 million people in the United States–approximately 20% of the population. Half of those afflicted with insomnia describe their insomnia as a health concern.⁸ Insomnia is more common in the elderly, in women, in individuals with medical or psychiatric disorders, or those working night or rotating shifts. One fifth of the US population occasionally takes some form of sleep aid, whereas 1.7% receive hypnotic prescriptions annually.⁷ Approximately 15% of adults in the United States have been sufficiently impacted by insomnia to seek medical attention for it.

In at least one study, among younger people the primary sleep complaint is difficulty falling asleep, whereas older people report more difficulty staying asleep.⁷ Age is associated with increases in at least 3 primary sleep disorders: sleep apnea, periodic limb movements during sleep, and RLS.⁷

Societal Implications

Sleep specialists are represented by various disciplines, such as psychiatrists, pulmonologists, and neurologists, many who claim board certification. William Dement, MD, PhD, one of the world's recognized authorities in sleep medicine at the Sleep Disorders 2006 symposium, ascribed more than 50 000 deaths per year and more than $100 billion per year to preventable accidents related to sleep deprivation and sleep disorders.¹¹

When sleep is frequently insufficient or interrupted and not made up, the condition of sleep debt begins to accrue. As the debt expands, the trend is for patients not to adapt, but instead they become more impaired, fatigued, and increasingly capable of falling asleep at the wrong time. Awareness of the impairment may not be apparent to the patient. Excessive sleep debt has been attributed to accidents involving long-haul truckers and bus drivers, mistakes in medical practice, diminished workplace performance, and exacerbation of already existing medical conditions.

Falling asleep behind the wheel is the single most imminent danger associated with excessive sleepiness. Using data from the National Safety Council for the year 2000, Sassani et al¹² calculated the annual number of collisions, costs, and fatalities in the United States related to obstructive sleep apnea (OSA) to be 800 000, resulting in 1400 deaths and $15.9 billion in costs. In 2004, the US National Highway Traffic Safety Association (NHTSA) estimated that principal casual factors behind approximately 100 000 motor vehicle crashes comprised drowsiness and fatigue.¹³ In a 1999 NHTSA poll, 62% of the adults surveyed reported driving a car while feeling “drowsy,†and 27% reported dosing off at some time while driving. Given the personal and public safety aspects of driving while sleepy, clinicians expose themselves to liability if they do not advise patients with OSA or other sleep disorders not to drive until they are adequately treated.

EDS often indicates that the affected person is nursing a large sleep debt.13 A person in severe sleep debt can go from a wakeful state to one of being asleep in about 15 seconds. The National Transportation Safety Board attributes fatigue as a direct or contributing cause in every accident involving human error unless fatigue has been specifically ruled out. Caffeine can sometimes give a temporary boost, but in the end it is no substitute for sleep.

Primary Evaluation

- In general, are you sleeping well?

Particularly with a symptom as vague as sleep disruption, which may not be a disease in and of itself, it is useful to think of a model of assessment that incorporates not only objective signs but also patient-evaluated symptoms and QOL issues. To give a more complete picture of individual health as intended by the WHO, it may be helpful for the clinician to use the framework entitled Assessing the Impact of Disease (AID). This can be helpful in establishing dimensions of assessment.⁹ The AID concept incorporates symptoms, disease severity, and QOL (Figure).

Symptoms. Symptoms are a patient's experience of departure from a previous desired norm.⁹ They need not indicate illness as such. A symptom might vary in severity, character, or persistence, and it may vary in its level of importance to the patient. A symptom may also be diminished or ignored, whether consciously or subconsciously, for fear of embarrassment or ridicule. A person whose schedule allows only 6 nightly hours of sleep, for example, may not admit or even recognize being in a state of sleepiness and may self-medicate with caffeine and struggle to contain annoyance at things that should not bother him or her. Many people in the United States think they can get by with 6 hours of sleep, and that is seldom, if ever, sufficient for truly adequate daytime functioning.

Disease Severity. Disease severity is the objective assessment of disease through the established standard means of a complete history and physical examination and diagnostic testing.⁹ Applied to the general concept of EDS, the emphasis will often be on testing measures, as patients may present with vague or comorbid complaints. Various means of measurement, subjective and objective, are available, but, as to sensitivity, they are not the same. Over the course of a night in the laboratory, polysomnography measures airflow through the nose and mouth and respiratory flow and effort. Other measures include body position, heart rate, pulse oximetry, electroencephalogram, electrooculogram, and electromyogram. The Epworth Sleepiness Scale (ESS) is the standard measure of patient estimate of EDS.^14,15 The multiple sleeplatency test (MSLT) is a laboratory test and is the gold standard for quantifying sleepiness.¹⁶

QOL. The meaning of QOL varies. Recall the WHO definition of health as complete well-being and not merely the absence of disease. Physicians might not include psychological, social, and spiritual aspects into a health-related QOL (HRQOL) concept.⁹ If this is the case, the patient becomes the assessor. In clinical medicine, HRQOL integrates the psychological and social effect of illness and its treatment as the patient perceives it.

Screening

Nonpharmacologic. Good sleep practices are behaviors one might establish to ensure getting a good night's sleep. Such habits include not eating, drinking, or exercising in large amounts immediately before going to bed. Patients should establish regular times for retiring and rising and also allocate enough time for sleep and exercise during the day. Some behavioral treatments for insomnia include limiting the time spent in bed trying to obtain sleep, progressive muscle relaxation, and stimulus control (strengthening the mental connection between time spent in bed and sleep). Combined with behavioral approaches, stimulus control is an effective sleep strategy.

For those who can't arrange their schedule to allow enough sleep in 1 interval or for those with narcolepsy, napping at well-chosen times can be helpful. However, being unable to get through a day without a nap suggests the need for further investigation into the reason. For those with OSA, a continuous positive-airway pressure (CPAP) may be prescribed.²⁰ Despite its daunting appearance, usually after some adjustments for proper fit to an individual's needs, the CPAP can be highly effective. For those with shift-work sleep disorder (SWSD), the use of light during the night shift and preserving darkness during the day is very important.

Pharmacologic. For treating insomnia, some people find such nonprescription sleep aids as valerian, melatonin, kava-kava, tryptophan, or chamomile helpful for sleeping.1 However, there are no data to establish the efficacy or safety of such agents. For EDS, the number of people who selfmedicate with caffeine are legion. Medications used to stimulate alertness work through dopaminergic channels and are associated with significant abuse potential. Also of concern are their effects on cardiovascular function. A more recently developed drug, modafinil, minimizes these concerns. Any treatment for insomnia or EDS must be chosen judiciously to balance nighttime sleep with daytime wakefulness. The choice of medications to use are highly contingent on the patient's diagnosis and age, with dosages as low as possible. Any drug has side effects and people may respond idiosyncratically; sometimes drug or dosage must change. In addition, duration of action of the medication must be carefully considered; if a stimulant taken at noon disrupts a patient's sleep, that patient will be sleepy the next day. Similarly, sleep-promoting agents with half-lives longer than 6 hours, while improving sleep, will impair nextday function.

Despite the abuse potential of some sleep aids in individuals prone to substance abuse, people with insomnia rarely abuse these medications. Nevertheless, hypnotics, when withdrawn, should be gradually tapered.¹ For narcolepsy, a number of medications have been approved and are available. ²¹ Either stimulants or wake-promoting agents may be used to control daytime hypersomnia. Ancillary symptoms of narcolepsy outside of cataplexy may be treated with tricyclic antidepressants, selective serotonin-reuptake inhibitors, serotoninand norepinephrine-reuptake inhibitors, or, more recently, GABAB-receptor agonists. Other wakepromoting agents have also been approved for treatment of narcolepsy and can be used for treating such other causes of EDS as SWSD and apnea, according to sleep researcher Michael J. Thorpy, MD. Monoamine oxidase inhibitors have been used to treat cataplexy, but have not been formally studied. Other medications used to treat narcolepsy may be associated with cardiovascular issues or potential for abuse, all of which accentuate the need for accurate diagnosis and prudent prescribing.

Benefits of Treatment

Einstein College of Medicine, Montefiore Medical Center, 111 East 210th St, Bronx, NY

Poll.pdf. Accessed October 15. 2007.

3. Committee on Sleep Medicine and Research. Colten HR, Altevogt BM, eds. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: The National Academies Press; 2006: 20, 138.

5.Thorpy MJ. Which clinical conditions are responsible for impaired alertness? Sleep Med. 2005;6(suppl 1):S13-S20.

7. Hatoum HT, Kania CM, Kong SX, et al. Prevalence of insomnia: a survey of the enrollees at five managed care organizations. Am J Manag Care. 1998;4:79-86.

9. Mahowald MW. What is causing excessive daytime sleepiness? Evaluation to distinguish sleep deprivation from sleep disorders. Postgrad Med. 2000;107:108-123.

11. O’Hollaren MT. Basics in clinical practice: recognizing and treating sleep disorders. Medscape Today. September 8, 2006. http://www.medscape.com/viewprogram/5967. Accessed September 7, 2007.

13. National Center for Sleep Disorder Research/National Highway Traffic Safety Administration Expert Panel on Driver Fatigue and Sleepiness. Drowsy Driving and Automobile Crashes. http://www.nhtsa.dot.gov/PEOPLE/INJURY/drowsy_driving1/drowsy.html.

14. Simuni T. Diagnosis and management of Parkinson’s disease. Medscape Today. August 30, 2007. http://www.medscape.com/viewprogram/7698. Accessed September 5, 2007.

16. Bonnet MH, Arand DL. Impact of motivation on Multiple Sleep Latency Test and Maintenance of Wakefulness Test measurements. J Clin Sleep Med. 2005;1:386-390.

18. Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep.

19. Davis S, Mirick DK, Stevens RG. Night shift work, light at night, and risk of breast cancer. J Natl Cancer Inst. 2001;93:1557-1562.

21.Thorpy MJ. Cataplexy associated with narcolepsy: epidemiology, pathophysiology, and management. CNS Drugs. 2006;20:45-50.

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