Tuesday, March 31, 2015
By: Dr. Gregory Bourgeois with Shelby Dermatology
Psoriasis is a chronic condition characterized by thick, scaly, erythematous plaques on the skin that can affect some to nearly all of the body’s surface area. Two to four percent of the general population have this disease. Psoriasis can affect more than just skin as 30 percent of patients can develop a debilitating and destructive arthritis. Also, cardiovascular risk factors, such as the metabolic syndrome and its individual components, are more prevalent in psoriasis patients compared to those without psoriasis, and there is evidence to suggest that effective treatment for psoriasis can improve the cardiovascular health in these patients.
Effective treatment for psoriasis goes beyond topical corticosteroids. Although topical corticosteroids can be the only needed treatment for mild disease, patients with over three percent of their body surface area affected, painful psoriasis lesions in sensitive locations, or with arthritic symptoms may desire more systemic treatments. Over the last 20 years, dermatologists have seen a new era come for the treatment of psoriasis.
Research has evolved from the general description that T cells were involved in causing psoriasis to the discovery of new T cell subsets that drive the disease through specific cytokine pathways. We have gone from immunosuppressing systemic medications such as methotrexate and cyclosporine to immunomodulating biologic medications. These biologic medications are typically monoclonal antibodies that block cytokines directly involved in the pathogenesis of psoriasis. They have changed our understanding of psoriasis and have brought the most effective treatments to date for this devastating disease.
The biologic landscape has undergone significant shifting over the last couple of decades through translational bench-to-bedside medical breakthroughs. The tumor necrosis factor (TNF) alpha inhibitors were the first class of biologic medications to be used for psoriasis. This class had already found indications for rheumatoid arthritis, psoriatic arthritis, and Crohn’s disease prior to their approval for moderate to severe psoriasis as TNF-α plays a role in many chronic inflammatory diseases. When given continuously, the TNF-α biologics effectively treat psoriasis, often leading to consistent PASI 75 scores in approximately two-thirds of patients treated. A PASI 75 score is defined as a 75 percent improvement from the patient’s baseline psoriasis severity index.
As research elucidated the pathogenesis of psoriasis more specifically, more targeted biologic medications that disrupted the central cytokine pathways involved in psoriasis became available. Ustekinumab, an IL-12/23 blocking antibody biologic medication, is able to lead to PASI 75 scores in up to 80 percent of patients taking the medication. Within the last few months, the IL-17 blocking antibody biologic medication secukinumab was released with data that it leads to PASI 90 scores in around 60 percent of those who take it. There are five other drugs currently in phase II trials that target IL-17 or 23.
The biologic class of medications has truly been a remarkable addition to the armamentarium of psoriasis treatments. Although they are considered immunosuppressing, their side effect profile is slim because they are tailored to specific pathways within the disease they treat. Data over many years of use have shown them to be a very safe class of medication for psoriasis patients with proper follow up with their physician. As a dermatologist, I have found it very rewarding to change someone’s life that has been riddled with embarrassing and uncomfortable psoriasis lesions for years by treating them with these medicines. The biologic medications have “changed the game” in psoriasis treatment for the good of the patient’s overall quality of life.
Friday, March 20, 2015
By: S. Craig Greer, Director of Special Programs at ComfortCare Hospice
There is a great deal of discussion about end-of-life care and that’s good news. There are many grassroots movements urging people to have end-of-life conversations before a crisis or serious illness occurs. The documentaries Consider the Conversation and Consider the Conversation 2, ( http://www.considertheconversation.org/ ) as well as the PBS Frontline Special, Being Mortal ( http://www.pbs.org/wgbh/pages/frontline/being-mortal/ ) by physician Autl Gwande , give us a glimpse into how we are currently dying in the 21st Century. Likewise The Conversation Project (www.theconversationproject.org ) and Engage with Grace ( www.engagewithgrace.org ), have prompted people to reflect on the importance of starting the conversation with loved ones early and continuing throughout life as health care needs change.
But, there is also the story of Brittany Maynard and physician assisted suicide which brought to the forefront - “the right to die” movement. As a result we have a cacophony of voices using similar phrases, but having very different meanings.
Dr. Ira Byock, a palliative care physician and director of the Institute for Human Caring of Providence Health and Services, argued, correctly I believe, in an Op-Ed piece in the LA Times, language once used for hospice - like death with dignity, has been co-opted for the assisted suicide movement. ( http://www.latimes.com/opinion/op-ed/la-oe-0201-byock-physician-assisted-suicide-20150201-story.html#page=1 )
Hospice is not akin to physician suicide. Hospice is about quality of living with a terminal diagnosis until life comes to a natural end. Hospice neither prolongs life, nor hastens death – Hospice is about comfort and quality of life. Hospice is focused on aggressive management of pain and symptoms. Hospice is about helping people direct their own care based on their goals, values and beliefs. Do you want to go on a final trip? How can we make that happen? Do you want to spend more time with your family? How can we help you have the best days possible with the time you have left?
After nearly 15 years in hospice pastoral care and administration, I understand that there are times people want to give up. Patients can become depressed and worry about being a burden. I know sometimes pain can be unbearable. I have also seen those needs successfully and skillfully addressed by hospice physicians, nurses, social workers, chaplains and volunteers. I have seen many good lives lived more fully to the end when good care is provided.
I would not dare make a judgment about Brittney Maynard’s decision – nor would Dr. Byock in his recent editorial. But, what made suicide seem necessary? Was it a lack of options for excellent palliative and hospice care? We should not be rejoicing she had the option, but disheartened that there was not enough confidence in hospice and palliative care to alleviate her fears and her suffering and give her what she needed so she could spend more quality time with her loved ones.
We are in a time when hospice is being squeezed - just like all healthcare providers that receive Medicare dollars. Hospice is expected to do more with less. Meanwhile, physicians don’t have the time, training, or reimbursement to have the time consuming, frank discussions with patients and families which are needed much earlier in the disease process. And, as a culture we resist death at the cost of not living fully. Families are often in denial and, more often, just plain afraid to have the conversation. We trade precious moments for the hum of machines and treatments that can often make us sicker and have serious side effects that diminish the quality of living.
As a result patients are often referred to hospice very late and don’t receive all the benefits to which they are entitled. Far too many hospice patients die within 7-10 days due to late referrals from physicians or hospitals. These patients could often have had more quality time with their families and opportunities to set priorities if hospice had been presented as an option sooner.
Most humans are people pleasers – especially when it comes to their physicians. Most of us want our doctors to like us we want to comply and we hesitate to ask questions. We acquiesce to treatments suggested, often without understanding or asking the necessary questions – what are the side effects? What will it cost? What are the benefits? As a result, we don’t know there are other treatment options unless someone tells us. Procedure/treatment based reimbursement often drives recommendations; as a result patients may not ever be told there are indeed alternatives.
Most end-stage diseases can be manged well in the home. We need to improve end-of-life care, instead of reducing hospice benefits. In fact, hospice and palliative care benefits need to be expanded to cover chronic illnesses when improvement is not possible, and death may be years away. Disease management should replace aggressive treatments that do more harm than good. We should couple hospice/palliative care with treatments – and not deny aggressive treatments when patients choose hospice – which is yet another reason why many are afraid to choose hospice care.
Many years ago I met with nurses at a cancer clinic for a talk about hospice. I discussed our first priority was to find out the goals of the patient and their loved ones. I suggested the nurses probably did the same thing. The response floored me – “No, we just tell them when the next treatment is?” This was shocking to me and reflective of how medicine has become too focused on task, procedure, and treatment and less centered on the person receiving treatment. Medicine has become disease focused rather than patient focused.
My hope is that we do everything we can to continue this discussion of how we die. I hope we can exhaust every avenue of excellent palliative care and reduce the need and desire for assisted suicide. Physician assisted suicide is a slippery slope that has severe consequences, especially for the elderly.
Understand that hospice has never been about being cheerleaders for dying, rather hospice advocates for living well, all the way to the very end.
Wednesday, March 18, 2015
Ninth Circuit Affirms That Acquisition by St. Luke’s Health System Violated Section Seven of Clayton Act: Why You Should Care
By Phillip A. Nichols with Balch & Bingham LLP
You may be aware that in early 2014, a federal trial court in Idaho ruled that a completed acquisition by St. Luke’s Health System of the largest independent multi-specialty physician group in Idaho violated federal antitrust laws and ordered the transaction unwound because of anticompetitive effects in the market for adult primary care physicians (“PCPs”) in Nampa, Idaho. On February 10, the United States Court of Appeals for the Ninth Circuit issued an opinion affirming the Idaho district court’s decision in Federal Trade Commission and State of Idaho, et al. v. St. Luke's Health System, Ltd, and Saltzer Medical Group, P.A., No. 14-35173, slip op. (9th Cir. February 10, 2015).
The merger resulted in the combined entity having 80 percent of the PCPs in Nampa. While the district court accepted that St. Luke’s and Saltzer intended for the acquisition to improve patient outcomes and likely would have, it determined that the FTC had established a prima facie antitrust case based largely upon the combined entity’s market share and resulting ability to negotiate anticompetitive price increases in the PCP market in Nampa. The district court found that St. Luke’s attempt to rebut the prima facie case through expected efficiencies fell short because the efficiencies ultimately could have been achieved without the acquisition.
On appeal, the Ninth Circuit affirmed the district court’s decision. While the post-acquisition market share for the combined entity was more than enough to find the acquisition presumptively anticompetitive, it is noteworthy that both the trial and appellate courts found that internal correspondence among St. Luke’s executives referring to the combined entity’s ability to pressure payors for new, presumptively more lucrative, reimbursement arrangements bolstered the conclusion that the combined entity would use its increased market share to raise prices in the Nampa PCP market.
Although the Ninth Circuit expressed reluctance to even consider an efficiencies defense to a merger challenge under § 7 of the Clayton Act, it did recognize that such a defense could be successful upon a showing that the merger is not anticompetitive. The court unequivocally stated, however, that “[i]t [was] not enough to show that the merger would allow St. Luke’s to better serve patients.” Slip op. at 28. Notably, the court concluded that “the Clayton Act does not excuse mergers that lessen competition or create monopolies simply because the merged entity can improve its operations.” Slip op. at 29. According to the Ninth Circuit, this is true even where the merging parties’ claimed efficiencies are merger-specific. The Ninth Circuit also had no problem with the district court’s structural remedy of divestiture.
Hospitals and physician groups considering mergers in order to address the needs of the evolving health care market and the requirements of the Affordable Care Act should not lose sight of the application of relevant antitrust laws. While enhanced efficiencies and patient care may be laudable goals, potential merger partners must consider the competitive impact of such a merger. Consideration of the competitive impact will require a detailed analysis of the relevant market – both its geographic and product or service components – and the likelihood of increasing reimbursement rates following such a planned merger. Keep in mind that antitrust enforcement agencies will seek input from payors regarding likely competitive effects of a merger as well as the contours of the relevant market.
On a more basic level, please understand that if an anticipated result of a hospital’s acquisition of a physician practice will be higher reimbursement rates, expect antitrust trouble. That is just the type of result the antitrust laws seek to prevent. As the St. Luke’s executives no doubt have learned, it would be monumentally unwise to couch potentially higher reimbursement rates as a goal of the transaction. Even internal e-mail correspondence that may be characterized as puffing will only serve to weaken the likelihood of such a merger being approved.
Finally, hospitals and physicians should not dismiss competitive concerns simply because they operate in a relatively small city or town within a short distance of a major metropolitan area or because the total number of physicians involved seems small. Nampa, Idaho has a population of roughly 85,000 and is only about 21 miles from Boise. The medical group acquired by St. Luke’s had only 16 PCPs in Nampa.
Phillip A. Nichols is a partner in the Birmingham office of Balch & Bingham LLP.
Monday, March 16, 2015
Written by Jay Helms, TekLinks Health Service Group Sales Director
There is a certain local weatherman here in Birmingham who knows his stuff when it comes to tornadoes (snow & ice…not so much). Recently, he shared data defining the “new” tornado alley as a path pushing right through Alabama, which has brought disaster recovery to the forefront of business continuity for health care practices in Birmingham.
Sure, you may know how to protect your patients’ safety in the event of a tornado, flood or fire, but do you know how to protect their patient data? Preparing your practice for a disaster is crucial to keeping your practice and patient information safe. Hosting your EMR & ePHI in a highly secure and redundant data center helps prepare your practice in the event disaster strikes. By moving your ePHI from your onsite location and into the cloud (a secure data center), you won’t have to worry about losing your data under any circumstance.
Required HIPAA Rule 164.308(a)(7)(ii)(C) states that every War Eagle & Roll Tide covered entity must have a disaster recovery plan in place. This is particularly important if you have or are attesting for Meaningful Use - you've probably heard of, or experienced firsthand, the increasing amount of MU Audits being performed.
Many practices think they are covered because they have a “backup plan” for their data. While a backup plan compliments a disaster recovery plan and is a great first step, a backup plan is not the same as a DR plan. You must first consider how you're going to treat patients if a natural disaster makes your EMR unavailable. If your IT infrastructure is destroyed, most IT vendors in the Birmingham area do not inventory server infrastructure: it’s nearly impossible to do with the ever-changing technology, new requirements associated with PM/EMR version updates, etc. This means it will be a minimum of 2-3 weeks before your EMR is functioning again.
Let’s go back to the tornado scenario mentioned earlier. If a tornado thrusts your unencrypted server miles away from your office, and if the ePHI data on that server’s disks is retrieved by anyone other than your practice or an entity covered under your BAA, you’re forced to implement data breach procedures and make an expensive claim on your cyber security insurance policy. This is something that can easily be avoided with a true Disaster Recovery Plan.
We all want to avoid a disaster, but if we can't, the next best thing is to be prepared. Migrating to a TekLinks cloud environment optimizes your business continuity and disaster readiness, while helping to ensure compliance in 12 areas of the HIPAA Security Standards for Administrative, Physical, & Technical Safeguards for ePHI.
When choosing a technology partner to host your data, there are several things to consider: Security, Reliability, and Availability. TekLinks owns and operates Alabama’s first modular and fully redundant public data center, and our data center network hosts hundreds of customers of all sizes. A few key differentiators that set our data centers apart:
- Security: Audited to meet ISO 20000, SSAE-16 SOC 1 & SOC 2 Standards
- Reliability: Flywheels, UPS systems, and diesel generators provide redundant power solutions & optimal uptime
- Availability: Each facility boasts best-in-class networking, connectivity, and robust replication grids for secure data storage and access.
Our Assurances and Certifications: http://www.teklinks.com/managed/assurances-and-certs/
Schedule a data center tour with us today or take a virtual one: http://youtu.be/Ox9X4cSJOrA
Wednesday, March 11, 2015
By: Beth A. Steele, OD, FAAO UAB School of Optometry Associate Professor and Associate Dean for Clinical Affairs
With March designated by the American Optometric Association as Save Your Vision Month, I thought I would take a moment to remind everyone of the importance of annual eye health exams. The AOA currently recommends annual comprehensive eye exams for most age groups, particularly when known risk factors for eye disorders are present. Unfortunately, much of the general public is not aware of this, and does not fully realize why these recommendations exist. These exams are critical in aiding in the management of systemic disease, but in certain cases, may be life-saving.
When I think about the importance of regular eye exams, there are a few patients that come to mind. I share these stories and others with my patients, and students, to emphasize the value of regular, thorough eye examinations.
About two years ago, a 48 year-old man reported for his first eye exam ever. He had never had any problems with vision, and so never pursued eye care. He reported for this particular exam because he was struggling to read small print – something that virtually all 48 year olds struggle with, unless it has occurred earlier. The dilated portion of the eye exam revealed several hemorrhages in the mid-peripheral retina of one eye, a classic presentation for carotid artery disease. A subsequent carotid Doppler ultrasonography revealed 99% blockage of the ipsilateral carotid artery, which led to urgent endarterectomy. This patient was at severe risk of stroke and heart disease and had no idea. Since the time of the exam and subsequent surgery, the patient has committed to serious lifestyle changes, including regular health and eye care, and smoking cessation. He now feels better, is happier, and is convinced that the eye exam saved his life.
Another memorable patient was a 52 year-old who reported because her eyes felt dry. It had been 10 years since her last eye exam. The dilated exam revealed a large choroidal melanoma, the most common primary malignant tumor found inside the eye. Choroidal melanoma is both sight-threatening and deadly, as 90% metastasize to the liver. Unfortunately for this patient, the lesion had become so large that the eye had to be enucleated. These growths often cause visual disturbance, but in her case due to its specific location, it had not. With annual eye care, the growth might have been noticed early on, and not only prevented removal of the eye, but increased her chances for survival.
And then there is glaucoma …. Glaucoma is a commonly encountered condition, which if detected early, can often be treated before vision loss occurs. Unfortunately, when discovered in late stages, irreversible vision loss has occurred. There are many many more conditions that can present without any hint of a problem at all, both ocular and systemic, which can then be revealed by an eye exam.
But what about the things that do actually cause symptoms? Why do these still not always result in the eye care that is needed to correct them? Binocular visual dysfunction, for example, is commonly overlooked simply because the symptoms may seem to be as a result of a non-ocular problem. A school-age child who is struggling with reading might be assumed to have a learning disability, or a hyperactivity disorder, while quite often the difficulties can be improved or even eliminated with the proper eye care and vision therapy. The binocular vision disorder known as convergence insufficiency effects one in 10 school age children.
The eyes are highly valued by our patients for the precious sense they provide, but they can also serve the health care provider as what is often referred to as a “window” to the body. A comprehensive dilated eye exam allows a vascular and neurologic assessment, which can provide signs indicative of both ocular and systemic disease. Encourage your patients to receive annual eye care! For more information regular eye exam recommendations go to www.aoa.org
Tuesday, March 10, 2015
by David Clark, CFP®, CPA with Bridgeworth, LLC
When receiving recommendations from your financial advisor, do you often wonder if a conflict of interest might exist? Why is this particular recommendation being made? How much compensation is my advisor receiving?
For years now, Hollywood movies have cast a negative light on the financial industry (Wall Street, Boiler Room, The Wolf of Wall Street, just to name a few). In the real world, however, these movie-generating stories are not indicative of the industry as a whole. Unfortunately, with these extreme events receiving plenty of headline-grabbing attention, a level of skepticism towards the financial industry has developed among the general public. The basic way in which many advisors structure their business might contribute to this as well.
Commission-based advisors are compensated whenever activity occurs. Additionally, the commission to be collected by the advisor can vary depending on which product is eventually sold to the client. This structure can sometimes give the appearance that a conflict of interest might exist. For these advisors, however, as long as their recommendations meet the suitability standard (which simply requires the recommendation to fit the client’s investing objective, time horizon, and level of investing experience), their actions are viewed as acceptable. Even though most investors might not realize it, credentialed financial planners, specifically CERTIFIED FINANCIAL PLANNER™ professionals, are held to a much stricter standard of care, the fiduciary standard. This standard states that these advisors are legally required to place their clients’ best interests ahead of their own.
Just like certification within particular specialties of the medical profession is required to ensure that patients are receiving the quality of care that they need and deserve, other professional industries have put in place recognizable certifications, not only to protect the public, but also to uphold the standards and integrity of the profession. In the accounting industry, the CPA designation is widely recognized as the gold standard. When it comes to financial planning and wealth management, working with CERTIFIED FINANCIAL PLANNER™ professionals, who are held to a high level of ethical standards, helps to ensure that recommendations are being made in the client’s best interest.
The CFP® certification mark indicates a high level of competency, ethics, and professionalism. In order to obtain this designation, the financial advisor must have completed extensive course study, approved by the CFP Board, at a college or university. Following this, a comprehensive certification exam must be passed. A minimum of three years’ of experience is also required in the financial planning industry before being able to use the CFP® certification marks. The final step required before earning the CFP® designation involves a thorough background check, which is performed to verify that those seeking certification meet the expected ethical and practice standards put in place by the CFP® Board. Once certified, any violations of these standards could lead to disciplinary action, which might also include having the certification revoked. In addition to all of this, and as mentioned earlier, the CFP® Board’s Code of Ethics holds the CFP® professionals to the fiduciary standard of always acting in the best interest of their clients.
The world in which we live today is faster-paced than ever before, with plenty of complexity in all financial-related areas: budgeting, saving for retirement, estate planning, saving for children’s college, while also taking into consideration taxes and possible insurance needs. Finding the time, energy, and knowledge to not only develop a comprehensive financial plan, but also to implement and monitor it on a regular basis going forward, can be a daunting task. Fortunately, working with a CERTIFIED FINANCIAL PLANNER™ professional can give you the peace of mind that your best interests have been placed above all else.
I am proud to work at Bridgeworth, LLC, an independent Registered Investment Adviser (RIA). We are first and foremost a wealth management firm providing a holistic financial planning experience and as an RIA, we are a fiduciary. We have a fundamental obligation to act in the best interest of our clients when providing financial planning and investment advice. Furthermore, we have 23 members who have obtained their CERTIFIED FINANCIAL PLANNER™ certification, making Bridgeworth one of the largest groups of CFP® practitioners in the region.
Do you know what types of credentials or certifications your financial advisor holds?
Bridgeworth, LLC, is a registered investment adviser.
The CFP® certification trademark is owned by the CERTIFIED FINANCIAL PLANNER™ Board of Standards, Inc., in the United States and is awarded to individuals who successfully complete the CFP® Board’s initial and ongoing certification requirements.
Monday, March 9, 2015
By: H. Wayne Shew, Ph.D. (photo of Dr. Shew teaching)
*in conjunction with Alabama Allergy & Asthma Center
“A rose by any other name…” For most of us the word flower brings to mind something pretty to look at and/or pleasant to smell, and which grows in gardens or in pots on our patios. Flowers are typically thought of around Valentine’s Day, or birthdays, or anniversaries because they are often given as gifts to people you love or care about. They are also associated with funerals for the same reasons; we care about the deceased or his or her family, and want to show that love and concern by sending flowers.
Botanically speaking, the flower is the reproductive structure of plants. It is designed as the place to produce and house seeds until they are ready to be released from the plant to start another generation. Flowers are remarkable plant organs that can differ greatly from one species of plant to another. However, all flowers tend to have certain features in common which function to provide a means for the plant to reproduce itself.
What are the similarities between flowers, and what are some of the differences? Why talk about flowers when your allergy or someone else’s allergy is due to oak pollen or birch pollen and you don’t see anything you would call flowers on these trees? In fact, you might even be thinking, do oak trees have flowers? The short answer is yes, absolutely they do. If a plant produces a fruit, then by definition it also must produce flowers; fruits are the products of flowers. The function of the fruit is to house the seeds and in so doing to help insure that they are protected and get distributed. Seeds are the way that most plants propagate themselves and insure production of the next generation of that plant. Consider oak trees for example. Oaks produce acorns, the fruit of the oak tree, and each acorn contains one seed which can serve to reproduce that oak tree.
All flowers possess one or more of the following structures: stamens (male component of the flower—easy to remember that it is the male part since it has “men” in the name), carpels (female component of the flower—may be called a pistil), petals, and sepals. (See figure below.) The part of most interest to allergy sufferers is the stamen, which consists of a filament and an anther. The anther produces the pollen which is then shed from the flower. The pollen must be transported by some means to another flower, or in some cases to the carpel of the same flower, in order to effect reproduction. The transfer of pollen from one flower to another is called pollination. (Consideration and discussion of pollen will be presented in subsequent blogs.)
Flowers which are associated with allergy symptoms typically do not have showy flowers. In fact, the flowers are often never noticed by most people because they are “inconspicuous,” lacking color and fragrance. For example, think about oaks, trees which produce all of those brown things that fall on the ground or sidewalk in the spring which look like dead worms. Those “worms” are actually a cluster of dead, male flowers attached to one flower stalk. One cluster of these unisexual (male) flowers is called a catkin, a type of inflorescence. Each male flower in this inflorescence has anthers that produce large amounts of pollen. The pollen of each flower when combined with the pollen produced by all of the other flowers in the catkin along with that from all of the catkins on the tree, yields millions and millions of pollen grains which are dispersed into the air. This is why during March and April many of you will suffer from allergic rhinitis. The oak pollen present in the air in large amounts triggers allergic symptoms in many individuals. If you are allergic to oak pollen, “beware the Ides of April.”
To be continued in subsequent blogs….
Note catkins hanging down from limb of this water oak.
H. Wayne Shew, Ph.D.
NAB certified counter
BSC/AAAC Collection Station—Birmingham, Alabama
In conjunction with http://www.alabamaallergy.com/
Tuesday, March 3, 2015
By H. Andrew (Drew) Wilson, Jr. MD, FCCP
Diplomate, American Board of Sleep Medicine Pulmonary & Sleep Associates of Alabama
The first week of March 2015 has been designated as National Sleep Awareness Week, designed to help increase understanding of the importance of sleep in overall health and functioning. We will celebrate the occasion by highlighting one of the most common medical complaints experienced in society: Insomnia.
Insomnia is a sleep symptom that virtually everyone has at one time or another. It may take the form of difficulty falling asleep, staying asleep, or waking up earlier than desired, with some associated deficit in daytime functioning. Sometimes the sleep difficulty may last for days or even weeks, but often it will resolve without the need for a great deal of intervention by a physician.
There are a multitude of known causes of insomnia. We’ve all had those nights when stress, excitement or a change in schedule rob us of a good night’s sleep. Poor sleep habits such as daytime napping, heavy caffeine use, smoking, drinking alcohol at bedtime and use of electronic devices in the bed can dramatically affect sleep quality. Circadian rhythm shifts (i.e., jet lag or shift work) can realign the brain’s clock, moving the “sleep on” switch to a later hour. If such shifts occur on a recurrent basis, the brain is left in a constant state of playing catchup. Medications are notorious causes of insomnia - typical culprits include antidepressants, steroids, and beta blockers. Mood disorders such as depression and anxiety are common causes of insomnia. Medical conditions such as COPD, heart failure, and arthritis are frequently associated with sleep disruption. Obstructive Sleep Apnea can lead to insomnia by repeatedly fragmenting the sleep cycle. Restless Legs Syndrome and nighttime repetitive leg jerks, known as Periodic Limb Movement Disorder, can also result in trouble falling and staying asleep. And then, there are those folk who suffer from chronic insomnia that describe virtually lifelong difficulty sleeping.
Bottom line - sleep is a complex physiologic state, and the interplay of multiple influences can disrupt the harmonious functioning of the brain’s sleep centers.
So what’s a physician to do when confronted with the poor sleeper? First of all, realize insomnia is usually temporary. If insomnia lasts less than 3 months it can be considered short term, and there is often an identifiable stressor. These folk may benefit from a review of good sleep habits, perhaps a hypnotic such as zolpidem or eszopiclone, and a bit of reassurance. There are a number of basic sleep hygiene recommendations that can be recommended to all patients, whether they have insomnia or not. A list can be accessed at the National Sleep Foundation website: http://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips .
Patients with chronic insomnia are often more of a challenge. Chronic insomnia is typically the result of years of learned behaviors that may have medical, psychological and even genetic influences. There are many insomniacs that live in a state of hyperarousal such that they often do not feel especially sleepy during the day regardless of how little sleep they get at night. They’ve often tried all the OTC aids, melatonin, herbal remedies, and prescription hypnotics with usually limited benefit.
Some of the most helpful techniques in treating chronic insomnia include stimulus control, sleep restriction and Cognitive Behavioral Therapy. Stimulus control is geared to break the association that a patient has with being in bed and the inability to sleep. It works like this: if a patient is lying in bed more than 20” and is unable to sleep, he should get out of bed, go to another room, and do something rather non-stimulating, (i.e., reading) until he feels so sleepy he is ready to fall asleep. Only then should he go back to bed. If he again has trouble sleeping later that night, the process should be repeated. It may seem a bit contrived, but it does work, though it takes some discipline (and several books).
Sleep restriction is designed to increase sleep efficiency, which is the time a person is asleep relative to the time he is in bed. The physician should determine a patient’s usual bedtime and rise time to estimate his total hours in the bed. Next, ask the patient the total amount of sleep he thinks he actually gets, (or consider using a sleep diary for a more accurate estimate). Then, while maintaining the same rise time, adjust the patient’s bedtime to a later hour such that the time in bed approximates the estimated sleep time, (just be sure to allow at least five hours of time in bed). This process will typically lead to a mild state of sleep deprivation. The patient should avoid the temptation to nap during the day to preserve an adequate sleep pressure at the scheduled bedtime. Once it becomes easier to fall asleep at night, the bedtime can be set 15” earlier every few days until a more desirable bedtime is achieved. Again, this technique takes a fair amount of motivation and discipline on the part of the patient.
The other arm of management of chronic insomnia is what’s known as Cognitive Behavioral Therapy, or CBT. CBT addresses a patient’s ideas about sleep. Chronic insomniacs often harbor faulty beliefs about the reasons for their sleep problems and hold unrealistic expectations about what they should consider a good night’s sleep. Altering these beliefs may require several sessions using such techniques as biofeedback and relaxation training. CBT is often best handled by a psychologist with expertise in dealing with sleep issues.
To summarize, when your next patient comes in complaining of the inability to sleep, resist the urge to simply write a prescription for a hypnotic. Give such patients a list of good sleep habits. Assess their caffeine, tobacco, and alcohol intake. Review their medications. Ask about their sleep environment. Determine if they could be depressed, anxious or have new life stressors. Finally, ask if they snore or have daytime sleepiness, which may suggest OSA or another sleep disorder.
If your patient fails to respond to treatment, or if Sleep Apnea or another sleep disorder is suspected, consider referral to a sleep specialist.
Insomnia is common and often very treatable. If you can help your patient enjoy restful nights on a consistent basis, you will have earned yourself a good night’s sleep to boot.