Sleep problems and how to fix them

To sleep…perchance to dream

Insomnia, dissatisfaction with sleep quality or duration, is a common problem. Some 10% of Americans have chronic insomnia and another 15-20% have occasional insomnia.

While scientists do not fully understand why we (and virtually all living animals) need to sleep, lack of sleep contributes to many problems, including interpersonal, school and work functioning, depression and hypertension.

There are specific medical problems that may underlie insomnia. Restless legs and obstructive sleep apnea lead this list and will respond to specific therapies. Your bed partner is more likely to pick up on these than are you, and a session in the sleep lab will usually confirm the diagnosis.

Shift workers are particularly at risk for insomnia and the problem may not go away until you get a regular work schedule.

Most have insomnia as its own problem. Insomnia may have started at the time of a life stress or due to jet lag and then persists.

What can you do? There are many ‘common sense’ hints that may be all you need. Try to go to bed and get up at the same time every day, including weekends. Be sure your bedroom is dark and cool. Exercise early in the day, not in the evening. Do not work right up until bedtime; allow yourself time to decompress by relaxing reading or music. Do not eat within 2 hours of bedtime.

If these do not work, what next?

Sleeping pills, whether over-the-counter or prescription, are fine for short-term use but are not that effective when used chronically, and the more effective prescription drugs can have side effects.

Older individuals are at particular risk of falls, morning confusion and even dementia with chronic use of benzodiazepines (Valium, Ativan etc.). The so-called “Z drugs,” (Zolpidem, zaleplon and eszopiclone) have black-box warnings because of sleepwalking and other potentially risky sleep behaviors.

Sedating antihistamines like Benadryl have limited efficacy and cause dry mouth and daytime sedation. They are also potentially causes of dementia if used chronically.

Most experts strongly recommend cognitive behavioral therapy (CBTI) before medication. The success rate is high and there are no side effects. The problem is the lack of trained therapists and the cost.

An alternative is a web-based or phone app. These have been found to be almost as effective as in-person coaching. Two web-based programs that have good studies behind them are no longer available. I was able to download Shuteye, which promises a full year of coaching for $30 which appears good, but I have not fully tested it. Similar, and free, is Insomnia Coach, developed by the VA.

Also recommended, for technophobes, is the book Quiet Your Mind and Get to Sleep.

Should CBTI not work, young adults whose problem is falling asleep can try melatonin or a short-acting benzo. If sleep maintenance is the problem, low-dose doxepin or similar drugs are useful. Also approved for this use are three orexin receptor antagonists (ask your doctor!), which have fewer side-effects than benzos but are quite expensive. If you are going to use medication, be sure to also practice good “sleep hygiene” as noted above.

Sweet dreams.


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Medicare Advantage: Buyer beware

Medicare was established in 1965, freeing older adults from the trap of unaffordable health care in their senior years. It has been a highly successful program.

Medicare Part A, free for over 65’s and those of any age with permanent disability or chronic kidney failure, covers hospital care. Part B, for which you pay a monthly fee (usually taken out of your Social Security payment) covers doctors’ bills and other services. The more recently added Part D helps with prescription drugs. (Note that while Part D is optional, the cost goes up every year you do not take it.)

Because Parts A and B have deductibles, most people pay for a “medigap” policy to cover these.

In the spirit of “if it ain’t broke, fix it,” in 1982 Congress enacted laws establishing Medicare Part C, also known as Medicare Advantage, commonly abbreviated MA.

MA plans are run by private health insurance companies. They receive a fixed amount per enrollee from Medicare and are responsible for all health care costs. The amount per enrollee is adjusted upward if they can demonstrate that their members are sicker than average.

If you are 65 or older, you will soon be deluged with mailings and phone calls touting different MA plans and encouraging you to join their plan during the open enrollment period that runs Oct 15 to Dec 7 for the following year.

From a national viewpoint, MA has been a windfall for the insurance industry and a disaster for the federal budget. Insurers make double the amount per enrollee on MA than they do on commercial health plans for those under 65. The gross margins on MA enrollees in 2021 was $1730 per person vs $689 per person on commercial plans.

A recent report estimated that in 2022 MA plans cost Medicare at least $88 billion more than what it would have paid for the same people if they had stayed in traditional Medicare. How do insurers make MA so profitable? One way is through fraud. It has been widely documented that they use a variety of data mining techniques to make their enrollees appear sicker than they are, thereby getting excess funding that is not deserved.

Another way, of more concern to you if you are considering joining a MA plan, is by cutting expenses.

Under traditional Medicare, you can for the most part see any doctor you wish and be treated at any hospital. MA plans have a closed network: you must see a doctor in their plan and be hospitalized at a hospital in their network for your care to be covered.

If you are healthy and are sure you will be healthy all next year, you may not care. If you have a serious illness, you may be sorry to learn that the highly recommended specialist you want to see will not be covered, and the hospital with the most expertise in your condition likewise.

MA plans also require prior authorization for many surgeries and tests, unheard of under traditional Medicare. A government audit found that 13% of their denials were medically wrong.

If you need rehab after surgery, you should know that MA enrollees were much less likely to receive inpatient rehab at highly-rated facilities.

The pharmacy benefits under MA plans are often generous in covering cheap generic drugs but be aware that the common 20% co-pay may hit hard should you need one of the new highly effective but very expensive drugs for a serious condition.

Bottom line: MA plans often save you money by letting you avoid a Medigap plan (you still must pay Part B premiums) and add coverage for some things Medicare does not cover such as eyeglasses or limited dental or hearing aid coverage. The downside is that you will be restricted in your choice of doctors and hospitals and must accept that the plan will be able to over-ride some of your doctor’s decisions.

So… When the glossy ads hit your mailbox and telemarketers call, think carefully whether a contribution towards eyeglasses or a gym membership is worth it in the long run.


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Aging in Place: Part 2

Some more suggestions on how to start making your current home a place in which you can stay as you become frailer.

Stairs may become a problem as we transition from old to very old. I look upon stairs as a sort of built-in Physical Therapy, forcing us to strengthen our leg muscles with every climb, but arthritis, heart or lung issues or neurologic disease may eventually make that climb a challenge.

Ideally, if you are doing major home renovations, moving the master bedroom to the first floor will pay dividends in the long run. If this is beyond your budget, electric stair climbers may be the answer, with cost in the ballpark of $5000.

Over time, change most doorknobs to levers for easier turning.

Have proper storage, so that toys, shoes, boots, etc. are in a box or on low shelves and not sitting on the floor waiting to trip you.

Get a video doorbell tied to your phone so you do not have to rush to answer the door, and so that you can screen callers to be sure you want to answer it.

The last point brings up another: seniors are often targeted by scammers. Your local police department and/or Council on Aging probably offers lectures on how to avoid becoming the victim of a scam: attend one of these!

Finally, it is likely that at some point, one of a couple will become the primary caretaker for the other. Plan for this. Do not try to do it all. Accept help when it is offered, whether by family or friends. Use outside agencies for some meals and for respite care.

Join an on-line or in-person support group to share your experiences with others experiencing the same issues. Keep some “me time.” If you do not make time to relax and do something enjoyable, you will burn out sooner.

If you live alone, a personal alert system adds peace of mind for both you and your family.

Unless you have good long-term health care insurance, realize that costs of outside help are not covered by Medicare or other health insurance. Short-term help after a hospitalization is covered, but not the regular care needed to stay independent.

If you are very rich, no worries. If you are very poor, Medicaid will help. For most of us in between, be sure to budget and set aside money for these expenses.


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Aging in place - Part 1

A large majority of older people want to stay in their own homes rather than move to a retirement community or, heaven forbid, a nursing home. Closeness to friends and family is a key factor, as is the comfort of familiarity and the freedom to do what you want when you want.

At the same time, most of us develop at least some health issues as we age. Our strength, our balance, our vision and hearing inevitably decrease, no matter how healthy we are.

There are many things we can do now to make it easier to age in place. Some are very simple and inexpensive, others more costly.

A potentially serious problem for seniors is falls and resulting injury. To minimize the risk of falls:

Get rid of small rugs that slide. Have fewer rugs and be sure they are on a non-skid pad.

Have railings for all stairs, indoors and out.

Have adequate lighting, particularly by stairs and at entrances. Using higher wattage bulbs is the simplest way to do this, and if you need to, get an electrician to install new fixtures.

Use a night-light in your bedroom; falls getting up at night are common and can be serious.

Bathrooms need attention.

Install grab bars for every tub and shower – be sure your installer does this regularly.

Have a non-skid surface in the shower. A bench makes showering easier. This can be built-in (expensive) or a chair with good support (cheap).

If you much prefer a bath to a shower, invest in a walk-in tub.

Raise the height of your toilet seat with either a new unit or an add-on and consider a grab bar next to the toilet.

Kitchens also warrant attention.

Getting things down from high cabinets is difficult and can be hazardous if you use a chair or a ladder. Have your cabinets lowered, so that all the space you need to use can be reached easily. Slide-out shelves will make it easier to get what you want.

If you are facing the need for a wheelchair, be sure all surfaces are low enough that you can work in the kitchen from the chair. If you have an island in the kitchen, be sure there is at least four feet of space on all sides of the island.

All your chairs should have arms, to make getting in and out safer.

Part 2 next week!


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Should you be tested for Alzheimer's Disease?

Several recent studies have promised a reliable test to detect Alzheimer’s disease in people with mild memory loss. What are these and should you request one?

One test is a very expensive imaging test, a specialized PET scan, that will almost certainly not be covered by your insurance and is probably still best used in the research phase.

The other is a blood test – “phosphorylated tau” should you wish to Google it – that was reported to have over 90% accuracy in predicting Alzheimer’s in a group of elderly people (average age 74) who had either subjective memory loss, doctor-diagnosed mild cognitive impairment or dementia.

The blood test was better than both primary care physicians and dementia specialists in diagnosing Alzheimer’s disease and will probably soon be clinically available.

The real question, should the test be positive, is: what next?

The medicines available to treat Alzheimer’s are not miracles. Both the older oral medicines and the newer IV medicines slow down the progression of the disease but do not cure it.

Considerable media attention and soaring stock prices have greeted the newer IV agents, but their results are only mildly better clinically than the old ones, and their potential side-effects are worrisome, including bleeding in the brain.

The British agency responsible for approving new drugs in the National Health Service just turned down Biogen’s drug, Leqembi, and its U.S. FDA approval has been controversial.

There is hope, but it is yet unproven, that starting these drugs much earlier in the process might make them more effective. Hopefully clinical trials will be conducted to see if this is true.

My strong feeling is that for most people, the side-effects of the newer drugs outweigh their proven benefits.

Any medical test should only be done when knowing the results of the test is expected to have a beneficial effect on your health.

So, putting the horse in front of the cart, if you are worried about memory loss, have a full discussion with a doctor you trust. Ask what would happen after a positive test before you are tested. Then you can make an informed decision.


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Hello, Covid, my old "friend"

We’ve come to see you once again. (Cue Simon and Garfunkel)

The pandemic is behind us, and life has mostly returned to normal, but Covid has not disappeared. Instead, this summer has seen an increase in cases and in such measures as virus detection in wastewater samples.

Thanks to widespread vaccination and the immunity conferred by infection and recovery, we have not seen the huge numbers of hospitalizations and deaths that we did in 2020-21.

Covid is still a serious threat, particularly to the elderly and those with immune deficiency, and it has shown a remarkable ability to mutate into variants to which we are not fully immune. There has been a whole alphabet soup of new variants, and the original vaccinations you received will offer only limited protection to the current virus.

The FDA has recently approved a new vaccine and ordered the old ones taken off the market. The new vaccine is not perfect – the virus mutates too quickly – but should provide better protection and will be widely available in September.

While Covid is not “seasonal” the way influenza is, I expect an increase in infections as we get into colder weather and people congregate indoors.

What should you do?

If you have had a case in the last 3-4 months, the natural immunity this provides suggests you put off getting vaccinated until later in the fall.

If you have been lucky enough to avoid Covid over the summer, getting the new vaccine as soon as it is available is suggested, particularly if you are over 65.

Also, there is good evidence that wearing a mask in crowded indoor environments is helpful, as well as such commonsense advice as staying home when you are sick and using good hand-washing practice. This will reduce not only Covid, but other respiratory viruses.


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Getting the most out of a doctor visit

By now, most of us are all too aware that the doctor visit is becoming shorter and that the doctor seems to interact more with the computer than with you. It is frustrating to leave a visit that may have been made months in advance with your questions unanswered.

How can you get the most out of a medical appointment? The key is preparation.

Before you set out, you should have made sure that you have the correct date and time, that the doctor is on your insurance plan, and that if you need a referral, you have it.

Leave enough time to get there even if traffic backs up. Yes, you will probably have to wait, so bring a magazine.

If this is a new doctor, bring a list of all medicines you are taking, any medication allergies you have, major family history, recent test results and surgeries and hospitalizations you have had.

Key to a satisfactory visit is to know what you want from it. If you are scheduled for a follow-up of chronic health problems but you have a new symptom that worries you, get that out up front and not when the doctor has their hand on the door.

Bring notes and take notes. Have a written list of things you want to discuss in the order of priority you want to cover them.

It has been repeatedly found that most of what a doctor tells you is forgotten by the time you get to your car, so take notes of what you are being told. Doctors tend to slip into medical jargon, so do not hesitate to ask that they repeat something you do not fully understand.

It is very helpful to have a close friend or family member with you to act as a second set of eyes and ears, but be sure they understand what you want them to do and do not let them take over the visit. (Speaking of ears, if you need hearing aids, be sure to have them in for the visit!)

Be honest with your doctor. They have seen and heard it all, so any habits you have of which you are not proud, be upfront. Keeping secrets is not going to get you optimal care.

At the end of a visit, tell the doctor what you understood them to say and what is planned. It is rare that a problem is solved at one visit, so be clear in your mind if further testing is needed as well as what you should do if things do not go as expected. Be sure you know what to do before you leave.

If you are not comfortable with what you are told, do not hesitate to ask for a second opinion. This should not be threatening to a good doctor. In the case of a serious diagnosis, second opinions often change the diagnosis and/or the treatment.


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