The Classic SleepCast is a weekly blog dedicated to providing our patients with the latest in
sleep news and access to professionals who have dedicated their lives to this field.
New to Classic SleepCare? Read more about us
Barry Krakow, MD
Dr Krakow’s 27 years of sleep research have focused on the complex relationship between
physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical
center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.
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Janna Mantua is a PhD student in the Behavioral Neuroscience department at the University of Massachusetts. Her research focuses on sleep and aging, with specific projects on cognitive health, inflammation, memory formation, and neuroimaging. Prior to her PhD work, Janna was involved in research on sleep apnea and cognitive decline at the NYU Sleep Disorders Center.
Our over-riding premise in this post assumes that turning a patient into a regular user of PAP improves health benefits and saves healthcare dollars. Although the first half of the statement is a given, the second half remains controversial as we discussed in Part I. A fair number of research studies show cost-savings emerge by increasing PAP use, but no analysis has ever been conducted, to my knowledge, factoring in the costs of the number of trips to the sleep lab. Thus, to be fair, the remainder of this post must be weighed in balance against the speculative theory more trips to the sleep lab are not so costly as to eat up all the other gains to be realized, both to the patient and insurers. We’ll start with masks because as conventional wisdom goes, most sleep professionals and probably most patients perceive mask fit, mask leak, and mask comfort...Read more
Sleep medicine has always been at a severe disadvantage in the assessment part of diagnosing sleep disorders, because the conditions are not readily apparent to many individuals suffering from these conditions. When you suffer a sore throat, you often would have already spent years or decades of your life experiencing the absence of any symptoms in your throat. When it becomes sore, you immediately know something is wrong. By recalling past experiences and perhaps with the assistance of friends and family, you could determine the problem is nothing to worry about. It could be allergies or a virus. You would not usually jump to the conclusion you are suffering from throat cancer. Instead, you watch and wait, but if a fever develops or the pain worsens, you visit a doctor. From there, you receive a treatment plan and often recover in a few days, sometimes a little longer. When you...Read more
In Part I, we ran through a few examples comparing something as obvious as heart disease and the full insurance coverage often provided for related cardiac care to the problem of sleep disorders, in particular sleep apnea, and the general lack of interest and specific lack of coverage in promoting greater use of CPAP. In the zero sum game of healthcare, sleep medicine is increasingly looking like an imminent loser in so far as services are continuously downgraded to a point where patients either adapt to the PAP machine rapidly or the device is withdrawn. The epitome of such a model of care would be undergoing HST, then receiving an APAP device, and then when some proportion of patients struggle after say one month, insurance coverage ceases. The patient can always try again, but in this model, the general belief would be the patient just is not sufficiently motivated to...Read more
In clinic this week at my New Mexico sleep center, one of my sleep techs and I were discussing follow-up with a patient doing well with ABPAP therapy. He had lowered his pressures in the past year as he struggled with Aerophagia, but since starting Gabapentin for his leg jerks, he experienced far fewer episodes of air swallowing. He was very pleased with the results, and one of the main reasons for the visit was to raise his pressure settings back to higher levels. His data download confirmed some residual breathing events, mostly flow limitations and some hypopneas, and he was eager to raise pressures as well as to continue his gradual increases in the dosage of Gabapentin.In the last portion of the appointment, insomnia symptoms were discussed. He described the classic finding of racing thoughts or “I can’t turn off my mind.” When I hear these complaints, I often...Read more
One definition of rationality might be: “Rational behavior refers to a decision-making process that is based on making choices that result in the optimal level of benefit or utility for an individual, be it monetary or non-monetary.” If we substitute the word “business” or “corporation,” we could imagine such institutions make decisions either to improve the bottom line (profit) or their public relations image (reputation) or both.So, do health insurance companies act rationally? In certain ways they must do so, otherwise they would no longer make a profit or attract a large enough membership to maintain their profits. Therefore both profits and public relations are in play in their decision-making. But, inside the workings of these businesses, it should be obvious that select territories of operations appear more rational than others.Take the serious example of heart disease. How likely is an insurance company to deprive access to its consumers for...Read more
One of the most problematic and regrettable perspectives today in healthcare is the overall neglect or mismanagement of sleep complaints and related sleep disorders among mental health patients suffering suicidal ideation and behaviors. Not only are sleep disorders routinely ignored in these dire circumstances, but worse they are routinely misdiagnosed, under-treated or incorrectly treated. At the sleep conference, several of these points were highlighted, both during presentations of data about suicidal patients and by the failure to provide more penetrating analyses of the same data. As the best example of the latter phenomenon, several poster presentations as well as lectures given at the symposium consistently described biased recruitment strategies to exclude OSA/UARS patients from protocols examining insomnia or suicidal behavior or both. You might be puzzled on the rationale to exclude sleep-disordered breathing patients, especially if you imagine as I do that SDB is a regularly occurring feature of patients...Read more
One of the most interesting sessions I attended in Baltimore delved into the impact of sleep disorders in mental health patients. As I’ve repeated, ad nauseum, how we specialize in mental health patients with sleep disorders, this topic naturally piqued my curiosity, and it did not disappoint. Three main speakers covered specific topics often including case report information, and a fourth served as a discussant; this final speaker also brought up hypothetical cases to review to integrate the material from the earlier speakers. The three speakers gave very thoughtful and detailed lectures, all of which pointed to the imperative to closely examine the nature of the sleep disorders in various psychiatric patients. The first presentation was entitled, “Common Psychiatric Conditions in Adults who Present with Sleep Problems.” This talk presented by Dr. Sam Fleishman set the table by clarifying the need to realize that sleep symptoms—all manner of sleep symptoms—can...Read more