Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

For elderly patients with sleep apnea and insomnia, what is the comparative effectiveness of improving CPAP compliance using a sedative hypnotic (zolpidem) compared to cognitive-behavioral therapy?

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Cognitive-behavioral therapy for insomnia (CBT-I) versus zolpidem (non-benzodiazepine sedative hypnotic)

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Elderly patients (age >65) with sleep apnea and insomnia symptoms. These patients are generally Medicare patients. It is estimated that approximmately 10% of older adults have sleep apnea and co-existing insomnia symptoms

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

no

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Improvement in patient compliance with CPAP therapy and reduction of daytime sleepiness

Describe any health-related risks, side effects, or harms that you are concerned about.

Zolpidem is associated with risk of falls, addiction, and rebound insomnia. CBT-I is associated with daytime sleepiness during the acute phase of therapy.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Pulmonary disease/asthma

AHRQ Priority Populations

• Elderly

Federal Health Care Program

• Medicare

Importance

Describe why this topic is important.

Sleep apnea is a common disorder in older adults, affecting up to 20% of older patients, and can increase the risk of stroke, heart attack and death. In many cases, one of the symptoms of sleep apnea is insomnia, or difficulty maintaining sleep. Patients with sleep apnea and insomnia often have a difficult time tolerating CPAP therapy for their sleep apnea because the CPAP may temporarily exacerbate their insomnia. In many cases, Medicare patients undergo an expensive sleep apnea work-up (approximately $3000), are diagnosed with sleep apnea, are started on CPAP therapy (approximately $1000), but are non-compliant with CPAP therapy. Ultimately ,only 30-40% of older adults with sleep apnea are able to remain compliant with CPAP therapy. If zolpidem or CBT-I therapy is found to be more effective, this could help make sleep apnea treatment more successful and ultimately cost-effective in reducing the morbidity and mortality of untreated sleep apnea in older adults.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

In my clinical practice, I have observed that many older adults with sleep apnea also have insomnia symptoms, and that these insomnia symptoms often interfere with their compliance with CPAP. However, the optimal method to treat their condition remains uncertain and I do not know if it is worth taking the risks of prescribing sedatives to these older patients, or instead if CBT-I will be effective.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

While data exists to show that zolpidem and CBT-I can improve insomnia, there is no research available in older adults with sleep apnea and insomnia, and there is no information available about their effects on compliance with CPAP therapy. Thus, as a clinician and researcher, I am unsure what is the optimal treatment approach for the large percentage of patients I see that have sleep apnea and insomnia complaints.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

Determining the optimal treatment will allow clinicians to improve compliance with CPAP therapy for sleep apnea and thereby lead to more cost-effective care by minimizing non-compliance.

Describe the timeframe in which an answer to your question is needed.

2-3 years

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

none

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Determining the optimal treatment will allow clinicians to improve compliance with CPAP therapy for sleep apnea and thereby lead to more cost-effective care by minimizing non-compliance.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

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