Abordaje terapéutico del insomnio / Therapeutic approach to insomnia

El insomnio es la incapacidad para conciliar o mantener el sueño o la sensación de no haber tenido un sueño reparador que ocasiona disfunción diurna. Repercute de forma importante en la salud y la calidad de vida de quien lo presenta. Pese a ello, hasta el 10% de los pacientes insomnes no reciben el tratamiento adecuado. Debe realizarse un abordaje integral tratando las causas o desencadenantes y sus síntomas y valorando su repercusión en el paciente. El tratamiento debe basarse en estrategias de modificación de conductas y cambios en el estilo de vida a las que se asociará, cuando se considere necesario, tratamiento farmacológico. Los principales hipnóticos son las benzodiacepinas y los fármacos Z o hipnóticos no benzodiacepínicos, sin que se hayan encontrado evidencias de diferencias clínicamente significativas sobre la utilización de unas u otros. Ambos grupos terapéuticos son eficaces en el tratamiento del insomnio a corto plazo pero no se dispone de evidencia sobre su eficacia a largo plazo en este cuadro (AU)

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness (AU)

[Therapeutic approach to insomnia]. / Abordaje terapéutico del insomnio.

Insomnia is the inability to reconcile or maintain sleep or the feeling of not having a good night's sleep, resulting in daytime dysfunction. It affects health and the quality of life of patients who suffer from it. However, up to 10% of insomniac patients do not receive an adequate treatment. Insomnia requires an integrated approach, treating the causes or triggers and symptoms, and assessing their impact on the patient. Treatment must be based on strategies of changing behaviour and changes in lifestyle that are associated, and when deemed necessary, pharmacological treatment. The main hypnotics are benzodiazepines and Z drugs or non-benzodiazepine hypnotics, on not finding any evidence of clinically significant differences between the use of one or the other. Both therapeutic groups are effective in the treatment of insomnia in the short term, but there is no evidence on their long-term effectiveness.

Valoración Clínica y Calidad de Vida relacionada con la Salud del Paciente con Insomnio / Quality of life of people with insomnia in the Toledo health area

Objetivo. Valoración clínica y de la calidad de vida del paciente insomne. Tipo de estudio. Descriptivo transversal. Emplazamiento. Atención Primaria de Toledo. Población. Pacientes diagnosticados de insomnio antes de enero de 2008. Mediciones. Revisión historia clínica: registro de actividades diagnóstico-terapéuticas y entrevista telefónica para realizar historia del sueño y cuestionario EQ-5D. Resultados. N = 94. Edad media 60,3 ± 14,3 años. 79,8% mujeres. El 73,4% (IC 95%: 62,0- 80,0) presentaba eficiencia del sueño ≤ 90%. El 69,1% (IC 95%: 58,6-78,0) refería dormir mal. Repercusiones: 76,8% dice levantarse cansado, interfiere en la actividad del 70,6%; al 63,2% le ocasiona distracciones y al 39,7% somnolencia diurna. El 58,1% sufre insomnio de conciliación, 25,8% de mantenimiento, 8,6% despertar precoz. El 27,8% de pacientes recibió recomendaciones de higiene del sueño. Principios más prescritos: lorazepam (47,2%), lormetazepam (23,6%) y zolpidem (19,1%). Mediana de duración del tratamiento: 32 semanas (RI 58). Actualmente no tomaba tratamiento el 24,7%. De ellos, decía dormir bien el 21,7%. Consideraba su salud buena/muy buena el 17,2% de los tratados y el 26,1% de los no tratados. Presentaban peores puntuaciones en EVA del EQ-5D los de mayor edad (r = -0,33; p = 0,001), los que referían dormir mal (55,8 vs 53,2; t = 0,52; p > 0,05), aquellos con despertar precoz (F = 3,51; p = 0,01) y los tratados farmacológicamente (51,5 vs 61,5; t = 1,93; p = 0,06). Conclusiones. La mayoría de los pacientes insomnes continúa durmiendo mal y presenta mala eficiencia del sueño aún con tratamiento farmacológico. La principal repercusión es el cansancio, que interfiere en su actividad habitual. El insomnio repercute negativamente en la calidad de vida(AU)

Objective. Clinical assessment and quality of life of the insomniac patient. Design. cross-sectional study. Setting. Primary Health Care. Toledo (Spain). Participants. Patients diagnosed with insomnia before January 2009. Measurements. Medical history review: record of diagnostic and therapeutic activities. Telephone interview: sleep history and EQ-5D questionnaire Results. N = 94. Average age 60.3 ± 14.3 years, 79.8% are women. 73.4% (95%CI 62.0–80.0%) had less than 90% sleep efficiency and 69.1% said they sleep badly. Impact: 76.8% get up feeling tired; in 70.6% insomnia interferes with their activities, in 63.2% it causes distractions and in 39.7% daytime sleepiness. 58.1% have conciliation insomnia, 25.8% have maintenance insomnia, and 8.6% early awakening. 27.8% of patients received advice on sleep hygiene. The most commonly prescribed drugs were lorazepam (47.2%), lormetazepam (23.6%) and zolpidem (19.1%). Median duration of treatment was 32 weeks (RI 58). Currently 24.7% are not taking any treatment, 21.7% of whom said they sleep well. 17.2% of those who were treated and 26.1% of those who were not considered they were in good or very good health. Older patients (r= -0.33; p = 0.001), those who said they sleep badly (55.8 vs 53.2; t = 0, 52; p > 0.05), those with early awakening (F = 3.51; p = 0.01) and those on pharmacotherapy (51.5 vs 61.5; t = 1.93 p = 0.06) had the worst scores in the EQ5D. Conclusions. Most patients with insomnia continue to sleep badly and have poor sleep efficiency, even with pharmacological treatment. The main impact is tiredness, which interferes with their normal activities. Insomnia has a negative effect on the quality of life(AU)

Actitud de los médicos de Atención Primaria ante situaciones de incertidumbre / T he attitude of General Practitioners in situations of doubt

Objetivo. Se ha postulado la existencia de diferentes "estilos de práctica" (EP) como explicativo de las variaciones en la práctica médica (VPM) no justificadas por características específicas de los pacientes o de los médicos. Se pretende determinar si existe tal variabilidad en la actitud médica ante la incertidumbre y, secundariamente, establecer diferentes EP según la utilización de recursos sanitarios. Diseño. Estudio descriptivo. Emplazamiento. Atención Primaria. Participantes. Todos los médicos de Familia del Área Sanitaria de Toledo. Mediciones principales. Estudio basado en una encuesta con tres supuestos clínicos en los que no existen evidencias que apoyen una actitud determinada. En función de las respuestas afirmativas a las preguntas clave de los supuestos, se definieron tres clases de EP (EP1, EP2 y EP3), de menor a mayor utilización de recursos. Resultados. Se consideró EP1 al 21,6%, EP2 al 48,8% y EP3 al 29,6% de los médicos. La media de edad de los médicos EP1 fue menor que la de los EP2 y EP3 respectivamente (41,7 vs 46,4 vs 48,9; p=0,003), al igual que su experiencia profesional (13,9 vs 17,8 vs 21,0 años; p=0,008). El porcentaje de EP1 entre los médicos con formación MIR fue mayor (34,3% vs 16,7%; p=0,046), al igual que en médicos de atención continuada frente a médicos de consulta (40,7% vs 16,3%; p=0,014). Conclusiones. Se constata variabilidad en la actitud de los médicos ante la incertidumbre. Dado que las VPM podrían sugerir problemas de adecuación o de eficiencia, el mejor conocimiento de los factores influyentes es importante para mejorar la calidad de la atención sanitaria, pudiendo utilizarse el consumo de recursos como indicador de EP (AU)

Objective. The existence of different practice styles (PSs) has been postulated to explain variations in medical practice (VMP) not justifiable by specific characteristics of the patients or doctors. The objective is to establish whether this variability in medical attitude in the face of doubt does exist and, secondarily, to determine different PSs in relation to the use of healthcare resources. Design. Descriptive study. Setting. Primary Care. Participants. All the General Practitioners in the Toledo region. Main measures. Study based on a survey with three clinical assumptions in which there is no evidence of support of any particular attitude. In relation to the positive replies to key questions for the assumptions, three classes of PSs were defined (PS1, PS2 and PS3), from lesser to greater use of resources. Results. A total of 21.6% of doctors were considered as PS1, 48.8% as PS2 and 29.6% as PS3. PS1 doctors were on average younger than PS2 and PS3 doctors, respectively (41.7 vs 46.4 vs 48.9; p=0.003), and had less professional experience (13.9 vs 17.8 vs 21.0 years; p=0.008). A higher percentage of PS1 doctors had received the speciality of family doctor (34.3% vs 16.7%; p=0.046), and more were providers of continuous medical care rather than only attending patients in clinics (40.7% vs 16.3%; p=0.014). Conclusions. Doctors have a variable attitude when faced with doubt. Given that VMP could imply problems of suitability or efficacy, it is important to improve our understanding of the factors involved to be able to improve the quality of healthcare. The use of resources could possibly be used as an indicator of PSs (AU)

Prescripción de medicamentos de utilidad terapéutica baja en atención primaria de la provincia de Toledo: variabilidad de uso / Prescription of medicines of low therapeutic utility in primary care in Toledo province: variability of use

No disponible

No disponible

[The effect on the use of hospital resources in a geriatric domiciliary care program among the elderly patients with advanced cardiorespiratory diseases]. / Efecto sobre el consumo de recursos hospitalarios de un programa de atención geriátrica domiciliaria en personas ancianas con patología cardiorrespiratoria muy evolucionada.

BACKGROUND: One of the objectives of the geriatric home care teams is that of the follow-up of elderly patients having a high risk of hospital readmission. Although they have been operating in our country for years, no data shows the impact on the use of hospital resources in accordance with this follow-up. The objective of this study is that of analyzing the effect which the monitoring, by geriatric home care unit, involves on patients having very advanced chronic cardiorespiratory disease. METHODS: The patients with chronic cardiorespiratory disease followed up by the unit during the January 1995-January 1999 period were included, excluding those on follow-up for less than 3 months. A comparison is drawn among the number of hospital emergency room visits, hospital admissions and days of hospitalization for the year prior to the care provided by the unit and throughout the follow-up time thereof are compared. RESULTS: Eighty-one (81) patients, mean age 80.57 years (DE 7.39) and a median length of care per unit of nine (9) months (5-13.5), were included in the study. The uses per patient and month of follow-up decreased by 0.07 Emergency Room visits (0.02-0.11) (p = 0.04), 0.10 hospital admissions (0.07-0.14) (p < 0.001) and 2.01 days of hospitalization (1.87-2.15) (p < 0.001). CONCLUSIONS: A specialized geriatric home care unit reduces the use of hospital resources on elderly people diagnosed as severe chronic cardiorespiratory disease.