The document discusses sleep, insomnia, and their treatment. It defines insomnia as difficulty initiating or maintaining sleep. Insomnia can be transient, acute, or chronic. Common causes include medical, psychiatric, substance-related, and circadian issues. Treatment involves addressing underlying causes, improving sleep hygiene, cognitive-behavioral therapy including stimulus control and sleep restriction, and may include pharmacotherapy with hypnotics as a short-term option. Multicomponent cognitive behavioral therapy is most effective for insomnia.
It focuses on sleep medicine - sleep disorders, sleep stages, DSM classification, types, classifications, and pharmacological and non pharmacological management.
1) Insomnia is defined as difficulty initiating or maintaining sleep, leading to impaired daytime functioning. It can be transient, acute, or chronic.
2) Factors that can contribute to insomnia include lifestyle habits, poor sleep environment, working night shifts, alcohol/drug use, caffeine, and certain medications.
3) Symptoms of insomnia include difficulty falling asleep, waking frequently during the night, waking too early, and unrefreshing sleep. This can negatively impact mood, concentration, performance, health, and quality of life.
4) Treatment options include lifestyle and behavior changes, relaxation techniques, cognitive-behavioral therapy, sleep medications, and complementary medicines. Maintaining good sleep hygiene is
The document discusses various topics related to sleep including:
1. Sleep accounts for about 1/3 of our lifetime and 1/3 of the population has a sleep disorder.
2. Sleep is regulated by our circadian rhythm located in the hypothalamus and lasts approximately 24 hours.
3. A normal sleep cycle occurs every 90 minutes and includes NREM sleep, which accounts for 70-80% of sleep, and REM sleep, which accounts for 20-25% of sleep.
4. More than 80 known sleep disorders are classified as dyssomnias involving difficulties initiating or maintaining sleep or daytime sleepiness, or parasomnias involving abnormal events during sleep.
The document provides an overview of sleep and sleep disorders presented by Dr. Kaushik Nandi. It discusses the neurobiology of sleep and wakefulness including the arousal spectrum and sleep/wake switch regulated by neurotransmitters and brain regions like the hypothalamus. The stages of sleep are described based on EEG patterns and physiological characteristics. Assessment methods and classifications of sleep disorders by the DSM-5 and ICSD-3 are outlined. Insomnia disorder and Narcolepsy are explained in more detail regarding their diagnostic criteria, epidemiology, etiology, pathophysiology and treatment approaches.
Insomnia is defined as difficulty initiating or maintaining sleep, or both, despite adequate opportunity and time to sleep, leading to impaired daytime functioning. There are two types of insomnia: primary insomnia not associated with any other condition, and secondary insomnia caused by another condition like depression. Insomnia can be acute (lasting 1-3 weeks) or chronic (lasting over a month at least 3 times a week). Chronic insomnia is treated with relaxation techniques, sleep restriction therapy, and medication, while acute insomnia may not require treatment. Good sleep habits like regular sleep schedules and avoiding stimulants before bed can help treat insomnia.
Insomnia is a sleep disorder where people have difficulty falling asleep or staying asleep for a long period. There are two types - primary insomnia which is not associated with any health conditions, and secondary insomnia which is caused by other factors like stress, mental health issues, medications, or medical conditions. Insomnia can negatively impact people's daily functioning and is linked to higher risks of other health problems if left untreated.
This document provides an overview of sleep, its functions, stages and disorders. It defines sleep as a state of unconsciousness where the brain is more responsive to internal stimuli. Sleep has restorative and homeostatic functions. There are two main stages - NREM and REM sleep. Dyssomnias are disorders of sleep quantity/timing and include insomnia, hypersomnia, narcolepsy and sleep apnea. Parasomnias involve abnormal behaviors during sleep transitions and include nightmares, sleepwalking and REM sleep behavior disorder. Many common sleep disorders are described along with their symptoms, causes and treatment options.
Insomnia is not a disease but a sleep disorder symptom. There are two types: primary insomnia lasts for days or weeks, while secondary insomnia lasts for a month or longer. Over 50% of Malaysians and motor vehicle accidents are sleep-related. Stress, traumatic events, caffeine, alcohol, and medication misuse can cause insomnia. Older adults are more at risk. Symptoms include waking frequently at night, waking too early, and feeling tired after sleeping. Lifestyle changes like exercise, relaxation techniques, and avoiding screens before bed can help treat insomnia. Seeking medical help may also be necessary. Insomnia can negatively impact quality of life, so better sleep is important.
Disorders of sleep can be classified into dyssomnias, which involve disturbances in sleep quantity or timing; hypersomnias, which involve excessive sleepiness; and parasomnias, which involve abnormal behaviors during sleep transitions. The most common disorders include insomnia, sleep apnea, narcolepsy, and restless leg syndrome. Diagnosis involves polysomnography and other tests to evaluate sleep patterns and rule out underlying causes. Treatment depends on the specific disorder diagnosed.
The outcome of this course is for the learner to describe the normal stages of sleep, common sleep measurement tools sleep characteristic, common sleep disorders, the changes that affect the quality and quantity of sleep as an individual ages, and methods the healthcare provider can use to assess and assist clients with sleep disorders.
Insomnia is a sleep disorder where a person has difficulty falling or staying asleep. It can be transient (less than a week), acute (less than a month), or chronic (more than a month). Causes include stress, medications, sleep disorders, medical conditions, and psychological factors. Symptoms include daytime fatigue, sleepiness, mood changes, and poor concentration. Diagnosis involves assessing sleep history, medical conditions, medications, and sleep patterns. Treatments include behavioral changes, medications, herbal remedies, and addressing underlying causes. Complications include impaired job performance, accidents, psychiatric issues, health problems, and weakened immunity.
This document provides an overview of the assessment and management of insomnia. It discusses evaluating insomnia through sleep history, sleep diaries, polysomnography and assessing daytime sleepiness. It covers differentiating insomnia from other sleep disorders and identifying predisposing, precipitating and perpetuating factors. Management techniques discussed include sleep hygiene, relaxation therapy, sleep scheduling, cognitive therapy and sleep medications. Specific instructions are provided for implementing relaxation exercises, sleep scheduling and cognitive approaches like challenging dysfunctional beliefs. The risks and benefits of different medication classes are also summarized.
sleep disorders contains dyssomnias ,parasomnias ,and sleep disorder associated with other major medical disorders . Restless leg syndrome and PLM are also covered here. this ppt also shows how to differentiate between sleep terror and night mares . treatment of sleep disorders also included.
This document discusses sleep, sleep disorders, and their diagnosis and treatment. It covers:
- The stages and functions of normal sleep
- Tools used in sleep medicine like polysomnography
- Common sleep disorders like insomnia, hypersomnia, narcolepsy, sleep apnea
- Treatment approaches including behavioral therapies, pharmacological options, and management of specific disorders.
This document discusses sleep disorders and their classification. It begins by outlining normal sleep physiology and how much sleep is needed. It then classifies sleep disorders into two main categories: primary and secondary. Primary disorders include dyssomnias, which involve difficulties initiating or maintaining sleep, and parasomnias, which involve abnormal events during sleep. Several specific primary sleep disorders are described in detail, including insomnia, sleep apnea, narcolepsy, restless leg syndrome, sleepwalking, and nightmares. Treatment options focus on behavioral changes, therapy, and medication as needed.
This document provides information about sleep disorders and sleep hygiene. It defines sleep and describes the stages of sleep including NREM, REM sleep, and the progression through stages 1-3. It discusses factors that affect sleep, consequences of poor sleep, and categories of sleep disorders like insomnia. Assessment of insomnia and interventions like CBT and medications are outlined. General sleep recommendations are provided regarding sleep schedules, environment, and habits. Sleep hygiene tips conclude the document.
The document discusses sleep disorders and the measurement and stages of sleep. It provides details on:
1) How sleep is measured using EEG, EOG, and EMG electrodes to record brain waves, eye movements, and muscle activity.
2) The stages of sleep including NREM stages 1-4 and REM sleep, characterized by different brain wave patterns.
3) Common sleep disorders like insomnia, hypersomnia, sleep apnea, circadian rhythm disorders and parasomnias. Treatment options are also outlined.
Jessica Peeling was a 4th year medical student from UNECOM in Biddeford, Maine on rotation at the Falcon Clinic in Utica, NY. She gave a presentation on "Insomnia" during a luncheon at the office.
1. The document discusses various sleep disorders including insomnia, hypersomnia, parasomnias, and sleep-related breathing disorders.
2. Key diagnostic tests mentioned are polysomnography, multiple sleep latency test, and actigraphy which objectively measure sleep patterns.
3. Treatment options described for different sleep disorders include lifestyle changes, medications like benzodiazepines, melatonin agonists, antidepressants, and CPAP machines for sleep apnea.
The document summarizes the International Classification of Sleep Disorders Second Edition which classifies sleep disorders into 8 main categories. It provides details on the categories of Insomnias, Sleep Related Breathing Disorders, Hypersomnias of Central Origin, Circadian Rhythm Sleep Disorders, Parasomnias, Sleep Related Movements Disorders and Other Sleep Disorders. Each category contains multiple subtypes of sleep disorders defined by their symptoms, polysomnography findings, risk factors and treatment.
1. The document discusses sleep, sleep disorders like sleep apnea, and how sleep changes with age. It covers the definition of sleep, sleep stages, consequences of sleep deprivation, and prevalence of sleep disorders.
2. Treatment options for sleep apnea are discussed, including CPAP, oral appliances, and surgery. Diagnosis involves a sleep study.
3. Sleep changes as people age, with less deep sleep and more nighttime awakenings. Medical conditions can also affect older adults' sleep. Seeking help from a sleep specialist is recommended for persistent sleep issues.
The document discusses sleep problems in older adults. It covers epidemiology of sleep problems, changes in sleep with aging, evaluation of sleep including screening questions, office evaluation and objective tests. Common sleep disorders like insomnia, sleep apnea, periodic limb movements and restless legs syndrome are discussed. Treatment options and management of sleep problems are also covered.
Explores impact of disturbed sleep on symptom management in patients with concurrent serious illness and at the end of life. Presented during Hospice and Palliative Medicine Fellowship at the University of Kansas 2014
Introduction
The sleep – wakefulness cycle is genetically determined rather than learned and is established sometime after birth.Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity and [inhibition of nearly all voluntary muscle during REM sleep] reduced interactions with surroundings.
Sleep can be regarded as a physiological reversible reduction of conscious awareness. Nearly one third of human life is spent in sleep. Disorders of sleep can affect activities of daily living (ADL) of an individual.
Definition
It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases:
1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person fifi rst passes through these stages of NREM-sleep.
Stages of sleep
The EEG recording during the waking state shows alpha waves of 8-12 cycles/sec. frequency. The onset of sleep is characterised by a disappearance of the alpha-activity.
Stage 1, NREM-sleep is the first and the ligh test stage of sleep characterised by an absence of alphawaves, and low voltage, predominantly theta activity.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two typical EEG changes:
i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a charac teristic waxing and waning amplitude.
ii. K-complexes: High voltage spikes present intermittently.
Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec.
Stage 4, NREM-sleep shows predominant δ-activity in EEG. NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1 NREM-sleep. One of the most characteristic features of the REM-sleep is presence of REM or rapid (conjugate) eye move ments. The other features include generalised mus cular atony, penile erection, autonomic hyperactivity (increase in pulse rate, respiratory rate and blood pressure), and movements of small muscle groups, occurring intermittently. Although it is a light stage of sleep, arousal is diffificult. These stages occur regularly throughout the whole duration of sleep. The first REM period occurs typically after 90 minutes of the onset of sleep, although it can start as early as 7 minutes after going off to sleep, e.g. in narcolepsy, in major depression, and after sleep deprivation.
This document summarizes key aspects of sleep and sleep disorders. It discusses the physiological changes that occur during the different sleep stages of NREM and REM sleep. It also outlines different types of sleep disorders including dyssomnias like insomnia and hypersomnia, and parasomnias involving abnormal events during sleep. Specific disorders covered include sleepwalking, night terrors, sleep talking and bruxism. Nursing assessments and interventions for managing sleep disorders are also summarized.
This document discusses Restless Leg Syndrome (RLS), including its symptoms, causes, diagnosis, and treatment options. Some key points:
- RLS is a neurological movement disorder characterized by an irresistible urge to move the legs when at rest, usually accompanied by uncomfortable sensations.
- It is estimated to affect 5 million people in the UK, with a prevalence of 2-15%. It can be primary or secondary to other medical conditions.
- Diagnosis involves assessing symptoms, family history, and ruling out secondary causes through examinations and blood tests.
- Treatment includes lifestyle changes, medications like dopamine agonists or gabapentin, and in severe cases referral to a specialist may be considered.
this is useful for all the students of bachelors degree in nursing , mostly fresh students . this will be useful during their exam preparation, material for future as a tutor/lecturer/teacher/associate professors for nursing college. this can be useful for non nursing and non teaching faculty who needs health education regarding sleep and rest.
This document provides an overview of sleep disorders including insomnia, hypersomnia, narcolepsy, breathing-related sleep disorders, circadian rhythm disorders, parasomnias, and jet lag. It discusses the stages of normal sleep including light, intermediate, deep, and REM sleep. It covers causes, symptoms, and treatments for different sleep disorders. The functions of sleep are also reviewed including restoring the body, boosting immunity and mood, and facilitating memory processing.
The document reviews several sleep disorders according to the DSM-5 including insomnia disorder, hypersomnolence disorder, narcolepsy, breathing-related sleep disorders, circadian rhythm sleep-wake disorders, non-REM sleep arousal disorders, parasomnias, nightmare disorder, and restless legs syndrome. It discusses the diagnostic criteria, comorbidities, assessments, and treatment options for each disorder in detail across several sections.
Diagnosis and Treatment Insomnia for primary care physicianAndri Andri
This curriculum vitae outlines the education and experience of Dr. Andri, including obtaining a medical degree from the University of Indonesia in 2003 and specializing in psychiatry there in 2008. He has additional training in psychosomatic medicine from American and European institutions between 2010-2014. He currently works as a psychiatrist lecturer and head of the psychosomatic clinic at Omni Hospital. The document provides details on his competencies, sample cases, and a presentation on insomnia and related disorders.
This document summarizes the key points from a sleep presentation. It discusses what constitutes normal sleep, common sleep disorders like insomnia, sleep apnea, and consequences of abnormal sleep. It also covers how lifestyle factors like routines, medications, and naps can help improve sleep quality. Specific sections summarize findings on women's sleep, how their biology and life stages impact sleep, and the effects of poor sleep on health.
This document summarizes the key points from a sleep presentation. It discusses what constitutes normal sleep, common sleep disorders like insomnia, sleep apnea, and consequences of abnormal sleep. It also covers how lifestyle factors like routines, medications, and naps can help improve sleep quality. Specific sections summarize findings on women's sleep, how their biology and life stages impact sleep, and the effects of poor sleep on health.
This PPT aims to give Knowledge and Understanding about Sleep Talking, Types of Sleep Disorder, Stages of Sleep, Factor of Effecting Sleep Talking, Causes of Sleep Talking, Risk and Concern Associated with Sleep Talking, Diagnosis of Sleep Talking, Treatment of Sleep Talking.
The ABCs of Your ZZZs - Alison S. Kole, MD, MPH, FCCP, Pulmonologist Kerry K...Summit Health
Learn from our Sleep Disorder Center experts about the basics of good sleep and the physical impact of poor sleep. We will also discuss tips for improving sleep and the treatment options for common sleep disorders, such as sleep apnea, restless legs syndrome, and insomnia, among others.
This document discusses sleep disorders and provides information on various types of sleep disorders including dyssomnias, parasomnias, and disorders of sleep-wake schedules. It describes insomnia, hypersomnia, narcolepsy, sleep apnea, Kleine-Levin syndrome and other sleep disorders. It also discusses assessments and treatments for sleep disorders as well as nursing diagnoses and interventions to promote restful sleep.
Drug Treatment of Insomnia discusses the diagnosis and treatment of insomnia through both pharmacological and non-pharmacological means. It notes that insomnia is the perception of poor quality or inadequate sleep accompanied by distress or impaired function. Common patient populations with high rates of insomnia include women, the elderly, and those with psychiatric or medical disorders. Treatment includes lifestyle changes, cognitive behavioral therapy, and prescription medications like benzodiazepines, non-benzodiazepines, melatonin agonists, and the newer orexin antagonist suvorexant. A comprehensive sleep history should assess sleep patterns, quality, environmental factors, and behaviors to properly diagnose and treat insomnia.
Fibromyalgia is a chronic pain condition characterized by widespread muscle aches, pain and fatigue. While the exact cause is unknown, it involves dysregulation of the autonomic nervous system and neuroendocrine changes. The American College of Rheumatology diagnostic criteria includes widespread pain for over 3 months and tender points found in 11 of 18 sites. Treatment options with mild to moderate effectiveness include low-dose antidepressants, aerobic exercise and cognitive behavioral therapy, though more research is still needed on alternative therapies.
This document summarizes information about preterm labor prevention and treatment. It defines preterm labor and discusses risk factors like prior preterm birth, infections, and cervical length. Interventions discussed include progesterone supplementation, treating asymptomatic bacteriuria, and cervical cerclage for short cervix. Fetal fibronectin testing and transvaginal ultrasound are presented as tools to assess preterm labor risk based on cervical length and funneling.
The document discusses dementia, including its various types, symptoms, diagnostic criteria, assessment methods, and treatment options. It defines dementia as the loss of cognitive and intellectual function without impairment of perception or consciousness. The five major types of dementia are Alzheimer's disease, cerebrovascular disease, Lewy body disease, frontotemporal dementia, and Parkinson's disease with dementia. Assessment involves interviews, examinations, and tests to evaluate cognition, function, and rule out other conditions. Treatment focuses on enhancing quality of life and includes both non-pharmacological and pharmacological approaches.
This document outlines desirable components and characteristics for developing medical school cases for small group learning. It recommends that cases have clear, measurable learning objectives; content matched to the objectives; effective inserted questions to stimulate discussion; appropriate context and level; authentic problem scenarios; clear organization; appropriate length; high quality exhibits; up-to-date medical information; opportunities to use medical informatics; connections to other course content; and facilitator guides with discussion points. It also stresses obtaining feedback to improve cases.
The Role of Human Papillomavirus (HPV) Infection in Abnormalities of the CervixMedicineAndDermatology
The document discusses the financial burden that prescription drugs place on elderly patients. Only 75% of community dwelling Medicare beneficiaries have prescription drug coverage, and of those only half have continuous coverage over a year. The costs of prescription drugs are expected to reach $1.8 trillion from 2004-2013, far exceeding the allocated federal budget of $400 billion. The financial burden disproportionately impacts low-income elderly patients and can prevent them from affording necessary medications. The document outlines ways physicians can help elderly patients access affordable prescription drugs, such as utilizing patient assistance programs, state and local programs, and Medicare drug discount cards.
This document discusses medical considerations and recommendations for managing diabetes during Ramadan. It notes that fasting is prohibited if it poses health risks. For those with diabetes who choose to fast, risks include hypoglycemia, hyperglycemia, dehydration, and electrolyte abnormalities. It provides guidelines on fasting for those with type 1, type 2, or using insulin based on their risk level and treatment plan. Doctors should discuss concerns with patients and encourage frequent monitoring if fasting.
This document discusses HPV (human papillomavirus), its relationship to cervical cancer, and cervical cancer screening guidelines. It describes the different types of HPV and their risks, how HPV is transmitted, how infections typically progress, and methods of detection. The document also outlines cervical cancer screening guidelines and provides an introduction to colposcopy, using images to illustrate cervical abnormalities.
This document outlines four teaching formats to educate learners about developmental delay, mental retardation, pervasive developmental disorder, and autism:
1. Point of Care provides resources for immediate patient care and self-directed learning.
2. Morning Report discusses case studies highlighting key issues.
3. Noon Conference is a formal lecture presenting evaluation approaches and genetic testing options.
4. Self-Directed Learning is a web-based module teaching the basics through case-based examples. Each format identifies educational materials, pre-reading, teaching approaches, and evaluation methods.
This document discusses incorporating portable ultrasound technology into family medicine clerkship teaching. It describes how a 90-minute hands-on workshop is used to teach students basic ultrasound skills like identifying fetal anatomy and assessing the abdomen. Students practice scanning each other and sometimes make unexpected findings. Portable ultrasound can also be used in community outreach settings. The document provides resources for learning and teaching ultrasound skills pertinent to family medicine.
The USPSTF strongly recommends screening for colorectal cancer in adults aged 50-75 with fecal occult blood testing, sigmoidoscopy, or colonoscopy. It recommends against screening for ovarian and testicular cancer due to lack of evidence that screening improves outcomes and potential for harms from unnecessary procedures. For breast, lung, and prostate cancer, the USPSTF found insufficient evidence to recommend for or against routine screening due to uncertainty around benefits and harms of screening for certain age groups and cancer stages.
This study analyzed blood cultures from neonatal intensive care unit patients from 1997 to 2001 in Tripoli Medical Center, Libya. A total of 1431 blood culture sets from 1092 patients were positive for bacterial growth in 801 sets, representing 648 cases of neonatal bacteraemia. The most common causative agents were members of the Enterobacteriaceae family including Serratia, Klebsiella, and Enterobacter species as well as coagulase-negative and positive Staphylococci. Antibiotic susceptibility testing found high levels of resistance among the most frequent pathogens, though resistance to newer antibiotics like aztreonam and imipenem was less common. Resistance in Staphylococcus to anti-stap
This document outlines four formats for teaching approaches about Alzheimer disease: point of care, morning report, noon conference, and self-directed learning. For point of care, it suggests having web-based resources directly accessible in clinical settings to address common questions. The morning report format suggests discussing case-based materials covering major Alzheimer disease points, potentially using online teaching cases. For self-directed learning, it recommends online videos, comprehensive summaries of Alzheimer disease genetics from GeneReviews, and other resources.
This document provides guidance on screening, diagnosing, and managing hypertension through patient-centered care and therapeutic lifestyle changes. It presents a case study of a 45-year-old man with new onset high blood pressure and discusses further evaluation, initial recommendations, and follow-up based on guideline-recommended treatment goals. The document also addresses how care may differ based on patient characteristics and explores assessing psychosocial factors that could impact treatment.
This document discusses common causes of anemia by presenting several case studies and providing conceptual frameworks for evaluating patients. It covers increased red blood cell loss or destruction, decreased red blood cell production, plasma volume expansion, and maldistribution as primary causes. Specific conditions discussed include iron deficiency, hemolytic anemias, myelopathies, chronic kidney disease, and anemia of chronic disease. The importance of considering epidemiology and performing a full blood count with differential to form a differential diagnosis is emphasized.
This document discusses barriers to teaching addiction medicine in residency programs and strategies for overcoming them. It describes how a private foundation called MERF partners with family practice residencies to provide faculty development support through educational conferences and scholarships. This helps improve faculty expertise and attitudes, and allows for better integration of addiction curriculum that increases screening and treatment of substance use disorders. Evaluation found the program successfully increased faculty and resident knowledge and comfort with addiction medicine.
The document discusses community-acquired pneumonia (CAP), including common pathogens, signs and symptoms, diagnosis, and treatment options. The most common pathogens for typical CAP are Streptococcus pneumoniae, while atypical CAP is commonly caused by organisms such as influenza virus, Mycoplasma, and Chlamydia. Signs and symptoms include cough, fever, chills, dyspnea, and fatigue. Diagnosis involves a chest x-ray and labs such as a complete blood count and sputum/blood cultures. Treatment depends on severity and location (outpatient vs inpatient), but generally includes macrolides, fluoroquinolones, or doxycycline.
The document discusses community-acquired pneumonia (CAP), including common pathogens, signs and symptoms, diagnosis, and treatment options. The most common pathogens for typical CAP are Streptococcus pneumoniae, while atypical CAP is commonly caused by organisms such as influenza virus, Mycoplasma, and Chlamydia. Signs and symptoms include cough, fever, chills, dyspnea, and fatigue. Diagnosis involves a chest x-ray and labs such as a complete blood count and sputum/blood cultures. Treatment depends on severity and location (outpatient vs inpatient), but generally includes macrolides, fluoroquinolones, or doxycycline.
1. Multiple Sclerosis (MS) is a disease of the central nervous system that results in demyelination and damage to the protective covering of nerve fibers. It commonly causes visual issues, weakness, sensory problems, and other neurological symptoms.
2. The diagnosis of MS involves demonstrating dissemination of lesions in both time and space, either clinically or radiologically. The McDonald criteria from 2001 provides guidelines for diagnosing MS based on clinical attacks, MRI findings, and cerebrospinal fluid analysis.
3. Common symptoms of MS include visual problems, motor weakness, sensory issues like numbness and tingling, and bladder/bowel dysfunction. Symptoms vary depending on location of lesions in the brain and spinal
1. Multiple Sclerosis (MS) is a disease of the central nervous system that results in demyelination and damage to the protective myelin sheaths surrounding nerve fibers. Common symptoms include visual problems, muscle weakness, sensory issues, and coordination and balance issues.
2. The diagnosis of MS is based on clinical evidence of lesions in the brain and spinal cord disseminated in time and space. MRI and lumbar puncture are important tests to support the diagnosis.
3. There are different clinical courses of MS including relapsing-remitting, secondary-progressive, primary-progressive and progressive-relapsing. The McDonald criteria from 2001 is now commonly used to diagnose MS based on clinical and
This document provides information on smoking cessation and motivational interviewing techniques to help patients quit smoking. It discusses:
- The 5 A's approach to smoking cessation in primary care (Ask, Advise, Assess, Assist, Arrange).
- Stages of change model for behavior change, including precontemplation, contemplation and preparation stages.
- Motivational interviewing techniques like expressing empathy, developing discrepancy, avoiding arguments and rolling with resistance to help move patients through the stages of change.
- Using the 5 R's of relevance, risks, rewards, roadblocks and repetition when motivational interviewing with precontemplative and contemplative patients.
These simplified lecture slides by Dr Sidra Arshad offer a concise look at the cardiovascular effects of heart failure:
1. Define cardiac failure, its pathophysiology and clinical manifestations
2. Differentiate between the factors causing hyper-effective and hypo-effective heart functions
3. Differentiate between right and left heart failure based on their presentation
4. Outline the physiology of treatment of cardiac failure
Report Back from ASCO 2024: Latest Updates on Metastatic Breast Cancer (MBC)....bkling
Join Dr. Kevin Kalinsky, breast oncologist and researcher from Emory Winship Cancer Institute, to learn about the latest updates from The American Society of Clinical Oncology (ASCO) annual meeting 2024.
Interventional radiology is a medical specialty that uses imaging techniques, such as X-rays, CT scans, and ultrasound, to guide minimally invasive procedures to diagnose and treat a variety of conditions. These procedures can be an alternative to open surgery, often resulting in shorter recovery times for patients.
Lymphoma Made Easy , New Teaching LecturesMiadAlsulami
This lecture was presented today as part of our local Saudi Fellowship program. After three years of direct interaction with trainees and hematologists, I have started to develop an understanding of what needs to be covered. This lecture might serve as a roadmap for approaching and reporting lymphoma cases.
All the information you need to know about Hypothyroidism - Introduction,
Etiology, clinical manifestations, complications, pathophysiology,
diagnosis, treatment, precautions.
CASE PRESENTATION ON CEREBROVASCULAR ACCIDENT (ACUTE ISCHEMIC STROKE) WITH HE...Bhavana
This is a case presentation of a 70 year old female patient who was admitted in the hospital with the chief complaints of right sided upper limb and lower limb weakness and with mouth deviation towards the left, and nausea and fever.
These are the class of Drugs that are used to treat and prevent cardiac arrhythmias by blocking ion channels involved in cardiac impulse generation and conduction. Class I drugs like quinidine and procainamide block sodium channels to prolong the action potential duration, while Class IB drugs like lignocaine shorten repolarization. Class III drugs like amiodarone block potassium channels to prolong the action potential. Calcium channel blockers like verapamil inhibit calcium influx. Other drugs include adenosine for paroxysmal supraventricular tachycardia, beta blockers for supraventricular arrhythmias, and atropine for bradycardias. Adverse effects vary between drugs but include arrhythmias, heart block and QT prolong
Regenerative Medicine in Chronic Pain ManagementReza Aminnejad
Regenerative technologies are the future of medicine. The current clinical strategy focuses primarily on treating the symptoms but regenerative medicine seeks to replace tissue or organs that have been damaged by age, disease, trauma, or congenital issues.
Principles of Cleaning
Nonsurgical root canal treatment is a predictable method of retaining a tooth that otherwise would require extraction. Success of root canal treatment in a tooth with a vital pulp is higher than that of a tooth that is necrotic with periradicular pathosis. The difference is the persistent irritation of necrotic tissue remnants, and the inability to remove the microorganisms and their by-products. The most significant factors affecting this process are tooth anatomy and morphology, and the instruments and irrigants available for treatment. Instruments must contact and plane the canal walls to debride the canal.
Morphologic factors such as lateral and accessory canals, canal curvatures, canal wall irregularities, fins, cul-de-sacs, and isthmuses make total debridement virtually impossible. Therefore the goal of cleaning not total elimination of the irritants but it is to reduce the irritants.
Currently there are no reliable methods to assess cleaning. The presence of clean dentinal shavings, the color of the irrigant, and canal enlargement three file sizes beyond the first instrument to bind have been used to assess the adequacy; however, these do not correlate well with debridement. Obtaining glassy smooth walls is a preferred indicator. The properly prepared canals should feel smooth in all dimensions when the tip of a small file is pushed against the canal walls. This indicates that files have had contact and planed all accessible canal walls thereby maximizing debridement (recognizing that total debridement usually does not occur).
Principles of Shaping
The purpose of shaping is to
1) facilitate cleaning and
2) provide space for placing the obturating materials.
The main objective of shaping is to maintain or develop a continuously tapering funnel from the canal orifice to the apex. This decreases procedural errors when cleaning and enlarging apically. The degree of enlargement is often dictated by the method of obturation. For lateral compaction of gutta percha the canal should be enlarged sufficiently to permit placement of the spreader to within 1-2 millimeters of the corrected working length. There is a correlation between the depth of spreader penetration and the apical seal.5 For warm vertical compaction techniques the coronal enlargement must permit the placement of the pluggers to within 3 to 5 mm of the corrected working length.6
As dentin is removed from the canal walls the root is weakened.7 The degree of shaping is determined by the preoperative root dimension, the obturation technique, and the restorative treatment plan. Narrow thin roots such as the mandibular incisors cannot be enlarged to the same degree as more bulky roots such as the maxillary central incisors. Post placement is also a determining factor in the amount of coronal dentin removal.
Introduction of mental health nursing, Perspective of mental health and mental health nursing, Evolution of mental health services, treatment and nursing practices Mental health team, Nature and scope of mental health nursing, Role & function of mental health nurse inn various settings and factors affecting the level of nursing practice, concept of normal and abnormal behavior
A medical treatment that uses high doses of radiation to kill cancer cells or shrink tumors by damaging their DNA. When the DNA is damaged, cancer cells can no longer divide and grow, and they eventually die.
Artificial Intelligence, Synergetics, Complex System Analysis and Simulation ...Oleg Kshivets
5YS of local advanced non-small cell LCP after combined radical procedures significantly depended on: tumor characteristics, LC cell dynamics, blood cell circuit, cell ratio factors, biochemical factors, hemostasis system, anthropometric data, adjuvant treatment and procedure type. Optimal strategies for local advanced LCP are: 1) availability of very experienced thoracic surgeons because of complexity radical procedures; 2) aggressive en block surgery and adequate lymph node dissection for completeness; 3) precise prediction; 4) AT for LCP with unfavorable prognosis.
CASE PRESENTATION ON ACUTE GASTROENTERITIS.Bhavana
This is a case presentation of a 72 year old female patient who was admitted in the hospital with the chief complaints of loose stools since 6 Days and generalised weakness and history of one episode of vomiting (one day back).
VARSHA 4TH YEAR BSC NURSING ALL PAPER SAURASHTRA UNIVERSITY .pdf
Insomnia Presentation
1. SLEEP and INSOMNIA Lynn N. Stewart, M.D. Travis County Wellness and Health Clinic Austin, TX
2. Objectives By the conclusion of this lecture, you will be able to: Learn about the process of sleep Identify 4 main categories of insomnia Classify insomnia by stage List at least 5 common etiologies of insomnia Discuss 5 or more principles of sleep hygiene Give 5 guidelines for drug therapy
3. Why do we care about sleep? Sleep is a necessary restorative process that affects all aspects of functioning. Sleep is an active process for the brain. Early in sleep slow-rolling eye movements occur (non-rapid eye movement). Later—deeper in sleep–rapid eye movements (REM) are associated with irregular breathing and increased heart rate
4. Sleep Stages and their function Non-rapid Eye Movement (NREM) Stage 1: transition to sleep 5% total time Stage 2: 50% total time Stages 3 and 4: slow-wave sleep 10-20% total sleep time Restful and restorative sleep achieved here Rapid Eye Movement (REM) 20-25% total sleep time
5. Sleep Cycle and Architecture Normal, healthy people start with NREM1 then NREM 2, 3, 4, 3, 2, and then REM. Cycle repeats at 90-120 minute intervals Total cycle repeats 3-4 times a night NREM 3 and 4: more prominent is first half of the night, and decrease later on. REM: less prominent in the early night, and increases as the night progresses
6. Sleep at different ages Sleep varies with age Infants sleep 66% of the day; adults, 33% Elderly have a reduction in the depth, intensity , and continuity of sleep: Increased sleep latency Decreased REM latency Reduced NREM 3 and 4 Reduced total REM amount Frequent awakenings
7. So what keeps us awake? The Reticular Activating System (RAS) of the brain plays is mostly responsible for keeping us awake and alert. Narcolepsy is a clinical syndrome of daytime sleepiness with cataplexy (bilateral muscle weakness leading to partial or complete collapse), hypnagogic hallucinations, and sleep paralysis, and is associated with disordered REM sleep. Not all are required for the syndrome. A loss of orexin and hypocretin neuropeptides is typically found.
8. Types of Insomnia Is the problem not being able to fall asleep? -> Problems falling asleep are referred to as problems with “sleep latency.” Is the problem staying asleep? -> Problems staying asleep are referred to as problems with “sleep maintenance.”
9. Why Are We Talking About This? Up to 40% of adults are affected 1/3 adults are affected intermittently 10% are chronic Treatment alone costs $2-11 billion Total financial impact: $35 billion Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep Medicine Review. Sleep. 1999;22:1134-1156 Silber MH. Chronic insomnia. N Engl J Med. 2005;353:803-810 Saul S. Record sales of sleeping pills are causing worries. New York Times. Feb 7, 2006.
10. Definition The subjective experience of inadequate or poor quality sleep “I’M UP” I - difficulty I nitiating sleep M - difficulty M aintaining sleep U - U nrefreshing sleep P - P remature awakening
11. Daytime Consequences Tiredness and lack of energy Poor concentration and performance Irritability and/or depression Feeling unwell Less able to enjoy life Increased illness
12. Real Consequences Absenteeism Presenteeism Social disability Increased healthcare utilization Fewer promotions Auto accidents Insomniacs have 2.5x more accidents due to fatigue Depression
13. Real Consequences Sleep deprivation (less than 6 hours of sleep a night) is an independent predictor of future weight gain AND obesity in women. RR=1.32 for gaining >15kg (>33#) over 16 years for those who sleep 5 hours/night; RR=1.12 for 6 hours/night when compared against those who slept 7 hours/night (after adjusting for exercise and caloric intake). Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Family Practice News 36 (15 Oct 2006):44.
14. Sleep Deprivation Inadequate opportunity for sleep Feel sleepy during the day insomniacs typically feel tired, not sleepy Fall asleep at inappropriate times Such as while driving, at work during an interview, while at family events.
15. Hyper Arousal State from Insomnia Increased (short-term only) : Metabolic rate Heart rate Temperature Catecholamine metabolites Stress hormone levels Fast EEG activity (electrical recording of brain activity=Electro Encephalo Gram)
16. Risk Factors for Insomnia Prior episode Female gender (1.3x) Age > 65 (1.5x) half the population over age 65 40% of all hypnotic scripts Snoring Depression (which comes first?) Lower socioeconomic status Divorce / Separation Widowhood Concurrent medical problems
17. Stages of Insomnia Transient: < 4 nights (days to weeks) Acute: > 2 nights a week for 2 weeks Chronic: 3 or more nights a week, for 4 or more weeks (months to years) Critical: The inability to sleep during lectures
18. Psychiatric Causes of Insomnia Depression Generalized Anxiety Disorder Stress Post Traumatic Stress Disorder Obsessive Compulsive Disorder Adjustment disorders Personality disorders Bipolar disorder Dysthymia Anxiety Psychosis including schizophrenia
20. Medical Causes of Insomnia Genitourinary Benign Prostatic Hypertrophy Nocturia Incontinence Endocrine/Metabolic Hormonal disruptions Menopause Thyroid disease Endocrine hormone-secreting tumors Neurologic Alzheimer’s Huntington’s Parkinson’s Central Sleep apnea Seizures Headaches (cluster, migraine) Fatal Familial Insomnia (yes, it is fatal, and familial) You’d already know about it if it is in your family
21. Dyssomnia Dyssomnias are sleep disorders characterized by insomnia, excessive sleepiness, or abnormal sleep-wake timing Sleep Disorders Restless Legs Trouble falling asleep Patient very aware of movement/sensations Periodic Limb Movement Disorder Unrefreshing sleep, hypersomnia Leg contractions during stages 1 & 2 Patient usually unaware of movement
22. Intrinsic Dyssomnia Psychophysiological insomnia Sleep state misperception Idiopathic insomnia Narcolepsy Hypersomnia Recurrent, idiopathic, post-traumatic Restless legs syndrome Obstructive sleep apnea syndrome Central sleep apnea syndrome Central alveolar hypoventilation syndrome Periodic limb movement disorder Intrinsic sleep disorder NOS
24. Circadian Dyssomnia Time zone change (jet lag) syndrome Shift work sleep disorder Irregular sleep-wake pattern Delayed sleep phase syndrome Advanced sleep phase syndrome Non-24-hour sleep-wake disorder Circadian rhythm sleep disorder NOS Shifts with age (adolescent or elderly)
25. Parasomnias Parasomnias are sleep disorders characterized by abnormal behavioral or physiological events which occur during sleep or during sleep-wake transitions. Parasomnias typically do not cause insomnia or excessive sleepiness, but some are dangerous to the patient or others. Most are “normal” if done while awake More common in children than adults Most do not require therapy
26. Parasomnias Continued Arousal disorders: Confusional arousals Sleepwalking Sleep terrors Sleep-wake transition disorders: Rhythmic movement disorder Sleep starts Sleep talking Nocturnal leg cramps Parasomnias usually associated with REM sleep: Nightmares Sleep paralysis Impaired sleep-related penile erections Sleep-related painful erections REM sleep-related sinus arrest REM sleep behavior disorder
27. Parasomnias Continued Parasomnias NOS Sleep bruxism (tooth grinding) Sleep enuresis (bed-wetting) Sleep-related abnormal swallowing syndrome Nocturnal paroxysmal dystomia Sudden unexplained nocturnal death syndrome Primary snoring Infant sleep apnea Congenital central hypoventilation syndrome Sudden infant death syndrome Benign neonatal sleep myoclonus Other parasomnia NOS
29. Behavioral Causes Poor sleep hygiene (more later) Psychophysiologic Learned behavior Worring about getting to sleep/ trying too hard to sleep Leads to increased anxiety and arousal Perpetuates insomnia
30. Diagnosis The medical interview is everything focus on underlying causes Sleep partner should be present for the interview if possible Full medication list is required Be prepared to ask very direct questions about substances and alcohol use
31. Medical Interview Current state of complaint Onset, duration, frequency of insomnia Sleep history… is the trouble with: falling asleep? maintaining sleep? not being able to go back to sleep once up? early awakenings? not feeling rested?
32. Medical Interview Daytime consequences can you function/stay awake to drive? Do you experience (or bed-partner report): Leg or arm jerking while asleep? Loud snoring/gasping/choking, or stopping breathing when asleep? Uncomfortable feelings in your legs that go away with moving them?
33. Sleep Habits Usual bedtime Usual morning awakening time Time spent in bed awake prior to sleeping, and following the onset of sleep Estimated time spent asleep Do you take anything to make you sleep? Do you drink to help you go to sleep? What else do you do in your bedroom?
34. Sleep Habits Anything disruptive to sleep? Infants Noises Lights Snoring partner Partner with different bed/wake times TV Pets Not feeling safe where you sleep
35. Sleep Habits (bad!) Do you consume: nicotine, caffeine, alcohol, other stimulants, decongestants prior to bedtime? Half lives are important! t 1/2 nicotine = 1 hour, t 1/2 caffeine = 6 hours, t 1/2 alcohol depends on how much you’ve had Do you smoke/eat when you wake up, or perform other tasks like cleaning? Do you check the clock when you wake up? What is your pre-bedtime routine: exercise, work, TV, eating?
36. Half-lives: why you can’t go to sleep at 10pm if your last coffee was at noon.
37. What’s New With You? Medical issues Medication changes Lifestyle issues Work stress School stress Financial stress Relationship changes/stress Complaints from partner
38. Physical Exam For primary insomnia there are no characteristic exam findings Evaluate for symptoms/findings that suggest an underlying explanation
39. Sleep Diaries Usually kept daily for 1-2 weeks Help delineate variability in sleep from day-to-day May identify contributing factors May help patient more accurately perceive sleep
40. Sleep Diaries Bedtime Time to sleep onset Number of awakenings Time out of bed in morning Total sleep time (estimated) Use of sleep medications or other substances Quality of sleep Daytime symptoms Caffeine log Exercise log
42. Example Sleep Patterns 6.0 hours Yes 2+ 45 Depression Or anxiety ~5.5 hours 7.5 hours Total Time Asleep Yes No Early Morning Awakenings 6 2 Awakenings 45 10 Sleep onset (minutes) Insomnia Normal
43. Treatment Goals Alleviate underlying problems Prevent progression from acute to chronic Improve quality of life Treat depression Treat medical conditions Limit all medications whenever possible
44. Acute Insomnia Often does not require treatment Should be treated when: Daytime consequences warrant treatment Episodes last more than a few days Episodes become predictable Treating acute insomnia may help promote sleep hygiene Get a sleep diary from the patient
45. Chronic Insomnia Usually requires many different approaches Treat underlying condition first May need behavioral and pharmacologic therapy Treatment should be collaborative Get a sleep diary from the patient
46. Sleep Hygiene Hygiene: from where is the term derived? Hygeia (also Hygea, Hygia, Hygieia) This is derived from the name of the Greek goddess of health known as Hygeia the daughter of Aesculapius/Asklepios and sister to Panacea. While her father and sister were connected with the treatment of existing disease Hygeia was regarded as being concerned with the preservation of good health or the prevention of disease.
47. Sleep Hygiene--Basics Don’t spend excessive time in bed, including daytime napping. Get into bed when sleepy. Maintain a regular sleep/wake schedule Bed is for sleep and sex only, not TV! Increase exercise and fitness Avoid caffeine and nicotine at least 4-6 hours before going to bed.
48. Sleep Hygiene--Basics Never use alcohol to go to sleep. It induces sleep, but causes frequent awakenings Decreases REM sleep, increases stages 3 & 4 Chronic use causes insomnia, which can persist up to a year after cessation of all drinking Avoid excessive liquids or a heavy meal in the evening. Minimize noise, light, and temperature extremes during sleep. Move alarm clock away from bed if it is distracting
49. Sleep Hygiene--Relaxation Plan a relaxation period before bed, develop a bedtime routine. Attempts to address somatic and cognitive arousal Relaxation Therapy: Progressive muscle relaxation EMG Biofeedback Meditation Imagery training Self-hypnosis Diaphragmatic breathing
50. Sleep Hygiene—Sleep Restriction If unable to fall asleep within an acceptable amount of time (15-20 min), leave the bedroom, engage in a relaxing activity until sleepy, and then return to bed. This is called sleep restriction Repeat as necessary. Boring activities (reading the phone book) count. TV/video games doesn’t count as relaxing or boring—the flashing lights stimulate the brain.
51. Sleep Hygiene—Sleep Restriction Sleep Restriction Therapy Track average total sleep time per night Spend only this amount of time in bed; minimum being 4.5 hours. Once 90% of time in bed is spent asleep (sleep efficiency), increase total time in bed by 15 minutes every 5-7 days.
52. Sleep Hygiene—Sleep Restriction If sleep efficiency falls to less than 80%, decrease time in bed by 15 minutes Work set, daytime hours (whenever possible). As sleep consolidation improves, time in bed (and asleep) increases. Creates a mild state of sleep deprivation, and thus promotes more rapid sleep onset and more efficient sleep.
53. Sleep Hygiene—Cognitive Therapy Cognitive Therapy works to change beliefs about insomnia: Misconceptions about the causes Performance anxiety and loss of control over the ability to sleep Unrealistic sleep expectations Identify and replace dysfunctional beliefs and attitudes about sleep For example, questioning the idea that you must sleep 8 hours to function effectively
54. Behavioral Therapies Reliable and enduring improvements for chronic insomniacs Sleep latency insomniacs fell asleep faster than 81% of untreated controls Sleep maintenance insomniacs slept longer than 74% of untreated controls May be used in combination with other techniques or medications
55. Stimulus Control Therapy Based on premise that insomnia is a conditioned response based on cues associated with sleep Trains the brain to associate the bed / bedroom with sleep Leave the bedroom if not sleeping within 15-20 minutes Effective for sleep onset and sleep-maintenance
56. Other Therapies Regular exercise Helpful if timed in the late afternoon Any exercise, regardless of time of day, helps Promotes sleep depth and quality May be stimulating if done in closer to bedtime Phototherapy Exposure to daytime bright light is helpful in treating those with slow or fast circadian cycles May be especially helpful in the elderly
57. What works best? Multicomponent cognitive behavior therapy works better than both placebo and pharmacotherapy (medicines) in short and long term cases. Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med . 2004; 164: 1888-1896 Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatr . 1994; 151: 1172-1180. Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. J Consult Clin Psychol . 1995; 63:79-89.
58. If you have to use drugs: Pharmacotherapy Guidelines Use the lowest therapeutic dose Use for the shortest duration necessary Discontinue medication gradually Be alert for rebound insomnia Use agents with short half-lives to minimize daytime sedation
59. Drugs that make you sleep Drugs that make you sleep are called “hypnotics”. There are many types of hypnotics: Sedating antihistamines (over the counter) Herbals (over the counter) Benzodiazepines (prescription/controlled) Benzodiazepine-Like (prescription/controlled) Melatonin receptor agonists (prescription) Antidepressants (prescription) Antipsychotics (prescription)
60. Over the Counter Medicines—FDA approved and regulated Sedating antihistamines: diphenhydramine (Benadryl) and doxylamine Nighttime Sleep Aid Sleep Aid Liqui-Gels Maxium Strength Unisom Nighttime Sleep Aid Tylenol PM
61. OTC Medicines—FDA approved and regulated Sedating antihistamines continued: Not addictive, but tolerance develops quickly Daytime sleepiness, anticholinergic side effects common Dry mouth, constipation, urinary retention, memory impairment, confusion (dries up sinuses if post nasal drip is what keeps you up)
62. OTC Medicines--herbals Not FDA regulated: Valerian root Used for anxiety, and as a sleep aid Dosing uncertain Powerful odor Kava-kava Can cause liver failure Dosing uncertain Sateia MJ, Nowell PD. Insomnia. Lancet . 2004; 364:1959-1973
63. OTC Medicines--herbals Melatonin—hormone made by the pituitary gland in the brain (at night/when dark) Best for shift work/jet lag; shifts sleep to dark hours Schenck CH, Mahowald MW, Sack RL. Assessment and management of insomnia JAMA 2003;289:2475-2479. For insomnia not related to shift work/jet lag, there is NO convincing evidence it works. Silber MH, Chronic insomnia. N Engl J Med. 2005;353:803-810 Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of primary insomnia with melatonin: a double-blind, placebo-controlled, crossover study. J Psychiatry Neurosc. 2003; 28: 191-196
64. Prescription Medicines: Benzodiazepines Non-selectively bind to the benzodiazepine-GABA (Gamma-AminoButyric Acid) receptor complex in the brain Effective in inducing, maintaining, and consolidating sleep; and in decreasing daytime consequences of insomnia
65. Prescription Medicines: Benzodiazepines Side effects include daytime drowsiness, anterograde amnesia, impairments in memory and psychomotor performance. Addiction, habituation, tolerance, rebound insomnia, withdrawal symptoms, anxiety can all occur with benzo use When combined with alcohol, benzodiazepines can be deadly. Increases fall risk in the elderly (and concomitant hip fractures)
66. Prescription Medicines: Benzodiazepines No one medicine in the class works any better than any other medicine. Those with a short half-life work better for those who have trouble falling asleep Those with a longer half-life work better for those who cannot stay asleep No benzodiazepine is FDA approved for chronic use (think vioxx)!
67. Presciption Medicines: Benzodiazepines—how they work Generic name (brand)--duration/onset of effects used for Triazolam (Halcion) – short/rapid sleep onset insomnia; pregnancy category X Estazolam (ProSom) – intermed/rapid both sleep onset and maintenance insomnia; preg category X Temazepam (Restoril) – intermed/slow Sleep maintenance; pregnancy category X Flurazepam (Dalmane) – long/intermed Sleep maintenance—active metabolite for over 100 hours; X Quazepam (Doral) – long/intermed Sleep maintenance—active metabolite for over 100 hours
68. Prescription Medicines: Benzodiazepine Information 10-15% of users take them regularly for more than a year (not FDA approved) Many patients (not all) develop physical dependence and/or tolerance Once an effective dose is established, higher doses typically only increase side effects Sudden withdrawal can be dangerous to the patient
69. Prescription Medicines: Benzodiazepine Contraindications Pregnant women (most are category X) Untreated sleep-related breathing disorder Alcohol or substance abuse Patients who might need to awaken and function during their normal sleep period Parents, doctors, fire-fighters, etc. Monitor those with hepatic, renal, or pulmonary disease; and use with caution
70. Prescription Medicines: Benzodiazepine-Like Benzodiazepine-Like medicines selectively bind to the benzo-GABA receptor. The benzos we learned about before are non-selective; there should be fewer side effects with the Benzo-Like meds than true benzos. Exact mechanism of action is unknown Help people go to sleep (sleep latency), and stay asleep (sleep maintenance).
71. Prescription Medicines: Benzodiazepine-Like Eszopiclone (Lunesta)—intermed/rapid Sleep maintenance (metallic taste); pregnancy category C Zolpidem (Ambien)—short/rapid Sleep latency; side effects include: sleepwalking, sleep-related eating disorder; pregnancy category B (?C) Zolpidem controlled release (Ambien CR)—intermed/rapid Sleep latency, sleep maintenance; pregnancy category C Zaleplon (Sonata)—ultrashort Sleep latency, can take in the middle of the night if you awaken; pregnancy category C
72. Prescription Medicines: Benzodiazepine-Like Zolpidem (Ambien) and Zaleplon (Sonata) Zolpidem t ½ = 2.5 hours; no residual effects if taken 5 hours before awakening; works well for freq. awakenings; Preg. B, and generally regarded safe in nursing Zaleplon t ½ = 1 hour; no residual effects if taken > 2 hours before awakening; works well for terminal insomnia; Preg. C Relatively new = relatively expensive
73. Prescription Medicines: Melatonin-Receptor Agonist Ramelteon (Rozerem)—short duration: 1-2.5 hrs Sleep latency, not sleep maintenance may increase prolactin levels (meaning you may lactate—typically undesired, especially in men) Dizziness, nausea, headache all common No dependence, withdrawal, or rebound insomnia! NOT a controlled substance New medicine, long-term effects unknown; pregnancy category C, activity not through GABA receptor complex Do not take after a high-fat meal
74. Prescription Medicines: Other Drugs (antidepressants) Amitriptyline (Elavil) Tricyclic antidepressant, inhibits norepinephrine and serotonin uptake in the CNS—pregnany category C Doxepin (Adapin) Tricyclic antidepressant, inhibits norepinephrine and serotonin uptake in the CNS—pregnancy category C Trazadone (Desyrel) sedating antidepressant (non-TCA/non SSRI)—cat. C Mirtazapine (Remeron) Sedating antidepressant, antagonizes alpha2-adrenergic and serotonin 5-HT2 receptors (tetracyclic)—pregnancy category C
75. Prescription Medicines: Other Drugs (antidepressants) Antidepressants only work well if patient is depressed; otherwise, trazadone and elavil work, but not as well as Ambien (Benzo-Like). Should not be used in combination as a sleep aid if the patient is taking some other form of antidepressant. Antidepressants used as sleep aids are not addicting. Antipsychotics should only be used in psychotic patients or occasionally the elderly in an institutional setting, if they cannot tolerate other medicines
76. If all else fails If your bed partner sleeps well, but keeps you up by snoring, moving, coughing, etc., sleep in a different bed or in a different room.
77. Summary Be alert for symptoms of insomnia and depression Determine specific type of sleep problem Make a differential diagnosis Don’t neglect behavioral therapies Pay attention to onset of action/duration of effect of all medicines used Teach ALL insomniacs proper sleep hygiene
78. References 1) AAFP and American Academy of Sleep Medicine Monograph “Strategies for Managing Insomnia” 1999 2) Roth T, Roehrs T. Insomnia: Epidemiology, characteristics, and consequences. Clin Cornerstone 2003;5(3):5-15 3) Neubauer DN. Pharmacologic approaches to the treatment of chronic insomnia. Clin Cornerstone 2003;5(3):16-27 4) Smith MT, Neubauer DN. Cognitive behavior therapy for chronic insomnia. Clin Cornerstone 2003;5(3):28-40 5) Kupfer DJ, Reynolds CF. Management of Insomnia. NEJM 1997;336:341-46
79. References 6) National Center on Sleep Disorders Research… Insomnia: Assessment and Management in Primary Care. NIH/NHLBI, 1998: 1-16 7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine. 1998;19:157-68 8) Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997;154:1417-1423 9) Krystal AD. Insomnia in women. Clin Cornerstone 2003;5(3):41-50 10) Ward SH, Ward LD. The evaluation and management of insomnia in primary care. Patient Care . July 2006;40:46-55. 11) Gritz BF. “Overview of Insomnia” CME-TAFP Primary Care Lecture Series. Dec 6, 2006.