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Define primary insomnia:
- Difficult initiating or maintaining sleep, or nonrestaurative sleep
- ≥3/wk for ≥1 month (ie chronic)
- not occur in the presence of a mental or comorbid medical condition
- causes next-day functional impairment
If insomnia is not >30d, what else is required to meet def'n?
Must have significant neurobiological or functional impairment
List 3 different patterns of insomnia:
- Frequent awakenings during the night (sleep maintenance)
- awakening in the small hours
- Nonrestorative sleep
- Daytime impairment
- Difficulting initiating sleep
2 medical conditions that can lead to insomnia:
- Periodic limb movement disorder
- Resltess leg syndrome
- Nocturnal panic attacks
Two things you can ask patients to do when they present with acute insomnia?
- Sleep diary (www.sleepfoundation.org - sleepiness diary)
- Complete an Epworth Sleepiness Score (www.standford.edu/~dement/epworth.html)
3 kinds of functional impairment in insomnia?
- *most ppl cope very well with little sleep
- -fatigue or malaise
- social/vocational/school impairment
- mood disturb or irritable
- daytime sleepiness
- reduced motivation, energy
- error-prone, accidents at work or driving
- tension headaches or GERD 2/2 sleep loss
- sleep concerns
- Interpersonal deficits - irritability, impatience
- decreased creativity
Additional questions on history important to include in a sleep Hx?
- type of problem - nature, frequency, severity
- AbN events during sleep - leg movements, snoring, etc
- Daytime fxn - napping, drowsiness
- Sleep hygiene
- beliefs about sleep
- past sleep patterns
- onset and worsening of problem
3 suggestions for stimulus control advice for insomnia?
- Don't go to bed until you are sleepy
- Use bed/bedroom only for sleep and intimacy
- Get out of bed when you are unable to sleep after 15 minutes - do something relaxing
- Get out of bed the same time every morning
- Don't nap during the day
List 3 suggestions for improved sleep hygiene
- Sleep only as much as you need to feel refreshed the next day
- Exercise regularly
- Bedroom comfortable, dark and quiet
- Eat regular meals, don't go to bed hungry
- Avoid drinking too many fluids in the evening
- Reduce your caffeine intake
- Avoid drinking alcohol - espy evening
- Avoid cigarettes
- Don't try too hard to fall asleep
- Put the clock under the bed or face it away from you so you can't see it
Cancer Prevention - Ideal BMI to reduce risk?
18.5 to 24.9
Cancer prevention - ideal exercise?
- Moderate-to-vigorous levels of physical activity
- ≥ 30 min/ day
- ≥ 5 days/wk
- (shown to reduce CRC and BRCA)
Cancer prevention - 2 types of food to eat more of?
- Eat less of processed and red meats - strong association with CRC
- Eat more:
- Fruits (3-4/d), vegetables (4-5/d), whole grains (6-8/d)
- All fibre rich with nutrients and phytochemicals = anti-caricinogenic
Cancer prevention - how much alcohol to drink?
- Increased cancer risk with >2/d males, >1/d females
- So max 2/d Males and 1/d Females respectively
- (*zero for head and neck Ca survivors)
DEMENTIA - 6 main steps for assessing
- 1) Pt Hx
- 2) Collateral family/caregiver Hx
- 3) PE
- 4) Brief cognitive test
- 5) Basic labs
- 6) Structural imaging (if certain criteria met)
DEMENTIA - Specific items on Hx for each area in regard
- Evolution of illness: gradual/insidious (AD) vs. stepwise (Vascular)
- Habits - EtOH abuse, smoking Hx
- FHx - dementia, FHx CVA
- PMHx - vascular events (CVA), renal failure, HTN, DM, lipid status or repetitive head trauma
- (Vascular RF's - HTN, DM, Smoking, FH CVA, Lipid status)
DEMENTIA - Visual hallucinations and fluctuant course - what will you look for on PE?
Parkinsonian features - hyperreflexia, rigidity, extensor plantar responses, frontal gait apraxia
DEMENTIA - Name 2 other tests of cognitive fxn beside Folstein MMSE?
- 7-minute screen
- General Practitioner Assessment of Cognition
- Behavioral Neurology Assessment
DEMENTIA - In addition to memory impairment, Dx requires at least 1 of 4 other cognitive domains be impaired. Name them.
- LANGUAGE (expressive or receptive)
- GNOSIS (ability to recognize objects, faces or other sensory info)
- EXECUTIVE FXN (abstraction, reasoning, judgement)
- PRAXIS (learned motor sequence)
DEMENTIA - What is the DDX for cognitive disorders, besides Alzheimer disease?
- Vascular Dementia
- Frontotemporal dementia
- Dementia associated with Parkinson disease or with Lewy Bodies
DEMENTIA - Of the following, which tests are basic workup? Selectively applied? Insufficent evidence?
- CBC, Lytes, FBG, Genetic testing - Apolipopr- E gene
- HIV Ig, HomoCysteine levels
- RBC folate, Serum B12, Serum calcium, Serum folic acid,
- Syphillis, TSH
- CBC - basic
- Lytes - basic
- FBG - basic
- Genetic testing - insufficient evidence
- HIV Ig - insufficient evidence
- HomoCys - insufficient evidence
- RBC folate - insufficient evidence
- Serum B12 - selectively
- Serum calcium - basic
- Serum folic acid - insufficient evidence
- Syphillis - selectively
- HIV Ig - selectively
Basic for all patients
CBC, Serum Ca, Electrolytes, FBG
Selectively chosen based on PMHx, cognitive and PE
- Syphillis screening
- HIV Ig
- Serum B12
Insufficient evidence to recommend testing of:
- RBC folate
- Serum folic acid levels
- HomoCysteine levels
- Genetic testing - Apolipopr E gene
DEMENTIA - What are specific recommendations for neuroimaging - age?
Age < 60 yrs
DEMENTIA - neuroimaging recommendations for PMHx?
- Recent and significant head trauma
- History of Ca (esp'ly types that metastasize to brain)
DEMENTIA - neuroimaging recommendations for Meds?
Use of anticoagulations or Hx of bleeding d/o
DEMENTIA - neuroimaging criteria for HPI?
- Rapid ( over 1 or 2 months) unexplained decline in cognition or fxn
- Short duration of dementia (< 2 years)
- Unexplained neurologic Sx (severe h/a, seizures)
- Hx urinary incontinence or gait disorder (= NPH)
- Unusual or atypical cognitive Sx or presentation (progressive aphasia)
DEMENTIA - neuroimaging criter on PE?
- Any new localizing sign (hemiparesis, etc)
- Gait disturbance
DEMENTIA - All Criterias for CT Head for dementia
- <60 yrs
- Recent and signify head trauma
- Hx of cancer
- Anticoagulated or bleeding d/o
- Rapid (< 2 mos) unexplained decline
- Short duration of dementia (< 2 years)
- Unexplained neuro Sx
- Hx urinary incontinence and gait d/o (NPH)
- Unusual or atypical cognitive Sx or presentation
- Any new localizing sign
- Gait disturbance
Clinical features suggesting presence of delirium?
- Disturbed consciousness (sleepy)
- Disturbed attention (rambling, agitated)
- Disturbed cognition (disoriented, incoherent, shouting, hallucinaitons)
- Altered sleep-wake cycle
- Acute onset
- fluctuating coarse
- end-stage illness
Delerium - 2 categories of end-of-life delirium? Salient features of each.
- Hypoactive - psychomotor retardation, lethargy, sedation, reduced awareness
- hyperactive - agitated, hypervigilance, hallucinations, delusions
- (3rd - mixed)
End of life delirium - 5 nonpharmacological and supportive strategies to reduce terminal delirium?
- Minimize immobilizing catheters, IV lines and restraints
- Avoid immobility, early mobilization
- Monitor nutrition
- Provide visual and hearing aids
- Monitor closely for dehydration
- Control pain
- Review medications
- Monitor bladder and bowel fxn
- Reorient communications with patient
- Objects to reorient patient (clocks, familiar objects)
- Cognitively stimulating activities
- Sleep hygiene measures
- Quiet at night
What is the most suitable medication for end-of-life delirium (none are approved, but certain have been shown to be safe and effective)
- 1st - Haloperidol most acceptable for delirium near end of life (+/- lorazepam for severe agitation)
- 2nd - chlorpromazine acceptable alternative
At which doses of haloperidol do EPS risks increase?
- Increase EPS > 4.5 mg/d (vs. atypical anti-psychotics)
- Decreased EPS < 3.5 mg/d (vs. atypicals)
30% of dying patients with delirium aren't well controlled with antipsychotics - what others meeds work?
- Benzodiazepines - midaz, lorazepam
What is the evidence for meds for hypoactive delirium?
Very little - no recommended meds
Delerium - DSM-IV Criteria
- Disturbance of consciousness, attention, cognition
- abrupt onset
- fluctuating course
- related to medical causes
4 Causes of delirium?
- Fecal impaction
- Bladder retention
- Anticholinergic meds/ med interactions
- Sepsis, organ failure
OBESITY - screening in adult?
BMI and waist circumference if BMI 25-35
OBESITY - mental health consequences of obesity?
depression, anxiety, personality d/o, self-esteem
OBESITY - mechanical health consequences of obesity?
OA, OSA, GERD, Urinary incontinence, intertrigo, falls and fractures
OBESITY - metabolic health consequences of obesity?
DM, DLP, fatty liver, HTN, Cancer, PCOS/Infertility, gallbladder disease
OBESITY - List 4 things of assessment on Hx?
- Weight history
- Weight loss history
- Psychiatric assessment
- Motivation/readiness for change
- barriers to weight loss/maintenance
- social history
- workplace/disability/insurance/support systems
OBESITY - List 4 meeds associated with weight gain
- Psychiatric - antidepressants (TCA, MAOI, specific SSRIs), antipsychotics, lithium
- Anticonvulsants - valproic acid, carbamazepine
- Steroids - corticosteroids, estrogen and progesterone
- Insulin and most oral hypoglycaemic agents
- Highly active retroviral therapy
OBESITY - List 4 barriers to weight management
- 1) SES - can't afford equipment/gym/supplements, etc
- 2) Emotional - depression, OCD, addictions, psychosis, borderline PD
- 3) Comorbidities - a. ADHD, b. poor dentition, c. urinary incontinence, d. fecal incontinence, e. colitis f. CV and Resp disease - limits exercise. g. pain
- 4) Lack of time - most common
- 5) Saboteurs - esp. big wgt difference b/w partners.
- 6) Sleep disorder
- 7) Night eating, binge eating
OBESITY - Name 5 Stimulus Control Techniques to reduce hunger/overeating
- do not allow yourself to become starving
- 3 meals/day, same time and place
- eat while seated with full place setting
- eliminate distractions
- use small plates
- focus on the food and the sensation of fullness
- do not place cooking containers with food on the table
- cook small amounts of food
- eat slowly, take breaks, put down utensils
- shop after eating
- clean plate into garbage
- avoid second serving
OBESITY - 3 medical/surgical treatments
- 1) Orlistat (Xenical)
- 2) Sibutramine (Meridia)
- 3) Bariatric surgery
OBESITY - Indications, dose, outcomes of Orlistat
- BMI > 27 with complications from wgt OR BMI > 30
- Orlistat 120mg TID ac meals
- Inhibits pancreatic lipase - increases faecal excretion of fat
- Wgt loss of 2-2.5kg, 30% reduction of DM type II
OBESITY - Contraindications/Not suitable for Orlistat
- High calories from non-fat sources - CHOs or EtOH
- dietary inconsistencies
OBESITY - Dose and MOA of Sibutramine (Meridia)
- Meridia 10-20mg PO qD
- Increased satiety, SNRI. Can't use with anti-depressants
- ?same indications as for orlistat
OBESITY - Indications for Bariatic surgery
- >45kg over IBW
- BMI > 40 x 5+ years
- BMI > 35 with comorbidities for 5+ years
DRY EYES - Dx for dry, gritty eyes x 3/12, dry mouth, conjunctival injection, clouding cornea, fissures over mucous membranes?
DRY EYES - What labs would you order to confirm your diagnosis? List 3.
- Antinuclear antibody (ANA)
- Anti-SSA (Ro)
- Anti-SSB (La)
- Rheumatoid factor
DRY EYES - Name an eye test that could evaluate this patient's eye symptoms.
Schirmer test or rose bengal test
DRY EYES - List 3 treatment options for dry eyes.
- 1) Artificial tears ( non-preservative are better)
- 2) Pilocarpine (muscarinic)
- 3) Cevimeline (muscarinic)
DRY EYES - List 3 treatment options for dry mouth.
- Daily fluoride use and sour lemon lozenges
- OTC salivary substitutes
- Interferon alpha
DRY EYES - Dose of Pilocarpine and Cevimeline
- Pilocarpine 5mg PO BID
- Cevimeline 30mg PO TID
DRY EYES - Dx Criteria for Sjogren's Syndrome
- 4/6 criteria, 1 of which is + minor salivary gland Bx or +ive antibody test:
- 1) Ocular Sx
- 2) Oral Sx
- 3) Ocular signs - +ive Schirmer or Rose bengal test
- 4) Histopathology
- 5) Salivary gland involvement (+ive salivary test)
- 6) Presence of Ig for anti-SSB or anti-SSA