Sleep Disorders

More than one third of American adults experience persistentinsomnia, the second most common complaint-afterpain-in the primary care setting. However, insomnia hasoften been ignored, trivialized, or summarily (often erroneously)attributed to underlying or preexisting psychologicalproblems. This handbook is the first clinically oriented textdedicated to the evaluation and treatment of insomnia.

An 88-year-old woman is admitted for severe dyspnea thathas worsened over the past month. Dyspnea on exertionis now elicited by everyday activities, even walking acrossthe room. Orthopnea and paroxysmal nocturnal dyspneahave progressed to the point that she has been unable tosleep at all the past several nights. She also tires very easilyand thinks her ankles are more swollen than previously.She denies chest pain or pressure.

An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.

ROCHESTER, N.Y. -- Childhood obesity remained a focus of pediatrics during the year, along with concerns about safety, particularly the safety of psychiatric medications.

A 36-year-old man complains of right foot pain of several months' duration that limits his ability to run. He has been able to keep running by icing the foot and by stopping his running program for a few days when the pain increases.

TORONTO -- For patients with fluid-retaining conditions, the simple act of lying down in bed at night may cause a fluid shift to the upper body that results in obstructive sleep apnea, a small study here suggested.

TORONTO -- For patients with fluid-retaining conditions, the simple act of lying down in bed at night may cause a fluid shift to the upper body that results in obstructive sleep apnea, a small study here suggested.

AUCKLAND, New Zealand -- When infants take lengthy naps in child safety seats, the babies may risk life-threatening oxygen desaturation, according to a small study.

AARHUS, Denmark -- A first-time major mental illness can strike mothers with dramatic suddenness within three weeks of delivering a first child, researchers here reported.

TORONTO -- For sleep-deprived new mothers, some planning and training may translate into nearly an extra hour of welcome shuteye, according to a small study here.

AARHUS, Denmark -- Bedwetting not controlled by standard therapy may be caused by excess sodium and urea excretion, possibly brought on by a surfeit of prostaglandin E2, suggested researchers here.

ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

NEW ORLEANS, Nov. 22 -- In the aftermath of Hurricane Katrina, patients here suffered from a generalized anxiety disorder dubbed "Katrina Brain," a psychiatrist reported here.

NEW ORLEANS -- Research has challenged the conventional wisdom that depressed patients need three to four weeks to respond to antidepressant medication and that any earlier response is due to the placebo effect, said an investigator here.

NEW ORLEANS -- As many as 30% of patients with bipolar disorder go untreated for 10 years or more, largely because the condition is so tricky to diagnose, said investigators here.

NEW ORLEANS -- The pathology behind insomnia may be more than a consequence of mental disorders such as depression, anxiety, and alcohol abuse, investigators here said. It may be a harbinger of an underlying cause.

WASHINGTON -- In a majority of patients with fibromyalgia, Lyrica (pregabalin) maintains its painkilling effect for several months, a researcher said here.

PHILADELPHIA -- Allergic reactions are among the most common side effects of complementary and alternative therapies, researchers reported here, but that doesn't stop patients with allergies from using them.

STANFORD, Calif. -- Allowed a 40-minute nap midway through 12-hour night shifts, emergency room residents and nurses responded with more vigilance and vigor, found researchers here.

Although it has been evident since the early days of the HIV epidemic that a dementing illness often accompanies HIV infection and that the virus invades the nervous system soon after systemic infection, the clinical syndrome has evolved with the introduction of antiretroviral therapy.

A 61-year-old woman presented with progressive dyspnea of 5 months' duration. She first noticed dyspnea while engaged in her usual daily activities, and it gradually progressed in severity. A primary care physician prescribed bronchodilators without relief. She was subsequently referred for a pulmonary evaluation.

A 48-year-old woman complains of finger and knuckle pain in her right hand of 1 year's duration. She is right-handed. The pain is located over the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the index and middle fingers. The pain has recently become more intense and now makes it difficult to sleep and to grasp objects.

THECASE:An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema. Congestive heart failure is diagnosed, and the patient is admitted to the care of a hospitalist. A standard therapeutic regimen, including diuretics, angiotensin-converting enzyme inhibitors, and oxygen, is instituted, in addition to the patient's home regimen of isosorbide mononitrate, glipizide, and amlodipine. The hospitalsubstitutes pravastatin for the patient's atorvastatin. A Foley catheter is inserted by a urologist because of the patient's benign prostatic hypertrophy. The patient complains of insomnia and is given diphenhydramine. His hospital course is otherwise uneventful.

An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema.

SEATTLE -- Surgery to correct obstructive sleep apnea (uvulopalatopharyngoplasty) is more likely to have complications if the condition is severe, a concurrent retrolingual procedure is done, BMI is high, or there are medical comorbidities, found a VA study.

CHICAGO -- Vivid ghost stories recounted by apparently healthy patients may be a sign of somatic neuropathology, researchers reported here.

CHICAGO -- Parkinson's patients were able to control symptoms of early-stage disease for at least 85 weeks using a once-daily transdermal patch delivering investigational rotigotine, investigators reported here.

SAN ANTONIO -- Children with high blood pressure are more likely to snore and have other sleep disordered breathing problems than normotensive peers, researchers reported here.

ABSTRACT: Signs that strongly suggest Parkinson disease (PD) include unilateral hand tremor, slowed or decreased movement, and gait changes. Postural alterations include leaning forward or asymmetric shoulder height; the arm may not swing when the patient walks, or it may be held flexed at the elbow. Patients may report increasing difficulties in occupational and social functioning. Mimics of PD include essential tremor, normal pressure hydrocephalus, other neurodegenerative diseases, and drug-induced parkinsonism. Most patients report such nonmotor symptoms as sleep disturbances, visual difficulties, bowel and bladder problems, fatigue, depression, and anxiety. Cognitive impairment in many patients takes the form of slowing of memory and difficulty with visual spatial tasks and executive function. A more realistic treatment goal than tremor eradication is improved overall mobility.

An 80-year-old man has had an asymptomatic, flesh-colored swelling on his right ear for 4 to 5 months. In the center is a 1-mm white scab pointing downward from the helix. At times, the patient shaves a white spicule that grows in this crusted area. He sleeps on his right side and does not use a cell phone.