• • Provide information on eating disorder programs • • Review nutritional information and recommended dietary program and offer referral to a registered dietician • • Teach stress management and relaxation techniques for persons and families, to be used especially at mealtimes • • Provide education on health effects of laxatives and diuretics • • Reinforce the long-term nature of these disorders and the need for follow-up and treatment • • Point out that under stress, regressive behaviors can occur • • Involve the family in identifying symptoms to identify and report • • Encourage regular dental care for those who purge • • Teach strategies for managing self-destructive behaviors in ways that do not reinforce them • • Provide referral for individual or family therapy
NRS 451 READING_CASE3
Latest 2023 / 2024
Dunphy, L.M., Winland-Brown, J. E., Porter, B.O. & Thomas, D.J. (2019). Primary Care-The art and science of Advanced Practice Nursing-An interprofessional approach. (5th ed.)
Philadelphia: F.A. Davis Company.
• Chapter 70: Sleep Wake Disorders: Insomnia (p.1167-1173) (WO3.3)
• SLEEP–WAKE DISORDERS
• Description and classification of sleep–wake disorders have been expanded in DSM-5 to reflect the important diagnostic overlay of medical conditions that affect normal sleep patterns. Of particular importance to primary care are insomnia disorder, obstructive sleep apnea hypopnea (OSAH) (see Chapter 29), substance/medication induced disorder (see Chapter 65), and restless legs syndrome (RLS). Insomnia disorder is presented in detail because it is an underpinning of each of these disorders. The criteria and important contributing factors for insomnia disorder and RLS are discussed.• Box 70.5 Education and Referral for Patients With Eating Disorders • Source: Vitousek KB, Orimoto L. Cognitive-behavioral models of anorexia nervosa, bulimia nervosa, and obesity. In: Kendall P, Dobson KS, eds. Psychopathology and cognition. San Diego, CA: Academic Press; 1993:191.
• INSOMNIA DISORDER
• Insomnia disorder, or difficulty sleeping, is an extremely common problem, yet it is one that is etiologically complex. It is defined as difficulty in falling or staying asleep, waking up too early in the morning, or any combination of these.
• EPIDEMIOLOGY AND CAUSES
• It is estimated that 10% to 15% of the primary-care population report daytime impairment because of insomnia, and that 6% to 10% meet criteria for the disorder.Women appear to be slightly more affected than men, and up to 50% of sufferers have a comorbid mental disorder. Difficulty maintaining sleep is the most common complaint. 1 / 4
• Acute insomnia may be precipitated by physical or emotional discomfort. Examples include pain, acute illness, and environmental disturbances such as noise, light, and temperature. Sleeping at a time that is inconsistent with daily biological (circadian) rhythms because of plane travel across time zones (jet lag) or shift work may also precipitate acute insomnia. Pain may contribute to wakefulness; indeed, often the question “Does the pain awaken you at night?” is an important piece of information in determining the severity of pain.
• PATHOPHYSIOLOGY
• Normal sleep is a periodic state of rest accompanied by varying degrees of unconsciousness and relative inactivity. It is normally an easily reversible, regular, recurrent state. The functions of sleep are restorative and hemostatic, critical for normal thermoregulation and energy conservation. Sleep disturbance is often an early symptom of impending mental illness.• Two physiological states compose sleep: non–rapid eye movement (NREM) and rapid eye movement (REM) sleep. In NREM sleep, most physiological functions are markedly lower than in wakefulness, although there may be episodic, involuntary body movements during NREM sleep. In contrast, REM sleep is characterized by physiological activity levels similar to those in wakefulness and a high level of brain activity and is sometimes called paradoxical sleep. NREM sleep is composed of stages 1 through 4, with stages 3 and 4 being deep sleep. Typically, NREM sleep is punctuated with an REM cycle every 90 to 100 minutes during the night. The first REM period tends to be the shortest, lasting less than 10 minutes; later REM periods may last 15 to 40 minutes each. Most REM periods occur in the last third of the night; most stage 4 sleep occurs in the first third of the night.• These sleep patterns change over the course of a person’s life. In young adulthood, REM comprises about 25% of sleep, and NREM approximately 75%. These figures remain fairly constant in normal sleep, although there is a reduction in both slow-wave sleep and REM sleep in older persons. NREM sleep increases after exercise and starvation and is thus thought to be associated with satisfying metabolic needs.• Daily variations in a variety of physiological functions affecting the endocrine, thermoregulatory, cardiac, pulmonary, renal, gastrointestinal, and neurobehavioral systems, as well as sleep–wake cycles, are governed by the 24-hour circadian rhythm in humans. The timing and internal architecture of sleep are coupled directly to the output of the endogenous circadian pacemaker. Misalignment of the output of the endogenous circadian pacemaker with the desired sleep–wake cycle can, therefore, induce insomnia, decrease alertness, and impair performance of shift workers, and accounts for the phenomenon of jet lag. Sleep deprivation for prolonged periods can lead to hallucinations, ego disorganization, and delusions, and REM-deprived patients may exhibit irritability and lethargy.
• CLINICAL PRESENTATION
• Insomnia may not be the chief reason for an office visit. It may be detected, however, by incorporating sleep-related questions into the general review of systems. Direct inquiry is important because patients with chronic insomnia often have never discussed their 2 / 4
• Focus on History: Insomnia Disorder
• Questions to ask:
• • How has the person been sleeping recently?• • How long has the person had difficulty sleeping?• • Does the person have any underlying psychiatric or medical conditions?• • Is the person’s sleep environment conducive to sleep? For example, are there any problems that would make sleeping difficult, such as noise, temperature, light, or space?• • Does the person work shift work or odd hours?• • What does the person do in the evenings and to prepare to go to sleep?• • What time does the person usually go to sleep? Get up? Are these hours the same on the weekday as well as the weekend?• • Does the person travel frequently?• • Does the person use caffeine, alcohol, drugs, or tobacco? If so, how much, and what are the specifics concerning the patient’s use?• • Does the person have difficulty staying awake or report dozing off during normal daily activities?• • Does the person report any daytime consequences of not sleeping?• • Does the person take daytime naps?
• • Does the person (or his or her partner) report:
• • Loud snoring, gasping, or stop breathing at night? (suggests sleep apnea) • • Legs or arms jerking during sleep? (suggests periodic limb movement) • • Creeping, crawling, or uncomfortable feelings in the legs that are relieved by moving them? (suggests restless legs syndrome) problem or have lived with it for so long that they think nothing can be done about it. The primary consequences of acute insomnia are sleepiness, negative mood, and impairment of performance, with severity related to the amount of sleep lost on one or more nights.Patients with chronic insomnia frequently complain of fatigue, mood changes (e.g., depression, irritability), difficulty concentrating, and impaired daytime functioning.• The assessment should include questions about sleep, as well as questions about daytime functioning, where the full effects of altered sleep are manifested. The amount of sleep required for each individual to subjectively feel refreshed varies markedly. Although the ability to maintain sleep alters with age, the individual’s need for sleep does not change significantly. The patient’s medical history and comorbidities are other important parameters that should be documented. Many medical problems, such as gastroesophageal reflux disease, worsen at night because they may be aggravated by recumbency.• It may also be helpful for the patient to keep a sleep diary over 2 to 4 weeks. A sleep diary is a useful tool to track exactly when and under what conditions the patient sleeps, as well as diet, exercise, and drug habits that may help reveal the underlying problem. In addition, a record of all exercise and physical activity may prove helpful. The sleep diary also helps to further define the nature of the sleep problem, as patients should document what time they got into bed, what they did until they fell asleep, what time they recall falling asleep, any night-time awakenings (including ability to fall back asleep), and what 3 / 4
time they awoke in the morning. Consider screening for insomnia as part of regular patient care (Schutte-Rodin et al., 2008).
• DIAGNOSTIC REASONING
• Symptoms • The diagnosis of insomnia disorder is made clinically using DSM-5 criteria; please refer to the DSM-5 for complete diagnostic criteria. Symptoms should occur frequently and for
a significant duration of time. Common symptoms include:
• • Poor quality of sleep (difficulty falling asleep, difficulty staying asleep, and/or early morning awakening) • • Trouble sleeping is not an effect of a medication or drug.• Collateral information from family or bed partners can be helpful to corroborate the diagnosis. Excessive daytime sleepiness can be assessed using the Epworth Sleepiness Scale. Polysomnography (sleep study) cannot distinguish those with insomnia from those without, and thus is only indicated if sleep apnea, periodic limb movements, or a REM sleep behavior disorder is suspected, or if usual treatment fail.• Differential Diagnosis • It is necessary to rule out all potential underlying causes of insomnia. Boxes 70.6 and 70.7 list medical and psychiatric causes of and contributors to insomnia. A thorough medication history must be taken, including all over-the-counter drugs, such as decongestants and cough syrups that contain decongestants, which act as stimulants. In addition, a complete history of all herbal remedies used, especially teas that may contain caffeine or ginseng and a variety of other central nervous system stimulants, should be obtained. When patients buy products in health food stores, they often do not think of them as “drugs.” The patient also should be screened for any illicit drug and alcohol use.
• MANAGEMENT
• Nonpharmacological Management • Insomnia can be a chronic, lifelong illness, and given the chronic nature of this problem, long-term treatment is often advisable. Evidence supports the efficacy of CBT for the first-line treatment of chronic insomnia (Schutte-Rodin et al., 2008). CBT can occur in an individual or group setting over 6 to 8 weeks. The clinician should review sleep hygiene strategies with the patient and identify any barriers to implementation (see Box 70.8).Any coexisting medical, psychiatric, or pain conditions should be adequately treated.• Box 70.6 Medical Causes of and Contributors to Insomnia
• • Painful conditions, such as arthritis and muscle cramps • • Fibromyalgia • • Delirium or dementia (“sundowning”) • • Acid reflux, gastroesophageal reflux disease, or duodenal ulcers • • Conditions causing shortness of breath • • Thyroid disease • • Obesity (also associated with sleep apnea)
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