Wk4 Discussion Essay Paper

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 1 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

South University College of Nursing and Public Health Graduate Online

Nursing Program

Aquifer Family Medicine

Family Medicine 03: 65- year-old woman with insomnia

Author:Author: William Hay, MD; Associate Editor: Martha P. Seagrave RN, PA-C; Case Editor: William Hay, MD

INTRODUCTION HISTORY

DIAGNOSES

FINDINGS

NOTES

BOOKMARKS

MENUMENU

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 2 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

You meet with Dr. Lee during your afternoon clinic to discuss your nextYou meet with Dr. Lee during your afternoon clinic to discuss your next patient.patient. Wk4 Discussion Essay Paper

!

You are doing an eight-week clerkship in a family medicine practice. Christina, the medical assistant, hands you the progress note for the next patient, which identifies the patient as Mrs. Gomez, “a 65-year-old woman who is here today reporting that she can’t sleep.”

Dr. Lee, your preceptor, fills you in: “Mrs. Gomez has been a patient here for several years. Difficulty sleeping is a new issue for her. Her past medical history is significant for hypertension and diabetes. Generally, she has been doing well, although I notice that her last hemoglobin A1c has climbed to 8.7%.”

Question What are common causes of insomnia in the elderly?

The suggested answer is shown below. Wk4 Discussion Essay Paper

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 3 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

Letter Count: 0/1000

SUBMITSUBMIT

Answer Comment Common causes of insomnia in the elderly:

1. Environmental problems 2. Drugs/alcohol/caffeine 3. Sleep apnea 4. Parasomnias: restless leg syndrome/periodic leg movements/REM sleep behavior disorder 5. Disturbances in the sleep-wake cycle 6. Psychiatric disorders, primarily depression and anxiety 7. Symptomatic cardiorespiratory disease (asthma/chronic obstructive pulmonary disease/congestive heart failure) 8. Pain or pruritus 9. Gastroesophageal reflux disease (GERD) 10. Hyperthyroidism 11. Advanced sleep phase syndrome (ASPS)

Common Causes of Insomnia in the Elderly

TEACHING POINTTEACHING POINT

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 4 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

Common Causes of Insomnia in the Elderly

1. Issues that may lead to an environment that is notenvironment that is not conducive to sleepconducive to sleep.

Specific examples include: noise or uncomfortable bedding. You can teach the patient sleep hygiene techniques that will

increase the likelihood of a restful night’s sleep.

2. The use of prescription, over-the-counter, alternative,prescription, over-the-counter, alternative, and recreational drugsand recreational drugs might affect sleep.

Patients should be counseled to avoid caffeine and alcoholavoid caffeine and alcohol for four to six hours before bedtime.for four to six hours before bedtime.

3. Sleep apneaSleep apnea is common in the elderly, occurring in 20% to 70% of elderly patients.

Obstruction of breathing results in frequent arousal that the patient is typically not aware of; however, a bed partner or family member may report loud snoring or cessation of breathing during sleep.

4. In restless leg syndromerestless leg syndrome, the patient experiences an irresistible urge to move the legs, often accompanied by uncomfortable sensations.

5. In periodic leg movementperiodic leg movement and REM sleep behaviorREM sleep behavior disorderdisorder, the patient experiences involuntary leg movements while falling asleep and during sleep respectively.

As in sleep apnea, the sleeper is often unaware of these behaviors and a bed partner or family member may need to be asked about these movements.

6. Disturbances in the sleep-wake cycleDisturbances in the sleep-wake cycle include jet lag and shift work.

7. Patients with depression and anxietydepression and anxiety commonly present

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 5 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

with insomnia.

Any patient presenting with insomnia should be screened for these disorders.

8. Patients with shortness of breath due to cardiorespiratorycardiorespiratory disordersdisorders often report that these symptoms keep them awake.

9. Pain or pruritusPain or pruritus may keep patients awake at night.

10. Those with GERDGERD may report heartburn, throat pain, or breathing problems.

These patients may also have trouble identifying what awakens them.

Detailed questioning may be needed to elicit the symptoms of this disorder.

11. Elderly patients with hyperthyroidismhyperthyroidism frequently do not present with typical symptoms such as tachycardia or weight loss, and laboratory studies may be required to detect this problem.

12. Circadian rhythms change, with older adults tending to get sleepy earlier in the night. In advanced sleep phaseadvanced sleep phase syndrome (ASPS)syndrome (ASPS), this has progressed to the point where the patient becomes drowsy at 6 to 7 p.m. If they go to sleep at this hour, they sleep a normal seven to eight hours, waking at 3 or 4 a.m. However, if they try to stay up later, their advanced sleep/wake rhythm still causes them to awaken at 3 or 4 a.m. This can be difficult to distiguish from insomnia.

References

Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med. 2018 34(2):205-216. doi: 10.1016/j.cger.2018.01.008.

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 6 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

SLEEP HYGIENE TEACHING Dr. Lee tells you, “Poor sleeping habits can also cause insomnia. Here is a handout on sleep hygiene. For some patients, simply correcting their sleep habits by following these tips will correct their quality of sleep.”

You review the handout.

Good Sleep Hygiene

Your Personal Habits

Fix a bedtime and an awakening time.Fix a bedtime and an awakening time. The body “gets used to” falling asleep at a certain time, but only if this is relatively fixed. Even if you are retired or not working, this is an essential component of good sleeping habits.

Avoid napping during the day.Avoid napping during the day. If you nap throughout the day, it is no wonder that you will not be able to sleep at night. The late afternoon for most people is a “sleepy time.” Many people will take a nap at that time. This is generally not a bad thing to do, provided you limit the nap to 30 to 45 minutes and can sleep well at night.

Avoid alcohol four to six hours before bedtime.Avoid alcohol four to six hours before bedtime. Many people believe that alcohol helps them sleep. While alcohol has an immediate sleep-inducing effect, a few hours later as the alcohol levels in the blood start to fall, there is a stimulant or wake-up effect.

Avoid caffeine four to six hours before bedtime.Avoid caffeine four to six hours before bedtime. This includes caffeinated beverages such as coffee, tea and many sodas, as well as chocolate, so be careful.

Avoid heavy, spicy, or sugary foods four to six hoursAvoid heavy, spicy, or sugary foods four to six hours before bedtime.before bedtime. These can affect your ability to stay asleep.

TEACHING POINTTEACHING POINT

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 7 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

Exercise regularly, but not right before bed.Exercise regularly, but not right before bed. Regular exercise, particularly in the afternoon, can help deepen sleep. Strenuous exercise within the two hours before bedtime, however, can decrease your ability to fall asleep.

Your Sleeping Environment

Use comfortable bedding.Use comfortable bedding. Uncomfortable bedding can prevent good sleep. Evaluate whether or not this is a source of your problem, and make appropriate changes.

Find a comfortable temperature setting for sleeping andFind a comfortable temperature setting for sleeping and keep the room well ventilated.keep the room well ventilated. If your bedroom is too cold or too hot, it can keep you awake. A cool (not cold) bedroom is often the most conducive to sleep.

Block out all distracting noiseBlock out all distracting noise, and eliminate as much light as possible.

Reserve the bed for sleep and sex.Reserve the bed for sleep and sex. Don’t use the bed as an office, workroom or recreation room. Let your body “know” that the bed is associated with sleeping.

Getting Ready For Bed

Try a light snack before bed.Try a light snack before bed. Warm milk and foods high in the amino acid tryptophan, such as bananas, may help you to sleep.

Practice relaxation techniques before bed.Practice relaxation techniques before bed. Relaxation techniques such as yoga, deep breathing and others may help relieve anxiety and reduce muscle tension.

Don’t take your worries to bed.Don’t take your worries to bed. Leave your worries about job, school, daily life, etc., behind when you go to bed. Some people find it useful to assign a “worry period” during the evening or late afternoon to deal with these issues.

8/2/19, 10)13 PMFamily Medicine 03: 65-year-old woman with insomnia – South Univers…llege of Nursing and Public Health Graduate Online Nursing Program

Page 8 of 58https://southu-nur.meduapp.com/document_set_document_relations/30223

Establish a pre-sleep ritual.Establish a pre-sleep ritual. Pre-sleep rituals, such as a warm bath or a few minutes of reading, can help you sleep.

Get into your favorite sleeping position.Get into your favorite sleeping position. If you don’t fall asleep within 15 to 30 minutes, get up, go into another room, and read until sleepy.

Getting Up in the Middle of the Night

Most people wake up one or two times per night for various reasons. If you find that you get up in the middle of night and cannot get back to sleep within 15 to 20 minutes, then do not remain in the bed “trying hard” to sleep. Get out of bed. Leave the bedroom. Read, have a light snack, do some quiet activity, or take a bath. You will generally find that you can get back to sleep 20 minutes or so later. Do not perform challenging or engaging activity such as office work, housework, etc. Do not watch television. Wk4 Discussion Essay Paper