clinical management, adult Flashcards

Question

How is chronic illness defined?

Answer 1

``` Gradual onset Lengthy or indefinite duration Multivariate causation (which may change over time) Focus on functional status rather than individual diagnoses OSA better characterized as chronic rather than acute disease ```

Answer 2

Systematic behavioral approach to help patients with chronic conditions participate actively in self-monitoring of systems or physiologic processes, decision making (i.e. managing the disease or its impact, based on self-monitoring), and problem-solving disease, medication, and health management Role management emotional management

Answer 3

Group size 3-6 patients | 4 sessions 1-2 hrs each

Answer 4

Psychoeducation in presentation format (discussion, emphasis questions) Social cognitive therapy (how people learn by modeling) self efficacy outcome expectations Stages of change Video and discussion for modeling

Answer 5

Precontemplation: no intention to change, i.e. snorer can’t see the problem, can’t see “what all the fuss is about” Contemplation: “fence sitting”, some recognition there may be a problem with snoring/apneas, May need to do something about it. Change often triggered by bed partner moving out of shared bed. Preparation: change in both intention and behavior. Consult w/ PCP re: snoring/apneas is example of patient showing that he understands the problem and is now prepared to take some action. Referral to sleep specialist, PSG, etc. Action: relates to how patient modifies his behavior, experience, and/or environment to make the necessary change. Learning about OSA, learning about CPAP, what it does, undergoing titration study, being committed to Tx for specific time period, learning to seek help. Maintenance: undertaking CPAP for at least 6 mos. Patient taking ownership of having OSA and the undertaking that this Tx intervention gives health and life choices. Continually update and seek help when there are mask/machine problems Relapse: needs to be seen as normal, generally not possible to use mask/machine all the time. What is important is what the patient does during the relapse period, how can get back on track, for example cold/flu/traveling has been resolved. Relapse if the rule, not the exception

Answer 6

Positional therapy Recommended for patients with any breathing abnormality during sleep: obstructive apnea mixed/central apnea UARS, most of breathing issues while sleeping in supine position Sleeping in other positions, the severity of events reduces to AHI <5-10 patients w/o OSA, but snore supine patients who have not responded to other treatments and mainly struggle while supine

Answer 7

Supine problems are high (55.9% had at least twice as many breathing problems while supine) Prevalence of supine disturbance is much higher (65-69%) in patients with mild/mod. OSA Mild OSA is less likely to succeed with CPAP

Answer 8

Any form of therapy with will help patients roll back onto their side at night Tennis ball technique: Tennis ball in wide cloth band or belt attached to waist, when patient rolls over onto back, pressure causes them to roll back over An Alarm system: momentarily wake up when rolling onto back The Sleep positioner: Device consists of foam block placed on back The positioner The BPOD unit: located on midline of chest and will detect position Thoracic anti-supine board The supine position prevention vest Zoma positional sleeper Vest-type design

Answer 9

Indicated for chronic nightmares, sometimes used in acute Disturbing dreams and/or nightmares , regardless of nighttime awakening Belief that chronic nightmares appear to be driven by a conditioning process-function as a learned behavior Common co-morbidities in nightmares: anxiety, depression, PTSD Contraindications: caution with PTSD and daytime imagery concerns (e.g. flashbacks, daycares, trauma memories) Inability to access imagery system No evidence that IRT works w/parasomnias, RBD, hypnagogic hallucinations consider whether PTSD needs to be the focus of therapy

Answer 10

IRT views nightmares as a learned behavior (bad things= bad dreams) Nightmares occur frequently in childhood and adolescence 6.8% of sample (mean age 17) w/nightmares 20% in 11-14 years old Peak in early childhood (2.5 yrs, 42%), followed by progressive decline to adolescence with final prevalence of 7.3% (16 years) Adults: 40% report onset before 15 years old >50% of chronic nightmare sufferers developed nightmares before age 20

Answer 11

nightmares may represent specific marker for hx of sexual trauma in abused children and teens common for residual nightmares after successful PTSD treatment

Answer 12

Selecting a nightmare, facts about the nightmare changing it as you wish rehearsing the new set of images in a waking state

Answer 13

link between nightmares and sleep problems fear of nightmares provoking sleep onset insomnia Fear of returning to sleep post-nightmare provoking sleep maintenance insomnia Nightmares appear to fragment sleep and thus degrade sleep quality Raise questions about cause of nightmares: what is initial cause of cause of nightmares:? why do nightmares persist in some people? what might it mean is nightmares have not responded to tx w/meds or psychotherapy? Is it possible to imagine we have more control over nightmares that we might have thought possible?

Answer 14

opportunity to assess visualization exercises that patient has ability to create images and monitor for unpleasant images 7 simple behavioral techniques are taught (thought stopping, breathing, grounding, talking, writing, acknowledging, and choosing)

Answer 15

imagery is natural component of human brain imagery is accessed repeatedly throughout the day to solve problems- for ex, remember where you put something, driving instructions capacity to actively engage one's imagery system: "active daydreaming" or "guided daydreaming" imagery exercises are not meant to be intense efforts yielding meditative or hypnotic-like states; they may or may not be comfortable. Best to evoke pleasant images when re-engaging the system. Goal=imagery is naturally occurring form of thinking with practice of pleasant imagery, it becomes clear that the mind can influence some of the images that emerge in the mind's eye. If images can be influenced in a waking state, might not such influence extend to sleep state?

Answer 16

Write new dream for learning purposes Practice rehearsing pleasant dream for 5-20 min per day for 1 month No more than practicing 2 "new dreams" per week f/u at 4 and 12 weeks to review process

Answer 17

discourage practicing more distressing dream first: learn process first. Avoid giving suggestions for the new dream Never offer examples of a changed dream until they try for themselves.

Answer 18

Group vs indiv- more RCT using groups longer vs shorter treatment time: 7-10hrs for goups, less for individual more vs less exposure de-emphasizes exposure, but some aspects of talking about nightmares is inherently exposure

Answer 19

located behind eyes light information communicated from IPRGCs IPRGCs contain melanopsin melanopsin is a photopigment sensitive to short-wave (blue-green) light IPRGCs send excitatory input to SCN via Retino-hypothalamic tract (RHT) SCN neurons generate circadian rhythms through transcription-translation molecular feedback loops self sustaining every 24.12 hrs circadian clock gene feedback loops present in virtually all cells in body.

Answer 20

Bright light for advanced sleep phase

Answer 21

Significant delay in phase of major sleep period (> 2 hrs relative to socially acceptable time) Sx present 3 months Ad lib sleep improves sleep quality, quantity, consistency associated features: sleep initiation insomnia, alcohol and hypnotic use at BT delay during teen years 7% of population longer tau

Answer 22

Align sleep schedule to natural delayed phase Dim light 2 hrs prior to BT Bright light only after CBTmin 0.3-0.5 mg melatonin 2-6 hrs prior to bedtime

Answer 23

Significant advance in phase of major sleep period (> 2 hrs relative to socially acceptable time) Sx present x at least 3 mos Ad lib sleep improves sleep quality, quantity, consistency associated features: early am awakening, Est. 1% of population likely low (less likely to be seen as problem) Tau <24 hrs

Answer 24

Bright light in evening | Avoid bright light in morning

Answer 25

Absence of well-defined circadian pattern to sleep-wake cycle TST comparable to healthy same-aged peer but lacks major sleep period across 24 hr day 3 or more sleep episodes (1-4 hr each) w/ longest period typically occurring between 2-6 am Sx present for at least 3 months Associated features: Most commonly associated w/ AD, other neurodegenerative d/o Env disruptions: ICU, hospital, rehab units Hypnotics contraindicated

Answer 26

Increase circadian amplitude: sleep hygiene, meal timing, social activities, AM bright light Melatonin as a mono therapy may have negative effects on mood Hypnotics contraindicated

Answer 27

Diagnostic criteria: Pattern of circadian misalignment will typically present as relatively steady, continual delay in sleep-wake timing Sx present x 3 months Associated features: Can present as periods of insomnia, EDS, or asx depending upon when individual is trying to sleep relative to his/her circadian period N24SWD most commonly found in individual who are blind (13-50%) Rare/controversial in sighted individuals (DSWPD with long tau?)

Answer 28

Sighted individuals w/ N24SWD: same as for DSWPD Melatonin receptor agonist (ramelteon, tasimelteon) or melatonin (<0.3mg) Administer 1-2 hrs before desired bedtime Once entrainment is established over the course of a month, can switch to melatonin (<0.5mg) 2-6 hrs before bedtime to maintain entrainment

Answer 29

Dx criteria: Complaints of insomnia or EDS and decreased TST assoc w/ jet travel across at least 2 time zones Assoc daytime impairment (fatigue, malaise, decision-making, reaction times, athletic performance) And/or Somatic complaints (GI disruptions) Occurs within one to two dats after travel Associated features: Limited data suggests increased difficulties for middle to older adults (>50 yo) vs younger (<30) Limited data suggests that jet lag could precipitate a relapse of depressive episode (for westward travel) or a hypo manic episode (for eastward travel)

Answer 30

As a general rule for infrequent travelers: maximize daytime light! Westward travel: strategies for delaying sleep (clock needs to shift later) evening light approaching CBTmin to provide the greatest delaying effects (seek light 4 hrs before CBTmin, avoid light 4 hrs after CBTmin Avoid bright light in the morning for the first few days Eastward travel: strategies for advancing sleep (clock need to shift earlier in time) Avoid bright light in the evening, seek bright light in the morning Avoid light 4 hrs before CBTmin and seek light 4 hrs after CBTmin When eastward travel exceeds 9 time zones, it becomes more advantageous to make any adjustments as if the trip were a 14 hr westward journey

Answer 31

Diagnostic criteria: Complaints of insomnia and/or EDS along with insufficient TST Difficulties caused by a work schedule that routinely occurs during habitual sleep time Sx present for at least 3 months Most harmful to least: night shift, rotating, early morning, afternoon/evening, daytime Duration shift work: hours per shift (>12 hrs/shift), no. Of years engaged in regular shift work Direction of rotation (counterclockwise worse Than clockwise) Speed of rotating shift work: faster rotation (i.e. multiple rotations within 1 week), may be worse that slower rotation

Answer 32

2004: 13.5% US engages in shift work 22 million shift workers in US alone (2018) Increased risk for metabolic, CV, reproduction, GI, mood, substance use and other sleep d/o Known probable carcinogen (WHO, IARC)

Answer 33

Best treatment= stop shift work if possible! Stimulants (modafanil) approved to increase alertness during shift work Match work shift with circadian profile of employees Use of sedatives not recommended Align as close to natural sleep-wake rhythm as possible Increase amplitude of circadian signals Estimate CBTmin for strategic light therapy FEO support entrainment Scheduled naps

Answer 34

Good for: intense preoccupation w/sleep, sleep-related anxiety too much effort Contraindications: Those w/ concrete approach, need more seasoned behavioral sleep therapist Rationale: Because sleep is a voluntary process, attempts to put it under voluntary control will likely make it worse. Contemporary understanding of PI fits w/ psychobiological inhibition/attention-intention-effort model where mental and behavioral focus on sleep process is regarded as inhibitory to sleep engagement

Answer 35

Consider sleep “normalcy” Measure sleep normalcy (can use sleep effort scale) Develop formulation of insomnia as sleep effort syndrome Draw helpful parallels Give up trying to sleep: Method 1: turn the tables and be carefree about insomnia Method 2: try to stay awake as long as possible Use of humor PI is embedded in all aspects of CBT PI has evidence as standalone therapy Sig reductions in SOL and WASO PI often included in CBT

Answer 36

Use w/ heightened somatic and/or cognitive arousal | More effective for sleep onset arousal

Answer 37

``` 4 procedural elements to focus on: Quiet environment Object to dwell on Passive attitude Comfortable position ```

Answer 38

Dr. Edmund Jacobson invented PMR in 1920’s as way to help his patients delay w/ anxiety He felt that relaxing the muscles could relax the mind as well PMR involves tightening one muscle group while keeping the rest of the body relaxed and then releasing the tension PMR often combined with breathing exercises or mental imagery

Answer 39

Prescribe 2 relaxation exercises per day: one at night and one during the day Allow for few weeks of daytime practice before nighttime Relaxation should not be done while waiting to fall asleep

Answer 40

Making more preferred activities contingent on less preferred activities (e.g. do relaxation before watching TV)

Answer 41

``` PMR Autogenic training (imagine peaceful scene, repeats phrases to self) Meditation (yoga, mindfulness) Imagery Biofeedback ```

Answer 42

There is support for mono therapy, CBTI, and other multi component therapies AASM supports as primary treatment for insomnia

Answer 43

Gross indication: Insomnia, including beginning, middle and end of time spent in bed EBT for older adults Specific indication: For sleep difficulties in which subjective SE based on 1-2 wk sleep log is <85% Or <80% in older adults Contraindications: individuals that need to maintain optimal vigilance to avoid serious accidents (long haul truck drivers, air traffic controllers) Conditions that are exacerbated by sleepiness or deep sleep (epilepsy, parasomnias, SDB) One of the most reliable ways to strengthen homeostatic sleep drive and increase propensity for sleep during upcoming nights

Answer 44

Rapid sleep onset and well-consolidated night of quality sleep (core goals or insomnia tx) are achieved rapidly and reliably at start of SRT According to 3P model of insomnia, behavioral principles and cognitive tendencies that perpetuate sleep disturbance are often the most promising targets for intervention (many perpetuating factors: spending too much TIB, anticipatory anxiety about prospects for sleep, inordinate concern re: daytime performance deficits, are addressed by SRT) SRT tightens regulatory control of sleep by endogenous circadian pacemaker

Answer 45

Early phase: 2 week sleep log Initial TIB = Avg TST (no < than 5 hrs sleep) If SE>90% (85% in seniors), TIB increased by 15 min If SE< 85% (80% in seniors), TIB decreased to avg TST If SE 85-90%, no changes made Middle phase: Follow above SE guidelines for extending or decreasing sleep Completing SRT: Satisfying nocturnal sleep Good daytime functioning Endpoint should be max TIB w/o compromising SE Modifications: TIB +30 min initially

Answer 46

Approach that avoids the shock of radically reduced TIB | Goal: decrease TIB-TST discrepancy by cutting back TIB in incremental parts over the next several weeks (~6 weeks)

Answer 47

2 week sleep diary Starts w/modest decrease of TIB Start with 1/2 the difference between baseline TIB and baseline TST (e.g. 2 hr discrepancy, can cut 120 min by 20 min. For 6 weeks) Adherence generally better Prescribed bedtime rather than “go to bed when sleepy” If goal is reached early, “hold the course” for a few weeks to ensure Effective as mono therapy and multi component

Answer 48

Cues are associated emotional reactions The bed and bedroom has become cues for distress and frustration of trying to fall asleep Internal cues: mind racing, anticipatory anxiety, physiological arousal External cues: bed, etc.

Answer 49

Goal is to re-associate the bed and bedroom with sleep 1. Get out of bed after 15-20 min if unable to fall or return to sleep and go to another room 2. Engage in quiet activities outside of bedroom (e.g. TV, reading) until you feel very sleepy. Do not exercise, eat, smoke or take showers or baths. Do not lie down or fall asleep when not in bed 3. If you return to bed and still cannot fall asleep within 15 min., repeat step 2. Do this as often as necessary throughout the night 4. Set your alarm and get up at same time every morning

Answer 50

``` Maintain regular mealtimes Wind-down for the hour before bed Limit liquids in evening Avoid caffeine witching 6-8 hrs of bedtime Do not consume ETOH too close to bed Do not smoke before bed or during the night Avoid napping Exercise regularly Create a sleep-friendly environment Stay in bright light in the morning Limit bright light in the evening ```

Answer 51

Develop a hierarchy of fear-invoking activities or thoughts from least to most frightening with the child These activities or thoughts are paired with a relaxing activity

Answer 52

Motivational interviewing

Answer 53

``` Weak recommendation for: suvorexant lunesta zalpelon zolpidem triazolam temazepam ramelteon doxepin ``` ``` Recommendation to not use: trazodone tiagabine diphenhydramine melatonin tryptophan valerian ```

Answer 54

CBT-I is standard of Tx carries favorable benefit : risk ratio all patients w/chronic insomnia should receive CBT-I as primary intervention Meds for chronic insomnia should be considered mainly in the following patients: 1. unable to participate in CBT-I 2.Still have symptoms despite participation in CBT-I 3. In select cases, temporary adjunct to CBT-I

Answer 55

The first is that all patients with chronic insomnia receive CBT-I as the initial treatment intervention. This is a strong recommendation based on moderate quality evidence. The second is that a shared decision-making approach be employed by clinicians in determining whether pharmacotherapy should be employed for those patients who did not achieve adequate response with CBT-I (weak recommendation based on low quality evidence).

Answer 56

Occasional, short-term insomnia affects 30% to 50% of the population. The prevalence of chronic insomnia disorder in industrialized nations is estimated to be at least 5% to 10%.

clinical management, adult Flashcards

(80 cards)