HPDP2 Midterm 1 Study Guide PDF

HPDP2 – Midterm #1 Study Guide 1. ​ List and recognize the four types of “difficult patients” and list and apply strategies on how to deal effectively with them as listed in Feldman (great matching type question). The Angry Patient -​ Harsh nonverbal communication: -​ Rigid posturing,...

HPDP2 – Midterm #1 Study Guide 1. ​ List and recognize the four types of “difficult patients” and list and apply strategies on how to deal effectively with them as listed in Feldman (great matching type question). The Angry Patient -​ Harsh nonverbal communication: -​ Rigid posturing, piercing stares, a refusal to shake hands, gritting teeth, and confrontational or occasionally abusive language. -​ More subtle behaviors: -​ Refusing to answer questions; failing to make eye contact; or constructing nonverbal barriers to communication, such as crossed arms, turning away from the clinician, or increasing the physical distance between them. -​ Management: -​ Evaluation and understanding should begin the therapeutic process. -​ Responding calmly and constructively confronting without judgment or projection with “You seem angry” tests whether the clinician has correctly identified the emotion of the patient. -​ This invitation offers patients the opportunity to explicitly express their feelings and conveys a sense of curiosity (as opposed to judgment). -​ Try not to react -​ Encouraging the expression of anger helps to identify unresolved conflicts that can interfere with providing appropriate care. The Silent Patient -​ Silent patients offer little verbally. -​ The patient may seem withdrawn indicated by: -​ Sitting a greater distance from the clinician than usual, failing to make eye contact, seeming distracted, or not acknowledging the clinician’s attempts at interaction. -​ The patient may seem anxious evidenced by nervous or repetitive habits such as nail-biting, pacing, or folding and refolding papers. -​ The patient may exhibit signs of sadness like deep sighs, red eyes, or tears. -​ Causes of Silence: -​ Alzheimer’s, anger, cultural or language barrier, hearing impairment, quiet person, etc. -​ Management:  -​ When confronted with a silent patient, exploring the behavior is usually best begun by reflecting, “You seem quiet today.” This offers the patient the opportunity to acknowledge the behavior and share the reason for it. -​ Elicit a response (What can you share with me about what has been going on?”) -​ Emphasize the importance of collaboration -​ Respond to hearing impairment or language barrier cues. The Demanding Patient -​ Patients often make various requests or demands in the course of their visit for things such as diagnostic tests, referrals to specialists, and for specific treatments. -​ Demands are often tied to dissatisfaction w/ the recommended evaluation, desire for secondary gain, treatment concern about the accuracy of the diagnosis, or a failure to solicit important aspects of the history. -​ Possible causes: -​ Anger (feels wronged or previous bad outcome), -​ Fear (afraid of serious illness if not attacked quickly), -​ Frustration (feels no progress has been made), -​ Personal responsibility for health outcomes (untrusting of physicians), -​ Doubt (Unsure of physician’s knowledge) -​ Management -​ Why the demand is important to the patient -​ Solicit the patient’s goal (“How had you hoped I would help you?”) -​ Acknowledge unexpressed emotions -​ Solicit perspective -​ Inform the patient of realistic limits. (On opioids, “it can lead to addiction”) The Yes, But… Patient -​ When problems are being discussed, this type of patient’s nonverbal behavior is usually engaged and active: leaning forward, bright affect, and dynamic gestures. As recommendations for evaluation and treatment are made, however, the patient typically becomes withdrawn, eye contact diminishes, and language becomes significantly less animated. -​ As the clinician makes recommendations, the patient often responds with the classic, “I’d like to do that but ….” -​ Another consideration is that the patient comes from a highly controlling family and is attempting to follow the recommendations but for psychosocial reasons is unable to. -​ Management -​ It is important to clearly communicate that to get better the patient must take responsibility for their health.  -​ The next step is to ask what the patient thinks would be helpful in solving the problem. -​ As we discuss options, it will help if you share what’s possible for you and what’s not.” -​ Make sure the patient agrees with the diagnosis -​ Setting limits and providing explicit feedback can teach patients to collaborate more effectively. -​ Being aware of “yes, but” patterns can help promote a strategy of shared responsibility and prevent the ultimately unhelpful rescuing behaviors that interfere with successful treatment 3. ​ List and define the different theories behind what leads to practitioner well-being and burnout and list and apply different strategies to enhance practitioner well-being. Practitioner Well-Being Practitioner Well-Being -​ Must balance your physical, emotional, and spiritual health. -​ Patient-clinician relationship is an important factor of satisfaction. Personal Philosophy ​ The deeply held beliefs and values that address the most fundamental questions of our lives: meaning and purpose of life, death, joy, and suffering; why things happen the way they do; the nature of our relationship to other people/the world; and the nature of our goals/responsibilities. ​ Guides the way we perceive and respond to our world and helps us identify our place in it. Control Model Relational Model -​ We often perceive being in control (of -​ Emphasizes relatedness rather than diseases, Pts, & teams) as an ideal state control -​ Reductionism -​ Adds an appreciation of context & -​ Linear causality relationship -​ Adverse Consequences: -​ Understand patients are multi-dimensional -​ Limits opportunity to be (biological, experiential, functional, successful spiritual) -​ Accepting responsibility for -​ Pts responsible for their own lives → outcomes we have no control of is Avoid unrealistic expectations. highly stressful! -​ Focus on experience → more meaningful -​ Control → Hierarchical work and ↓ burnout relationship -​ Creates distance in patient-clinician relationship. Skills to Thrive Time Management -​ Work-life balance (work, family, & recreation)  -​ Manage the appointment time w/ you Pt (focus on most important issues) Communication -​ Skill for eliciting deeper levels of patients’ stories, responding to their emotions, and reflecting our understanding back so that they feel heard. Coaching & Negotiation -​ Help facilitate patients in articulating their own values, goals, and opinions, including their feedback about their medical care. -​ Helps share responsibility more effectively and more realistically. Self-Reflection & Self-Care -​ Healthy work environments – respect values and culture of teamwork -​ Be able to reflect on our own feelings and actions, to acknowledge our vulnerabilities and needs, to seek and courageously follow our sense of calling, and to act in support of our own health. 4. ​ Describe the difference between Type 1 and Type 2 Diabetes Mellitus Diabetes: A disease in which the body does not produce or properly utilize insulin. -​ “A syndrome w/ disordered metabolism and inappropriate hyperglycemia due to either a deficiency of insulin secretion or to a combination of insulin resistance and inadequate insulin secretion to compensate for the resistance.” Ethnicity & DM -​ 14.2% of Native Americans & Alaskan Natives -​ 6.0% of Alaskans, 29.3% of American Indians (Pima) -​ 11.8% of non-Hispanic blacks -​ 10.4% of Hispanics -​ 8.2% Cubans, 11.9%% Mexican American, 12.6% Puerto Ricans -​ 7.5% of Asian-Americans -​ 6.6% of non-Hispanic whites Type 1 Diabetes: -​ Type 1 is an autoimmune destruction of pancreatic islet B cells that results in a lack of insulin production -​ Usually arises in children around 10-14 yrs of age but can occur later in life as well (/ 100 mg/dL, blood pressure >/ 130/85 mm Hg, triglycerides > 150 mg/dL, and HDL cholesterol < 40 for men or < 50 mg/dL; need 3 of the 5 criteria to meet disease requirements -​ Higher risk for development of diabetes and CVD -​ 3 most common complications are retinopathy, diabetic neuropathy and diabetic nephropathy -​ Retinopathy and other ocular complications: retinopathy can be proliferative or non-proliferative; premature cataracts can occur and seem to correlate with duration of DM and severity of chronic hyperglycemia; may predispose to glaucoma -​ Diabetic Nephropathy: type 1 DM has higher chance of developing nephropathy compared to type II, but ESKD is more prevalent in type II given there are more individuals affected by type II; improved glycemic control and hypertension correction (w/ the benefits of ACEi’s) can help prevent -​ Diabetic Neuropathy: peripheral and autonomic neuropathy  -​ Cardiovascular Complications: Hypertension, heart disease (CAD), peripheral vascular disease -​ Skin and Mucous Membrane Complications: candida infections, hypertriglyceridemia may cause pancreatitis or eruptive xanthomas, “shin spots” -​ Bone and joint complications: can cause hand stiffness, frozen shoulder, carpal tunnel, Duputyren contractures 8. ​ Understand, explain and describe pertinent patient education points for a patient living with Diabetes Mellitus (Type 1 and Type 2). -​ Since diabetes is a lifelong disorder, education of the patient and the family is probably the most important obligation of the clinician who provides care -​ Self monitoring of glucose levels should be emphasized, especially in pts that require insulin, and instructions must be given on proper testing and data collection -​ Patients taking insulin should have an understanding of the actions of basal and bolus insulins- they should be taught to determine whether the basal dose is appropriate and how to adjust the rapidly acting insulin dose for the carbohydrate content of a meal -​ Friends/family should be taught signs/symptoms of hypoglycemia and how to treat low glucose emergencies -​ Strenuous exercise can precipitate hypoglycemia, and patients must therefore be taught to reduce their insulin dosage in anticipation of strenuous activity or to take supplemental carbohydrate -​ Exercise training also increases the effectiveness of insulin, and insulin doses should be adjusted accordingly -​ Advice on personal hygiene, including detailed instructions on foot and dental care, should be provided -​ Infections release high levels of insulin antagonists and can bring an increase in insulin requirements -​ vigorous efforts should be made to persuade patients with newly diagnosed diabetes who smoke cigarettes to stop, since large vessel peripheral vascular disease and debilitating retinopathy are less common in nonsmoking patients with diabetes -​ Routine Exams: -​ BP at every visit -​ HbA1c every 3 months -​ Dental Exam every 6 months -​ Cholesterol annually -​ Cardiac eval with diagnosis and annually -​ Dilated Eye exam annually -​ Foot exam annually and at each visit -​ Kidney function annually 9. ​ Discuss the diabetes research studies: Diabetes Prevention Program, the UK Prospective Diabetes study, the Diabetes Control and Complications Trial, the Steno-2 Study, and the Kumamoto study. -​ Diabetes Prevention Program -​ Focus: Type II DM prevention -​ Aimed to evaluate lifestyle interventions and metformin use in preventing the development of type II DM in high-risk individuals -​ Intervention with a low-fat diet and 150 minutes of moderate exercise (brisk walk) per week reduced progression of T2DM by 71%. -​ Participants who took Metformin 850mg BID reduced their risk of developing T2DM by 31%. -​ Demonstrated that lifestyle changes (diet and exercise) are highly effective in reducing the risk of developing type II DM, and metformin provided some benefit -​ UK Prospective Diabetes Study -​ Focus: Type II DM management and complications -​ Provided key insights into the benefits of intensive glucose control in reducing the risk of diabetes-related complications, such as retinopathy and nephropathy. -​ Intensive treatment with either a sulfonylurea, metformin, or a combination of the two, or insulin, achieved an HbA1c of 7%. This level of glycemic control lowered the risk of microvascular complications (retinopathy and nephropathy) in comparison to diet alone. -​ In overweight/obese individuals, Metformin therapy was more beneficial than diet alone in reducing the number of patients who suffered MI and stroke. -​ Showed that tight blood glucose control reduces the long-term complications of diabetes -​ Diabetes Control and Complications trial -​ Focus: Type 1 DM management -​ A landmark study demonstrating the benefits of intensive insulin therapy in preventing long-term complications of type I DM -​ Showed that maintaining near normal glucose levels could delay or prevent the onset of diabetic complications, such as retinopathy, nephropathy and neuropathy -​ Kumamoto Study -​ Focus: Type II management in Japan -​ Highlighted the benefits of intensive insulin therapy in preventing complications in type II DM pts -​ Demonstrated that maintaining tight glucose control thru insulin therapy could significantly reduce the risk of diabetic complications -​ Steno-2 Study -​ Targeted multiple concomitant risk factors (diet, smoking cessation, exercise, and pharmacologic therapy) for both microvascular and macrovascular disorders in  T2DM. After a mean follow-up of 7.8 years, cardiovascular events (eg, myocardial infarction, angioplasties, coronary bypass grafts, strokes, amputations, vascular surgical interventions) developed in 44% of Pts in the conventional arm and only in 24% in the intensive multifactorial arm—about a 50% reduction. -​ Rates of nephropathy, retinopathy, and autonomic neuropathy were also lower in the multifactorial intervention arm by 62% and 63%, respectively. -​ The interventional group continued to have a lower risk of retinal photocoagulation, kidney disease, cardiovascular endpoints, and cardiovascular mortality. 10. Explain and define the epidemiology and basic pathophysiology of CRC -​ Pathophysiology -​ Majority are adenocarcinomas → tend to be bulky exophytic masses or annular constricting lesions. -​ >50% ♂/ 60-70% ♀ are proximal to splenic flexure -​ ↑ # of the cecum and ascending colon CA -​ CRC thought to arise from malignant transformation of adenomatous polyp (or serrated polyp) -​ 25% of >50yo have premalignant polyp -​ Takes ~10 years for a polyp to transform (5 years if FHx) -​ Most polyps and CRC are asymptomatic -​ Removal of polyps prevents CA -​ Polyps that are “advanced” (>1 cm in size, adenomas w/ villous features or high-grade dysplasia, or serrated polyps w/ dysplasia) = ↑ risk of cancer. -​ Epidemiology -​ 2nd leading cause of death due to malignancy in the U.S. -​ 4.1% of Americans will develop CRC with a 40% death rate -​ Incidence: 151,030 new cases annually (as of Sept. 2024), 53,200 deaths -​ FHx of CRC is present in 30% of patients -​ Inflammatory bowel disease increases risk -​ Sex is NOT a factor -​ Race -​ AA > White > Hispanic > Asian > Native American -​ Risk Factors -​ Age (the older you are, the higher the chance) -​ Family history -​ IBD (individual themselves, or family member) -​ Dietary a & other lifestyle factors -​ ↑ risk w/ red meats and diets high in fats -​ ↓ risk w/ fruits, vegetables, high fiber, (also: CaCO3, folate, vits. A,C,E), & prolonged ASA and NSAID use  -​ “Other” 11. Understand, list and describe the procedure for CRC screening: age, tests, follow up and treatment Begin at 45 years old -​ With recommended f/u in 5-10 years Begin earlier for higher risk -​ At 40 y/o if a first-degree relative is diagnosed greater than 60. -​ Colonoscopy every 10 years At 40 y/o or 10 years younger than first-degree relative at diagnosis (if the relative is less than 60 years old at diagnosis), or 2 first-degree relatives -​ Colonoscopy every 5 years Speaker Notes Fecal Occult Blood Test (FOBT) -​ Every year starting at age 45 or every 5 years if performed with flex sig. -​ For 7 days before and during the stool collection period, avoid NSAIDs; 3 days prior to and during the test period, do not eat red meat or take vitamin C in excess of 250 mg/day. -​ One time testing is 13% sensitive → Up to 65% sensitive in asymptomatic patients who participate in regularly scheduled. Fecal Immunochemical Test (FIT)  -​ Preferred over FOBT -​ Tests for human globin -​ Less false (+) than FOBT Fecal DNA (Multi-target DNA Assay) -​ Recommended interval uncertain. -​ Newer technology. No recommendations from USPSTF, or American College of Gastroenterology -​ Low sensitivity → Detected only 1/2 of cancers and only 18% of all advanced neoplasms -​ An available first generation fecal DNA panel detected only one-half of cancers; however, a 2nd generation assay detected 90% Sigmoidoscopy -​ Every 5 years; also recommended to be performed w/ FOBT -​ 60cm flex sig permits visualization of rectosigmoid and descending colon (~2feet) -​ Risk of perforation of colon is 1 : 10,000 patients Barium Enema/Double Contrast -​ Every 5 years. -​ 50% sensitivity for polyps > 1cm and 55 - 85% for early stage cancers Colonoscopy -​ Every 10 years -​ Flexible scope permits visualization of entire colon (5 ft long) -​ Bowel Prep is what patients find most difficult. CT Colonoscopy -​ Virtual Colonoscopy - “Colonography” -​ Best for larger polyps → Sensitivity: 95% CA, 84-92% >10mm, 57-84% 6-9mm -​ Advantages: less invasive, safer w/ no perforation or sedation risks, substantially lower cost, offers complete colonic exam in patients with tortuosity or tumor that may prevent passage of a colonoscope, can assess colonic wall thickness and structures outside the colonic lumen -​ Disadvantages: not entirely noninvasive (requires rectal tube and insufflation), same cleansing prep as for colonoscopy, inability to perform biopsy of suspicious findings at time of exam may require additional follow-up conventional colonoscopy, less sensitivity for detection of very small polyps and superficial mucosal abnormalities than with colonoscopy Colonoscopy Pill Camera -​ A capsule endoscopy camera is swallowed and travels through your digestive tract, taking pictures that are transmitted to a recorder you wear. Carcinoembryonic Antigen -​ Tumor markers: Serum CEA level >5 ng/mL = poor prognostic indicator (Normal 65yrs old -​ More prevalent in African American, American Indians, Asian/Pacific Islanders -​ Family Hx of prostate cancer: 6x ↑ risk -​ Implicated (not proven): Dietary (high fat), Cadmium & rubber mfg, Androgen exposure 14. List and describe strengths/limitations of screening exam types for CaP and the appropriate normal and abnormal levels for each Despite lack of effectiveness, CaP screening has become common practice. -​ Available Screening Tests: DRE, PSA testing, and transrectal U/S -​ Tests used in combination to ↑ accuracy of findings. -​ Combining DRE, PSA, & TRU/S-directed needle Bx (if either of the 2 tests is abnormal) is the MC strategy. ⇒ Needle Bx -​ No proven reduction in disease-specific mortality w/ this or any other CaP screening strategy. Digital Rectal Exam (DRE) Palpation of prostate through rectal wall -​ Limited aspect of gland examined; Can note nodularity and asymmetry. -​ Variability in exam technique & interpretation of findings -​ Limited sensitivity and specificity -​ Useful for detecting some tumors -​ Detection rates of CaP using DRE = 1.5% to 7% (Mostly advanced; Stage T3+) -​ No controlled studies showing mortality reduction Prostate Specific Antigen (PSA) PSA is serine protease produced by prostatic epithelial cells -​ Malignant and benign tissues make PSA; PSA leaks more into the blood vessels when cells are disorganized like in prostate cancer. -​ Lack of specificity for screening  -​ False (+) → PSA levels ↑ w/ age, prostatitis, BPH, rigorous prostate massage -​ False (-) → Medications (Proscar/finasteride) -​ Cut-Off Point = 4.0 mg/dL -​ 4.0-10.0 mg/dL → Problematic -​ Repeat PSA testing at appropriate interval -​ Ultrasound (TRUS) and/or needle Bx -​ >10.0 mg/dL → Highly suggestive of CaP F/U of Abnormal Results -​ If abnormal DRE or PSA → TRUS needle biopsy is usual method -​ Abnormal DRE w/ ↑PSA → Biopsy -​ ↑ PSA level with normal DRE → another PSA, TRUS and/or biopsy Prostates Screening Algorithm 15. List the risks/benefits of CaP screening and likely treatment outcomes CaP Screening Guidelines ACS -​ Recommends that PSA and DRE should be offered annually starting at age 50, to men who have at least a 10 year life expectancy -​ Information should be provided on the potential risks and benefits of screening -​ Earlier screening tests needed (age 45) for high risk groups → African American ♂ and 1st degree relative with CaP USPSTF -​ Guidelines do NOT recommend screening w/ DRE and/or PSA testing for asymptomatic men. -​ Patients who request screening should be given “objective information” on harms and benefits of early detection and treatment -​ Grade C (Not recommended) -​ Screen men aged 55-69 y.o. on an individual basis. -​ Grade D for men aged 70+ American College of Physicians, American Society of Internal Medicine, and AAFP -​ Recommend that screening should be an informed decision based on a discussion of risks and benefits of screening, diagnosis and treatments for prostate cancer Screening Risks/Benefits Possible Benefits -​ Finding prostate cancers that may be at high risk of spreading, so that they can be treated before they spread. This may lower the chance of death from prostate cancer in some men. -​ Some men prefer to know if they have prostate cancer. Possible Harms -​ CaP screening effects on mortality are still undetermined. -​ False (+) test results: Can lead to unnecessary tests, like a biopsy of the prostate. They may cause men to worry about their health. -​ Screening finds prostate cancer in some men who would never have had symptoms from their cancer in their lifetime. Treatment of men who would not have had symptoms or died from prostate cancer can cause them to have complications from treatment, but not benefit from treatment → overdiagnosis. -​ Complications from treatment (urinary incontinence, erectile dysfunction, bowel problems) CaP Treatment Nutritional Approaches to Prevention -​ Less fat and red meat -​ Johns Hopkins Study = ↑ metastatic CaP w/ ↑ red meat intake. -​ Tomato based foods and lycopene  -​ Vitamin E & Vitamin D -​ Selenium -​ Lycopene has no discernible effect on established CaP Localized stage of disease -​ Watchful waiting → Active surveillance to avoid Tx in men who may never require it while recognizing and treating men w/ higher-risk disease. -​ Effective management for appropriately selected Pts (low PSA, small volume, well-differentiated cancers, and life expectancy 50° = surgery -​ Adams Test: Patient bends forward as if they’re touching their toes. A scoliometer can be used to measure how level the back is, anything greater than 5° off center is a positive adams test = scoliosis -​ Ottawa Criteria: Determines which patients with ankle injury gets x-ray -​ Low back pain -​ Mechanical: Due to specific trauma or strenuous activity but the precise cause is only found in 20% of patients. There’s accompanied inflammation and irritation  of supporting structures. Pain more prominent during flexion (bending over) and heavy lifting. -​ Tx: NSAIDs, RICE/RAH, stretching, strengthening exercises, changing the way one stands, sits, lifts, and sleeps, refer to PT -​ Neurogenic: Pain is nerve mediated, from a compressed spinal cord or nerve root. Can be chronic or episodic, resulting in shooting pain (radiculopathies) or paresthesias (stiffening or numbness). -​ Tx: NSAIDs, narcotics, transcutaneous electrical nerve stimulation (TENS), PT, MRI, Neuro consult, neurosurgery, pain management -​ Factitious: When the patient falsifies their back pain for financial gain, narcotics, and disability status. -​ Special tests -​ Wadell’s sign: If the patient claims to experience pain when you push down at the top of the head -​ Hoover test: when pressure is felt under the paretic leg when the non-paretic leg is raised and no pressure is felt in the non-paretic leg when the paretic leg is being raised. -​ Tx: Short term rx, refer to pain management -​ Carpal Tunnel Syndrome: compression of the median nerve, leading to numbness or pain in the hand and fingers -​ Tx: wrist movements, splits, wrist pad -​ Tennis Elbow: lateral epicondylitis -​ Golfer’s Elbow: medial epicondylitis -​ Tx for both elbow dx: RICE, NSAIDs, Injection, stretch and strengthen, brace -​ Patellofemoral pain syndrome (PFPS): Anterior knee pain -​ Tx: brace, strengthening exercises -​ Ankle strain/sprain: MC orthopedic injury. There are inversion and eversion sprains. X-ray criteria determined by Ottawa criteria. Ecchymoses are a possible presentation -​ Tx: NSAIDs, RICE, strengthening exercises -​ Plantar fasciitis: Tear or strain in the plantar fascia under the foot, can occur due to trauma, poor arch support, bone spurs -​ Tx: splits, stretching, rolling out (frozen water bottle) 19. List, describe and recognize the phases of sleep throughout the human life cycle Non-REM/REM Sleep Sleep consists of non-rapid eye movement (non-REM) and rapid eye movement (REM) sleep cycles. 4 stages of non-REM sleep -​ Stage 1 = disappearance of the alpha pattern, the appearance of slower theta waveforms (2–7 cps) along w/ slow, rolling eye movements.  -​ Stage 2 = appearance of low-frequency, high-amplitude discharges (K complexes) w/ variable-amplitude discharges (sleep spindles) → MAJORITY OF SLEEP -​ Stage 3 = emergence of slow waves (high-amplitude, low-frequency delta waveforms) making up at least 20% of sleep time -​ Stage 4 = when slow delta waves comprise >50% of sleep time. -​ Stage 3 & 4 = “deep” sleep (high-arousal thresholds and persistent grogginess on awakening). Important for growth, tissue repair, immune function, and daytime alertness. REM sleep: distinct state of sleep characterized by wake-pattern EEG, skeletal muscle paralysis, and rapid, conjugate eye movements. CNS predominantly active → dreams occur. -​ W/ the initiation of sleep, we descend through the non-REM stages w/in 45–60 minutes before beginning the first REM cycle, which tends to be brief. -​ REM sleep is intertwined w/ non-REM sleep. -​ As the night progresses, less time is spent in slow-wave sleep, and REM cycle duration ↑, eventually comprising 25% of total sleep time. The non-REM/REM cycle typically lasts 90–110 minutes, w/ about 4 complete cycles per night. Sleep & Human Life Cycle Newborns Newborns spend 70% of their day asleep. -​ Typically will sleep for 2–3 hour stretches and awake to feed. They sleep 16-18 hrs/day. -​ REM = non-REM sleep, w/ REM sleep initiating their cycle. -​ Need more REM sleep to aid w/ neurologic development. -​ At 2 months → Develop circadian rhythm w/ release of melatonin and growth hormone regulation. -​ Causes them to sleep for longer stretches at night and take shorter naps during the day = sleep consolidation and regulation. Childhood Children need more sleep than adults. -​ Daytime napping becomes less frequent as the child turns 4/5 y.o. -​ 5–10 y.o. → nocturnal sleepers w/ few arousals. -​ Total sleep time gradually ↓ throughout childhood, but for hormonal and psychosocial reasons, the amount and quality of sleep drops sharply w/ puberty. -​ Recommended sleep duration: 3-6y.o. = 10–13 hours; 6–12y.o. is 9–12 hours. -​ Sleep deprivation: Difficulty learning, fatigue, daytime restlessness, impulsive behaviors, and the full spectrum of ADHD → Consider poor sleep hygiene or medical conditions (ex. OSA) Adolescence & Young Adulthood -​ Able to maintain the high sleep efficiency of childhood, w/ few nighttime arousals and little daytime sleepiness, although ↓ in slow-wave sleep. -​ Have an altered release of melatonin that perpetuates these tendencies to delay sleep. -​ High prevalence rates of mood and anxiety disorders w/ strong emotions at this stage make transient insomnia more common → difficulty falling asleep and/or staying asleep -​ Early experiences w/ various substances affecting sleep (caffeine, nicotine, alcohol, marijuana, hallucinogens, and stimulants) can also be strong factors. -​ Physical illnesses producing inflammation, pain, endocrine, and metabolic imbalances can all impact sleep (R/O by clinical assessment). -​ Excessive daytime sleepiness at this age is usually due to sleep deprivation, but substance abuse, infection (MONO), and narcolepsy need to be considered. Middle Adulthood & Old Age Old age → Sleep needs may increase/decrease -​ Most changes are in quality & duration. -​ Sleep tends to be lighter as people age, w/ more frequent awakenings. → Less time in deep sleep. -​ Sleep timing may “phase advance” w/ earlier bedtimes and early morning awakenings. -​ More frequent daytime napping is very common in older adults.This, along w/ ↓ daytime physical activity, further erodes nighttime sleep efficiency. -​ Clinical sleep disorders also ↑ w/ age → OSA, periodic leg movements, restless legs syndrome (RLS), depression, anxiety, alcohol, and pain. 20. List and describe the process for assessing if a patient has a sleep disorder Sleep Disorders Epidemiology -​ 35% of adults experience sleep related sx’s annually -​ 10–15% suffer chronic insomnia -​ ~4% suffer from sleep apnea Lack of Sleep has Multiple Effects Average sleep requirement is 6–9 hours for a healthy adult (human range is thought to be 3-12 hours) -​ ↓ Sleep = Diminished energy and mental efficiency -​ Newborns spend 70% of their day asleep -​ Children need more sleep than adults -​ Old age: may increase/decrease -​ Most changes are in quality and duration (less time in deep sleep) Physiology -​ Hypothalamic suprachiasmatic nucleus (SCN in the hypothalamus) → Circadian pacemaker -​ Pineal gland → Secretes melatonin Assessing Sleep Disorders Clinical Assessment Office Setting Always screen for daytime sleepiness and nighttime sleep Sxs: 1)​ How are you sleeping? 2)​ How much sleep do you get in a typical night? 3)​ How much sleep do you typically need to feel your best? 4)​ Do you feel alert during the day? -​ F/U questions should determine specific disorders of either sleep or wakefulness. -​ Pediatrics/Geriatrics → often the parent, spouse, or caregiver who notices a problem. -​ Sleep diaries & Sleep quality rating scales are helpful. Wearable technology & pressure sensor pads can document sleep time and breathing rhythms. Polysomnography Alternating periods of wakefulness, REM sleep, and non-REM sleep each have a characteristic EEG, peripheral muscle, and autonomic nervous system pattern that can be documented by polysomnographic (PSG) recording. -​ PSG allows clinicians to make specific Dx based on electrophysiologic monitoring of EEG, electrooculogram, electromyogram, nasal airflow, ear oximetry, and electrocardiogram. -​ Most Pts w/ insomnia can be assessed w/o PSG, but people w/ suspected disorders other than insomnia will likely need referral and comprehensive assessment w/ PSG. 21. List, describe and apply the Epworth Sleepiness Scale and the STOP-BANG questionnaire Epworth Sleepiness Scale The Epworth Sleepiness Scale is a validated instrument used to assess pathological sleepiness in Pts. -​ Self-administered questionnaire → Measure of Sx during 8 activities -​ Rate from 0-3 the chances of falling asleep while engaged in 8 different activities. -​ 0 = would never, 1 = slight, 2 = moderate, 3 = high -​ Total score 10+ → Refer to sleep specialist Epworth Scale Activities: 1)​ Sitting and reading  2)​ Watching TV 3)​ Sitting inactive in a public place 4)​ As a passenger in a car for an hour without a break 5)​ Lying down to rest in the afternoon when circumstances permit 6)​ Sitting and talking to someone 7)​ Sitting quietly after lunch without alcohol 8)​ In a car, while stopped for a few minutes in traffic STOP-BANG The STOP-BANG questionnaire screens for obstructive sleep apnea (OSA). -​ S - Snoring -​ T - Tiredness -​ O - Observed apnea -​ P - Pressure (High blood pressure) -​ B - BMI (BMI >35) -​ A - Age (>50 y.o.) -​ N - Neck (Circumference >17” for males, 16” for females) -​ G - Gender (Male) 22. List, define and describe the categories of sleep disorders: insomnia, hypersomnia, parasomnia and the individual disorders in each classification as listed in Feldman. Sleep Disorder Categories 3 Categories of Sleep Disorders 1)​ Insomnia - Disorders of initiating and maintaining sleep 2)​ Hypersomnia - Disorders of excessive daytime sleepiness 3)​ Parasomnia - Abnormal sleep behaviors Insomnia Clinical Dx: Transient & chronic insomnia, chronobiologic insomnia, comorbid insomnia secondary to other conditions (RSL, periodic leg movements, mood & anxiety D/O, alcohol & drugs, medications, caffeine & stimulants, pain, & medical D/O affecting sleep. Hypersomnia Clinical Dx: Sleep apnea syndrome, narcolepsy, idiopathic CNS hypersomnolence, delirium, advanced dementia, & traumatic brain injury.  -​ Narcolepsy - Disorder in which elements of sleep intrude into wakefulness (and vice versa) -​ 4 primary Sx: (1) Excessive daytime sleepiness, (2) Cataplexy - brief loss of muscle tone triggered by strong emotions, (3) Sleep paralysis - transient immobility on awakening, (4) Hypnagogic hallucinations -​ Kleine-Levin Syndrome: condition characterized by periods of excessive Hypersomnia & ↑ sleep times w/ frequent recurrences of Sx. -​ Possible increased eating & hypersexuality, duration of 30 Obstructive Sleep Apnea (OSA) Treatment -​ CPAP is 1st line -​ Dental Appliances -​ Surgical interventions -​ Can target any of 3 areas that can cause blockage (Nasal, Palate, or Tongue Region) -​ Can rearrange anatomy to ensure patent airways during sleep. Delayed Sleep Phase Syndrome (DSPS) Many cases of both transient and chronic insomnia are due to underlying chronobiological or circadian rhythm disturbances. → “Hypothalamic circadian pacemaker” or Circadian body clock -​ May be transient (jet lag, shift work syndromes, seasonally affected disorder - SAD), or chronic (DSPS, advanced sleep phase syndrome, irregular sleep wake cycle, and free-running sleep syndrome from blindness) In DSPS, Pts are “obligate” night owls, staying up late into the night through varying proportions of choice and biological drive. It is a circadian rhythm D/O that can improve w/ treatment. -​ May lead to disruptive behavior, hyperactivity, distractibility, failure to attend, and learning problems in school. -​ Treatment: A phase-shift approach of consistent bed times, good sleep hygiene, bright light therapy, and melatonin Insomnia Diagnosis & Treatment Treatment requires a holistic approach that can include use of medication as well as cognitive and behavioral strategies to reduce anxiety and changes to improve sleep hygiene. 1)​ Reframing the psychosocial context of sleep disturbance -​ Modifying family routines; Add naps during the day. -​ Sleep hygiene (Avoid caffeine/alcohol, Standardization of bedtime, Bedroom only for sleeping & sex) -​ Chronobiological interventions (light therapy). 2)​ Cognitive behavioral therapy -​ Counsel Pts to change critical beliefs that induce anxiety around falling asleep and to motivate them to change bedtime behaviors that may be perpetuating insomnia. -​ Motivate Pts to practice cognitive skills that will help minimize the worry and frustration that induces the physiologic stress response and impedes sleep. 3)​ Medical treatment (sedative-hypnotic drugs) - Short-term 4)​ Treat underlying secondary medical conditions 24. List, define, describe and recognize the stages of the Optical Model of Stress as listed in Feldman Ch 36 Optical Pathway Model: depicts stressors as light rays filtered through successive lenses representing the individual’s perception (threat appraisal), coping, physiologic processes, and arousal reduction activities, and then projected onto illness outcome screens. -​ Each lens either augments or diminishes the intensity of light on its pathway to illness outcome, and represents a potential focal point for the clinician’s Dx of a stress influence or risk factor for patient illness. -​ Each lens also represents a potential focus of preventive health care or intervention. Perception: refers to the person’s appraisal of the threat involved in various stressors. -​ The degree of control individuals prefer to have in their lives + the amount of control they perceive they have over specific stressors.  -​ For example: the degree of openness to change or the extent to which one values change influences whether a particular life change, such as a child leaving home, is perceived as a threat to the self or an opportunity for growth -​ Thus, a parent with a high need to control an adolescent child’s outside activities experiences more stress when the child struggles toward emancipation than does a parent who has less of a need for control and who trusts the child’s judgement Coping: refers to methods one uses to mitigate the influence of stressors perceived as threatening. -​ “Exposure management” - attempts to increase or decrease the amount and intensity of stressors encountered. -​ Thus, an overworked, overcommitted manager might attempt to mitigate stress by withdrawing from some commitments, by reducing work hours, and by delegating more responsibility to subordinates -​ Social support - are an important stress buffer, and successful coping with stressors may involve both developing confiding relationships and increasing the amount of one’s self-disclosure about the effect of stressors in one’s life. -​ There is some evidence that emotional self-disclosure about stressors enhances immune functioning -​ “Stimulus screening” - involves techniques to focus attention on relevant stimuli and to regulate the overall flow of stimulation to one’s optimal level of functioning. Physiologic Response: to stressors that lead to target organ pathology are autonomic hyperreactivity and immunosuppression -​ Hyperreactivity (defense reaction) -​ Has been shown to be a factor in disease processes specific to vulnerable organ systems in persons with established disease -​ Thus, exaggerated pressor responses in hypertensives, increased electromyogram responses in those suffering from tension headaches and chronic back pain, disturbances in glucose metabolism in insulin-dependent diabetics, and bronchoconstrictive responses in asthmatics are all examples of hyperreactivity in the presence of a definable stressor -​ Immunosuppression (defeat reaction) -​ Occurs through the mechanisms of increased levels of circulating corticosteroids, catecholamines, and opioids and decreased levels of growth hormone and prolactin under conditions of chronic or prolonged stress -​ Sometimes referred to as the defeat reaction, this response pattern occurs when patients are exposed to long-term stressful situations that tend to overwhelm ordinary coping mechanism, thus leading to despair or deep sorrow in situations that appear to be beyond all hope and rescue Arousal Reduction Activities: strategies to individuals to mitigate physiologic activation and disruption of homeostatic processes in conditions of stress -​ Health-enhancing -​ Exercise, which expends accumulated corticosteroids and dampens sympathetic activation through the release of endorphins, and various approaches to stimulating the parasympathetic nervous system -​ Examples: relaxation exercise, abdominal breathing, self-hypnosis, meditation, soothing music, massage, and contact with nature -​ Health-degrading -​ Attempts at physiologic arousal reduction but that actually magnifies the stress response and leads to target organ disease -​ Examples: substance abuse, tobacco use, and eating disorders Various illness outcomes of stress include: biomedical disease manifested in specific organ systems; emotional and cognitive disorders, and behavioral disorders, and overuse of healthcare resources. Methods to Decrease Stress 1)​ Communication → Optimism + Praise beneficial lifestyle changes -​ Counseling (Time management, Perception, Coping) 2)​ Nonpharmacologic interventional related to perception and coping.  3)​ Health-enhancing arousal reduction techniques. 4)​ Referral for psychotherapy Nonpharmacologic Interventions -​ Improve time management -​ Pursue short term psych counseling -​ Improve sense of humor -​ Clarify values -​ Pursue personal/vocational activities -​ Cultivate social support network w/ life values -​ Increase assertiveness -​ Explore “purpose of life” -​ Reduce exposure to unnecessary -​ Cultivate spiritual and transcendent stressors activities (prayer, rituals, retreats) -​ Monitor sensory input -​ ↑ emotional self-disclosure -​ Help others Health Enhancing Arousal Reduction Techniques For patients showing a high degree of autonomic hyperreactivity, arousal reduction strategies can work synergistically w/ perception and coping skills, as well as w/ pharmacological interventions. -​ Meditation -​ Abdominal breathing -​ Self-hypnosis -​ Singing -​ Relaxation exercises -​ Tai chi -​ Time in nature -​ Soothing music -​ Massage -​ Yoga