Sleep Disorders

Q:Recent research has defined mild cognitiveimpairment as a transitional state between thecognitive changes of normal aging and Alzheimerdisease (AD) and other dementing illnesses. Whatcriteria are used to differentiate mild cognitiveimpairment from more innocuous syndromes, such asbenign senescent forgetfulness? Are patients with mildcognitive impairment considered to have incipientclinical AD?

For 2 days, a 45-year-old woman has had a painful rash on her left upper chest,upper back, neck, shoulder, and upper arm; she has also had pain around herleft ear. She describes the pain as burning, needlelike, and so severe that it hasprevented sleep; it is unrelieved by topical emollients. The rash was precededby 24 hours of a similar burning pain in the same area. No neurologic deficitsare associated with the rash. She has no history of rashes; no pain or rashesoccur elsewhere on her body.

A 41-year-old woman presents as a new patient, with complaintsof chest pain and palpitations that occur intermittentlyand are not associated with activity, meals, or position.She says these symptoms have been present forsome time, and she expresses frustration that her previousphysician was unable to find their cause or to amelioratethem.

The patient is a 4-year-old boy who hasbeen coughing persistently for the past 2months. The mother reports that aboutthe time the coughing began, the childhad a “cold” with nasal congestion andfever. These symptoms resolved, but acough ensued. The mother tried usingover-the-counter medications, includingcough suppressants, but the cough hasnot abated. It occurs during the day andat night. It is disrupting the child’s sleep,and the teachers at his day-care centerare concerned that he may be infectingother children.

A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had boutsof severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products(ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and mayvomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care centerfor intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. Accordingto the patient, a visit to the urgent care center “completely ruins our day.”

In recent years, 2 large randomized,controlled studies have documentedthe efficacy of the anticonvulsantgabapentin in the management ofpainful diabetic neuropathy (PDN)1and post-herpetic neuralgia (PHN).2Although vastly different in origin,these 2 neuropathies have exhibitedsome similarities in their response totherapeutic agents of various classes.The discovery that yet another typeof pharmaceutical is useful in treatingpain from either PDN or PHN hasraised questions about the similaritiesand differences in the managementof these 2 painful neuropathicsyndromes.

Q:Which patients with chronic respiratory disorders are good candidatesfor pulmonary rehabilitation? When is it a better option than surgery?

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.

A 45-year-old man has a history of migraine that started shortly after puberty. The headaches became more frequent andsevere 3 years ago, when the patient was promoted from metal worker to shift boss.

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.