Functional Limitations and Developmental Delays

IntroductionThis lesson provides an overview of the assessment of functional limitations in the context of diagnosing and treating disorders that can cause diminished function. We'll cover:History Physical examination Common screening and diagnostic tests Health-promotion behaviors and early identification of problems

What and When to AssessAssessment of functional limitations involves obtaining information to determine a person's ability to achieve the basic activities of daily living and perceive, integrate, store, retrieve, process, or produce information.Difficulties in these areas may be attributed to any or all of these causes:Motor deficits Sensory deficits Mental retardation or developmental disabilities Cultural deficits Environmental deficits Emotional disturbancesThese deficits usually result in significant difficulties with cognitive ability, communication, and socialization. The Americans with Disabilities Act defines disability as any impairment that limits a major life activity. Developmental disability is a chronic or physical impairment that results in the delay or failure to achieve normal developmental milestones. These impairments usually occur before the age of 22 years, and any child who does not meet growth and developmental expectations should be evaluated.Functional limitations can also affect patients older than 22 years; sleep disorders can affect an individual's ability to carry out activities of daily living (ADLs), and falls in older individuals can certainly affect their ability to participate in major life activities.

HistoryFamily historyCentral nervous system (CNS) disorders Mental retardation Epilepsy Evidence of school problems Specific learning disabilities

HistoryPrenatal historyHistory of stillbirths, deaths, or other problems during prior pregnancies Use of drugs or alcohol Radiographs taken during pregnancy Exposure to virusesPerinatal historyNeonatal infections Asphyxia Increased bilirubin levels Difficulty during labor

HistoryDetermine when various milestones were achieved, especially those pertaining to speech and language and behavioral function. Other information may be helpful in assessing limitations on activities in an adult patient.Preschool educational and learning historyInformal setting: what was learned Formal setting: relationships with other children and teachers Teachers' reports on child's performance and behavior in the classroomSchool-age educational and learning historyGrade placement Whether special-education evaluations were performed and their results Whether grades were repeated Standardized test scores How instruction was provided, whether the method was appropriate for the child's learning needs, and whether the content was aligned with the child's experienceEmployment and legal historyWhether the subject is able to obtain and maintain employment Whether the subject has been involved in legal issues related to his or her behavior

HistoryA family's interactions greatly affect a child's development. Children of hostile, rejecting, authoritarian parents tend to be most severely affected, but parents who are too lax, provide too little nurturance, or fail to supervise their children can tend to cause children to exhibit aggressive behavior problems that persist into adolescence and adulthood.Psychosocial historyParents' ability to promote cognitive abilities and social development, including language and cultural background, quality of verbal interaction, disciplinary practices, and ability to set standards Additional details about the home environment Environmental exposures, including exposure to lead or alcohol Emotional and social behavior (the nurse practitioner may administer scales to record teacher and parent ratings of general behavior or get results from another source) Intelligence tests to measure general knowledge, reasoning, judgment, and analytic skills that are expected to develop through experiences encountered in the process of growing up Current functional level of adults with developmental disabilities Capabilities of older adults with regard to carrying out ADLs

Physical ExaminationConduct a comprehensive physical examination, paying special attention to particular areas:Assess growth parameters and head circumference Assess the child for dysmorphism Assess pigmentary abnormalities Assess physical anomalies such as abnormal palmar crease, syndactyly, unruly hair, malformed ears, skin tags, and facial abnormalities Perform an expanded neurologic examination Assess neurologic soft signs Perform a sensory evaluation to assess visual and auditory problems Evaluate the four milestones Evaluate the gait of an adult patient with any deficit Consider administering the Mini-Mental State Examination to screen for cognitive impairments in an adult

Physical ExaminationDiagnostic proceduresNewborn screening for phenylketonuria, hypothyroidism, and other metabolic disorders; requirements vary from state to state Screening for iron deficiency and lead toxicity, both of which are easily acquired and can contribute to developmental delays Electroencephalography and neuroimaging; appropriate when there is a clinical suspicion of seizure or encephalopathy, microcephaly, or rapidly expanding head circumference Chromosomal and molecular biologic testing for Fragile X, the most common inherited cause of mental retardation Urine and plasma testing for amino acids Urine metabolic screening Developmental screening tests Stanford-Binet Intelligence Scale

Health-Promotion Behaviors and Early Identification of ProblemsIf assessment indicates a lack of health-promotion behaviors, reinforce these behaviors as appropriate Provide routine screening, with more frequent screening of at-risk populations Monitor the child's development as a routine part of the well-child examination to enhance recognition of developmental disorders, recognizing abnormal appearance and function during routine examinations and listening carefully to parental concerns and observations about the child's development during all encounters

IntroductionIn this lesson we'll cover disorders pertinent to developmental delays and disabilities:Down syndrome Autistic-spectrum disorders (ASDs) Mental retardation Muscular dystrophy Learning difficulties

IncidenceDevelopmental delays and disabilities encompass deficits in cognitive, social, and emotional function that impair a person's ability to perceive, integrate, store, retrieve and produce information. Examples of disorders associated with these deficits include cerebral palsy, mental retardation, learning difficulties, blindness and deafness, central processing disorders, muscular dystrophy (MD), and pervasive developmental-delay disorders such as autism, Asperger syndrome, Down syndrome, Fragile X syndrome, and childhood schizophrenia.Developmental disabilities affect an estimated 17% of children under the age of 17 in the United States Developmental delays in early childhood are strongly associated with the diagnosis of developmental disabilities later in childhood; other disabilities may be related to a caregiver's failure to establish proper feeding or interaction with the child Mental retardation is the most common cause of speech delay, accounting for 50% of cases Approximately 2% to 3% of the general population is considered mentally retarded Mental retardation is more common in males than females About 10% of mentally retarded individuals are identified as such during infancy and early childhood The remaining 90% of mentally retarded individuals fall into the mildly retarded range (intelligence quotient [IQ] of 50 to 69)

PathophysiologyGenetic: inborn errors of metabolism and chromosome disorders Intrauterine: congenital infections, placental-fetal malfunction, complications of pregnancy Perinatal: prematurity, postmaturity, metabolic disorders Postnatal: endocrinopathies, metabolic disorders, trauma, infections, poisoning, maltreatment Cultural-familial: low family intelligence, environmental deprivation

HistoryA developmental evaluation helps obtain insight into a child's level of cognitive and social function, data that assist in determining a cause, and data relevant to developing a plan of care. This information is best obtained by a multidisciplinary team.When taking a routine history, recognize medical, genetic, and environmental risk factors for developmental delay Obtain a complete history whenever there is reason for concern Ask the parents about the child's current skills to help assess developmental delay

Physical ExaminationConduct a comprehensive physical examination, paying special attention to particular areas:Ears, nose, and throatincluding brainstem auditory responseto evaluate hearing loss and ophthalmic disorders Speech and language General appearance, including observed dysmorphic features of Down syndrome, Fragile X syndrome, and Angelman syndrome Skin, including observed signs of neurocutaneous disorders Neurologic system Musculoskeletal system Cardiovascular system to detect any congenital heart defects Development Behavior

Physical ExaminationDiagnostic proceduresElectroencephalography DNA testing for Fragile X syndrome or MD Chromosomal testing and karyotype analysis for any child with dysmorphic features Lead screening Thyroid testing if a decreased rate of linear growth or dry skin or hair is observed Creatine kinase level if DMD or BMD is suspected Audiometry testing Developmental testing, including the Parents' Evaluation of Developmental Status, the Checklist for Autism in Toddlers, and the Pervasive Developmental Disorders Screening Test Stage I

Physical ExaminationDiagnosisThree critical components for school learning and behavior are attention, memory, and the coordination of these processes There are three types of delay Disorders with IQ-achievement discrepancy involve specific learning disorders that may occur in any area of academic achievement, particularly in reading (dyslexia), arithmetic (dyscalculia), and writing (dysgraphia) In children with minimal brain dysfunction, family history usually shows affected members (especially among male relatives), physical-examination findings are normal, behavior problems may be present, and intelligence tests reveal average intelligence Disorders without IQ-achievement discrepancy include disorders in which IQ and achievement are equal but at low- to below-normal levels Slow learners tend to have IQs in the 80s Clumsiness, motor impersistence, and right-left confusion are twice as common in slow learners as in children with learning disorders History reveals developmental delay, especially in language A family history of school problems may be present In mental retardation, IQ and achievement are 2 SD below average; sensory deficits, motor handicaps, speech and language delays, seizure disorders, and behavior problemscommon and signs of significant developmental delayare evident by 2 years Gross motor delaysin particular, gait developmentand expressive language delay may indicate MD Autistic impairment can range in severity with regard to social interaction, communication, activities, and interests

TreatmentThe only significant approach to treatment is prevention or early diagnosis Low IQ scores and failure to develop communicative language by 5 years of age correlate positively with a poor prognosis for response to treatment Individuals with developmental disorders may need inpatient or residential placement or, less drastically, a special educational program The plan of care should address nutrition, safety, discipline, and sexuality

EducationBe tactful Discuss the child's needs, including social support and physical therapy Suggest counseling to help the whole family adapt to the impact of a developmentally delayed child Encourage genetic counseling Stress the need for parents and family members to stay actively involved Provide information about infant and special-education programs Review the importance of adequate nutrition Discuss discipline

Follow-Up and ReferralFollow-upDirect management efforts toward the impact on and support of the familyReferralRefer any patient who may have a developmental delay or disability to a professional or multispecialty center whose staff can thoroughly examine the patient and follow through with the needed treatment plan

Board Questions Down syndromeIn Down syndrome, which of the following is true?Most infants affected with Down syndrome are born to women older than age 35 yearsDown syndrome is noted in about 1 in 10,000 live birthsDown syndrome is associated with decreased maternal serum AFP levelAntenatal serum analysis is sufficient to make the diagnosis

Down syndrome is the clinical manifestation of trisomy ____.-13-15-18-21

Elevated inhibin-A is noted when a pregnant woman is at increased risk of having an infant with:Down syndromeEdward syndromeOpen neural tube defectHemolytic anemia

A 25 year old woman presents in the 10th week of gestation requesting antenatal screening for Down syndrome. What advice should the NP give?-because of her age, no specific testing is recommended -she should be referred for second trimester ultrasound-screening that combines nuchal translucency measurement and biochemical testing is recommended-she should be referred to a genetic counselor

Introduction

In this lesson we'll cover fetal alcoholspectrum disorders and health promotion related to alcohol use during pregnancy.

IncidenceFetal alcoholspectrum disorders (FASDs) cause profound lifelong effects on children and their families. A woman who drinks alcoholic beverages during her pregnancy puts her child at risk for growth retardation, central nervous system (CNS) disorders, and birth defects.Incidence has increased in the last 15 years Although FASD is found in all races and socioeconomic groups, there is a higher incidence in women in lower socioeconomic groups who are older than 30 years and have a history of binge drinking Most common among indigenous American populations One in six women of childbearing age drinks enough during pregnancy to harm an unborn child; perhaps 10% of women drink during pregnancy, and 2% engage in binge drinking Approximately 20 in 10,000 children are born with fetal alcoholspectrum; Alcohol-related neurodevelopmental disorder (ARND) is more common Children with FAS or ARND are at increased risk of physical abuse Maternal history of alcohol use during pregnancy increases risk More common among foster, adopted, and neglected children

PathophysiologyCausesFAS is caused by the exposure of the fetus to toxic levels of alcohol, which results in severe physical defects and CNS changes, including retardation ARND is milder with fewer physical abnormalities than FAS but with significant CNS changes that may not be observed until the child is older The amount of alcohol exposure that causes FAS and ARND is still unknown Chronic use or binge drinking causes the most CNS damage The impairments associated with FAS are often a reflection of underlying structural changes in the corpus callosum

HistoryInfantsSlow growth patterns Developmental delays Short attention span Poor motor control Irritability and overreaction to sounds Excessive crying Poor sleep patterns Seizure disordersToddlersLack of bonding Phobias, tantrums, emotional instabilitySchool-age childrenPeak school performance in grades 6 through 8 Average IQ of 70 to 90 Math and language deficits ImpulsivityAdolescentsPoor judgment Carelessness Poor use of time Desire for immediate gratification Inappropriate sexual behaviors Alcohol use

Physical ExaminationConduct a comprehensive physical examination, looking carefully for common findings in FASDs:Microcephaly Absence or underdevelopment of the philtrum (hallmark of FASD) Posteriorly displaced jaw Dental anomalies Eye ptosis Short palpebral fissures Strabismus Hypertonia Finger anomalies Short, flat nose with a high tip Malformed ("railroad track") ears or hearing deficits Back, neck, and spine defects Hyperactivity Small stature

Physical ExaminationDiagnostic proceduresNo definitive test with which to diagnose FAS exists; diagnosis is based on clinical presentation or suspicion of alcohol exposure in utero A diagnosis of FAS requires three findings Diagnosis is important because the patient will qualify for services under the Americans with Disabilities Act FAS is most commonly misdiagnosed as attention deficithyperactivity disorder (ADHD) FAS is generally diagnosed at school age, when a child is referred for learning disorders or ADHD Magnetic-resonance imaging test may reveal certain findings indicative of FAS

TreatmentPrevention (i.e., education on the dangers of drinking during pregnancy) is key to stopping FAS, but early detection is crucial in mitigating its devastating effects when a woman does choose to drink while pregnant Careful monitoring of the child's development can indicate when and where additional interventions are needed The average child with FAS stays with the birth parent less than 4 years and is at increased risk for neglect and physical abuse No treatment exists for FAS; however, medications can be used to address symptoms The plan of care should address nutrition, exercise, schooling, and parenting issues

Education, Follow-Up, and ReferralEducationFAS is preventable Educate women of childbearing age about the dangers of alcohol on relation to fetal developmentFollow-upRoutine periodic follow-up of the affected child is recommendedReferralIf prenatal alcohol exposure is unconfirmed, consider referring the child to a multidisciplinary team A pregnant woman whose alcohol exposure exceeds seven drinks per week or three drinks on multiple occasions should be referred for assistance Refer the child to a multidisciplinary team if the child's parent or caregiver expresses concern Refer the child if characteristics of an FASD are present

Board Question Fetal AlcoholConcerning the use of alcohol during pregnancy, which of the following statements is most accurate?Although potentially problematic, maternal alcohol intake does not increase the risk of miscarriageRisk to the fetus from alcohol exposure is greatest in the third trimester No level or time of exposure is considered to be safeRisk of fetal alcohol syndrome is present only if alcohol exposure has occurred throughout the pregnancy

IntroductionFalls are injuries sustained as a result of kinetic forces incurred during a loss of balance that involves a change in spatial orientation. In this lesson we'll discuss the factors that increase susceptibility to falls and ways to prevent falls.

IncidenceEmergency-department visits related to falls are more common in children younger than 5 years and adults 65 years and older than in other groups Incidence increases steadily during the middle years and peaks in people over the age of 80, when sensory impairments are more common Between 30% and 40% of community-dwelling adults older than 65 fall each year; higher rates occur in nursing homes Between 20% and 30% of those who fall suffer serious injuries and complications Falls account for 70% of accidental deaths in people older than 70 One half to two thirds of falls occur around or in the person's home Hip fractures resulting from falls account for most hospitalizations for fractures and are the second major cause of hospitalization for women 85 years and older Percentages of fall-related deaths are highest for men in all age categories Approximately 10% of all falls among elderly persons occur during acute illness

PathophysiologyCausesEnvironmental hazards account for about 25% to 45% of falls Falls by men often result from slips, whereas women tend to trip and then fall Most people who fall say that being in a hurry was the cause of the fall Most older adults believe their falls result from internal factors (e.g., dizziness, poor balance), not external factors (e.g., rugs, poor lighting) The physiology of aging increases the risk of falling by increasing the serum concentration and half-life of some drugs, the incidence of syncope, and the severity of injury Heavier people tend to sustain less severe injuries Falls on hard, nonabsorptive ground surfaces (e.g., tile, wood, concrete) are more likely to result in injury

PathophysiologyThe more risk factors a person has, the greater the likelihood of falling.Risk factorsPrior falls Gait disturbance (increases risk threefold) Physical inactivity Weakness of the leg muscles (increases risk fourfold) Use of an assistive device Depression Age greater than 80 years Balance difficulty Urinary incontinence Change in housing conditions Poor pulse rate after standing Parkinsonism Arthritis Divorced, widowed, or unmarried status Low body-mass index Incomplete step continuity Poor vision Peripheral neuropathy Polypharmacy

HistoryAssessment toolsSplatt I hate falling

HistoryMedical history (in patients with a history of falls)Anxiety during ambulation Sweating or trembling during (but not before) ambulation Clutching at objects or people while walking Watching own footsteps when walking Reluctance to walk or change positionMedication historyBenzodiazepines, tricyclic antidepressants (TCAs), and the newer selective serotonin-reuptakeinhibitor agents (SSRIs) have been correlated with falls No significant differences between the risk of falls associated with TCAs or SSRIs

Physical ExaminationConduct a comprehensive physical examination, paying special attention to particular areas:Posture-related changes in vital signs Presence of cardiac arrhythmias Presence of carotid bruits Focal deficits Stability and mobility problems Leg weakness

Physical ExaminationIt is important to determine whether a fall is in itself the primary event or whether it is the result of an undetected decline in health resulting from another condition. The diagnostic procedures you perform will change, depending on a patient's preexisting conditions.Diagnostic proceduresComplete blood count, vitamin B12 determination, and basic metabolic panel to rule out anemia, electrolyte imbalances, dehydration, and hypoglycemia or hyperglycemia as a cause of the fall Thyroid-function testing Radiographs (depending on the extent of injury) Electrocardiogram, Holter monitoring, or echocardiography to rule out syncope resulting from arrhythmia Urinalysis to rule out infection Brain imaging and other testing as needed, depending on the history and physical-examination findingsDifferential diagnosisFall related to functional decline Fall as primary event (results of diagnostic procedures are negative except for those directly related to injuries) Syncope

TreatmentNonpharmacologicSafe-falling techniques Intervention strategies that mitigate the effects of a fall Proper fitting and use of assistive devices Physical exercise in healthy older patients Fall-prevention strategies for skilled-nursing facilities

TreatmentTreat injuries sustained in earlier falls as necessary Diagnose and treat osteoporosis to reduce the risk of fall-related fractures Institute prophylactic measures against osteoporosis

EducationHelp older patients and their families and caregivers identify and reduce environmental hazards in the home Reorient the patient to risk perceptions if a switch in the living environment is made (e.g., moving from a rural community to an urban one or from one house to another)Teach the patient how to use assistive devices safely Monitor and adjust medications; stop psychotropic medications, if possible Tell the patient to avoid wearing multifocal glasses while walking Encourage the patient to exercise Work to prevent falls in the nursing home

Follow-Up and ReferralFollow-upAssess the patient at each visit for fall susceptibility Ensure that the patient is implementing prevention practicesReferralRefer an older patient who has sustained at least one other fall within 3 months of the fall for which he or she is currently seeking care to a geriatric specialist for assessment Consider referrals to social services, home health care, physical therapy (especially if a gait or balance problem was assessed), optometric and ophthalmologic examination, and a podiatrist (for appropriate footwear)

Board Questions - FallsMost falls in older adults occur in:A health care instituteA public placeThe patients homeAn outdoor setting

An NP is asked to evaluate a 77 year old woman who recently had an unexpected fall. The patient is normally healthy and has no mobility limitations or other obvious risk factors. During the history, the NP learns that the patient did not attempt to break the fall, I just suddenly found myself on the floor. This statement suggests:-a previously undiagnosed cognitive impairment that requires further evaluation-the underlying sensory deficits (visual, hearing) are the most likely cause of the fall and require physical assessment-that a history of alcohol use or abuse should be explored-a syncopal episode requiring a cardiovascular and neurological evaluation

In an older adult, the greatest risk of long term complication is associated with fracture of the:ForearmSpineAnkleHip

Fall risk in an older adult is decreased with the use of which of the following footwear?-sandal-jogging shoe-slipper-semi rigid sole shoe

An older adult who has recently fallen has a(an) ____ times increased risk of falling again within the next year.-1 to 2-2 to 3-3 to 4-4 to 5

With the use of insulin, fall risk in an older adult is most likely to occur ______ of the medication?at the onset of actionat the peak of actionat the middle point of duration of actiontoward the end of anticipated duration of action

With use of a benzodiazepine in an older adult, the risk of fall is most likely to occur _____ of the medication.at the onset of actionat the peak of actionat the middle point of duration of actiontoward the end of anticipated duration of action

IntroductionSleep disorders include a variety of disorders that interfere with the quality and quantity of sleep. In this lesson we'll cover the following sleep disorders:Obstructive sleep apnea Restless-legs syndrome Insomnia

IncidenceThe average adult needs 6 to 9 hours of sleep per night More than 50 million people have some type of sleep disorder, and nearly one third of Americans have difficulty sleeping over the course of a year Sleep disorders are associated with high rates of work absenteeism and accidents More women have sleep difficulties than men Women older than 40 are more likely to complain of difficulty sleeping Men tend to nap more than women do Common sleep problems include insomnia, restless-legs syndrome (RLS), periodic leg movements in sleep (PLMS), chronobiologic disorders, hypersomnias such as narcolepsy and sleep apnea, and parasomnias such as sleep terrors, sleepwalking, and nightmares

IncidenceInsomnia, the most frequent sleep complaint, can be classified as a primary disorder, a secondary disorder, transient (lasting only a few nights), short-term (1 month), or chronic (>1 month) Approximately half of all persons 65 and older experience insomnia A strong link exists between insomnia and depression OSA affects nearly 15 million people; between 1% and 3% of children have OSA, and approximately 2% of women and 4% of men have OSA in midlife RLS affects about 10% of the population Sleep problems may be related to mood disorders, immune dysfunction, and cardiovascular disease Only one third of patients report problems with sleeping to the primary care providers, and only 5% seek treatment

PathophysiologyNormal sleep cycleThe circadian process is a natural rhythm that causes an increase in sleepiness twice during a 24-hour period, typically between midnight and 7 AM and again between 1 and 3 PM. A normal sleep cycle is a complex, electrophysiologic active process consisting of two types of sleep: rapid eye movement (REM) and non-rapid eye movement (NREM) NREM sleep consists of four stages A person alternates between NREM and REM sleep Sleep cycles vary with age, medical and psychiatric illness, and medications The hypothalamus controls the processes of sleep and wakefulness; homeostasis and circadian rhythmicity regulate the amount and timing of sleep Sleep debt is cumulative and must be paid back hour for hour; it is healthier to get the requisite amount of sleep each night

PathophysiologyInfluences on the sleep/wake cycleNeurotransmitters (-aminobutyric acid) Growth hormone secreted during NREM sleep Light Melatonin Anatomic structure of the airway Dopaminergic functionRisk factorsHistory of sleep disorders Psychiatric disorders Anxiety Depression Alcohol, tobacco, or drug use Pain and discomfort Orthopnea Nocturia gastroesophageal reflux disease (GERD) Asthma Fibromyalgia Travel across time zones

HistoryCurrent complaintAsk about current symptoms of sleeplessness Pursue current symptoms further Ask about recent stressors Work with the parent or caregiver to determine the child's symptoms Confirm sleep patterns with the patient's sleep partner Obtain subjective descriptions and feelings about the patient's sleep to serve as the basis for clinical management

HistoryMedical historyPsychiatric disorders, including anxiety or depression Thyroid disorders Renal disorders GERD Orthopnea Nocturia Fibromyalgia Chronic obstructive pulmonary disease Arthritic disorders Neurologic disorders (e.g., Parkinson disease, head trauma, cerebrovascular accident) Cardiovascular disorder (e.g., hypertension, or congestive heart failure) Iron deficiency

HistoryMedication historyMelatonin Sleep aids Cold and allergy medications Alcohol Nicotine Prescription drugs that may cause insomnia

HistoryFamily historySleep disorders RLS PLMSDietary historyCaffeine (3- to 7-hour half-life) Alcohol use

Physical ExaminationConduct a comprehensive physical examination, paying special attention to particular areas:Physical or organic causes of insomnia Vital signs General appearance Head, eyes, ears, nose, and throat (HEENT) Lungs Cardiovascular system (baseline assessment) Abdomen

Physical ExaminationDiagnostic proceduresTests to help rule out endocrine, renal, or cardiac disorders that may precipitate sleeping disorders Sleep diary Epworth Sleepiness Scale, a validated screening method with standardized questions Actigraphy Electroencephalogram (EEG) to identify the patient's sleep stages and changes specific to psychiatric problems Electromyogram (EMG) to record the state of muscle contraction when a muscle is stimulated Electrooculogram (EOG) to help correlate brain waves with eye movements Polysomnigraphy (PSG)

Physical ExaminationDifferential diagnosisMost sleep disorders are categorized as one of four major symptoms: insomnia, hypersomnia, parasomnia, and sleep-wakeschedule disturbance Differential diagnosis consists of determining underlying causes of sleep disorders

TreatmentPatient's descriptions and subjective feelings should serve as the basis for clinical management.Nonpharmacologic: insomniaTreatment plan with specific short-term goals Sleep-hygiene measures are advised for all patients, regardless of treatment Cognitive therapy Chronobiologic treatment Stimulus-control therapy Relaxation therapy based on meditation, imagery, and progressive muscle relaxation Sleep-restriction therapy

TreatmentNonpharmacologic: OSAMeasures to control snoringNonpharmacologic: sleep terrorsMeasures to control sleep terrorsNonpharmacologic: RLS and PLMSSleep-hygiene measures Avoidance of antidopamine medicationsneuroleptics, metoclopramide, antidepressants, and calcium channel blockerswhich aggravate RLS National support group

TreatmentPharmacologic: insomniaSedating antidepressants Hypnotics Antihistamines Herbal therapies or nutritional supplements Melatonin-receptor agonist. Example: ramelteon (Rozerem) Barbiturates are not recommended because they decrease REM sleep and may cause an REM rebound effect Short-term therapy with benzodiazepines may be used in conjunction with a sleep-hygiene program (short-term insomnia)Pharmacologic: RLS and PLMSDopamine agonists (preferred treatment) Sedative-hypnotics (e.g., clonazepam) Antihypertensive agents (e.g., clonidine) to reduce subjective complaints and improve patient's ability to fall asleep Opioids Anticonvulsants (e.g., gabapentin, carbamazepine) Benzodiazepines to increase sleep continuity (these do not reduce the number of leg movements, however)

EducationTeach a sleepwalker's parents or caregivers how to take protective measures Advise teenagers on how to manage sleep Tell the patient to avoid caffeine, alcohol, and excessive time in bed while awake Recommend a white-noise machine to help block out environmental noises Tell patients with a delayed sleep phase to avoid late-night activity Tell the patient to avoid any foods or drinks that seem to intensify insomnia or interfere with sleep Caution the patient against drinking alcohol with benzodiazepines Help the patient adjust to jet lag or shift work

Follow-Up and ReferralFollow-upReevaluate patients who have been taking benzodiazepines for 2 to 3 weeks Reevaluate the patient if insomnia continues for more than 3 weeksReferralRefer any patient with refractory insomnia to a sleep-disorders center Make a physician referral, if necessary, for prescription of controlled substances

SummaryFunctional Limitations:Assessment Developmental Delays and Disabilities Fetal AlcoholSpectrum Disorders Falls Sleep Disorders