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17.08.2014

Best medication for insomnia in elderly, pulsatile tinnitus usmle - For Begninners

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Patient information: See related handout on insomnia, written by the authors of this article. Multiple factors can lead to insomnia in hospitalized patients, including sleep disorders, psychological and physical factors, certain medical conditions, medications, environment, clinical activities, and poor sleep hygiene. A lack of diurnal light cycles also can contribute to insomnia, as can clinical activities performed at night.
If a hospitalized patient complains of insomnia, the physician should obtain a thorough sleep history. If insomnia is caused by a medical problem, treatment of the underlying condition should improve the patient's sleep. Other nonpharmacologic therapies for insomnia in the hospital include white noise or music, back massage, and warm drinks. Pharmacologic therapy should be considered if treatment of the underlying problem does not resolve the insomnia or if a hospitalized patient has failed or refused nonpharmacologic therapy. A prospective single-center study examined 100 hospitalized patients' preference for pharmacologic versus nonpharmacologic therapy for insomnia. Antidepressants, including trazodone, mirtazapine, and tricyclic antidepressants (TCAs), also have been used for insomnia (TABLE 1). For hospitalized patients, pharmacists can recommend appropriate hypnotics and dosages based on patients' renal and hepatic function and age. For patients who need a hypnotic after discharge, pharmacists should recommend that a short-term prescription (2-4 weeks) of the lowest effective dose be given.22 Patients should be advised to avoid alcohol with hypnotics.
Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated.


An approach to the evaluation and treatment of the patient with insomnia is shown in Figure 1. The patient should be questioned about sleep patterns, sleep environment, and sleep hygiene at home to determine whether the insomnia is a new problem or a continuation or exacerbation of an existing problem. Data on the use of pharmacologic therapy for the treatment of insomnia in hospitalized patients are limited; most information is extrapolated from outpatient data.
Forty patients developed insomnia while in the hospital; the other 60 had insomnia prior to admission. TCAs are sedating, but they are not recommended, especially in the elderly, because of their anticholinergic and adverse cardiovascular effects. They can also recommend that hypnotic orders be written at bedtime as needed or scheduled nightly while allowing for patient refusal of the medication.
However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. Drug choices for insomnia in hospitalized patients include benzodiazepines (BZDs), BZD receptor agonists (BZD-RAs), melatonin RAs, antidepressants, and antihistamines (TABLE 1). Thirty-one percent of inpatients who were prescribed a hypnotic continued their home medication.
If the patient's insomnia persists, nonpharmacologic treatment should be used, when possible, to minimize drug interactions and side effects. Evidence-based recommendations for the assessment and management of sleep disorders in older persons.
Insomnia among hospitalized elderly patients: prevalence, clinical characteristics and risk factors.


The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RTCs.
Hospitalized patients' preference in the treatment of insomnia: pharmacological versus non-pharmacological. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. A more comprehensive evaluation should be pursued with nonresponders or if a comorbid condition is present or suspected.The evaluation of chronic insomnia should involve a detailed history and examination to detect any coexisting medical or psychiatric illness and may include an interview with a partner or caregiver. The choice of drug depends on comorbid conditions, drug pharmacokinetics, and hospital formulary.
Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Hospital pharmacists should expand their role to include providing recommendations to physicians and counseling to patients regarding pharmacologic and nonpharmacologic treatments for insomnia to help optimize patient care and reduce costs. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena.



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