By V. Nemrok. Emmaus Bible College.

Patients should be advised to leave the bed after they have perceived not to sleep within approximately 20 minutes discount cetirizine 5mg, rather than actual clock- watching which should be avoided discount 5mg cetirizine. Relaxation training (Standard) such as progressive muscle relaxation buy cetirizine 5mg on line, guided imagery, or abdominal breathing, is designed to lower somatic and cognitive arousal states which interfere with sleep. Instructions: Progressive muscle relaxation training involves methodical tensing and relaxing different muscle groups throughout the body. Cognitive therapy seeks to change the patient’s overvalued beliefs and unrealistic expectations about sleep. Cognitive therapy uses a psychotherapeutic method to reconstruct cognitive pathways with positive and appropriate concepts about sleep and its effects. Common cognitive distortions that are identifed and addressed in the course of treatment include: “I can’t sleep without medication,” “I have a chemical imbalance,” “If I can’t sleep I should stay in bed and rest,” “My life will be ruined if I can’t sleep. Many therapists use some form of multimodal approach in treating chronic insomnia. Sleep restriction (Guideline) initially limits the time in bed to the total sleep time, as derived from baseline sleep logs. This approach is intended to improve sleep continuity by using sleep restriction to enhance sleep drive. As sleep drive increases and the window of oppor- tunity for sleep remains restricted with daytime napping prohibited, sleep becomes more consolidated. When sleep continuity substantially improves, time in bed is gradually increased, to provide suffcient sleep time for the patient to feel rested during the day, while preserving the newly acquired sleep consolidation. In addition, the approach is consistent with stimulus control goals in that it minimizes the amount of time spent in bed awake helping to restore the association between bed and sleeping. Paradoxical intention (Guideline) is a specifc cognitive therapy in which the patient is trained to confront the fear of staying awake and its potential effects. Biofeedback therapy (Guideline) trains the patient to control some physiologic variable through visual or auditory feedback. Sleep hygiene therapy (No recommendation) involves teaching patients about healthy lifestyle practices that improve sleep. It should be used in conjunction with stimulus control, relaxation training, sleep restriction or cognitive therapy. Instructions include, but are not limited to, keeping a regular schedule, having a healthy diet and regular daytime exercise, having a quiet sleep environment, and avoiding napping, caffeine, other stimulants, nicotine, alcohol, excessive fuids, or stimulating activities before bedtime. Evidence be prescribed a drug with a longer half-life; a patient who com- for their effcacy when used alone is relatively weak38-42 and no plains of residual sedation might be prescribed a shorter-acting specifc agent within this group is recommended as preferable drug. Benzodiazepines not spe- cifc side effect profle, cost, and pharmacokinetic profle may cifcally approved for insomnia (e. For example, trazodone might also be considered if the duration of action is appropriate has little or no anticholinergic activity relative to doxepin and for the patient’s presentation or if the patient has a comorbid amitriptyline, and mirtazapine is associated with weight gain. However, the effcacy of low-dose trazodone treatment failures, sedating low-dose antidepressants may next as a sleep aid in conjunction with another full-dose antidepres- Journal of Clinical Sleep Medicine, Vol. These medications have been associated with reports of disruptive sleep related behaviors including sleepwalking, eating, driving, and sexual behavior. General comments about sedatives/hypnotics: • Administration on an empty stomach is advised to maximize effectiveness. Certain antidepressants (amitriptyline, doxepin, mirtazapine, paroxetine, trazodone) are employed in lower than antidepressant therapeutic dos- ages for the treatment of insomnia. These studies, of varying with their comorbid conditions and concurrent medications. It is unclear to what pharmacological Treatment Failure extent these fndings can be generalized to other presentations of insomnia. As but a wealth of clinical experience with the co-administration recommended, alternative trials or combinations may be useful; of these drugs suggests the general safety and effcacy of this however, clinicians should note that if multiple medication tri- combination. A combination of medications from two different als have proven ultimately ineffective, cognitive behavioral ap- classes may improve effcacy by targeting multiple sleep-wake proaches should be pursued in lieu of or as an adjunct to further mechanisms while minimizing the toxicity that could occur pharmacological trials. Other prescription drugs: Examples include gabapentin, Mode of Administration/Treatment tiagabine, quetiapine, and olanzapine. Evidence of effcacy for these drugs for the treatment of chronic primary insomnia is in- Frequency of administration of hypnotics depends on the suffcient. Avoidance of off-label administration of these drugs specifc clinical presentation; empirical data support both is warranted given the weak level of evidence supporting their nightly and intermittent (2-5 times per week) administration. Prescription drugs- Not recommended: Although clinical practice is true “as needed” dosing when the patients chloral hydrate, barbiturates, and “non-barbiturate non-benzo- awakens from sleep. Over-the-counter agents: Antihistamines and antihis- Duration of treatment also depends on specifc clinical char- tamine-analgesic combinations are widely used self-remedies acteristics and patient preferences. Evidence for their effcacy and safety is very notics prior to 2005 implicitly recommended short treatment limited, with very few available studies from the past 10 years duration; since 2005, hypnotic labeling does not address dura- using contemporary study designs and outcomes. Antidepressants and other drugs commonly mines have the potential for serious side effects arising from used off-label for treatment of insomnia also carry no specifc their concurrent anticholinergic properties.

Thiazides may have therapeutic value in idiopathic hypercalciuria quality 10 mg cetirizine, especially when Thiazide diuretics associated with renal stones 5mg cetirizine sale. Can be measured in a 24-hour urine Sodium sample along with creatinine and calcium buy cetirizine 10 mg without prescription. Calcium carbonate requires stom- tions, including about one-half who were taking hormone ach acid for absorption, so it is best dosed in the presence therapy. The risk of hip fracture 500 mg at a time since absorption decreases as the dose was not statistically different in the treated versus placebo increases above this level. However, the Calcium citrate does not require stomach acidity for subset analysis of only those patients who adhered to treat- absorption, and absorption is probably similar if taken with ment (those taking more than 80% of their supplements) meals. This suggests that the elderly may beneft from increased protein intake in addition to suffcient cal- Calcium Supplements cium, vitamin D, and physical activity. If calcium intake from meals is insuffcient and cannot be corrected, then calcium supplementation should be con- Potential Side-effects of Calcium Supplementation sidered. Lactose intolerant patients, vegans, chronic glu- Gastrointestinal Symptoms cocorticoid users, and those with a history of stomach sur- Gastrointestinal symptoms (bloating, gas, constipa- gery or malabsorptive bariatric procedures, celiac disease, tion) can be a problem in some patients. Adequate Evaluation for lactose intolerance, celiac disease, or lack vitamin D levels are also necessary to optimize absorption. Since these women citrate are the most common forms available, but other were permitted to use additional supplements on their forms may also be found, including lactate and gluconate. They are much more expensive and offer low calcium intake increases the risk of calcium oxalate no added health beneft. Calcium carbonate is about 40% kidney stones, probably due to binding of ingested calcium calcium. Calcium lactate is only 13% elemental by about 50% in patients receiving a normal calcium calcium, and calcium gluconate is 9% calcium. What Nutritional Recommendations are increased risk of kidney stones with calcium supplementa- Appropriate for Pregnancy and Lactation? Healthy eating in pregnancy and lactation has a sig- Prostate Cancer nifcant effect on both the mother and the child and can Prostate cancer risk was increased in 3,612 men fol- have a tremendous impact on their health, morbidity, and lowed prospectively who had an increased amount of dairy even mortality. Developing healthy eating behaviors requires active participation by the pregnant woman, as 4. Low levels of vitamin D result in decreased intestinal nutrition counseling and education. Meal plans including calcium absorption and cause secondary hyperparathyroid- optimal caloric intake and weight gain should be tailored ism and bone loss. Physicians should perform a thorough history and In addition to bone loss, vitamin D defciency has physical examination prior to conception. For example, the physical fnding of acanthosis cle tone and balance and reduces fall risk. Physicians should pay particular tation often delay diagnosis until 30- to 34-weeks gesta- attention to stopping any medications that could be poten- tion, well after the effects of hyperglycemia have begun to tially harmful to the fetus. Patient Education During Pregnancy A prenatal nutrition questionnaire helps the practitio- Pregnant women are more susceptible to food-borne ner to identify pregnancy-related problems affecting appe- illnesses and should practice safe food handling. Patients should also be queried on personal unpasteurized dairy products; thoroughly wash fresh pro- nutritional habits, including vegetarian, vegan, lactose-free duce before consuming it; and ensure that meats, poultry, and gluten-free diets, as well as cravings and aversions. All patients would beneft from referral to a dietician who Caffeine during pregnancy can increase the incidence specializes in nutrition in pregnancy and can evaluate the of miscarriage and stillbirth when consumed in large quan- patient’s individual habits, create an individualized meal tities. Generally, consuming less than 300 mg of caffeine plan, and address any special needs. Many women incorrectly estimate their daily weight gain for pregnant women who are obese. However, experts believe that it may be safe to gain little or no weight in pregnant women who are obese, additional calories may in this special population. Healthcare profes- Physical activity is also an important aspect of a sionals should determine the appropriate caloric intake for healthy pregnancy. Simple carbohydrates and Table 30 Dietary Reference Intakes for Womena,b Adult Lactation Nutrient woman Pregnancy (0-6 mo) Energy (kcal) 2,403 2,743 , 2,855c d 2,698 Protein (g/kg/day) 0. Protein is essential for the expansion Trans fatty acids may cross the placenta and may have of plasma volume; the generation of amniotic fuid; and to adverse effects on fetal development. Pregnant women who are vegetarian or Micronutrient Needs During Pregnancy vegan must be referred to a dietician specialized in preg- Pregnant women require specifc micronutrients to nancy to assist in specialized meal planning and recom- meet their gestational needs. Women should pay simplest way to assure that a woman is getting adequate close attention to the type of fat being consumed. Public Health Service recommends that all women in women are falling signifcantly short of recommended lev- their childbearing years consume 400 µg/day of folic acid. Women should be Women should maintain a daily iodine intake of 250 encouraged to eat 12 ounces of fsh per week. Maternal milk is also at the is needed for fetal erythropoiesis and an increase in mater- appropriate temperature, and breastfeeding creates a bond- nal red blood cell mass. Vitamin D requirements also do not change eral requirements all increase during lactation. Caloric intake exceeds prepregnancy demands by Vitamin A is imperative for fetal eye development and approximately 650 kcal/day in average sized women has been known to be defcient in developing countries.