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When the above measures are insufficient, medications may be useful Pharmacologic measures currently rely primarily on safe hypnotic medications that are difficult to overdose with Lorazepam (05 mg orally nightly), temazepam (75 15 mg orally nightly) and the nonbenzodiazepine hypnotics, zolpidem (5 10 mg orally nightly), and zaleplon (5 10 mg orally nightly), are often effective for the elderly population and can be given in larger doses twice what is prescribed for the elderly in younger patients A new nonbenzodiazepine hypnotic, eszopiclone (2 3 mg), is similar in action to zolpidem and zaleplon but dissimilar in that it is not restricted to short-term use A lower dose of 1 mg is indicated in the elderly or those with hepatic impairment It is important to note that short-acting agents like triazolam or zolpidem may lead to amnestic episodes if used on a daily ongoing basis Longeracting agents such as flurazepam (half-life of > 48 hours) may accumulate in the elderly and lead to cognitive slowing, ataxia, falls, and somnolence In general, it is appropriate to use medications for short courses of 1 2 weeks The medications described above have largely replaced barbiturates as hypnotic agents because of their greater safety in overdose and their lesser hepatic enzyme induction effects Antihistamines such as diphenhydramine (25 mg nightly) or hydroxyzine (25 mg nightly) may also be useful for sleep, as they produce no pharmacologic dependency; their anticholinergic effects may, however, produce confusion or urinary symptoms in the elderly Trazodone, an atypical antidepressant, is a non habitforming, effective sleep medication in lower than antidepressant doses (25 150 mg at bedtime) Priapism is a rare side effect requiring emergent treatment Ramelteon is a new melatonin receptor agonist that helps with sleep onset and does not appear to have abuse potential It is hard to assess its clinical usefulness thus far Triazolam has achieved popularity as a hypnotic drug because of its very short duration of action Because it has been associated with dependency, transient psychotic reactions, anterograde amnesia, and rebound anxiety, it has been.

In general, there are two broad classes of treatment for insomnia, and the two may be combined: psychological (cognitive-behavioral) and pharmacologic In situations of acute distress, such as a grief reaction, pharmacologic measures may be most appropriate With primary insomnia, however, initial efforts should be psychologically based This is particularly true in the elderly to avoid the potential

removed from the market in several European countries If used, it must be prescribed only for short periods of time

2 Hypersomnias (Disorders of Excessive Sleepiness)

This disorder is characterized by cessation of breathing for at least 30 episodes (each lasting about 10 seconds) during the night There are two types: obstructive and central (See 9)

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ache and anxiety; however, modafinil appears to be generally well tolerated Modafinil may reduce the efficacy of cyclosporine, oral contraceptives, and other medications by inducing their hepatic metabolism Imipramine, 75 100 mg daily, has been effective in treatment of cataplexy but not narcolepsy Nocturnal myoclonus and REM sleep behavior disorder can be treated with clonazepam with variable results There is no treatment for Kleine-Levin syndrome Treatment of sleep apnea is discussed in 9

Process Billing Due List When using the billing due list, shown in Figure 7-31, be sure to select the inter-company billing documents

3 Parasomnias (Abnormal Behaviors during Sleep)

Velvety, tan, or pink macules or white macules that do not tan Fine scales that are not visible but are seen by scraping the lesion Central upper trunk the most frequent site Yeast and short hyphae observed on microscopic examination of scales

The essential factor in prevention is personal hygiene Wear open-toed sandals if possible Use of rubber or wooden sandals in community showers and bathing places is often recommended, though the effectiveness of this practice has not been studied Careful drying between the toes after showering is essential A hair dryer used on low setting may be used Socks should be changed frequently, and absorbent nonsynthetic socks are preferred Apply dusting and drying powders as necessary The use of powders containing antifungal agents (eg, Zeasorb-AF) or chronic use of antifungal creams may prevent recurrences of tinea pedis

Tinea versicolor is a mild, superficial Malassezia furfur infection of the skin (usually of the upper trunk) This yeast is a colonizer of all humans, which accounts for the high recurrence rate after treatment The eruption is often called to patients attention by the fact that the involved areas will not tan, and the resulting hypopigmentation may be mistaken for vitiligo A hyperpigmented form is not uncommon

1 Macerated stage Treat with aluminum subacetate solution soaks for 20 minutes twice daily Broad-spectrum antifungal creams and solutions (containing imidazoles or ciclopirox instead of tolnaftate and haloprogin) will help com-

Lesions are asymptomatic, but a few patients note itching The lesions are velvety, tan, pink, or white macules that

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