Functional Limitations and

Developmental Delays
Introduction
This 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 Assess
Assessment 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 disturbances
These 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.
History
Family history
Central nervous system (CNS) disorders
Mental retardation
Epilepsy
Evidence of school problems
Specific learning disabilities
History
Prenatal history
History of stillbirths, deaths, or other problems
during prior pregnancies
Use of drugs or alcohol
Radiographs taken during pregnancy
Exposure to viruses
Perinatal history
Neonatal infections
Asphyxia
Increased bilirubin levels
Difficulty during labor
History
Determine 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 history
Informal setting: what was learned
Formal setting: relationships with other children and teachers
Teachers' reports on child's performance and behavior in the classroom
School-age educational and learning history
Grade 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
experience
Employment and legal history
Whether the subject is able to obtain and maintain employment
Whether the subject has been involved in legal issues related to his or her
behavior
History
A 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 history
Parents' 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 Examination
Conduct 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 Examination
Diagnostic procedures
Newborn 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 Problems
If 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
Introduction
In this lesson we'll cover disorders
pertinent to developmental delays and
disabilities:
Down syndrome
Autistic-spectrum disorders (ASDs)
Mental retardation
Muscular dystrophy
Learning difficulties
Incidence
Developmental 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)
Pathophysiology
Genetic: 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
History
A 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 Examination
Conduct 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 Examination
Diagnostic procedures
Electroencephalography
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 Examination
Diagnosis
Three 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
Treatment
The 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
Education
Be 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 Referral
Follow-up
Direct management efforts toward the
impact on and support of the family
Referral
Refer 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 syndrome
In Down syndrome, which of the following is true?
Most infants affected with Down syndrome are born to women
older than age 35 years
Down syndrome is noted in about 1 in 10,000 live births
Down syndrome is associated with decreased maternal serum
AFP level
Antenatal 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 syndrome
Edward syndrome
Open neural tube defect
Hemolytic anemia

A 25 year old woman presents in the 10
th
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 alcohol
spectrum disorders and health promotion
related to alcohol use during pregnancy.
Incidence
Fetal 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 alcohol
spectrum; 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

Pathophysiology
Causes
FAS 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
History
Infants
Slow growth patterns
Developmental delays
Short attention span
Poor motor control
Irritability and overreaction to
sounds
Excessive crying
Poor sleep patterns
Seizure disorders
Toddlers
Lack of bonding
Phobias, tantrums, emotional
instability
School-age children
Peak school performance in
grades 6 through 8
Average IQ of 70 to 90
Math and language deficits
Impulsivity
Adolescents
Poor judgment
Carelessness
Poor use of time
Desire for immediate
gratification
Inappropriate sexual behaviors
Alcohol use

Physical Examination
Conduct 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 Examination
Diagnostic procedures
No 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
Treatment
Prevention (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 Referral
Education
FAS is preventable
Educate women of childbearing age about the dangers
of alcohol on relation to fetal development
Follow-up
Routine periodic follow-up of the affected child is
recommended
Referral
If 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 Alcohol
Concerning 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 miscarriage
Risk to the fetus from alcohol exposure is greatest in the third
trimester
No level or time of exposure is considered to be safe
Risk of fetal alcohol syndrome is present only if alcohol exposure
has occurred throughout the pregnancy
Introduction
Falls 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.
Incidence
Emergency-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
Pathophysiology
Causes
Environmental 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
Pathophysiology
The more risk factors a person has, the greater the likelihood of falling.
Risk factors
Prior 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
History
Assessment tools
Splatt
I hate falling

History
Medical 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 position
Medication history
Benzodiazepines, 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 Examination
Conduct 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 Examination
It 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 procedures
Complete 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 findings
Differential diagnosis
Fall related to functional decline
Fall as primary event (results of diagnostic procedures are negative
except for those directly related to injuries)
Syncope
Treatment
Nonpharmacologic
Safe-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
Treatment
Treat injuries sustained in earlier falls as
necessary
Diagnose and treat osteoporosis to reduce
the risk of fall-related fractures
Institute prophylactic measures against
osteoporosis
Education
Help 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 Referral
Follow-up
Assess the patient at each visit for fall susceptibility
Ensure that the patient is implementing prevention
practices
Referral
Refer 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 - Falls
Most falls in older adults occur in:
A health care institute
A public place
The patients home
An 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:
Forearm
Spine
Ankle
Hip

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 action
at the peak of action
at the middle point of duration of action
toward 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 action
at the peak of action
at the middle point of duration of action
toward the end of anticipated duration of action


Introduction
Sleep 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
Incidence
The 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
Incidence
Insomnia, 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
Pathophysiology
Normal sleep cycle
The 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
Pathophysiology
Influences on the sleep/wake cycle
Neurotransmitters (-aminobutyric acid)
Growth hormone secreted during NREM sleep
Light
Melatonin
Anatomic structure of the airway
Dopaminergic function
Risk factors
History 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
History
Current complaint
Ask 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
History
Medical history
Psychiatric 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
History
Medication history
Melatonin
Sleep aids
Cold and allergy medications
Alcohol
Nicotine
Prescription drugs that may cause
insomnia
History
Family history
Sleep disorders
RLS
PLMS
Dietary history
Caffeine (3- to 7-hour half-life)
Alcohol use
Physical Examination
Conduct 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 Examination
Diagnostic procedures
Tests 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 Examination
Differential diagnosis
Most 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
Treatment
Patient's descriptions and subjective feelings
should serve as the basis for clinical
management.
Nonpharmacologic: insomnia
Treatment 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
Treatment
Nonpharmacologic: OSA
Measures to control snoring
Nonpharmacologic: sleep terrors
Measures to control sleep terrors
Nonpharmacologic: RLS and PLMS
Sleep-hygiene measures
Avoidance of antidopamine medications
neuroleptics, metoclopramide, antidepressants,
and calcium channel blockerswhich aggravate
RLS
National support group
Treatment
Pharmacologic: insomnia
Sedating 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 PLMS
Dopamine 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)
Education
Teach 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 Referral
Follow-up
Reevaluate patients who have been taking
benzodiazepines for 2 to 3 weeks
Reevaluate the patient if insomnia
continues for more than 3 weeks
Referral
Refer any patient with refractory insomnia
to a sleep-disorders center
Make a physician referral, if necessary, for
prescription of controlled substances
Summary
Functional Limitations:
Assessment
Developmental Delays and Disabilities
Fetal AlcoholSpectrum Disorders
Falls
Sleep Disorders