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Am Fam Physician. 2000;61(2):542

Elderly Drivers

(Australia—Australian Family Physician, July 1999, p. 663.) When adjusted for the distance driven, elderly drivers in Australia have the highest rate of fatal crashes of any age group, a statistic that may be mirrored in the United States. Because the number of elderly drivers is expected to increase, physicians need to be aware of legal and medical considerations regarding driving. Many organizations provide information for elderly persons and their families about local regulations and alternative forms of transportation. It is recommended that this information be available at physician offices. Elderly drivers at increased risk of crashing include those who drive frequently, particularly those who drive during peak traffic times, in bad weather or at night. Involvement in any form of accident, even a minor mishap, is a strong indicator of risk for a major crash within five years. Patients with medical contraindications to driving should be strongly counseled to voluntarily cease driving and be given information on alternative forms of transportation. The dangers do not end once the patient quits driving. Patients may require counseling about hazards of walking in high-traffic areas. Many elderly pedestrians overestimate their walking speed when approaching oncoming traffic or may be unfamiliar with the use of crossings and traffic markers.

Insomnia in Elderly Patients

(Australia—Australian Family Physician, July 1999, p. 653.) Insomnia leads to fatigue and napping, adversely affecting daytime functioning. Sleep disturbances are more common in elderly persons. Insomnia may be characterized by decrease in deep restorative (slow-wave) and rapid-eye movement (REM) sleep, increased nighttime wakefulness, fragmented sleep and decreased sleeping time despite increased time in bed. Insomnia may have a genetic predisposition, but it is also associated with medical conditions including arthritis and other chronic pain conditions, gastrointestinal problems, dyspnea, Alzheimer's disease and Parkinson's disease. Use of certain medications as well as use of alcohol can also cause sleeplessness. The assessment of patients with sleep problems should include detailed sleep history and search for medical causes of insomnia. If no treatable cause is found, patients should receive advice that focuses on sleep hygiene to promote healthy, natural sleep. Moderate exercise and increased light exposure may dramatically increase sleep efficiency. Use of hypnotic medications is now discouraged because of adverse effects and the development of tolerance. If used, the duration of use should be kept to a minimum (less than two weeks). Long-acting benzodiazepines are generally inappropriate.

Hidradenitis Suppurativa

(Australia—Australian Family Physician, July 1999, p. 727.) Hidradenitis suppurativa is a chronic inflammatory condition of the apocrine glands. This skin infection most commonly involves the axillae and perineum. Hidradenitis suppurativa occurs principally in obese women younger than 30 years. No immunologic abnormality has been demonstrated with this condition, but it is often associated with increased androgen levels. The differential diagnosis includes furunculosis, infected epidermoid cysts and granulomatous disease. When the inguinal and perineal areas are involved, Crohn's disease and lymphogranuloma venereum must be considered. Although long-term clindamycin and antiandrogen therapy may benefit some patients, surgical excision is the most effective treatment for hidradenitis suppurativa.

Pain Relief for Plantar Fasciitis

(Australia—Australian Family Physician, July 1999, p. 697.) Plantar fasciitis is inflammation of the plantar fascia at its insertion into the calcaneus. It is especially common in athletes and in persons over 40 years of age, especially in persons who are obese. The pain characteristically is most severe upon rising in the morning and when walking after an extended rest. Symptoms usually resolve spontaneously, but this can take 12 to 24 months. Treatments include avoiding the precipitating activity, doing stretching exercises, using posterior night splints or shoe orthotics, undergoing ultrasound and taking nonsteroidal anti-inflammatory drugs. Strapping is another technique that may provide relief. A nonstretch tape is applied in a figure-eight pattern of three or four layers to the painful foot. The tape should be worn day and night to support the plantar structures.

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