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Insomnia remains one of the most common sleep disorders encountered in the geriatric clinic population, frequently characterized by the subjective complaint of difficulty falling or maintaining sleep, or nonrestorative sleep, producing significant daytime symptoms including difficulty concentrating and mood disturbances.
A search of the literature was conducted to review the epidemiology, definition, and age-related changes in sleep, as well as factors contributing to late-life insomnia and scales utilized for the assessment of insomnia in older people. The aim is to summarize recent diagnostic guidelines and both nonpharmacological and pharmacological strategies for the management of insomnia in the older population.
Insomnia remains a clinical diagnosis. There are several demographic, psychosocial, biologic, and behavioral factors that can contribute to late-life insomnia. Older adults are at higher risk for the medical and psychiatric effects of insomnia.
The most important aspect in evaluation of insomnia is detailed history taking and thorough physical examination. Nonpharmacological treatment options have favorable and enduring benefits compared to pharmacological therapy.
Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med. 2018;14(6):1017–1024.
The population of older adults continues to expand rapidly from the current 205 million persons aged 60 years or older, to a projected 2 billion by 2050.1 One of the most common sleep disturbances in the older population is insomnia.2–4 As many as 50% of older adults complain about difficulty initiating or maintaining sleep.5 Prevalence of insomnia is higher in older individuals than in the younger population.6 The overall prevalence of insomnia symptoms ranges from 30% to 48% in the elderly,5,7,8 whereas the prevalence of insomnia disorder ranges from 12% to 20%.9 Insomnia is often classified by the predominant symptom of either difficulty in sleep onset or sleep maintenance. Sleep maintenance symptoms are most prevalent among individuals with insomnia (50% to 70%), followed by difficulty in initiating sleep (35% to 60%) and nonrestorative sleep (20% to 25%).10 A study of 6,800 older adults (age 65 years or older) observed an incidence rate for insomnia symptoms of 5% per year,11 with a yearly incidence of 7.97% at 1-year follow-up.12 Approximately 50% of the patients with symptoms of insomnia will have a remission during the follow-up period, with higher remission rates among older males relative to females.12,13
Insomnia is broadly defined as dissatisfaction with sleep either qualitatively or quantitatively. This is usually associated with one or more of the following: (1) difficulty initiating sleep, (2) difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings, and (3) early-morning awakening with inability to return to sleep.14 The fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) emphasizes that a sleep disturbance causes clinically significant distress or functional impairment, and occurs at least 3 nights a week for at least 3 months despite adequate opportunity to sleep, whereas the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) requires at least 1 month of symptoms not explained by another sleep-wake disorder, illicit substance use, or coexisting medical and psychiatric disorders. The term "nonrestorative sleep" is no longer an accepted diagnostic symptom for the DSM-5; however, it still remains in the ICD-10 criteria. The pathophysiology of insomnia disorder induces a state of hyperarousal during sleep and wakefulness. Hyperarousal is manifested as an elevated whole-body metabolic rate during sleep and wakefulness, elevated cortisol and adrenocorticotropic hormone during the early sleep period, and reduced parasympathetic tone in heart rate variability.15 An important change with respect to diagnostic classifications was defined in the DSM-5 and the third edition of the International Classification of Sleep Disorders (ICSD-3). Insomnia in the ICSD-3 is defined as a complaint of trouble initiating or maintaining sleep that is associated with daytime consequences and is not attributable to environmental circumstances or inadequate opportunity to sleep. This replaces earlier categories of primary and secondary forms of insomnia in favor of a broad category for insomnia disorder when insomnia is comorbid with medical or psychiatric conditions.16 In a study of 6,800 elderly patients (older than 65 years), Foley et al. demonstrated that 93% have one or more comorbid conditions and other factors, most commonly depression, chronic pain, cancer, chronic obstructive pulmonary disease, cardiovascular diseases, medication use, and factors associated with aging (retirement, inactivity, or caregiving).11,17–20 The increased prevalence of chronic conditions in later life may explain most insomnia symptoms in the older population; 1% to 7% of insomnia in later life occurs independently of chronic conditions.20,21 Reduced mobility, retirement, and reduced social interaction are sources of sleep disturbances.22–24 Caregiving may be responsible for ruminations and anxiety while trying to sleep. Women who are caregivers are found to have increased prevalence of sleep complaints.18,25 Women are more often the primary caregivers for their children, parents, or partner, in addition to working outside of the home, affecting their total sleep time. Women are also more likely than men to complain of sleep problems and see a general practitioner for those complains.
Spielman and colleagues demonstrated a three-factor model for understanding the etiology and persistence of insomnia. This model identifies predisposing, precipitating, and perpetuating factors that combine to raise the likelihood of insomnia above the insomnia threshold.26
These include demographic, biologic, psychological, and social characteristics. Women older than 45 years are 1.7 times more likely to have insomnia than men.7 Those divorced, separated, or widowed are also more likely to have insomnia than married individuals.7 Lower levels of education or income may contribute to insomnia in some cases.7,27 Smoking, alcohol use, and reduced physical activity are other factors associated with higher rates of insomnia in older adults.7,18
These factors generally include stressful life events or medical conditions that may disrupt sleep. Older adults with respiratory symptoms, physical disability, and fair to poor perceived health are at increased risk of insomnia.11 Medications such as beta blockers, glucocorticoids, nonsteroidal anti-inflammatory drugs, decongestants, and antiandrogens may be one of the factors contributing to insomnia. Several studies have demonstrated that patients with depression and generalized anxiety disorder have higher rates of insomnia.11,13,28
These factors often consist of behavioral or cognitive changes that arise as a result of acute insomnia. An acute episode of insomnia will not necessarily develop into chronic insomnia without these provoking behavioral and cognitive events. Examples include spending excessive time in bed, frequent naps, and conditioning (increased anxiety before sleep onset due to fear of spending another sleepless night). Nonpharmacological treatment options often target these perpetuating factors.
Along with many physiologic changes seen with aging, significant changes also occur in sleep and circadian rhythm across the lifespan. Differentiated by waveforms on electroencephalogram and other physiologic signals, sleep is currently classified into four stages. The first three are non-rapid eye movement (NREM) stages: stage N1, N2, and N3 sleep. Rapid eye movement (REM) sleep occurs in the fourth stage, stage R sleep.29 Stage N1 sleep is the lightest stage and it accounts for 18% of older adults' sleep time.30 In stage N2 sleep, brain waves slow, body temperature begins to drop, and heart rate slows as sleep deepens, accounting for 48% of sleep time. Sleep further deepens in stage N3 sleep, characterized by very slow brain waves referred to as delta or slow wave sleep. This stage accounts for 16% of sleep.30 Stage R sleep is "paradoxical sleep" because brain activity is similar to that in awake state with increased sympathetic tone characterized by rise in blood pressure and heart rate but with muscle atonia.31 Dreaming occurs in this stage of sleep and accounts for 18% of sleep time in older adults.30 Total sleep time decreases considerably from 10 to 14 hours a night in the pediatric age range, to 6.5 to 8.5 hours a night as a young adult, then decreases at a slower rate in the older age range to 5 to 7 hours a night, and plateaus at about 60 years of age.32 The natural shortening of their total sleep time in some older adults may generate unrealistic expectations about sleep duration, producing anxiety that could cause or worsen insomnia.
Beginning in middle age, adults spend less time in slow wave sleep and REM sleep. Sleep efficiency continues to decrease past age 60 years. There is a prominent increase in wakefulness after sleep onset, but no change is observed in sleep latency.32 It is common for healthy older adults to exhibit a temporally advanced sleep phase (falling asleep early and waking up early).5 However, this may not be true for older adults with insomnia symptoms, who have a delayed circadian phase.33 These individuals tend to have circadian dispersion and lack of synchronization compared to healthy subjects.33 Early awakenings may result in frequent daytime naps, which further accentuates the problem of insomnia during the night.34 Important time cues (zeitgebers) for circadian rhythm may erode as one ages; for example, elderly individuals may lack fixed work schedules or meal times due to retirement, which further contributes to insomnia. Healthy elderly individuals sleep as well as younger subjects according to an epidemiological study done by Ohayon.7 Research shows that older individuals may be more tolerant of sleep deprivation than younger ones. A study on psychomotor vigilance task performance after several nights of sleep deprivation in women aged 20 to 30 years compared to older women aged 55 to 65 years found younger women had more prominent impairments with sleep deprivation compared to an older age group.35 The American Insomnia Survey of 10,094 individuals 18 years and older noted self-reported complaints of insomnia rates were lower in older adults (older than 65 years) compared to the younger group (18 to 64 years). This highlights the importance of approaching any complaint of insomnia in the older population with more vigilance.9
Insomnia is associated with significant morbidity if left untreated. The strongest level of evidence is for mental illness. Older individuals with insomnia have a 23% increase in risk of development of depression symptoms.36 Several studies have documented an increased risk of depression in older patients with persistent insomnia.37–39 A recent study noted 44% of older patients with persistent insomnia continued to have depression 6 months later as compared to only 16% of those without insomnia.39 Insomnia and mental disorders such as depression and anxiety have a bidirectional relationship.40 Additionally, insomnia also confers an increased risk of suicidal tedencies.41 A meta-analysis of insomnia symptoms and its association with heart disease, after adjusting for age and other cardiovascular risk factors, identified that risk ratios for heart disease from insomnia symptoms ranged from 1.47 to 3.90.42 Sleep loss and insomnia are associated with hypertension, myocardial infarction, and perhaps stroke.43–46 In the Sleep Heart Health Study, a community-based cohort, adults (middle-aged and older) who reported 5 hours of sleep or less were 2.5 times more likely to have diabetes, compared with those who slept 7 to 8 hours per night.47 Another study has also demonstrated that people with insomnia are at greater risk for metabolic syndrome.48 Recent research also demonstrates that insomnia symptoms may lead to increased rates of cancer such as prostate cancer.49 Long-term insomnia symptoms are also associated with greater risk of developing cognitive impairment.50,51 A cross-sectional correlation between poor sleep quality and cortical atrophy has been shown in community-dwelling older adults.52 Insomnia is regarded as an independent risk factor for work disability, sick leave, and reduced work performance.53 Economically driven analyses conclude that insomnia is associated with high direct and indirect costs for the health care system and society.54
The evaluation and diagnosis of insomnia is a clinical one, based on a thorough clinical history of the sleep problems and relevant comorbidities obtained from the patients, their partners, and/or caregivers. Evaluation of insomnia symptoms presents challenges as they may occur as a primary disorder or result from other comorbid conditions. The clinician should evaluate the nature, frequency, evolution, and duration of symptoms, as well as the response to treatment. Using various sleep diaries and questionnaires, a thorough assessment of insomnia can be achieved. A Consensus Sleep Diary that includes detailed questions can assist in obtaining additional sleep history.55 The temporal aspects of sleep (time at which a patient goes to bed, attempts at sleep, wake-up time, and final time out of bed), quantitative aspects (sleep onset latency, number and duration of awakenings, wakefulness after sleep onset, total sleep time), and qualitative aspects (subjective sleep quality, satisfaction) should be noted. Behavioral factors, such as the use of electronic devices before going to bed, should also be addressed because these can suppress bedtime melatonin production, adversely affecting circadian rhythm.56 Environmental factors including bedroom temperature, light intensity, sound level, and sleep patterns of the partner should also be assessed. The clinician should also inquire about symptoms generated by other sleep disorders including obstructive sleep apnea (snoring, breathing pauses), restless leg syndrome (urge to move the extremities), parasomnias (unusual sleep behaviors), and circadian rhythm disorders (unusual sleep timings). Determining the use of alcohol, caffeinated drinks, cigarettes, and any other substance that can adversely affect the quality of sleep is also very important. An insomnia evaluation should also include a history and physical examination related to medical and psychiatric disorders that can exacerbate insomnia. Neurological disorders (stroke, migraine), chronic pain, endocrine disorders (hypothyroidism/hyperthyroidism), chronic obstructive pulmonary disease, asthma, gastroesophageal reflux, and congestive heart failure can lead to or worsen insomnia. The clinician should also ask about depression, bipolar disorder, and anxiety disorders. Medication use should be reviewed, as sedatives, antidepressants, antihypertensives, steroids, and antihistamines can interfere with sleep.
Wrist actigraphy, which monitors and stores movement data for up to 28 days, can be used to monitor treatment response and to screen for other circadian disorders.57–59
Polysomnography is not recommended for the evaluation for insomnia, but contributes to the evaluation of sleep apnea or parasomnias.60
Numerous insomnia rating scales record symptoms and monitor the response to treatment.
The Insomnia Severity Index measures the subjective symptoms and negative outcomes of insomnia over the previous 2 weeks. On this scale, scores higher than 14 suggest "clinical insomnia."61 The Pittsburgh Sleep Quality Index, a 19-item questionnaire, measures 7 domains of sleep over the prior month. Global scores higher than 5 indicate clinically significant sleep disturbances.62
Daytime imaging studies are not needed for diagnosis of insomnia; however, if performed, MRI studies detect gray matter reduction in the frontal lobes of the brain63–65 and reduced hippocampal volume.66–68
If left untreated, insomnia can have multiple medical and psychological consequences, emphasizing the importance of insomnia at any age. Treatment can be divided into nonpharmacological and pharmacological options.16,24,25,69 Aging increases body fat, and reduces total body water and plasma proteins, resulting in increased drug elimination half-life and the potential risk of adverse effects. Older adults should therefore be treated with nonpharmacological options prior to pharmacological options.16,70
There are several nonpharmacological options for the treatment of insomnia, including relaxation techniques, improving sleep hygiene, and cognitive behavioral therapy. These options are effective in managing insomnia for extended periods of time, even in patients with cognitive impairment.71
Education regarding sleep hygiene consists of several interventions that promote healthy stable sleep and a nondisruptive sleep environment. These include avoiding daytime naps, maintaining a regular sleep schedule, limiting substances such as caffeinated beverages, nicotine, and alcohol that adversely affect sleep, and exercising at least 6 hours before bedtime.72,73
When sleep hygiene is not effective, Cognitive Behavioral Therapy for Insomnia (CBT-I), effective in older adults, should be attempted.73–75 The American College of Physicians recommends CBT-I as first-line management for insomnia in adults.76 It consists of 6 to 10 sessions with a trained therapist that focus on cognitive beliefs and counterproductive behaviors that interfere with sleep.
This therapy involves restricting time in bed to the number of hours of actual sleep, until sleep efficiency improves. If after 10 days sleep efficiency remains lower than 85%, sleep time in bed should be restricted by 15 to 30 minutes until sleep efficiency improves. Time in bed is gradually advanced by 15 to 30 minutes when the time spent asleep exceeds 85% of total time in bed.77
This therapy attempts to reassociate use of the bed and the desired bedtime to sleep only. This includes going to bed only when one feels tired, not using bed for reading, working, or lounging, leaving the bed if unable to sleep in 15 to 20 minutes, and maintaining a constant wake-up time each morning.78
These include progressive muscle tensing and relaxing, guided imagery, paced diaphragmatic breathing, or meditation.25
Due to financial constraints and lack of psychological resources needed for CBT-I, a shorter form of therapy known as brief behavioral therapy for insomnia is also available and involves core techniques from CBT-I, directed at improving circadian regulation of sleep in more than two sessions. It has been found to be effective in the geriatric population, with benefits persisting for 6 months and beyond.79 Internet-based behavioral therapies have also been found to be effective in older populations.80 Multicomponent cognitive behavioral therapy that involves sleep hygiene measures, relaxation techniques, sleep restriction, and stimulus control is also as effective in older adults as a stand-alone treatment.81,82
There are several pharmacological options available for use in older patients with insomnia. Pharmacological treatments are primarily classified as benzodiazepine sedatives, nonbenzodiazepine sedatives, melatonin receptor agonists, antidepressants, and orexin receptor antagonists. Recently published clinical practice guidelines of the American Academy of Sleep Medicine for the pharmacological treatment of chronic insomnia represent an evidence-based review of each class of drug commonly used in the treatment of insomnia.83
Both benzodiazepines and nonbenzodiazepine receptor agonists have a common mechanism of action. They work by binding to a specific receptor site on gamma-aminobutyric acid type A receptors, with the difference being nonbenzodiazepines are more selective for the alpha-1 subclass of receptors, which while causing sedation has minimal anxiolytic, amnesic, and anticonvulsant effects compared to that of benzodiazepines.84 Both classes of drugs effectively treat insomnia-related parameters such as sleep onset latency, number of nighttime awakenings, total sleep time, and sleep quality in the short term, but not with chronic use.85–87
Prolonged use of these drugs can lead to tolerance, dependence, rebound insomnia, residual daytime sedation, motor incoordination, cognitive impairment, and increased risk of falls in institutionalized older individuals.88 These drugs can have additive effects if taken together. Because of these adverse effects, and the equivalent or superior response seen with CBT-I for longer duration therapy, use of these drugs should be avoided in older individuals. The recent 2015 Beers criteria strongly advise avoiding these drugs in the elderly.89
Pharmacokinetic properties of these drugs dictate the differences between the drug effects on sleep parameters. Zolpidem has a shorter half-life (2 to 3 hours) and so may have less potential for residual daytime adverse events than zopiclone, which has a longer half-life (5 to 6 hours). However, the shorter half-life of zolpidem renders it less useful in treating sleep maintenance insomnia. These drugs have a faster onset of action and therefore can be used in treating sleep onset insomnia (reduce sleep onset latency).84
Although the benefits outweigh the harms, there have been reports of impairment in daytime concentration tasks, such as driving while on zopiclone.90,91 In women, in whom zolpidem clearance occurs more slowly than in men, morning blood levels following the recommended previous bedtime dose could be considerably higher, affecting psychomotor performance.92 In 2013, this led the United States Food and Drug Administration (FDA) to require the manufacturers of zolpidem to lower the recommended dose, particularly for women, from 10 mg to 5 mg for immediate-release preparations, and 12.5 mg to 6.5 mg for extended-release forms. It also required manufacturers to lower the recommended doses for men.
Various antidepressants, including phenylpiperazine compounds (trazodone), tricyclic antidepressants (doxepin), and serotonergic antidepressant (mirtazapine), have sedating properties and are often used for the treatment of insomnia. Trazodone: It is widely prescribed for insomnia in doses of 25 to 100 mg. A study on trazodone comparing its effect with zolpidem in 21 to 65 year olds showed it has similar efficacy for sleep latency and sleep efficiency, with these effects dissipating after the first week.93 Adverse events such as dizziness, cardiac arrhythmias, orthostatic hypotension, and potential priapism can be significant in the elderly population.94 Clinical practice guidelines from the American Academy of Sleep Medicine suggest that clinicians not use trazodone for sleep onset or maintenance insomnia because its harms outweigh benefits.83
Doxepin: Of all the antidepressants, only doxepin is FDA approved for insomnia at doses of 3 to 6 mg. It is selective for histamine 1 receptors. Studies of men and women age 65 years and older with doses of 1 mg and 3 mg have shown that doxepin 1 mg and 3 mg significantly improved measures of sleep onset (patient reported), sleep duration, sleep quality, and global treatment outcomes over the 12-week study period.95 Higher doses of doxepin 3 mg and 6 mg to adults (18 to 64 years) with chronic primary insomnia has also been reported to lead to significant and sustained improvements in sleep maintenance and early morning awakenings.96
Mirtazapine: This antidepressant with strong 5-HT2 antagonism may also improve insomnia. In a study of adults age 18 to 75 years old with mean age of 40.9 years, the mirtazapine group had significant improvement in sleep latency, sleep efficiency, and awakenings after sleep onset after only 2 weeks of treatment.97 It may be preferred over other drugs as it produces sedative effects solely through histamine receptor antagonism.97 Because of conflicting evidence and habituation to its sedative effects, it should not be used to treat insomnia in the absence of depression.
Ramelteon: It is also FDA approved for treatment of insomnia. In a study of older adults (age 65 years or older), treatment with ramelteon significantly reduced patient reports of sleep latency over 5 weeks of treatment with no significant rebound insomnia or withdrawal effects.98 It is not associated with dependence, memory disturbances, and nocturnal gait instability in older individuals.99,100
Valerian: As a dietary supplement it lacks FDA approval and monitoring. Its mechanism of action is believed to occur through interaction with the neurotransmitter gamma amino-butyric acid and its receptors. There are limited studies of valerian in elderly individuals and data are lacking in terms of its efficiency in treating insomnia.
Melatonin: Melatonin at a dose of 2 mg has been approved in Europe for the short-term treatment of insomnia in patients age 55 years and older based on decline in melatonin production seen with age.101 Treatment has been shown to be effective for primary insomnia in some studies; however, formal recommendations for the use of melatonin in the treatment of insomnia requires further research.83,101,102
Suvorexant: It is the first FDA-approved dual orexin receptor antagonist and may be prescribed up to a 20-mg dose. It targets wakefulness-promoting neuropeptides that regulate the sleep-wake cycle, demonstrating its efficacy in decreasing sleep latency and in increasing total sleep time. Suvorexant has been studied in both elderly (age 65 years or older) and non-elderly (age 18 to 64 years) patients, identifying no significant efficacy or safety differences between these two groups.103 Although it is well tolerated by older adults, long-term data are still lacking.103–105
Insomnia is very prevalent in older adults. Using the history and physical examination along with insomnia scales, clinicians can evaluate and treat insomnia in our rapidly aging population. Behavioral and cognitive behavioral therapies offer very effective longer duration treatment and are recommended as first-line treatment options for insomnia compared to hypnotic medications in older adults.
All authors have seen and approved the manuscript. The authors report no conflicts of interest.
cognitive behavioral therapy for insomnia
Diagnostic and Statistical Manual for Mental Disorders
United States Food and Drug Administration
International Statistical Classification of Diseases and Related Health Problems
International Classification of Sleep Disorders
non-rapid eye movement
rapid eye movement
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Kucharczyk ER, Morgan K, Hall AP. The occupational impact of sleep quality and insomnia symptoms. Sleep Med Rev. 2012;16(6):547–559. [PubMed]
Leger D, Bayon V. Societal costs of insomnia. Sleep Med Rev. 2010;14(6):379–389. [PubMed]
Carney CE, Buysse DJ, Ancoli-Israel S, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep. 2012;35(2):287–302. [PubMed Central][PubMed]
Wood B, Rea MS, Plitnick B, Figueiro MG. Light level and duration of exposure determine the impact of self-luminous tablets on melatonin suppression. Appl Ergon. 2013;44(2):237–240. [PubMed]
Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57(5):761–789. [PubMed Central][PubMed]
Buysse DJ, Ancoli-Israel S, Edinger JD, Lichstein KL, Morin CM. Recommendations for a standard research assessment of insomnia. Sleep. 2006;29(9):1155–1173. [PubMed]
Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519–529. [PubMed]
Littner M, Hirshkowitz M, Kramer M, et al. Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep. 2003;26(6):754–760. [PubMed]
Bastien CH, Vallieres A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. [PubMed]
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Altena E, Vrenken H, Van Der Werf YD, Van den Heuvel OA, Van Someren EJ. Reduced orbitofrontal and parietal gray matter in chronic insomnia: a voxel-based morphometric study. Biol Psychiatry. 2010;67(2):182–185. [PubMed]
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Joo EY, Kim H, Suh S, Hong SB. Hippocampal substructural vulnerability to sleep disturbance and cognitive impairment in patients with chronic primary insomnia: magnetic resonance imaging morphometry. Sleep. 2014;37(7):1189–1198. [PubMed Central][PubMed]
Neylan TC, Mueller SG, Wang Z, et al. Insomnia severity is associated with a decreased volume of the CA3/dentate gyrus hippocampal subfield. Biol Psychiatry. 2010;68(5):494–496. [PubMed Central][PubMed]
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Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. Am J Psychiatry. 2002;159(1):5–11. [PubMed]
Rieman D, Perlis ML. The treatments of chronic insomnia: a review of benzodiazepine receptor agonists and psychological and behavioral therapies. Sleep Med Rev. 2009;13(3):205–214. [PubMed]
Shub D, Darvishi R, Kunik ME. Non-pharmacologic treatment of insomnia in persons with dementia. Geriatrics. 2009;64(2):22–26. [PubMed]
Montgomery P, Dennis J. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2002;(2):CD003161. [PubMed]
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Alessi C, Vitiello MV. Insomnia (primary) in older people. BMJ Clin Evid. 2011;2011:2302. [PubMed Central][PubMed]
Montgomery P, Dennis J. A systematic review of non-pharmacological therapies for sleep problems in later life. Sleep Med Rev. 2004;8(1):47–62. [PubMed]
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Spielman AJ, Saskin P, Thorpy MP. Treatment of chronic insomnia by restriction of time in bed. Sleep. 1987;10(1):45–56. [PubMed]
Bootzin RR, Epstein D, Wood JM. Case Studies in Insomnia: Stimulus Control Instruction. New York, NY: Plenum Medical; 1991.
Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–895. [PubMed Central][PubMed]
Cheng SK, Dizon J. Computerised cognitive behavioural therapy for insomnia: a systematic review and meta-analysis. Psychother Psychosom. 2012;81(4):206–216. [PubMed]
Epstein DR, Sidani S, Bootzin RR, Belyea MJ. Dismantling multicomponent behavioral treatment for insomnia in older adults: a randomized controlled trial. Sleep. 2012;35(6):797–805. [PubMed Central][PubMed]
Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol. 2006;25(1):3–14. [PubMed]
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349. [PubMed Central][PubMed]
Jacobson SA. Clinical Manual of Geriatric Psychopharmacology. 2nd ed. Washington, DC: American Psychiatric Publishing; 2014.
Morin CM, Vallieres A, Guay B, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005–2015. [PubMed Central][PubMed]
Wu R, Bao J, Zhang C, Deng J, Long C. Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. Psychother Psychosom. 2006;75(4):220–228. [PubMed]
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004;164(17):1888–1896. [PubMed]
Berry SD, Lee Y, Cai S, Dore DD. Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Intern Med. 2013;173(9):754–761. [PubMed Central][PubMed]
American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227–2246. [PubMed]
Leufkens TR, Ramaekers JG, De Weerd AW, Riedel WJ, Vermeeren A. Residual effects of zopiclone 7.5 mg on highway driving performance in insomnia patients and healthy controls: a placebo controlled crossover study. Psychopharmacology. 2014;231(14):2785–2798. [PubMed Central][PubMed]
Leufkens TR, Vermeeren A. Highway driving in the elderly the morning after bedtime use of hypnotics: a comparison between temazepam 20 mg, zopiclone 7.5 mg, and placebo. J Clin Psychopharmacol. 2009;29(5):432–438. [PubMed]
Farkas RH, Unger EF, Temple R. Zolpidem and driving impairment--identifying persons at risk. N Engl J Med. 2013;369(8):689–691. [PubMed]
Walsh JK, Erman M, Erwin CW, et al. Subjective hypnotic efficacy of trazodone and zolpidem in DSMIII-R primary insomnia. Human Psychopharmacology. 1998;13(3):191–198.
Mendelson WB. A review of the evidence for the efficacy and safety of trazodone in insomnia. J Clin Psychiatry. 2005;66(4):469–476. [PubMed]
Krystal AD, Durrence HH, Scharf M, et al. Efficacy and safety of doxepin 1 mg and 3 mg in a 12-week sleep laboratory and outpatient trial of elderly subjects with chronic primary insomnia. Sleep. 2010;33(11):1553–1561. [PubMed Central][PubMed]
Krystal AD, Lankford A, Durrence HH, et al. Efficacy and safety of doxepin 3 and 6 mg in a 35-day sleep laboratory trial in adults with chronic primary insomnia. Sleep. 2011;34(10):1433–1442. [PubMed Central][PubMed]
Winokur A, DeMartinis NA 3rd, McNally DP, Zary EM, Cormier JL, Gary KA. Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia. J Clin Psychiatry. 2003;64(10):1224–1229. [PubMed]
Roth T, Seiden D, Sainati S, Wang-Weigand S, Zhang J, Zee P. Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia. Sleep Med. 2006;7(4):312–318. [PubMed]
Zammit G, Wang-Weigand S, Rosenthal M, Peng X. Effect of ramelteon on middle of the night balance in older adults with chronic insomnia. J Clin Sleep Med. 2009;5(1):34–40. [PubMed Central][PubMed]
Mets MA, de Vries JM, de Senerpont Domis LM, Volkerts ER, Olivier B, Verster JC. Next-day effects of ramelteon (8 mg), zopiclone (7.5 mg), and placebo on highway driving performance, memory functioning, psychomotor performance, and mood in healthy adult subjects. Sleep. 2011;34(10):1327–1334. [PubMed Central][PubMed]
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Norman JL, Anderson SL. Novel class of medications, orexin receptor antagonists, in the treatment of insomnia - critical appraisal of suvorexant. Nat Sci Sleep. 2016;8:239–247. [PubMed Central][PubMed]


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Odds Honcho John Avello, of the Wonderful Wynn Las Vegas Sportsbook: Talks Mayweather Fight, NFL, Wynn Sports Betting App (Nevada Only) and Potential Presidential Betting?
1. This weekend could very well be Floyd Mayweather Jr.'s last fight. He will enter the squared circle against Andre Berto.
2. The NFL has its first full slate of regular season football games this Sunday.
3. It was announced this week that Wynn Las Vegas will host the first Democratic debate on October 13th.
Who better to speak with about these things than Wynn Las Vegas sportsbook manager and CYInterview regular John Avello.
During our conversation, Mr. Avello revealed to us that in a few months, residents and tourists of the state of Nevada will be able to bet sports on their smart phones, with the Wynn's own sportsbook betting app. We also discussed whether a person might be able to make a wager, in the future, on who the next President of the United States will be. The head oddsmaker was as interesting as always when covering these topics.
You can read the highlights and listen to the entire CYInterview below:
Listen to the entire John Avello CYInterview:
Have trouble listening to the audio? Listen here
Browse CYInterview.com while you listen – Click here
As for the fight this Saturday night at the MGM Grand Garden Arena between undefeated Floyd Mayweather Jr. and Andre Berto, unsurprisingly, Floyd is a heavy favorite. You would have to wager $30 to win $1. On the other side, for every $1 you wagered, you would win $16 on Berto if he won the fight. Mr. Avello says there have already been six and seven figure bets on the heavy favorite, Mayweather, to win:
"You have to put up $30 [on Mayweather] to win $1, which is a pretty good piece, but if it's a sure thing, you know, why not? And, but we all know that nothing is for sure. Anything can happen. Mayweather says it's his last fight, I'm not a believer of that. I think he'll be back to fight another fight whether he wins or loses this fight. When that will be, I don't know. But I just think it be very hard for him to walk away from the game when he's actually at the top of his game.
On the other side, if you want to take Berto and take a 16 to 1, put up $1 to $16, you're welcome to do that side also. So if you feel the underdog has a real shot, we're offering the value on it. … I think the price might be a little too high [on Mayweather] even for the guys that think he's gonna win. Put up $30 to win $1 is probably not a wise bet."
This weekend provides us with the first full slate of NFL regular season games. John told us the first week of the NFL always brings a big crowd. When it comes to bets on who will win the Super Bowl this year, he says there has been a lot of action on a variety of teams. He breaks down where the money has been wagered going into the season:
"There's been quite a bit of action, even on some of the shorter price teams. Seattle was once 5 to 1, they're now 4 [to 1]. Green Bay was once 10 [to 1]. They're now 6 [to 1]. The [Indianapolis] Colts were once 14 [to 1], they're now 6 [to 1]. So there's been even some money on the shorter price teams. On the longer price teams, Dallas, 18 [to 1], now down to 14 [to 1]. The [Philadelphia] Eagles, 22 [to 1], now down to 12 [to 1]. The [Miami] Dolphins are getting some play. They were 50 [to 1] at one time. Now they're down to 25 [to 1]."
It was announced this week that Wynn Las Vegas would host the first Democratic debate on October 13th. The Wynn Las Vegas veteran tells us his thoughts on his resort getting this notable event:
"I think it's great. It's sure gonna bring a lot of exposure to the property. I also think it's just a great thing for the town and they can't hold it at a better spot here than Wynn. So I'm excited about it."
It is not currently possible to place a bet, in any Las Vegas sportsbook, on who will be the next President of the United States. Mr. Avello says he would love to see the rule changed, so the Wynn could offer wagers on political propositions. He says there may be another opportunity in the future for a rule change so people could then place a wager on their favorite politician to win the White House:
"I think so. We were close a few years ago. We were trying. It is in our regulations that we don't do it and we can't do it. But there was a time a couple years ago where we were trying to have that changed and I think we may take another shot at that maybe in the future to get it changed again. I think it would be great betting. You can just put it up and book it for two years and the way, we all know how presidential elections, you know, favorites and underdogs radically change through the course of time. So it would just be a great betting proposition I believe for the town."
Finally, John tells us about the Wynn's upcoming cell phone sports betting app and what else is going on at the Wynn Las Vegas sportsbook:
"Just that the books are thriving, doing well. A lot more sports players now probably than ever before. We're opening up a mobile app here at Wynn soon within the next couple of months so people will be able to wager on their mobile apps anywhere within the boundaries of Nevada. So the business is doing well and glad to be a part of it."
You can find out more about Wynn Las Vegas at http://www.wynnlasvegas.com/
You can email Chris Yandek at email@example.com
You can follow Chris Yandek on Twitter here.

subset: commoncrawl


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Ambitious plans for an entirely green "forest city" in China may soon become a reality with construction breaking ground on the innovative project aimed at turning a suburb of the Guangxi city of Liuzhou into the world's first literal "urban jungle."
Designed by Stefano Boeri, an Italian architect known for his "vertical forest" buildings in Milan, this new mini-city will span over 175-hectacres and house 30,000 people. The development is just the latest way that the Chinese government is attempting to combat the deadly smog that plagues its country.
The new city, which is a true trail-blazer when it comes to sustainable living on an urban scale, will use geothermal and solar power in order to be entirely energy self-sufficient. Despite using no coal or fossil fuels, this new complex will be completely functional as a modern city. Residents can expect to have all the luxuries of a contemporary, urban lifestyle, as the plans include commercial, residential and recreational spaces, along with schools and a hospital.
Many green initiatives are focused on achieving a net zero contribution to pollution, suggesting that it is easier to start by doing no harm, rather than good. However, the "forest city" of Liuzhou is focused on actively battling China's air pollution problems. The entire complex will be covered with almost 1 million plants and 40,000 trees, enough vegetation to absorb nearly 10,000 tons of carbon dioxide and 57 tons of pollutants each year. In addition to removing toxic particles from the environment, these plants will also produce nearly 900 tons of oxygen annually.
Not only does the vegetation improve the lives of its human inhabitants, by providing them with cleaner air, cooler temperatures and natural noise barriers, but it also benefits the local ecosystem. The carefully-orchestrated growth of vegetation, made up of more than 100 different types of plants, is expected to provide a more hospitable environment for the region's local animal and insect species.
Construction is scheduled to finish on the project in 2020, and residents and visitors will be able to access the city via a high-speed electric train from Liuzhou proper.
Meanwhile, Boeri's firm also has other plans for China, including building the country's first "vertical forest" in Nanjing and an even more ambitious proposal to turn the smoggy Hebei capital of Shijiazhuang into a "forest city" on an even grander scale.
By Emma Abrams
[Images via Stefano Boeri Architetti]
Follow Shanghaiist on WeChat


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NEW YORK (MarketWatch) -- Intel INTC, +0.11% was last up 29 cents at $27.29, and was set up to stretch its winning streak to 12 sessions. That would surpass the 11-session win streak the chipmaker's stock recorded from Sept. 6, 1996 to Sept. 20, 1996. During the current streak, the stock has now gained 11%; during the September 1996 streak, the stock gained 21% (to $12.17 from $10.07). If Intel stays positive, the stock would have posted gains in 19 of the last 20 sessions.
Intel set to stretch win streak to 12 sessions
Quote References
+0.06 +0.11%


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General Motors returned to profitability in the first three months of the year, the automaker reported Monday. It was GM's first profit since 2007.
GM, which emerged from bankruptcy last July, earned $865 million on revenue of $31.5 billion. A year ago, GM's predecessor company lost nearly $6 billion on revenue of only $22.4 billion, as sales plunged and the company hurtled toward bankruptcy.
GM had reported losses the two previous quarters since emerging from bankruptcy. But the profit in the first quarter was expected.
Worldwide vehicle sales jumped 24% to 1.9 million vehicles, as sales in the U.S. rose 15% and sales in China surged 71%. GM also had free cash flow of $991 million in the period, leaving it with $35.7 billion in cash on hand.
"We're pleased with our first-quarter performance, in particular achieving profitability," said chief financial officer Chris Liddell in the company's statement. "We're also steadily growing in emerging markets, keeping our costs under control, generating positive cash flow and maintaining a strong balance sheet."
This return to profitability is an important first step for the company being able to sell shares in an initial public offering, and for taxpayers to get back some or all of the $50 billion in bailouts the automaker received last year. GM repaid its government loans in April, but most of the help was in return for Treasury receiving a 61% stake in the automaker. A sale of stock and a strong earnings stream are necessary for the government to get that money back.
GM had previously said it hoped to be ready for an IPO by the end of the year, but that timing would depend on both profitability and market conditions. Liddell wouldn't give any further guidance on the timing Monday.
"Making a profit in the first quarter means we're better off than we would have been otherwise," he said. "That's heartening. I wouldn't take too much from that. The IPO will happen in good time when the company is ready and the market is ready."
[via CNN Autos]
Photo courtesy of paul (dex) down under under the Creative Commons License


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Botanical Me Lip Balm .15oz
Botanical Me Lip Balm Is packed with a special formula of moisturizing and healing properties making it the best you will ever use! The lip balm come in two flavors; Botanical Me Madagascar Mint Lip Balm and Botanical Me Apricot Argan Lip Balm.
Botanical Me Madagascar Mint Lip Balm is made with fair trade shea butter, spearmint and exotic foraha oil form Madagascar instantly moisturizes even the most chapped lips.
Botanical Me Apricot Argan Lip Balm contains organic fair trade argan oil from Morocco, shea butter and virgin apricot kernel oil. The best lip balm you will ever use!
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Choose a lip balmApricot Argan, Madagascar MintBeeswax, jasminum sambac (jasmine flower) wax, tocopherol (vitamin E), butyrospermun parkii (fair trade organic & raw fair shea butter) fruit, mangifera indica (mango seed) butter, persea gratissima (avocado) oil, triticum vulgare (wheatgerm) oil, jojoba chinensis (jojoba) oil, callophyllum inophyllum (foraha) oil, aroma (flavor)*.*Essential oils of spearmint, ylang ylang & lavender. No synthetics or artificial flavors. We keep it real!
How to use:
Apply to dry lips as often as desired. Use before bed, and wake up to healthier, softer lips. Can be worn under lipstick too.


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This large format solvent printer Flora LJ-3208K utilizes 8 Konica Minolta KM1024 or KM512 print heads. Working at double CMYK colors modes, it achieves the maximum printing speed of 140m²/h and upmost resolution of 720×1440dpi.
Apart from the advantages of high print speed and high precision, its print head possesses high compatibility with the ink. There is a plurality of inks applicable for users to choose. Therefore, this device is flexible in usage.
1.Under multiple-point support, the integral steel frame enables the large format solvent printer to operate stably at high speed without any mechanical vibration, with the print precision guaranteed.
2. This machine accomplishes optimal printing quality due to the industrial automatic cloth feeding and collecting systems that prevent the medium from corrugating and moving.
3. Under the assistance of the negative pressure system, it offers smooth ink supply while printing at high speed.
4. The optical fiber system is able to transmit a large capacity of image datum rapidly.
5. Our large format solvent printer adopts the special cloth lifting device to keep the moving accuracy of the cloth, as well as the printing precision.
6. This machine is configured with multi-drying system, which consists of the special heating and drying fans, cold wind diversion drying system, traditional segmented heating panels and a specially mounted separated sealed drying system. Therefore, the printed image will be dried as quickly as could in the process of printing at high speed. Meanwhile, our large format solvent printer makes full use of the cold wind diversion system to keep the ink and print medium cool promptly back to the common status. At the premise of improving the ability of the medium to absorb the ink, this system makes the image glossy and vivid.Technical Parameters
|Printing control
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|8 Konica printing heads
|Printing speed
|KM512/42PL printing head or KM1024/14PL printing head
|Draft output: 108m²/h, 92m²/h, 140m²/h, 135m²/h
|Standard output: 70m²/h, 59m²/h, 92m²/h, 85m²/h
|High precision output: 54m²/h, 45.7m²/h, 70m²/h, 66m²/h
|Ultrahigh precision output:36.8m²/h, 30.3m²/h, 48.6m²/h, 46m²/h
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|Inkjet technology
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|Max. width 330cm, diameter of coil 35cm, weight 100kg
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|Heating power
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|Input voltage: AC 200 to 240V, single phrase, 50/60Hz,16A (system), 20A (heating)
|Warranty period
|One year (customers can consult the local dealer about the detailed information)
Related Names
Solvent Printer | Solvent Printer Price| Large Format Printer | Large Format Solvent Printer | Flora Printer


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Princeton Instruments offers a compact, fully integrated, aberration-free spectrograph with an integrated low-noise, cooled detector called the FERGIE™ spectroscopy system. FERGIE's ecosystem includes everything from fiber optics, calibration sources and lasers to ingeniously designed light-coupling FERGIE CUBES and powerful software.
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Client Manager
Client Manager(Business Development Executive)
Client Manager(Business Development Executive)
Department: Department of Corporation, Section 1
Location: Guangzhou
Reports to: Partner
Main Duties & Responsibilities
General Marketing
§ Preparing and managinglegal newsletters
§ Co-authoring articles for legal newsletters and other publications
§ Writing articles
§ Preparing annual submissions for various legal directories
§ Preparing marketing materials
§ Arranging for and organizing seminars or presentations
§ Submitting news and materials to such Chambers/Guild/Journal
§ Working with team on other business developing initiatives and projects
Business Development
§ Attendingand assisting with events, seminars, trade fairs, Consulate events
§ Building network or direct client relationship through contact by telephone or by email
§ Following up on online leads
§ Contributing to discussions on LinkedIn and other internet forums
§ Liaising with Embassies, Consulates and Chambers of Commerce for seeking the business opportunity
§ Assisting in preparing legal documents, business meetings and negotiations
§ Preparing pitches and RFPs.
Client Management
§ Establishing and maintaining client relationship
§ Formulating the client management and strategy
§ Cooperating with lawyers to ensure client satisfaction
§ Forming bridge between client and Chinese colleagues (i.e. communicating with client directly by phone or email; be in charge of any client request and response)
§ Reviewing English emails / documents drafted by Chinese colleagues
§ Starting date: a.s.a.p.
Competitive package: Fixed salary + variable bonus
Person Specification
Experience working in China (preferably from consulting or legal business)
Legal degree
Foreign national
Proficient in English
Social skills
Great discipline to work in a free role with limited instructions
Contact information
Add: 23/F, R&F Center, 10 Huaxia Road, Tianhe District, Guangzhou
Attn:Lillian XU
E-mail: email@example.com
Tel:020-2826 1765
ZL Law Firm Description
Founded in 1993, Zhong Lun Law Firm is a leading full service law firm in China. With over 280 partners and over 1800 professionals working in fifteen offices in Beijing, Shanghai, Shenzhen, Guangzhou, Wuhan, Chengdu, Chongqing, Qingdao, Hangzhou, Nanjing, Tokyo, Hong Kong, London, New York, Los Angeles and San Francisco, Zhong Lun is capable of providing clients with high-quality legal services in more than 20 countries across a wide range of industries and sectors through our specialized expertise and close teamwork.
Zhong Lun Guangzhou Office is conveniently located at the center of Pearl River Delta. We are made up of a group of excellent and skilled lawyers. They combine a unique mix of Chinese cultures and international outlook, possessing not only the essential language skills but also a clear understanding of the values and thinking of our foreign clients as well as their partners in China. Our lawyers are therefore capable of supplying a quality and depth of legal service that we believe simply cannot be matched in this area.


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We report on digitally printed distributed feedback lasers on flexible polyethylene terephthalate substrates based on methylammonium lead iodide perovskite gain material. The perovskite lasers are printed with a digital drop-on-demand inkjet printer, providing full freedom in the shape and design of the gain layer. We show that adjusting the perovskite ink increases the potential processing window and decreases the surface roughness of the active layer to less than 7 nm, which is essential for low lasing thresholds. Prototype inkjet-printed perovskite lasers processed on top of nanopatterned rigid as well as flexible substrates are demonstrated. Optimized perovskite gain layers printed on PET substrates demonstrated lasing and showed a linewidth of 0.4 nm and a lasing threshold of 270 kW/cm2. In addition, printing of a distinct shape shows a high level of uniformity, demonstrated by a low spatial resolved full width half maximum variation over the whole printing area. These results reveal the possibilities of digital printed perovskite layers towards large-scale and low-cost laser applications of arbitrary shape.
© 2018 Optical Society of AmericaFull Article | PDF Article
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Guy L. Whitworth, Jonathan R. Harwell, David N. Miller, Gordon J. Hedley, Wei Zhang, Henry J. Snaith, Graham A. Turnbull, and Ifor D. W. Samuel
Opt. Express 24(21) 23677-23684 (2016)
Philipp Brenner, Tim Glöckler, Diana Rueda-Delgado, Tobias Abzieher, Marius Jakoby, Bryce S. Richards, Ulrich W. Paetzold, Ian A. Howard, and Uli Lemmer
Opt. Mater. Express 7(11) 4082-4094 (2017)
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Opt. Express 25(24) A1154-A1161 (2017)


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On this trip to the North you will discover the authentic Tenerife.
The first stop is in old-world Masca, a secluded village in Teno Rural Park. Enjoy the breath-taking ravine that sweeps down to the see far below. The tour continues through the Park where you will find the Teno Lighthouse situated onone of the wildest coastlines in Tenerife. Then we will visit Los Silos Village where you can see the skeleton of a whale, an important part of the culture of Isla Baja.
Lunch will take place in an old hardware store that has been turned into a restaurant. There you will have a traditional Canarian lunch.
After lunch you will continue your route to Los Realejos. A short walk will take you to an unusual fire station of historical interest. It marked a step forward, welcoming in its time the first steam engine to the archipelago.
Other Details
The tour has a maximum of 20.
Warm clothes and comfortable footwear is necessary.
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Price List
|Children (3 -12)
|Infants (0 - 3)
Desde zona Sur
68.00 €
34.00 €
0.00 €
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Enhance your Profit with This 12-Step Plan
Posted on Monday, February 25, 2019 Share
Chances are, you have some great ideas on ways to increase profits at your company. But it takes more than ideas to make progress. It takes specific goals and a plan that will put feet under your ideas.
Set up a profit enhancement road map within the next year at your company by following these 12 steps:
1. Select critical profit projects you want to work on and determine the target results for each project. For example, you may want to increase sales by 10 percent or reduce order-processing time by one day.
2. Assign a "Profit Champion" on your staff for each project. This person will be responsible for heading up and monitoring the effort.
3. List the benefits of each project. These might involve the company, manager, staff or customers.
4. Predict outside roadblocks. Identify obstacles and determine how you will deal with them. These might involve other departments, management, customers or suppliers.
5. Anticipate why your Profit Champions might go off track. When employees have to start doing things differently, they may veer off course. For example, let's say the sales people have to meet one night a week to get the extra training needed.
6. Determine how results will be measured and establish employee rewards. Creating long-and-short-term rewards will help keep employees on board and motivated to reach your profit goals.
7. List resources required to accomplish the project. Resources might include information, field experts, time with executive management, and even intangibles such as support dealing with other employees. Make sure your Profit Champions have access to the resources and are empowered to use them.
8. Break the profit project down into subtasks. List the activities your Profit Champions need to perform to accomplish the goal.
9. Assign due dates for each subtask. Keep deadlines reasonable.
10. Make a "to-do" list for each subtask. Start with the earliest due date.
11. Keep in contact with your Profit Champions. Hold employees to deadlines and reporting requirements. In meetings, ask them if they have any additional thoughts for profit ideas seeded by the work they've been doing.
12. Empower your staff members to make real and lasting change. Coach your Profit Champions to overcome obstacles, experiment with new ideas and succeed.
Posted in Tax Topics For Individuals
Disclaimer: The information contained in Dulin, Ward & DeWald's blog is provided for general educational purposes only and should not be construed as financial or legal advice on any subject matter. Before taking any action based on this information, we strongly encourage you to consult competent legal, accounting or other professional advice about your specific situation. Questions on blog posts may be submitted to your DWD representative.


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A rainbow of stones reminiscent of the Bifrost Bridge help you sort your stitches. This unique stitch marker set features seven stone stitch markers. These snag-free stitch markers are made of hammered, antiqued copper which has been annealled, filed, sanded and polished to make sure it's smooth knitting all the way! All hang from my special stitch marker keeper.
Choose the necklace option to wear them when you aren't using them. If you choose the necklace option, the keeper will hang from a 30" length of copper plated iron chain. In the last photo you can see Janel Rohrig of @frumpyknits wearing her stitch marker necklace.
These markers will fit over a 5mm or US 8 needle or smaller.
The seven stones are chosen to correspond the the chakras-- Garnet for the base chakra, carnelian for the creative centre or second chakra, pale agate for the solar plexus, moss agate for the heart chakra, lapis lazuli for the throat chakra, amethyst for the third eye and clear quartz for the crown chakra.
I designed these stitch marker sets because I love to knit sweaters in the round from the top down. (You don't need a pattern, just a bit of maths. If you haven't tried it, give it a go! You'll never look back!
Anyway, I was always losing those little plastic stitch markers. I never liked them anyway. I thought why not make something as beautiful as knitting? Why not make jewellery *for* knitting?
These markers make a gorgeous, decadent gift for the flash knitter in your life. Just think: whenever they move to a new stitch they will think with fondness on how clever you are.
All my jewellery is made by hand by my partner Mike and myself in a converted 18th century naval school on the wild North coast of Scotland. All pieces come gift wrapped with lavender and Scottish heather.
Copyright © 2019 Feral Strumpet. Powered by Shopify.


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Brugge Foto is an event with photography exhibitions in 10 beautiful locations in Bruges. Together, all locations form a unique photo art discovery route. All venues in town center are within walking distance.
The festival shows the great diversity that exists in the world of the photographic image, paying attention to documentary photography, photographic essays, contemporary and conceptual photography. More than 40 Belgian and international photographers exhibit.
Full program available at www.bruggefoto.be
multiple venues
Bruges, Belgium
December 03, 2017 to January 07, 2018


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OMT stands for Osteopathic Manipulative Therapy. Clear as mud? OMT is a specialized form of medicine usually performed by physicians who are DOs, or, Doctors of Osteopathic Medicine.
I'm a DO physician. That means I am a fully licensed physician, I completed the same four years of medicine as my MD colleagues and the same three years of residency in Family Medicine. The biggest difference in training was that in addition to typical training, DOs receive specialized training in the musculoskeletal system — your body's interconnected system of nerves, muscles and bones, and training in osteopathic manipulation. DO physicans can be found in all specialties, but not all DOs choose to continue doing manipulation in their practice.
Getting back to OMT, it is a specialized form of medicine using a set of hands-on techniques to diagnose, treat and prevent illness or injury. These techniques let us apply pressure to certain joints, tissues and bones to release tension, encourage blood flow and promote normal healing. This can range from popping joints, also called "high-velocity, low-amplitude" techniques, to gentle soft tissue and muscle stretching techniques.
Osteopathic medicine was begun in the late 1800s by Dr. A.T. Still MD, DO. Dr. Still believed that by correcting problems in the body's structure, using manual techniques, the body's ability to function and to heal itself could be greatly improved. He also promoted the idea of preventive medicine and endorsed the philosophy that physicians should focus on treating the whole patient, rather than just the disease. Dr. Still began the first osteopathic medical school in Kirksville, Missouri.
The tenants and practices of Dr. Still continue to be taught to medical students today, along with research from numerous other physicians over the past 125 years.
OMT can be used to treat a wide variety of common ailments such as headaches, arthritis, stress injuries, sports injuries and back pain. It can also be beneficial for patients with asthma, carpal tunnel and menstrual pain. Every individual is unique and so each person needs a customized approach. OMT has been shown to be an effective alternative and complement to medication and other therapies.
I love using OMT in my practice. It's a wonderful appointment for me when the patient comes in for manipulation and I can use my hands to make the patient feel better before they leave my office.


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Take advantage of the expertise from industry leaders and portfolio managers by registering for our webcasts.
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Recorded: October 4, 2018 Expiry: October 4, 2019


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It has officially been more than a week since I've gone for a run.
After last Saturday's failure, I made sure that my back had all the time it needed to recover. However, during my week off I signed up for the Ragnar Relay Del Sol in Arizona and took a peak at their suggested training plan and holy moly am I behind! Last week, I created a personalized training schedule for myself. Although this is not my first time training for a race, this will be the first time I attempt to incorporate one day of yoga each week. I've practiced yoga casually in the last 5+ years, committing to weekly yoga classes for 6 or so months at a time, and then abandoning the practice when life got busy. I've noticed that in the last year or so since my last batch of yoga classes, I've lost all of my flexibility (for serious, I can run a half marathon and NOT tough my toes? What the heck?). And after my back injury, the need to build core and back strength is even more apparent. So, to yoga I will go!
On Saturday, I went to a Vinyasa class at Jai Yoga. I did not expect the class to be so advanced. I did not expect there to only be 5 other students. And I did not expect the teacher to walk around the class softly speaking the different poses we should move through rather than stand at the front of the room demonstrating the poses to us. Then again, I'm pretty proud to say that I could keep up the majority of the time (and I think the teacher even complimented me on one of my poses – WIN!). There were several poses I could not do (aka could not even fathom how I would attempt them), but the teacher seemed ok suggesting easier poses for me to try (and seemed ok with me just laying there, which I did on more than one occasion). After the class, I commented to the teacher that the class was a bit above me but that it felt awesome to at least try – and would you believe that he responded that I should just keep coming back and after a few classes I'd be up to par? Really? If you say so? I don't think I'll be able to catch up that fast, but I did like the class… so I'm going to try and go back on Tuesday night.
I can't wait to start my training tomorrow morning. I stocked up on my new and favorite recovery foods (helloooo chocolate milk, you delicious drink). My legs are itching to get out there and run again after this long, extended break. Wish me luck!


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If you're having trouble deciding on which show to go see during your stay in Las Vegas, we're here to help! Our upcoming Countdown to Vegas newsletters will provide information on all the entertainment Las Vegas has to offer. This week, we spotlight the Treasure Island Cirque Du Soleil show Mystère.
You will not be disappointed with the truly creative visual, musical and acrobatic show that is Mystère. The show offers performances that push the envelope to present a truly awe-inspiring show you would have previously thought impossible.
The theatrical and breathtaking acrobatic performances venture to the edge of human possibility. Don't waste your time or money trying to seek out a front row seat, because the further back you sit, the more you'll appreciate the astonishing and terrifying leaps and twists performed by these incredible artists which use every inch of corner, ceiling and hanging space. Performers exhibit a combination of strength and stamina as they hurl themselves into the air and contort themselves into different poses that seemingly break the laws of human capabilities.
All of the performers have exquisite vibrant costumes that enhance the magical atmosphere and create another world on stage. There are gymnasts dressed like ethereal angels, bird-like performers adorned in feathers, creatures resembling giant colorful giraffes that move around on stilts, acrobats with multiple long blue goblin-like faces and a finale including a stage-sized snail creature complete with twitching tail.
The music that accompanies the performances also sets the show apart. The sweet soprano of the lead singer transports you to a simpler time and the thumping of the drums throughout the show makes your heart beat faster as you watch acrobats soar through the air. The stringed instruments stir the soul during the more subtle and sensual moments. A sample of the music can be found here.
The comic relief is provided by a pair of clowns that couldn't be more contradictory. You meet the first before the show even starts. A disgruntled clown warms up the audience by leading people to the wrong seats. Dressed in a rumbled suit, he gets increasingly more frustrated and ends up ripping up tickets, kicking people out of the theater and throwing popcorn on unsuspecting spectators. Security roughly throws him out, but he makes several additional appearances in an attempt to steal the spotlight.
Another clown dressed like a baby in search of its mother terrorizes an unlucky audience member intermittently during the show. The victim is subjected to spray from the clown's baby bottle, a ride in a fast moving golf cart and a costume change into a baby outfit. The clowns provide the perfect complement to the high-flying acts and passionate dance performances.
The exotic and vibrant costumes, the skilled performers, memorable music and close proximity to the JCK Las Vegas Show are more than enough reasons to make Mystère one of the shows you should see in Vegas.Follow JCK on Instagram: @jckmagazine
Follow JCK on Twitter: @jckmagazine
Follow JCK on Facebook: @jckmagazine


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Jun 14, 2018
BOJ Is Drifting Further From the Global Pack: Decision-Day Guide
Bloomberg News,
(Bloomberg) -- No change at the Bank of Japan.
That's the unanimous view of economists for the two-day policy meeting that concludes in Tokyo on Friday, leaving the BOJ increasingly out of step with the U.S. Federal Reserve and the European Central Bank.
With Governor Haruhiko Kuroda set to stick with his current interest-rate and asset-purchase settings, BOJ watchers will focus on how he explains the recent weakening of inflation in Japan. The contrast with other economies is particularly stark this week, after the Fed raised rates on Wednesday and the ECB on Thursday said it would halt its bond-buying program by year-end.
The divergence in policy may add pressure on the yen to weaken, helping Japan's exporters and assisting the BOJ's inflation campaign by increasing import costs.
The policy statement will be released around midday, followed by a press conference with Kuroda at 3:30 p.m. local time.
Japan's consumer price index, excluding fresh food, rose at a slower pace of 0.7 percent in April, leaving the BOJ further from its 2 percent target than at the last policy meeting and pushing the likelihood of an increase in rates further into the future.
Any change on Friday in the BOJ's assessment of current CPI levels to reflect the latest data could foreshadow a softening of confidence in price projections due for review next month. If there is a downward assessment, Kuroda is likely to make every effort to play down the policy implications.
To date he's maintained the view that price momentum, including a tight labor market, is still in place. Kuroda has also emphasized the importance of continuing with persistent monetary easing, regardless of policy divergence with the Fed and ECB.
The BOJ's bond purchases have dropped well below its guideline for buying 80 trillion yen of debt annually, leading some strategist to suggest that reference to this figure could eventually be removed from the policy statement. But such move would also risk of rekindling premature exit talk.
Policy Recap
Key elements of the BOJ's yield-curve control policy:
- Negative interest rate of minus 0.1 percent charged on some of the reserves financial institutions keep at the BOJ
- Yield target of about 0 percent for 10-year Japanese government bonds
- Increase JGB holdings by about 80 trillion yen ($723 billion) a year
- Increase holdings of exchange-traded funds by 6 trillion yen a year and Japanese real-estate investment trusts by 90 billion yen annually
To contact the reporter on this story: Toru Fujioka in Tokyo at firstname.lastname@example.com
To contact the editors responsible for this story: Brett Miller at email@example.com, Paul Jackson
©2018 Bloomberg L.P.


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HELENSBURGH Rugby Club have been dramatically reinstated in West Division 1 for next season after league restructuring plans were approved.
After picking up just one win last season, the Burgh were destined to play next season in West Division 2.
But they will now stay up thanks to Cumbernauld RFC's proposal at the West Regional Club meeting on Monday night was passed by 13 votes to 10.
As a result there will now be three leagues instead of four in the West of Scotland rugby set-up, with leagues consisting of 12 teams as opposed to 10.
That means Helensburgh will avoid relegation, with Cambuslang and Stewartry moving up from West 2, and Greenock joining the division after being relegated from National Division 3.
With a number of clubs folding this year, several divisions finished fixtures as early as January, and new Burgh rugby club chairman Stuart Ashdown said the Ardencaple side were fully supportive of the change.
He said: "As a club we think it's a great idea; the restructuring of going from four leagues to three means there are more teams in each league for a start, so instead of some of the leagues being short of players and their leagues finishing in February, most of the leagues will go on until March now.
"Hopefully we can retain more players because the leagues will be bigger and last longer, and we'll have more home games to play which is good for the club."
Ashdown admitted it was a difficult season last year for Helensburgh, but he hopes the appointment of new head coach David Calderwood and the restructuring of the league will see the Grizzlies be more competitive in 2017/18.
"We're glad we'll be staying in Division 1 for another season," he continued.
"Last season was a tough one for the club. We had an availability problem. We're obviously closely linked with the naval base and a lot of the players are under operational commitments as well as social ones with the club, so we did find it a bit difficult at times to fulfil fixtures.
"But we've got a new coach and we're trying to build a new team ethos and so far it's looking quite positive for next season.
"Last season in games there were a few mishaps or a few mistakes that cost us games, but overall the performances and the standard of rugby the team put out was of a very high standard, and we're going to take that on to next season."
Fort William side Lochaber have also joined the West set up, with Clydesdale also set to rejoin the leagues. after folding earlier this year.
West 1: Allan Glens, Annan, Cambuslang, Carrick, East Kilbride, Garnock, Greenock, Helensburgh, Irvine, Kilmarnock, Oban, Stewartry.
West 2: Birkmyre, Clydebank, Cumbernauld, Cumnock, Lenzie, Loch Lomond, Millbrae, Paisley, Strathaven, Strathendrick, Uddingston Waysiders.
West 3: Bishopton, Clydesdale, Cowal, Glasgow Uni Medics, Hyndland, Isle of Mull, Lanark, Lochaber, Moffat, Police Scotland Glasgow, Shawlands, Wigtownshire.


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LONDON (MarketWatch) -- General Motors GM, -0.31% is close to a deal to sell its Saab Automobile unit, the Wall Street Journal reported on Friday, citing a person familiar with the matter. GM in February sought protection from creditors for Saab in an effort to sell or spin off the unit. The company has said its goal is to have a deal with one of three bidders by the end of June. Along with Koenigsegg, the final candidates are reportedly Renco Group Inc., a private holding company, and Merbanco Inc., a Wyoming-based private investment group.
GM close to deal to sell its Saab unit: report
Quote References
-0.11 -0.31%


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