chapter 7: sleep and sleep disorders Flashcards
sleep
state in which a person lacks conscious awareness of environmental surroundings, but can be easily aroused
physical and mental functions affected by sleep
mood, behavior, memory, hormone secretion, glucose metabolism, immune functions, body temperature
who’s most likely to have sleep disturbance?
what’s the dif bt sleep disturbance and sleep disorder?
chronically ill ppl
disturbance = broad term for poor sleep quality for whatever reason
disorder = problems unique to sleep: insomnia, sleep apnea, narcolepsy, periodic limb movement, circadian sleep disorders –> often missed or unreported
Sleep wake cycle - what controls it
controlled by forebrain (cerebral cortex, hypothalamus, thalamus) and brainstem
wake behavior
integrated network of arousal systems from brainstem and forebrain
–> ARAS (ascending reticular activating system) and other neurotransmitters
Histamines in hypothal
Orexin = imp neuropep in hypothal
issues with wake bahavior stuff
Alzheimers = lose cholinergic neurons in forebrain –> sleep probs
Parkinsons = loss of dopamine neurons in ARAS –> sleepy
Narcolepsy = lack of orexin
OTC can inhibit histamine sometimes –> sleepy
sleep behavior
neurons in hypothal inhibit ARAS
neurotransmitters and peptides promote sleep (GABA, GHRH)
infection = proinflammatory cytokines (ILs and tumor necrosis factor) –> sleepy
Postprandial = after food = peptides from GI after eating = sleepy
Melatonin= from pineal –> turns off wakefulness mechanisms when it gets dark
circadian rhythm
Regulated by suprachiasmatic nucleaus (SCN) in hypothalamus –> master clock
-light from retina –> SCN –> other brain parts
LIGHT IS STRONGEST TIME CUE
sleep architecture
Nighttime sleep recorded by polysomnography (PSG)
-brain waves
-eye movement
-muscle tone
Two sleep states
-REM and NREM
-go through 4-6 cycles bt them lasting 60 to 110 mins
NREM
75-80% of sleep
N1 = slow eye movement –> easy to wake
N2 = most time here = HR and temp drop= visible on EEG
N3 = deepes= slow wave sleep = delta waves on EEG = sleep intensity - not as common in old ppl
REM
20-25%
-brain waves resemble wakefulness
-postural muscles inhibited –> loss of muscle tone
-vivid dreams
effects of insufficient sleep
Neurologic
-cognitive impairment and behavioral changes (grumpy)
Immune
-worse
Respiratory
-asthma exacerbated
Cardiovascular
-Heart disease
-high BP
-stroke
GI
-higher risk for obesity
-GERD
Endocrine
-risk for type 2 diabetes
-insulin resistance
-low growth hormone
sleep disturbance in hospital
-noise and light 24/7
-illness keeps you awake
-boredom and daytime napping
-meds –> esp opiods –> can fuck with sleep
*lack of sleep makes you less tolerant to pain though
Insomnia
most common sleep disorder (1/3 adults)
-difficulty falling asleep/staying asleep –> wake up too early –> wake up not refreshed
Acute = 3 nights a week for less than a month
Chronic = acute symptoms and daytime problems for 3+ months (10-15% Amers)
insomnia prevelence
women more than men
divorced/widowed more than married
poor and less educted more than alternative
contributions to insomnia
-irregular sleep schedule
-afternoon naps
-being in bed awake for a long time
-sleeping in late
-exercising near bedtime
-stimulants
-Alc makes you sleepy, but fucks with REM, so you wake up during night
-meds (esp SSRIs)
Onset is usually after stressful life event
manifestations of insomnia
-difficulty falling asleep
-frequent awakening
-prolonged nighttime awakenings
-feeling unrefreshed in morning
diagnostic stdies
Self report = diary/log for 1-2 weeks or screening questionairre
Actigraphy = on wrist –>measures gross motor activity –> time awake and asleep
Polysomnography = PSG = muscle tone (EMG), eye movement (EOG), brain activity (EEG) –> all electodes –> only done if there’s symptoms of another sleep disorder (not insomnia)
**can also measure HR, RR, resp effort, airflow, pulse ox
Intrerprofessional care
-education on sleep hygiene
-CBT-I = stress management, limit non sleepy time in bed, no naps, no pre sleep excersise
-Drugs
-complementary/alt therapies = melatonin and valerian (not for insomnia), relaxation, white noise
Drugs for insomnia
Benzodiazepine hypnotics = Triazolam (sleep onset) and Temazepam (onset and maintenance)
-activate GABA receptors
-only use for 2-3 weeks; don’t use other ones; interact with alc and CNS depressors
Nonbenzodiazepine hypnotics = Zaleplon (onset), Zolpidem and Eszopliclone (onset and maintenance)
-3 months to a year
-act as GABA receptors –> safer than benzos
-shorter half life -> don’t take with food though
-many forms
Orexin-receptor antagonists
-Suvorexant
-1 per night within 30 mins of sleep
Melatonin-receptor agonist
-Ramelteon
-fast, you dont get tolerant, doesn’t work great
Antidepresants
-Tricyclic ones (doxepin and amitriptyline) –> low doses for isomnia
-Trazadone –> sketchy
Antihistamines
-Diphenhydramine, OTC pain meds, doxylamine –> all kinda sketch
Assessment of insomnia
sleep history
ask ab diet, caffeine, and alc intake
ask about sleep aids: OTC, Rx, herbal, supplements (kava is toxic to liver)
Sleep diary for 1-2 weeks
med history, works schedule, travel
Nursing diagnoses
sleep deprivation
impaired sleep
Implementation for insomnia
sleep hygiene and CBTI
-tell to decrease caffeine intake – half life is 6 hrs or up to 9 hrs in old ppl
-keep room dark and cool (avoid clock watching)
-teach ab meds: don’t take with fatty food, alc, or CNS depressants –> don’t plan skilled actiities for morning
Sleep Disordered Breathing
snoring
apnea (90+% reduction in airflow)
hypopnea (30-90% airflow reduction)
obstructive sleep apnea
Obstructive sleep apnea (…hypynea syndrome)
partial or complete upper airway obstruction and reduced tone during sleep; lasts 10-90 secs –> airway narrows due to muscle tone relaxation or tongue goes backwards
Can cause hypoxemia and hypercapnia –> ventilatory stimulants which cause arousal
Usually during REM when muscle tone is at lowest
Risk factors for OSA
obesity (bmi over 30)
age (over 65)
neck circumference over 17”
craniofacial abnormalities
acromegaly
smoking
OSA manifestations
frequent arousals
insomnia
daytime sleepiness
witnessed apneic episodes
snoring
morning headache
irritability
personality changes
Complications of OSA
HTN
cardiac changes
poor concentraton/memory
impotence
depression
link bt CV issues and sleep apnea
apnea = hypoxia and increased intrathoracic pressure ==> SNS activation and increased VR and reduced oxygenation of heart ==> HTN, dysrhythmias, HF
Diagnosis of OSA
-usually use PSG
requires documentation of apna or hypopnea of at least 10 s
OSA = over 5 episodes an hour with 3-4% decrease in O2 sat
Treatment of mild sleep apnea
sleep on side
elevate head
avoid sedatives and alc 3-4 hrs b4 sleep
weight loss
oral appliance –> special mouth guard
meds tend to make it worse
Severe sleep apnea treatment
more than 15 apnea events/hr
-Continuous Positive Airway Pressure (CPAP) is effective, but poor adherence
-Bilevel Positive Airway Pressure (BiPAP) is similar but with lower exhale pressure
-need to wear 4 hrs/night to reverse CV risk
If in hospital, still should wear CPAP and cautious use of narcotics/sedatives
Surgical treatment for OSA
Uvulopalatopharyngoplasty (UPPP or UP3) = removes tissue
Genioglossal advancement and hyoid myotomy (GAHM) tonge/mandible atch
Radiofrequency ablation (RFA) = least invasive
Neurostimulators = imlants that stimulate hypoglossal nerve to increase muscle tone in airway
Post op = risk of airway obstruction and hemorrhage
Periodic limb movement disorder (PLMD)
involuntary repetitive movement of limbs that affects ppl during sleep (usually legs)
-causes poor sleep
-treated with meds aimed at reducing limb movement/muscle activity and improving sleep quality
Circadian rhythm disorders
Occur when circadian time-keeping system loses synchrony with environment
-jet lag
-shift work sleep disorder
-symptoms = insomnia and excessive sleepiness
Narcolepsy
brain unable to regulate sleep-wake cycles normally
-causes uncontrollable urges to sleep –> straight into REM
Causes unknown –> assoc w/ destruction of orexin neurons –> happens after head injury, infection, or change in sleep
2 types of narcolepsy
Type 1 = with cataplexy (brief and sudden loss of muscle tone)
Type 2 = without cataplexy
Symptoms = sleep paralysis, cataplexy, fragmented nighttime sleep
Narcolepsy diagnosis
history
PSG
Multiple sleep latency test (MSLTs) = PSG and 4-5 naps every 2 hrs next day
Interprofessional management of narcolepsy
uncurable
reach ab sleep hygiene
take naps
avaid heavy meals and alc
ensure safety
teach ab meds
Narcolepsy drug therapy
Nonamphetamine wake-promoting
-modafinil and armodafinil = wake promoting drugs
-sodium oxybate (Xyrem) = metabolite of GABA –> for wakefulness and prevents cataplexy
SSRIs (fluoxetine and canlafaxine) treat cataplexy
Parasomnias
unusual and often undesirable behaviors that occur while falling asleep, transitioning bt sleep stages, or during arousal from sleep
-due to CNS activation
-In ICU might be misinterpreted as ICU psychosis
Parasomnia includes:
Sleepwalking - no memory of it
Sleep terror = sudden awakening; loud cry and panic
Nightmare = frightful or disturbing dream
-in critical care, some meds contribute to nightmares (sedative hypnotics, beta adrenergic antagonists, dopamine antagonists, amphetamines)
Gerontologic considerations of sleep
old age assoc w/
-overall shorter total sleep time
-decreased sleep efficiency
-more awakenings
-sleep disordered breathing may manifest with insomnia symptoms
-circadian shift
Circumstation stuff that fucks with old ppl’s sleep
Results of poor sleep in old ppl
medical probs/ chronic conditions/ medications
-awakening during night increases fall risk
-chronic sleep disturbance = disorientation, delerium, impaired cognition, accidents injury
AVOID LONG-ACTING BENZODIAZEPINES –> old ppl are more sensitive
Shift work sleep disorder
insomnia, sleepiness, fatigue
-increased stress, health risks, patient safety issues
Strategies
-on site napping
-consistent sleep-wake schedule
-sleep hygiene
