Sleep-Wake Disorders Flashcards
Sleep
1/3 of your life spent sleeping
US getting less sleep- 6-6 1/2 hours
50 to 80% mental health pts report sleep problems
Disrupted sleep involved in events:
- Pennsylvania’s 3 Mile Island reactor failure 1979
- Chernobyl nuclear meltdown, 1986: reactor lid blown off –> built dome to contain it
- Exxon Valdez oil spill, 1989
Sleep Needs
Newborns: 17-18 hours
Preadolescents: 10 hours
Adolescents: 9 hours
Adults/Elderly: 8 hours
Sleep-wake cycle
endogenously generated rhythm close to 24 hours, synchronized with the day/night cycle
sleep latency
bedtime to the beginning of sleep
sleep architecture
pattern of non-REM and REM in a 90 to 110 minute cycle
sleep efficiency
ratio of total sleep time to nocturnal time in bed
Biphasic Stage of Sleep
- Non-rapid eye movement (NREM) harder to awaken
-90 minutes after falling asleep
Four stages:
-stages 1 and 2—person easily aroused
-stages 3 and 4—slow-wave sleep (deepest state; restorative function) - Rapid eye movement REM
- Deep sleep; vivid dreaming
Sleep Disorders Summary
- Ongoing disruptions of normal waking and sleeping patterns –> excessive daytime sleepiness, inappropriate naps, chronic fatigue
- The inability to perform safely or properly at work, school, or home
- More common in women
- Prevalence increases w/age
- Occur independently of other mental disorders
- -> but also seen in patients with mental disorders
Circadian Rhythm
Internal clock coordinates sleeping, eating, mood
Body temperature (lower in early morning), and female menstrual cycle --> cortisol levels, hormone levels
Usually cued by sunlight:
- Internal pacemaker: in HYPOTHALAMUS (called Suprachiasmatic nuclei)
- External influences are light/dark cycle, mealtime and work patterns
Circadian Rhythm - 24 hour cycle
Effect on hormone releases
- -> ex. body temp lowest early am
- -> highest levels mid evening: temp, manual dexterity, reaction time, simple recognition, muscle tone
Circadian Rhythm Sleep Disorders
Mismatch between circadian rhythm and the timing and duration of sleep causing excessive sleepiness and/or insomnia and distress
- Synchronized-rhythms: peak at the same time
- Desynchronized-rhythms: peak at different times (can look like mental illness)
Circadian Rhythm: Sleep Disorders
- Delayed sleep phase type (“night owls”)
- Advanced sleep phase type (early risers, can’t stay awake in PM)
- Irregular sleep–wake type
- Shift work type
- 20% of US workforce, sleep shorter/poorer - Jet lag type- not in DSM 5 (traveling east = harder to reset to earlier time zone)
Circadian Rhythm: Interdisciplinary Treatment
- Melatonin
- Chronotherapy (delaying sleep time each night 3 hrs until target time is reached)
- Luminotherapy (more light during day to keep awake)
- Chronopharmaco-therapy (using stimulants to keep you awake, short acting, ex. caffeine)
Insomnia
- Difficulty falling asleep, maintaining sleep & early awakening (3 x per week for 3 months).
- Increases relapse risk in mental/medical disorders
- Daytime fatigue, diff concentration, bad mood w/no indication of another disorder
- 23.6% of non-institutionalized adults with 10-15% severe insomnia
- Other poss causes: mental disorders, pain, cardiac, gastrointestinal, pulmonary, Parkinson’s
Sleep Disorder Assessment
Sleep history and diary: better, worse, events naps, bedtime, supplements, meds, caffiene, alcohol, shift work
- Recent changes in relationships
- Fatigue and stress
- Time zone changes: takes 4-6 days to recover
Rule out substance or meds, mental health and non-psychiatric medical conditions, normal sleep variations
Impact on work, relationships, health
Insomnia Nursing Management
Polysomnography: records brain patterns during sleep in a sleep lab, confirms sleep disorders, describes sleep architecture and any abnormalities (picture page 632)
Nursing Diagnosis:
- Sleep pattern disturbance
- Sleep deprivation
- Insomnia
Insomnia Evidence-Based Treatments: Long Term
Long term- BEHAVIORAL interventions produce more sustained effects than drugs.
–>they REDUCE sleep onset time, DECREASE awakenings, and INCREASE total sleep time
Stimulus control: use bed only for sleep/sex, white noise, phone off, blacken windows, note on door, enlist support of family and friends, cool temp
Sleep restriction: try to avoid naps and sleep only during regular sleep hours
Relaxation: deep breathing, stretching, meditation, progressive relaxation, visualization
Avoid before sleep: heavy meal, spicy food, caffeine (6 hours), cigarettes (1 hour), stimulants, exercise (3 hours)
Try warm milk, melatonin (1 mg may work better than a larger dose), valerian root supplements
Avoid alcohol, it disrupts sleep later
Cognitive-behavioral therapy to sort out difficult situations, positive self-talk
Sleep log
Music/reading
Bedtime ritual: same routine before sleep, time of day, preparation for sleep, 7-8 hours, arising at the same time each day
Insomnia Evidence-Based Treatments: Short Term
Sleep Meds for SHORT term only
Diphenhydramine (Benadryl): antihistamine, use intermittently
Benzodiazepine Receptor Agonists (BzRAs): facilitate GABA
- Benzos are addicting (schedule 4) and can cause confusion in the elderly
- ->ex. diazepam (valium), chlordiazepoxide (librium), lorazepam, (ativan), flurazepam (dalmane).
- BzRAs that are not benzos: Zolpidem (ambien), and zaleplon (sonata)
- Melatonin receptor agonist: Melatonin and Ramelteon (Rozerem)
Sedating antidepressants
Hypersomnolence Disorder
EXCESSIVE SLEEPINESS at least three times a week for at least 3 months.
Sleep at least 7 hours at night and at least one:
- Recurrent periods of sleep in same day
- Over 9 hours non-restorative sleep
- Difficulty being fully awake after abrupt awakening
Diagnosis: polysomnography followed by a multiple sleep latency test (20 minute measurements of sleep variables every 2 hours 5X a day)
How to treat Hypersomnolence Disorder?
Assess sleep patterns
Nursing interventions: sleep hygiene, help establish normal sleep patterns, stimulants
- Methylphenidate (Ritalin, Concerta)
- Pemoline (Cylert)
- Adderall (amphetamine and dextroamphetamine)
- Modafinil (Provigil) promotes wakefulness but pt. can take naps, cost is $1300 per month)
Caffiene- self med-3-5 hour duration
Narcolepsy
Irresistible URGE TO SLEEP at any time of the day, regardless of the amount of previous sleep (3 x per week for 3 months)
Short sleep episodes (attacks) 2 to 6 X a day- refreshing and at least 1 of the following:
- Cataplexy: bilateral loss of muscle tone while awake
- alert and oriented
- after strong emotion such as laughter -> lasts a few seconds, eyelids may droop, knees may buckle, slump in chair
- –> Within 6 months of onset spontaneous grimaces or jaw opening, tongue thrusting or global hypotonia w/o emotional trigger - Hypocretin deficiency in cerebral spinal fluid (causes cataplexy)
- Polysomnograpy shows shorter sleep latency
Other symptoms:
- Hypnagogic hallucinations: when falling asleep (visual or auditory)
- Sleep paralysis: can’t move or talk when falling asleep or waking up, terrifying
Nursing Management of Narcolepsy
Nursing assessment: sleep patterns
Nursing interventions:
- Tricyclic antidepressants: treat cataplexy
- Sodium Oxybate (Xyrem): for cataplexy and sleep, schedule 2
- CNS stimulants
- –methylphenidate (ritalin)
- –dextroamphetamine (dexadrine)
- –pemoline (cylert)
- –modafinil (provigil)
Patient education:
- Sleep deprivation makes cataplexy worse
- Develop strategies to manage symptoms
- –Naps
- –Activities while driving
- –Eating (sunflower seeds in the shell)
- –Windows open
- –Cool in car
- –Music, books on tape
- –Talking
Obstructive Sleep Apnea-Hypoapnea
Polysomnography of at least five obstructive apneas/hypopneas per hour of sleep and one of the following:
- Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses.
- Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep
Polysomnography of 15+ obstructive apneas and/or hypopneas per hour of sleep regardless of accompanying symptoms.
- Apnea, not breathing for 10 seconds to minutes
- Hypoapnea is excessively slow or shallow breathing
- Up to 20% US adults, 2/3 are obese
- 2-3 times more car wrecks
Patient Education for Obstructive Sleep Apnea
- Continuous positive airway pressure (CPAP)
- Weight loss strategies
- Changing to lateral sleeping position
- Oral appliance
What is the surgical treatment for Obstructive Sleep Apnea?
uvulopalatopharyngoplasty
–> CPAP machine
Central Sleep Apnea
Brain is not sending proper signals to the muscles that control breathing
No evidence of airway obstruction
- 5 or more episodes of apnea per hour
- Shortness of breath relieved by sitting up
- Insomnia or hypersomnia
- Difficulty concentrating
- Mood changes
- Morning headaches
- Snoring
Nursing Management of Central Sleep Apnea
- C-PAP
- Reduce opioid medications
- Treat medical conditions like heart failure which can cause it
- Oxygen
Restless Leg Disorder (RLD)
- –>intense desire to move legs accompanied by sensations of creeping, crawling, tingling, burning, or itching
- 3 X per week for 3 months
- Some antidepressants and anti-nausea drugs may worsen symptoms
- Not a side effect like akasthisia
- Treat if iron deficient
- Treat with Parkinson’s drugs (L-dopa), muscle relaxants, benzodiazepines, opioids
Patient Education for RLD
- Take pain relievers.
- Try baths and massages.
- Apply warm or cool packs.
- Try relaxation techniques, such as meditation or yoga.
- Establish good sleep hygiene.
- Exercise.
- Cut back on alcohol and tobacco.
Non-REM Sleep Arousal Disorder
- -> Recurrent episodes of incomplete awakening from sleep
- usually occurring during the first 1/3 of the major sleep episode accompanied by either sleep terrors or sleep walking
Interdisciplinary Treatment for sleepwalking
- Instruct to take precautions regarding possible sleepwalking episodes
- Benzodiazepines if potential for harm
- Hypnosis supplemented by psychotherapy
Sleep Walking
repeatedly walking about during sleep with a blank stare, minimally responsive to others and hard to awaken
Sleep Terrors
Recurrent abrupt terrified arousals from sleep usually with a panicky scream.
- intense fear and autonomic arousal such as mydriasis, tachycardia, rapid breathing, sweating.
- inconsolable.
Amnesia for the episodes
Little or no recall of terrorizing dream
Interdisciplinary Treatment for sleep terrors
- Cognitive and behavioral interventions: visualize different ending, stuffed animal, bedtime story
- Desensitization and relaxation techniques
- For PTSD use prazosin (Minipress)
Nightmare Disorder
Repeated occurrence of frightening dreams that fully awaken an individual occurring almost exclusively during REM sleep
-Cause unknown
Interdisciplinary treatment for nightmare disorder
- Psychotherapy aimed at conflict resolution
- Cognitive and behavioral interventions
- –> Imagery rehearsal therapy
- Prazosin (minipress)
Sleep Disorder Etiology
- Circadian rhythm disturbances
- The reticular activating system (RAS) in the brain maintains wakefulness. As the RAS cycle decreases, neurotranmitters that promote sleep take over.
- Histamine and Dopamine neurotransmitters-promote wakefulness
- Hypocretin: a neurotransmitter that regulates arousal, wakefulness. Cataplexy is caused by a lack of it.
- Adenosine and Gamma Aminobutyric Acid GABA- inhibitory neurotransmitters –> promote sleep
- Melatonin hormone derived from serotonin produced in response to darkness induces sleep
- Cortisol: stress hormone secreted by adrenal glands, levels vary throughout day lowest at night
- ->too high or too low at night messes up sleep
True or False: Obstructive sleep apnea is characterized by excessive sleepiness either during the day or for extended periods at night.
False.
- Obstructive sleep apnea involves snoring during sleep and episodes of sleep apnea that disrupt sleep and contribute to daytime sleepiness.
- -> Primary hypersomnia is characterized by excessive sleepiness either by daytime sleep episodes or sleeping extended periods at night.
