Sleep-Wake Disorders

Question 1

Sleep

Answer 1

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

Question 2

Sleep Needs

Answer 2

Newborns: 17-18 hours
Preadolescents: 10 hours
Adolescents: 9 hours
Adults/Elderly: 8 hours

Question 3

Sleep-wake cycle

Answer 3

endogenously generated rhythm close to 24 hours, synchronized with the day/night cycle

Question 4

sleep latency

Answer 4

bedtime to the beginning of sleep

Question 5

sleep architecture

Answer 5

pattern of non-REM and REM in a 90 to 110 minute cycle

Question 6

sleep efficiency

Answer 6

ratio of total sleep time to nocturnal time in bed

Question 7

Biphasic Stage of Sleep

Answer 7

1. 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)
2. Rapid eye movement REM
   - Deep sleep; vivid dreaming

Question 8

Sleep Disorders Summary

Answer 8

• 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

Question 9

Circadian Rhythm

Answer 9

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

Question 10

Circadian Rhythm - 24 hour cycle

Answer 10

Effect on hormone releases

• -> ex. body temp lowest early am
• -> highest levels mid evening: temp, manual dexterity, reaction time, simple recognition, muscle tone

Question 11

Circadian Rhythm Sleep Disorders

Answer 11

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)

Question 12

Circadian Rhythm: Sleep Disorders

Answer 12

1. Delayed sleep phase type (“night owls”)
2. Advanced sleep phase type (early risers, can’t stay awake in PM)
3. Irregular sleep–wake type
4. Shift work type
   - 20% of US workforce, sleep shorter/poorer
5. Jet lag type- not in DSM 5 (traveling east = harder to reset to earlier time zone)

Question 13

Circadian Rhythm: Interdisciplinary Treatment

Answer 13

1. Melatonin
2. Chronotherapy (delaying sleep time each night 3 hrs until target time is reached)
3. Luminotherapy (more light during day to keep awake)
4. Chronopharmaco-therapy (using stimulants to keep you awake, short acting, ex. caffeine)

Question 14

Insomnia

Answer 14

• 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

Question 15

Sleep Disorder Assessment

Answer 15

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

Question 16

Insomnia Nursing Management

Answer 16

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

Question 17

Insomnia Evidence-Based Treatments: Long Term

Answer 17

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

Question 18

Insomnia Evidence-Based Treatments: Short Term

Answer 18

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

Question 19

Hypersomnolence Disorder

Answer 19

EXCESSIVE SLEEPINESS at least three times a week for at least 3 months.

Sleep at least 7 hours at night and at least one:

1. Recurrent periods of sleep in same day
2. Over 9 hours non-restorative sleep
3. 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)

Question 20

How to treat Hypersomnolence Disorder?

Answer 20

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

Question 21

Narcolepsy

Answer 21

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:

1. 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
2. Hypocretin deficiency in cerebral spinal fluid (causes cataplexy)
3. Polysomnograpy shows shorter sleep latency

Other symptoms:

1. Hypnagogic hallucinations: when falling asleep (visual or auditory)
2. Sleep paralysis: can’t move or talk when falling asleep or waking up, terrifying

Question 22

Nursing Management of Narcolepsy

Answer 22

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

Question 23

Obstructive Sleep Apnea-Hypoapnea

Answer 23

Polysomnography of at least five obstructive apneas/hypopneas per hour of sleep and one of the following:

1. Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses.
2. 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

Question 24

Patient Education for Obstructive Sleep Apnea

Answer 24

• Continuous positive airway pressure (CPAP)
• Weight loss strategies
• Changing to lateral sleeping position
• Oral appliance

Question 25

What is the surgical treatment for Obstructive Sleep Apnea?

Answer 25

uvulopalatopharyngoplasty | --> CPAP machine

Question 26

Central Sleep Apnea

Answer 26

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

Question 27

Nursing Management of Central Sleep Apnea

Answer 27

- C-PAP - Reduce opioid medications - Treat medical conditions like heart failure which can cause it - Oxygen

Question 28

Restless Leg Disorder (RLD)

Answer 28

- -->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

Question 29

Patient Education for RLD

Answer 29

- 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.

Question 30

Non-REM Sleep Arousal Disorder

Answer 30

- -> 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

Question 31

Interdisciplinary Treatment for sleepwalking

Answer 31

- Instruct to take precautions regarding possible sleepwalking episodes - Benzodiazepines if potential for harm - Hypnosis supplemented by psychotherapy

Question 32

Sleep Walking

Answer 32

repeatedly walking about during sleep with a blank stare, minimally responsive to others and hard to awaken

Question 33

Sleep Terrors

Answer 33

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

Question 34

Interdisciplinary Treatment for sleep terrors

Answer 34

- Cognitive and behavioral interventions: visualize different ending, stuffed animal, bedtime story - Desensitization and relaxation techniques - For PTSD use prazosin (Minipress)

Question 35

Nightmare Disorder

Answer 35

Repeated occurrence of frightening dreams that fully awaken an individual occurring almost exclusively during REM sleep -Cause unknown

Question 36

Interdisciplinary treatment for nightmare disorder

Answer 36

- Psychotherapy aimed at conflict resolution - Cognitive and behavioral interventions - --> Imagery rehearsal therapy - Prazosin (minipress)

Question 37

Sleep Disorder Etiology

Answer 37

- 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

Question 38

True or False: Obstructive sleep apnea is characterized by excessive sleepiness either during the day or for extended periods at night.

Answer 38

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.