Sleep disorders

-

1. Sleep disorders

2. What is sleep? Sleep can be defined as a normal state of altered consciousness during which the body rests ; It is characterized by decreased responsiveness to the environment, and a person can be aroused from it by external stimuli.

3. NORMAL SLEEP REQUIREMENTS & PATTERNS Sleep duration and quality vary among persons of all age groups Infants - 16 Hours / Day Toddlers - 12 Hours / Day Preschoolers - 11 Hours / Day Schoolers - 9 - 10 hours / day Adolescents - 8 – 9 hours / day Adults - 6 – 8 hours /day

4. Phases of sleep 1.Slow-wave sleep ( NonREM ): Phase 1-4 2. Paradoxical/desynchronized sleep (REM- Rapid Eye Movements )

5. Slow-Wave ( nonREM ) Sleep Entrance to sleep • Takes appr . 90 minutes with 5-20 minutes intervals • Peripheral vessel tone and body functions decrease • Muscle tone decreases • 10-30% decrease in blood pressure, respiration rate and basal metabolism • Spinal reflexes can be elicited but stretch (deep tendon) reflexes are absent.

6. Slow-Wave ( nonREM ) Sleep Dreams cannot be remembered Theta and delta waves in EEG Duration and frequency decrease with age Has 4 different stages

7. Phase-1 nonREM Transition period between wakefulness and sleep; takes approximately 1-15 minutes. Eyes closed and relaxed... Light sleep, hallucination-like visions... α ( alpha) waves weaken, slower θ ( delta) waves emerge .

8. Phase-2 nonREM • First stage of the real sleep; takes about 20 minutes ... • Sleep spindles: 12-14 Hz sharp waves appear for 1-2 seconds . • Slow eye movements . • Hard to awaken . • Fragments of dreams may present

9. Phase-3 nonREM • Half-way deep sleep • Body temperature and blood pressure decreases • Harder to awaken • Low frequency δ (theta) waves • Sleep spindles are decreased • No slow eye movements

10. Phase-4 nonREM • Deepest sleep; takes about 30-40 mins . • δ ( theta) waves predominate • Most reflexes are intact; muscle tone slightly decreased • Sleep-walking; sleep-talking; snoring and bedwetting generally occurs in this stage.

11. Sleep Stages-EEG

12. REM Sleep • 5-30 minutes with 90 minute-intervals • Active dreaming (dreams are remembered) • Active body movements • More difficult to wake up with sensory stimulations • Waking up in the morning generally coincides with the last REM period. • Decrease in muscle tone (except respiratory and eye muscles) • Irregularity in heart and respiration rate. • 20% increase in brain metabolism

13. REM Sleep • Atonia in neck muscles • Rapid eye movements • Beta waves in EEG = paradoxical sleep, =desynchronized sleep

14. Physiological effects of sleep Sleep, • Helps the maintenance of normal activity level of CNS. • Helps to maintain the “balance” between the different parts of the CNS. • Increased sympathetic activity and muscle tone during the awake period decreases with sleep . Body temperature drops, energy loss decreases • Growth hormone and cortisol secretion increases • Phosphate excretion from kidneys increase • Melatonin secretion increases • Skin and tissue repair occurs

15. FACTORS AFFECTING SLEEP Physical illness ( eg . Nausea, mood disorders, breathing difficulty, pain ) Drugs and substances Lifestyle ( eg . Daily routines, exercises ) Usual sleep patterns and excessive daytime sleepiness Emotional stress Environment ( ventilation ) Sound Exercise and fatigue Food and caloric intake

16. Sleep disorders Dyssomnias Insomnia Hypersomnia Disorders of sleep –wake schedule 2. Parasomnias Stage IV disorders Other disorders

17. Insomnia Insomnia refers to disorder of initiation and maintenance of sleep. This includes frequent awakening during the night and early morning awakening.

18. Causes of Insomnia Medical illness: Any painful illness Heart disease Respiratory disease Brainstem lesions Delirium Musculo-skeletal disease Old age

19. Alcohol and drug use: Chronic alcoholism Delirium tremens Amphetamines or other stimulants Psychiatric disorders: Mania Major depression Dysthymia Schizophrenia and other psychosis Anxiety disorders

20. Social causes: Financial loss Separation or divorce Death of a close relative or spouse Retirement Stressful life situations Behavioural causes: Naps during the day Irregular sleeping hours Lack of physical exercise Excessive intake of beverages like coffee. Disturbing environment

21. Treatment A through medical and psychiatric assessment to identify the cause. Polysomnography : ( also called a sleep study, is a test used to diagnose sleep disorders.   Polysomnography  records brain waves, the oxygen level in blood, heart rate and breathing, as well as eye and leg movements during the study) Treat underlying cause Withdrawal of current medications if any Transient insomnia can be treated initially with hypnosis.

22. Non pharmacologic treatment for insomnia Progressive muscle relaxation Autosuggestion Meditation, yoga Stimulus control therapy: - Do not use the bed for reading and chatting. - Go to bed only for sleep.

23. Autosuggestion Autosuggestion are positive words and sentences use repeatedly to change ones own perception. It is an effective method for ending bad habits. Techniques: As you lie on your back in bed, rest your hands gently on your chest. Choose a positive suggestion to give yourself -- something short and direct. Example: "Tonight I will sleep deeply and peacefully... and I'll wake up tomorrow morning feeling great." Repeat the suggestion 10 times slowly in your mind -- or out loud, if doing so won't disturb a bedmate. Each time you repeat the suggestion, gently press your fingers into your chest. This helps "anchor" the suggestion in your body. Keep your eyes closed at all times.

24. Sleep hygiene Regular, daily physical exercise in the evening. Avoid fluid intake and heavy meals before bedtime. Avoid caffeine intake before sleeping hours. Avoid reading or watching television while in bed. Take warm milk before bedtime. Sleep in comfortable position.

25. Hypersomnia Hypersomnia is a disorder of excessive somnolence (DOES). It includes excessive day time sleepiness, sleep attacks during day time, sleep drunkenness ( Confusional arousals, also known as  sleep drunkenness   , consist of mental confusion or confusional behavior during or following arousals from sleep) .

26. Causes of hypersomnia Narcolepsy Sleep apnea:Repeated episodes of apnea during sleep. Kleine -Levin syndrome:Periodic episodes of hypersomnia. Not getting enough sleep at night (sleep deprivation)  Being overweight  Drug or alcohol abuse A head injury or a neurological disease, such as multiple sclerosis Prescription drugs, such as tranquilizers  Genetics (having a relative with hypersomnia)

27. Narcolepsy : Excessive daytime sleepiness characterized by: Sleep attacks Cataplexy - sudden decrease or loss of muscle tone, may lead to sleep. Sleep paralysis – it occurs either at awakening in the morning or at sleep onset. The person is conscious but unable to move his body. Hypnogogic hallucination - hallucination occur at the transition from wakefulness to sleep

28. Symptoms of hypersomnia : Feeling unusually tired all the time The need for daytime naps Feeling drowsy, despite sleeping and napping – not refreshed on waking up Difficulty thinking and making decisions – the mind feels ‘foggy’ Apathy Memory or concentration difficulties An increased risk of accidents, especially motor vehicle accidents.

29. Self-help strategies Avoid cigarettes, alcohol and caffeinated drinks near bedtime. Follow a relaxation routine to prevent night-time anxiety. Exercise regularly and maintain a normal weight for your height. Eat a well-balanced diet to prevent nutritional deficiencies. If possible, change environment to reduce disturbances – for example, don’t watch television in the bedroom. Be comfortable; make sure you don’t overheat or feel too cold in bed. Have a regular sleeping routine so that the body ‘knows’ it is time to sleep. Only go to bed when you feel sleepy .

30. Disorder of sleep- wake schedule: The person is not able to sleep when he wishes to, although at other time he is able to sleep adequately. Causes: Work shifts Unusual sleep phases

31. Stage IV sleep disorders Sleep walking ( somnobulism ) Night terrors :   episodes of screaming, intense fear during sleep . Sleep related enuresis Bruxism (tooth grinding) Sleep talking ( Somniloquy )

32. Sleep-walking: T his is a common abnormal behaviour during sleep. The person may walk around the house while still asleep. Sleep walking tends to affect children more than adults.

33. Other sleep disorders Nocturnal angina: Angina occurring at night. Rare condition.   Nocturnal Asthma: symptoms like chest tightness, shortness of breath,  cough , and wheezing at night, can make sleep impossible and leave you feeling tired and irritable during the day.  Nocturnal Seizures: Nocturnal epilepsy is a seizure disorder in which seizures occur only while sleeping. Several common forms of epilepsy, including frontal lobe epilepsy, can manifest in a nocturnal state.

34. Nursing diagnosis Disturbed sleep pattern related to lack of cues for day- night schedule; manifested by erratic sleep schedule, frequent naps and nocturnal wandering

35. Nursing interventions offer meals at regular times, corresponding to client’s previous pattern provide active meaningful activities during daytime hours, including exposure to natural light, and an outdoor environment when possible monitor frequency and duration of naps create an individualized bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom and settling a routine Do not wake even if incontinent. Change and assist the client to the bathroom when he or she spontaneously awakens if turning or other care is necessary, try to provide for periods up to 2 hours of undisturbed sleep time whenever possible