Sleep disorders premnath cnt

Non-organic sleep disorders...Dyssomnia, Parasomnia

1. NON-ORGANIC SLEEP DISORDERS Premnath R

2. THE WORST THINGS; TO BE IN BED AND SLEEP NOT, TO WANT FOR ONE WHO COMES NOT, TO TRY TO PLEASE AND PLEASE NOT

3. Physiology of sleep

4. Sleep can be regarded as a physiological reversible reduction of conscious awareness. It is observed in all mammals, all birds, and many reptiles, amphibians, and fish.

5. Sleep Accounts for nearly 1/3 rd of our lives A natural behavioural state characterized by: Reduction in voluntary motor activity Decreased response to stimulation (i.e., increased arousal threshold) Stereotyped posture

6. SLEEP ARCHITECTURE There are two types of sleep, non-rapid eye-movement (NREM) sleep and rapid eye-movement (REM) sleep. NREM sleep is divided into stages 1, 2, 3, and 4, representing a continuum of relative depth.

7. Entered through NREM REM sleep dominates last third of night REM sleep: 20-25% total sleep time

8. NREM In normal persons, NREM sleep is a peaceful state relative to waking. The pulse rate is typically slowed five to ten beats a minute below the level of restful waking and is very regular. Respiration is similarly affected, and blood pressure also tends to be low, with few minute-to-minute variations.

9. NREM Episodic, involuntary body movements are present in NREM sleep. Blood flow through most tissues, including cerebral blood flow, is slightly reduced.

10. REM Pulse, respiration, and blood pressure in humans are all high during REM sleep, much higher than during NREM sleep and often higher than during waking. Brain oxygen use increases during REM sleep. Thermoregulation is altered during REM sleep.

11. REM S leep v/s N on -REM S leep REM SLEEP NON- REM SLEEP Rapid conjugate eye movement Absence of eye movement Fluctuation of vital signs Stable vital signs Muscle twitching No muscle twitching Presence of dreams No dreams Originate in pontine reticular formation Originates in midline pontine and medullary nuclei ( raphe nuclei) Mediated by noradrenaline Mediated by serotonin

12. SLEEP CYCLE Sleep is divided into a 90 minute cycle of NREM sleep and REM sleep. This cycle is repeated 3-6 times during the night. Generally, a night of sleep begins with about 80 minutes of NREM and 10 minutes of REM sleep. There is more REM sleep on towards morning, which explains why when you awaken in the morning, you generally awaken from a dream.

13. Wake Up !!

14. NON-ORGANIC SLEEP DISORDERS

15. Sleep disorders are divided into subtypes; Dyssomnias Insomnia Hypersomnia Disorders of sleep-wake schedule Parasomnias Stage IV disorders Other disorders

16. Dyssomnias They are primarily psychogenic conditions in which the predominant disturbance is in the amount, quality or timing of sleep is due to emotional causes.

17. Parasomnias They are abnormal episodic events occurring during sleep; in childhood, these are related mainly to the child’s development, while in adulthood, they are primarily psychogenic.

18. DYSSOMNIAS

19. INSOMNIA It refer to the disorder of initiation and maintenance of sleep. This includes frequent awakening during night and early morning awakening.

20. Etiology Medical illness Alcohol and drug abuse Psychiatric disorders Social causes Behavioral factors

21. Clinical features of insomnia Individuals describe themselves as feeling tense, anxious, worried, or depressed at bedtime and as though their thoughts are racing They frequently ruminate over getting enough sleep, personal problems, health status and even death. Use of alcohol and other substances.

22. In the morning, they frequently report feeling physically and mentally tired; during the day, they characteristically feel depressed, worried, tense and preoccupied with themselves. Difficulty in falling asleep at night or getting back to sleep after waking during night.

23. Sleep is light, fragmented or unrefreshing Need to take something in order to get sleep Sleepiness and low energy during the day.

24. TREATMENT Thorough medical and psychiatric assessment Polysomnography Treatment of underlying physical/psychiatric disorder Withdrawal of current medications Benzodiazepines for short periods Non-benzodiazepine hypnotic Opioids Melatonin Low doses of atypical antipsychotics

25. Non-pharmacologic management Progressive relaxation Autosuggestion Meditation, yoga Stimulus control therapy Do not use bed for reading or chatting-go to bed for sleep only

26. Sleep hygiene Sleep as much as needed to feel rested; do not oversleep Exercise regularly Avoid forcing to sleep Keep a regular sleep and awakening schedule Avoid caffeinated drink at bedtime Avoid ‘night caps’ Do not go to bed hungry Adjust room environment Do not go to bed with worries Back rub, warm milk and relaxation exercises.

27. HYPERSOMNIA

28. It is also known as D isorder O f E xcessive S omnolence ( DOES )

29. Hypersomnia is characterised by recurrent episodes of excessive daytime sleepiness or prolonged night-time sleep. It includes sleep attacks during daytime, sleep drunkenness (person needs much more time to awaken, and during this period he is confused or disoriented).

30. Etiology Narcolepsy(Excessive daytime sleepiness characterized by sleep attacks, cataplexy, sleep paralysis and hypnagogic hallucinations) Sleep apnoea Kleine –Levin syndrome ( Periodic episodes of hypersomnia )

31. Dysfunctions in autonomic nervous system Drug or alcohol abuse Certain medications Medical conditions like multiple sclerosis, depression, encephalitis, epilepsy, obesity etc.

32. Clinical features Persons are compelled to take nap during day at inappropriate times Disoriented sometimes Anxiety, increased irritation, decreased energy, restlessness, slow thinking, slow speech, anorexia, hallucinations and memory difficulty Poor social, occupational and family functioning

33. TREATMENT Symptomatic treatment Changes in behavior and diet Avoiding alcohol Stimulants like amphetamine, methylphenidate and modafinil Clonidine , levodopa , bromocriptine Antidepressants, MAO inhibitors

34. DISORDERS OF SLEEP-WAKE SCHEDULE

35. It is characterized by a disturbance in the timing of sleep. The person with this disorder is not able to sleep when he wishes to, although at other times he is able to sleep adequately.

36. It is a form of dyssomnia caused by a conflict between a person’s circadian rhythm and the socio-economic demands of society, such as work and travel schedules.

37. Causes Jet lag or rapid change of time zone Work shift from day to night Unusual sleep phases (owls and larks)

38. PARASOMNIAS

39. STAGE IV SLEEP DISORDERS

40. SOMNAMBULISM Sleep-walking or somnambulism is a state of altered consciousness in which phenomena of sleep and wakefulness are combined.

41. During sleepwalking episode, the individual arises from bed, usually during first third of nocturnal sleep, and walks about, exhibiting low levels of awareness, reactivity, and motor skill. Most often he will return quietly to bed, either unaided or with a gentle assistance. Upon awakening, there will be no recall of event.

42. NIGHT TERRORS Night terror or sleep terror or pavor nocturnus , is a parasomnia disorder that predominantly affects children, causing feelings of dread or terror. Children usually described the experience as “bolting upright” with their eyes wide open, with a look of fear and panic, and will often scream.

43. SLEEP-RELATED ENURESIS Sleep related enuresis or bedwetting, involves urinating during sleep and occurs most often during deep sleep. It is frequently the result of a failure of brain to engage in appropriate “alarming” of bathroom needs during sleep before urination occurs.

44. BRUXISM It is characterized by the grinding of the teeth and typically includes the clenching of the jaw. While bruxism may be a diurnal or nocturnal activity, it is bruxism during sleep that causes majority of health issues and can even occur during short naps.

45. SLEEP-TALKING (SOMNILOQUY) It refers to talking aloud in one’s sleep. It can be quite loud, ranging from simple sounds to long speeches, and can occur many times during sleep. Listeners may or may not be able to understand what the person is saying .

46. OTHER SLEEP DISORDERS

47. NOCTURNAL ANGINA NOCTURNAL ASTHMA NOCTURNAL SEIZURES SLEEP PARALYSIS OBSTRUCTIVE SLEEP APNEA SYNDROME (OSAS) PERIODIC LIMB MOVEMENT DISORDER RESTLESS LEG SYNDROME

48. NURSING MANAGEMENT Assessment Usual activities in the hour before sleep Sleep latency Number and perceived cause of awakenings Regularity of sleep pattern Consistency of rising time Frequency and duration of naps Ease of falling asleep in places other than the usual bedroom Daily caffeine intake Use of alcohol, sleeping pills and other medications

49. Objective data may include visible signs of fatigue and lack of sleep, such as circles under the eyes, lack of coordination, drowsiness and irritability.

50. Diagnosis :- Disturbed sleep pattern related to (specific medical condition),use of or withdrawal from substances, anxiety or depression, circadian rhythm disruptions, familial patterns Interventions :- To promote sleep: Encourage activities that prepare one for sleep: soft music, relaxation exercise or warm bath Discourage strenuous exercise within one hour of bed time

51. Control intake of caffeine containing substances within 4 hours of bed time Provide a high carbohydrate snack before bed time Keep the temperature of the room between 68-72 degree F Instruct the client not to use alcoholic beverages to relax Discourage smoking and other tobacco products near sleep time Discourage day time napping Individuals with chronic insomnia should use sleeping medication judiciously

52. Diagnosis :- Risk of injury related to excessive sleeping, sleep terrors, or sleep walking Interventions :- Keep the side rails of the bed up Keep the bed in a low position Equip the bed with a bell that is activated when the bed is excited Keep a night light on and arrange the furniture in the bedroom in a manner that promote safety Administer drug therapy as ordered.

53. Diagnosis :- Disturbed sleep pattern related to enuresis as evidenced by frequent arousal of the child from bed. Interventions :- Assess for anatomical or urinary problems, if any. lnsist the parents to make the child void before bedtime ЕхрІаі n about the availability of bedwetting alarms Teach bladder stretching exercises Administer medications as per physician's order.

54. Thank you….