Sleep pattern and its disturbances

sleep pattern and its disturbances

1. SLEEP PATTERN AND ITS DISTURBANCES -by Shweta Sharma m.sc. nursing I year AIIMS,Jodhpur

2. OBJECTIVES The group will be able to:  Define sleep.  Describe physiology of sleep.  Enumerate the stages of sleep.  Explain the sleep requirements and pattern.  Describe the sleep cycle.  List and explain the Lifespan considerations growth via.  Understand and enumerate the common sleep disorders or disturbances.  Enlist and describe the assessment, nursing diagnosis and management of sleep.

3. DEFINITION Sleep is a condition of body and mind which typically recurs for several hours every night, in which the nervous system is inactive, the eyes closed, the postural muscles relaxed, and consciousness practically suspended. It is a periodic state of rest accompanied by varying degree of unconsciousness and relative inactivity.

4. SOME FACTS ABOUT SLEEP •Nearly 1/3 RD of our life is spent in sleep. •The record for the longest period without sleep is 18 days, 21 hours, 40 minutes during a rocking chair marathon. The record holder reported hallucinations, paranoia, blurred vision, slurred speech and memory and concentration lapses. •A new baby typically results in 400-750 hours lost sleep for parents in the first year. • 17 hours of sustained wakefulness leads to a decrease in performance equivalent to a blood alcohol-level of 0.05%. •Experts say one of the most alluring sleep distractions is the 24-hour accessibility of the internet.

5. FACTORS AFFECTING SLEEP •Environmental factors (e.g. ventilation) •Psychological and emotional stress •Physical illness (e.g. nausea, mood disorders, breathing difficulty, pain) •Drugs and substances (e.g. Tryptophan) •Lifestyle (e.g. daily routines, exercises) Usual sleep patterns •Excessive daytime sleepiness •Sound •Exercise and fatigue •Food and caloric intake •Smoking and alcohol

6. FUNCTIONS OF SLEEP •It is a time of restoration and preparation for the next period of wakefulness. •During NREM stage 4 body releases human growth hormone for the repair and renewal of epithelial and specialized cells such as brain cells. • Protein synthesis and cell division for the renewal of tissues occur during rest and sleep. •REM sleep appears to be important for cognitive restoration.

7. NORMAL SLEEP REQUIREMENTS •Infants -16 Hours /Day •Toddlers -12 Hours /Day •Pre-schoolers -11 Hours /Day •Schoolers- 9 to 10 hours /day •Adolescents -8 to 9 hours /day •Adults- 6 to 8 hours /day

8. CIRCADIAN CYCLE People experience cyclical rhythms as part of their everyday life. The most familiar rhythm is the 24 hr , day-night cycle known as the diurnal or circadian rhythm (derived from Latin: circa, “about,” and dies, “day”). Circadian rhythms influence the pattern of major biological and behavioural functioNs .

9. PHYSIOLOGY OF SLEEP THERE ARE Two stages of sleep: 1. Rapid eye movement (REM) sleep or d- sleep (desynchronized sleep or dreaming sleep) or active sleep. (comprising about 20-25% of total sleep) 2. Non-rapid eye movement sleep (NREM), or s- sleep (synchronized sleep) or quite sleep or orthodox sleep. (comprising about 75% of total sleep)

10. SLEEP CYCLE

11. NREM STAGE I Includes lightest level of sleep Stage lasts a few minutes Decreased physiological activity begins with gradual fall in vital signs and metabolism Sensory stimuli such as noise easily arouse sleeper If awakened, person feels as though daydreaming has occurred

12. NREM STAGE II Includes period of sound sleep Relaxation progresses Arousal is still relatively easy Stage lasts 10 – 20 minutes Body functions continue to slow

13. NREM STAGE III It involves initial stages of deep sleep Sleeper is difficult to arouse and rarely moves Muscles are completely relaxed Vital signs decline , but remain regular Stage lasts 15 – 30 minutes

14. NREM STAGE IV It is deepest stage of sleep It is very difficult to arouse sleeper If sleep loss has occurred, sleeper will spend considerable portion of night in this stage. Vital signs are significantly lower than during waking hours Stage lasts approximately 15 – 30 minutes. Sleep walking and enuresis sometimes occur

15. REM SLEEP •It is more difficult to arouse a person during REM sleep than during NREM sleep. •Breathing becomes more rapid, irregular and shallow, eyes jerk rapidly and limb muscles are temporarily paralyzed. •Heart rate increases, blood pressure rises and the body loses some of the ability to regulate its temperature. •This is the time when most dreams occur, and, if awoken during REM sleep, a person can remember the dreams. Most people experience three to five intervals of REM sleep each night.

16. 8 Common Sleep Disorders INSOMNIA SLEEP APNEA RESTLESS LEG SYNDROME REM SLEEP BEHAVIOR DISORDER NARCOLEPSY SLEEPWALKING SLEEP TERRORS BRUXISM (TEETH GRINDING)

17. INSOMNIA Characterized by difficulty falling asleep, staying asleep, or getting good quality sleep. Causes- Stress Traumatic events Anxiety or physiological causes such as caffeine or alcohol. Symptoms- daytime sleepiness, lack of energy and trouble learning. Treatment- Cognitive behavioral therapy and/or medication are often prescribed.

18. SLEEP APNEA Sleep disorder that occurs when a person’s breathing is interrupted during sleep. They stop breathing repeatedly during their sleep, sometimes hundreds of times. typically when normal breathing starts again, it starts with a loud snort or a choking sound. There are two types of sleep apnea: Obstructive Sleep Apnea (OSA) Central Sleep Apnea (CSA)

19. Treatment: CPAP (continuous positive airway pressure) machine, which keeps a person’s throat open via a steady stream of air.

20. RESTLESS LEG SYNDROME Restless legs syndrome (RLS) is a condition that causes an uncontrollable urge to move your legs, usually because of an uncomfortable sensation. It typically happens in the evening or nighttime hours when you're sitting or lying down. Symptoms- urge to move the legs Sensations that begin after rest Relief with movement Worsening of symptoms in the evening Night-time leg twitching

21. Treatment: Regular exercise; reduction in caffeine and alcohol. For severe cases, medication can be prescribed.

22. REM SLEEP BEHAVIOR DISORDER In a person with REM sleep behavior disorder (RBD), the paralysis that normally occurs during REM sleep is incomplete or absent, allowing the person to "act out" his or her dreams. RBD is characterized by the acting out of dreams that are vivid, intense, and violent. Dream-enacting behaviors include talking, yelling, punching, kicking, sitting, jumping from bed, arm flailing, and grabbing.

23. Cause: The mechanism in the brain that prevents motor movement while sleeping doesn’t function properly. Treatment: Medication is often advised.

24. NARCOLEPSY Narcolepsy is a chronic, neurological sleep disorder that causes excessive sleepiness and frequent daytime sleep attacks. The exact cause is unknown but it is linked to reduced amounts of a protein made in the brain called hypocretin. Symptoms- Sleep paralysis – A person cannot move as they start falling asleep or when they wake up. It may last 15 min. This can be a frightening experience for the patient.

25. Cataplexy – Sudden loss of muscle tone when awake that makes you unable to move, most of these attacks last less than 30 seconds and can sometimes be missed. The head will suddenly fall forward, jaw becomes loose, and knees become weak. In severe cases, a person may fall and stay paralyzed for several minutes. Treatment: Medication is often advised.

26. SLEEPWALKING/somnambulism IT is a behaviour in which a child appears to wake up during the night and walk or do other activities without any memory of having engaged in the activities. Sleepwalking tends to occur within an hour or two of falling asleep and may last on average between 5 and 15 minutes. Causes - Hereditary (i.e., the condition may run in families) •Interrupted sleep or inefficient sleep (including from disorders like sleep apnea) •Illness or fever •Stress, anxiety •Going to bed with full bladder •Noisy sleep environment/different sleep environment

27. Symptoms- •Getting out of bed and walking around. •Sitting up in bed and repeating movements, such as rubbing eyes or tugging on pyjamas. •Looking dazed (sleepwalkers' eyes are open but they do not see the same way they do when they are fully awake). •Not responding when spoken to. •Being difficult to wake up. •Sleep talking. •Urinating in undesirable places. Treatment: Reducing liquids near bedtime, A quiet sleep environment and maintaining a regular sleep schedule

28. SLEEP TERRORS Sleep terrors/night terrors are episodes of screaming, intense fear and flailing while still asleep. A sleep terror episode usually lasts from seconds to a few minutes, but episodes may last longer. During a sleep terror episode, a person may: •Begin with a frightening scream or shout •Sweat, breathe heavily, and have a racing pulse, flushed face and dilated pupils •Kick and thrash •Be inconsolable •Have no or little memory of the event the next morning •Possibly, get out of bed and run around the house or have aggressive behaviour if blocked or restrained

29. Causes- •Sleep deprivation and extreme tiredness •Stress •Sleep schedule disruptions, travel or sleep interruptions •Fever Treatment: Improve sleep environment, medication is given if the terrors are extreme.

30. BRUXISM (TEETH GRINDING) Bruxism is a condition in which you grind or clench your teeth during sleep. Causes: Most experts blame excessive stress and anxiety. Symptoms : Headaches and/or a sore jaw when waking in the morning. Complaints from annoyed bedmates. Treatment: Avoiding chewing any items that aren’t food, as it trains the jaw to clench. Most people with bruxism end up getting fitted with a mouth guard that can be provided by a dentist.

31. TREATMENT OF SLEEP DISORDERS 1 . Keep a sleep diary. 2. Improve sleep hygiene and daytime habits - Keep a regular sleep schedule - Set aside enough time for sleep - Make sure that the bedroom is dark, cool and quiet - Turn off TV, smartphone and computer diary.

32. 3. Eat right and get regular exercise - Stay away from big meals at night - Avoid alcohol before bed - Cut down on caffeine - Avoid drinking too many liquids in the evening - Quit smoking

33. 4. Get anxiety and stress in check -A relaxing bedtime routine -Abdominal breathing -Progressive muscle relaxation 5. Sleeping Pills -Only take a sleeping pill when there is enough time to get a full 7 to 8 hours of sleep. -Pay careful attention to the potential side effects, dosage instructions.

34. -Never mix alcohol and sleeping pills. -Never drive a car or operate machinery after taking a sleeping pill. Examples of sleeping pills- Antihistamines: Diphenhydramine Benzodiazepine: Estazolam Non-benzodiazepine: Eszopiclone Antidepressants: Imipramine, Amitriptyline

35. NURSING MANAGEMENT OF PATIENTS WITH SLEEP DISORDERS ASSESSMENT •Usual sleep •Time of sleeping and waking •Number of hours of undisturbed sleep •Quality of sleep •Number of naps •Effect on daily chores •Energy level •Means of relaxing before bedtime •Bedtime rituals •Sleep environment •Pharmacological aids •Nature of sleep disturbance •Onset •Cause •Severity •Symptoms •Interventions attempted and its result

36. NURSING DIAGNOSIS 1. Disturbed sleep pattern related to (specific medical condition); use of, or withdrawal from, substances; anxiety or depression; circadian rhythm disruption; familial patterns; evidenced by insomnia, hypersomnia, nightmares, sleep terrors, or sleepwalking. Goal - Client will be able to achieve adequate, uninterrupted sleep. 2. Risk for injury related to excessive sleepiness, sleep tremors or sleepwalking. Goal - Client will be free from risk of injury.

37. RESEARCH ARTICLES Insomnia and its associated factors: A cross-sectional study in rural adults of North India A community-based cross-sectional study was conducted by Rashmi Kumari et al on 405 rural adults of North India to determine the prevalence of insomnia in rural adults and to find out various associated risk factors and comorbidities. A 13-item self-reported insomnia symptom questionnaire was used to determine the prevalence of insomnia. Chi-square test was used to find out the association of various factors. The prevalence of insomnia was found to be 12.8%. Occupation, type of family, and socioeconomic status emerged to be significant determinants of insomnia. The presence of diabetes, chronic respiratory disorders, thyroid disorders, and any form of stress was significantly associated with higher prevalence of insomnia (P < 0.05 ). The study concluded that Insomnia is a common sleep disorder which is many times missed by a primary care physician until/unless asked for. Health-care professionals should assess the sleep pattern of every patient and give adequate counselling or treatment for the same.

38. 2.Sleep Quality and Quantity in Intensive Care Unit Patients: A Cross-sectional Study. A cross-sectional study was performed by Naik RD et al in medical ICU of a tertiary care hospital. A total of 32 patients admitted to the ICU for at least 24 h were selected. A 72-h actigraphy was done followed by a subjective assessment of sleep quality by the Richards-Campbell Sleep Questionnaire (RCSQ) . Patient's perspective of sleep quality and quantity and possible risk factors for poor sleep were recorded. Poor sleep was found in 15 out of the 32 patients (47%). The prevalence of poor sleep was higher among patients on mechanical ventilation. Patients with poor sleep had higher age, acute physiology, and worse actigraphy parameters. Only 55.63% of total sleep time was in the night. All patients had discomfort from indwelling catheters and suctioning of endotracheal tubes. All patients suggested that there be a minimum interruption in the sleep for interventions or medications . The study concluded that there is a high prevalence of poor sleep among patients admitted to the ICU. There is a need to minimize untimely interventions and design non-pharmacological techniques to allow patients to sleep comfortably.

39. THANK YOU FOR CONCENTRATING WITHOUT FALLING ASLEEP!!!