Sleep and Sleep Disorders

KEY POINTS
SLEEP
Sleep is a state during which an individual lacks conscious awareness of
environmental surroundings and from which he or she can be easily aroused. It is a basic,
dynamic, highly organized, and complex behavior that is essential for normal functioning
and survival.
Most adults require 7 to 8 hours of sleep within a 24-hour period.
Sleep duration equal to or less than 6 hours and more than or equal to 9 hours in
adults is associated with higher illness rates and early death.

PHYSIOLOGIC SLEEP MECHANISMS

The central nervous system (CNS) controls the cyclic changes between waking
and sleeping.
Wake behavior is associated with an activated cortical brain wave pattern. Various
neurotransmitters and neuropeptides (glutamate, acetylcholine, noradrenaline, dopamine,
histamine, serotonin, orexin) are involved in wake behavior.
Sleep behavior is regulated by a variety of neurologic structures. Sleep-promoting
neurotransmitters and peptides include GABA, galanin, melatonin, adenosine,
somatostatin, growth-hormonereleasing hormone, and proinflammatory cytokines.
Sleep architecture: Based on polysomnography (PSG) recordings, sleep is divided
into rapid eye movement (REM) and nonrapid eye movement (NREM) sleep.

INSUFFICIENT SLEEP
Sleep disturbances resulting in insufficient sleep are associated with poor sleep
quality and with health problems such as obesity.
Sleep loss alters immune function, reduces body temperature, and decreases
growth hormone and prolactin.
Fragmented or broken sleep is common in patients with medical and psychiatric
disorders.

SLEEP DISTURBANCES IN THE HOSPITAL

Hospitalization, especially in the intensive care unit (ICU), is associated with
sleep loss and sleep disturbances.
Environmental factors, medications, illness severity, and mechanical ventilation
contribute to poor sleep.
You have a critical role in creating an environment conducive to sleep, such as
scheduling activities, turning off lights, and reducing noise.

INSOMNIA
The most common sleep disorder is insomnia.
Behaviors, lifestyle, diet, and medications contribute to acute and chronic
insomnia.
 Symptoms of insomnia include difficulty falling asleep (long sleep latency),
frequent awakenings (fragmented sleep), prolonged nighttime awakenings or awakening
too early and not being able to fall back to sleep, and feeling unrefreshed on awakening.
The diagnosis of insomnia is made based on symptom self-report and on an
evaluation of a 1- or 2-week sleep log or diary completed by the patient.
Treatments are oriented toward symptom management and behavior change.
Many individuals with insomnia self-medicate with over-the-counter sleep aids.
Sleep hygiene is recommended as a first-line therapy for chronic insomnia.
Hypnotic and sedative medications are effective for improving sleep, but the
benefits for improving daytime functioning are less certain.
Nonpharmacologic therapies for sleep include cognitive behavioral therapy-
insomnia (CBT-I), yoga, and stress management.

NURSING MANAGEMENT: INSOMNIA

Sleep assessment is important in helping patients to identify behaviors and
environmental factors (e.g., noise, temperature) that contribute to poor sleep.
Specific nursing diagnoses identified as related to sleep include readiness for
enhanced sleep, sleep deprivation, disturbed sleep pattern, and insomnia.
Good sleep hygiene practices provide sustained benefit for the patient.

OBSTRUCTIVE SLEEP APNEA

The term sleep-disordered breathing (SDB) indicates abnormal respiratory
patterns associated with sleep.
Obstructive sleep apnea (OSA) is the most commonly diagnosed sleep-disordered
breathing problem.
Clinical manifestations of OSA include partial or complete upper airway
obstruction during sleep, frequent arousals during sleep, insomnia, excessive daytime
sleepiness, snoring, and witnessed apneic episodes.
Mild sleep apnea may respond to simple measures (e.g., sleeping on ones side
rather than on the back).
In patients with more severe symptoms, continuous positive airway pressure
(CPAP) by mask is the treatment of choice.
When patients with OSA are hospitalized, be aware that the use of opioid
analgesics and sedating medications may worsen OSA symptoms by depressing
respiration. Patients should continue CPAP use in the hospital.

PERIODIC LIMB MOVEMENT DISORDER

Periodic limb movement disorder (PLMD) is characterized by involuntary,
continual movement of the legs and/or arms occurring only during sleep.
PLMD is managed through medications that improve sleep and reduce the
incidence of leg movements, particularly newer-generation dopaminergic drugs.

CIRCADIAN RHYTHM DISORDERS

Circadian rhythm disorders occur when the circadian timekeeping system loses
synchrony with sleep and wake cycles.
 Jet lag disorder occurs when an individual travels across multiple time zones.
Ones body time is not synchronized with environmental time. Patients can be taught
strategies to combat jet lag.

NARCOLEPSY
Narcolepsy is a chronic neurologic disorder characterized by excessive daytime
sleepiness and unpredictable transitions from wake to sleep. The cause of narcolepsy
remains unknown, but it is considered an autoimmune disease.
Narcolepsy is diagnosed based on a history of sleepiness, PSG, and daytime
multiple sleep latency tests (MSLTs).
Drug therapy with amphetamine-like stimulants (modafinil [Provigil]), and
tricyclic antidepressant drugs is the main treatment for narcolepsy.
High doses of selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine
[Prozac], venlafaxine [Effexor]) may be prescribed for the management of cataplexy.
None of the current drug therapies cure narcolepsy or allow patients to
consistently maintain a full, normal state of alertness. Drug therapy is combined with
behavioral strategies.

PARASOMNIAS
Parasomnias are unusual and often undesirable behaviors that occur with sleep or
during arousal from sleep. They are due to central nervous system activation and often
involve complex behaviors.
Sleepwalking and sleep terrors are arousal parasomnias.
Nightmares are a parasomnia characterized by recurrent awakening with recall of
the frightful or disturbing dream. Nightmares are commonly reported by patients in the
ICU.

GERONTOLGIC CONSIDERATIONS: SLEEP

All aspects of sleep, including the duration, depth, and continuity of sleep, change
with age.
Older adults self-report greater problems getting to and maintaining sleep
compared with younger adults.
The prevalence of sleep disorders increases with age.

SPECIAL SLEEP NEEDS OF NURSES

Nurses on permanent night or rapidly rotating shifts are at increased risk of
experiencing shift work sleep disorder, insomnia, sleepiness, and fatigue.
Chronic fatigue in nurses on permanent night or rapidly rotating shifts is
associated with errors and reduced patient safety.
Strategies such as prophylactic napping and sleeping prior to work may help to
reduce sleep symptoms associated with shift work.