Chapter 31- Sleep

Restless leg syndrome (RLS)

A neurological sensorimotor disorder that causes an irresistible urge to move the legs while they are at rest. Most severe in the evenings and night and can severely disrupt sleep. Older patients are more prone to RLS.

How many sleep cycles does a person experience each night?

A person usually passes through 4-6 complete sleep cycles, each consisting of 4 stages of NREM sleep and period of REM sleep.

Parasomnias

Sleep disorders that can occur during arousal from REM or patrial arousal from NREM. They include sleep walking, night terrors, nightmares, teeth grinding, and bed wetting. More common in children.

Mixed sleep apnea

A combination of both Obstructive and central sleep apnea

Benzodiazepines

A common classification of drugs used to treat sleep problems when change in sleep hygiene is not effective. Should be carefully tapered off after long-time use. Associated with suicidal intentions.

Sleep apnea

A disorder in which the individual is unable to breath and sleep at the same time. Lack of airflow ranges from 10 seconds to 1-2 mins in length. There are 3 types of sleep apnea.

L-tryptophan

A natural protein found in foods such as milk, cheese, and meats like turkey and chicken that sometimes helps a person sleep

Melatonin

A neuro-hormone produced in the brain that helps control circadian rhythms. It is a popular nutritional supplement in the US used to aid sleep. Recommended dosage is 0.3-1 mg taken 2 hours before bedtime.

Narcolepsy

A rare CNS dysfunction of mechanisms that regulate sleep and wake states. During the day a person suddenly feels an overwhelming wave of sleepiness and falls asleep usually at inappropriate times. REM can happen as early as 15 mins within falling asleep. There are 2 states; with or without cataplexy.

Sleep

A recurrent, altered state of consciousness that occurs for sustained periods. Regulates body function and behavior responses.

Epworth Sleepiness Scale

A scale used to assess the degree of daytime sleepiness. A questionnaire with 8 questions about likeliness of being sleep during certain activities. A score of 10 or more is considered sleepy and 18 or more is very sleepy.

Insomnia

A symptom rather than the name of disease and is common among patients suffering from depression. Often associated with poor sleep hygiene. Leads to insufficient quantity and quality of sleep.

During NREM sleep

An individual progresses through four staes during a typical 90 minute sleep cycle. The quality of sleep from stage 1 to stage 4 becomes increasingly deeper.

Young adults

Average 6-8.5 hours of sleep nightly, but this varies. They spend 20% of their time in REM sleep which remains the remainder of life. Require adequate sleep to participate in busy daily life activities.

Toddlers and preschoolers

By age 2 children usually sleep through the night and take daily naps but by age 5 no longer take naps. They average 12 hours of sleep a day. About 20% is REM sleep. Bedtime fears and nightmares happen at this age.

A loss of REM sleep leads to

Confusion and suspicion. Prolonged sleep loss alters various body functions such as mood, motor performance, memory, and equilibrium.

What does CPAP stand for?

Continuous positive airway pressure

Stage 3 and 4

Deeper sleep called "slow-wave sleep" where person is more difficult to arouse. Stage 4 is the deepest stage or NREM where sleepwalking and enuresis (bed wetting) sometimes occurs

Biological clock

Every person has one it is normally synchronized by exposure to light and activity. Different people function best at different times of the day.

Sleep diary

For the patient and sleep partner to keep a sleep-wake log when it is obvious the patient is having serious sleep problems. Includes 24-hour information on waking and sleeping activities including work, mealtimes, alcohol and caffeine intake, length and time of daytime naps, bedtime routines, time the patient tries to fall asleep, and number of middle of the night awakenings.

Sedatives and hypnotics

Groups of drugs that induce and/or maintain sleep. Long-term use can disrupt sleep and lead to more serious problems.

Signs and symptoms

Have you been told that you snore loudly? Do you have headaches when you awaken? Ask bed partner or parents if patient has restful sleep or problems going to the bathroom frequently.

Severity

How long does it take you to fall asleep? How often during the week do you have trouble falling asleep or staying asleep?

The hypothalamus secretes __________ it promotes___________

Hypocretins, wakefulness and rapid eye movement (REM)

Sleep deprivation affects

Immune functions, metabolism, nitrogen balance, protein catabolism, and quality of life.

Sleeping temperatures

Infants sleep best when temp is between 64-70 degrees. Children and adults usually sleep better in cooler temperatures. Older adults like it warmer or sleep with extra blankets and covers.

Infants

Infants usually develop a nighttime pattern of sleep by 3mo. Take several naps during the day but usually average 9-11 hours of sleep during the night. Spend about 30% of time in REM sleep.

Process-C (Biological time clocks)

Influence the internal organization of sleep and timing and duration of sleep-wake cycles. It works simultaneously with Process-S to regulate sleep and wakefulness

REM sleep

Is the phase at the end of each 90 minute sleep cycle. Usually begins 90 mins after sleep has begun. You experience vivid, full-color dreaming. Loss of skeletal muscle tone occurs. It is very hard to arouse a person in REM sleep.

Treatment options for obstructive sleep apnea (OSA)

Life style changes like weight loss, improved sleep hygiene, CPAP, surgery, dental appliances,

Stage 1 and 2

Lighter sleep where person is easily arousable.

Older adults

More than 50% of people age 65 and older report regular problems with sleep. Spend more time in stage 1 and have less stages 3 and 4. To compensate they increase the number of naps they take during the day. Medical conditions, meds, and substance abuse is common factors altering sleep.

Adolescents

Need between 8.5-9.5 hours of sleep each night, however the typical teenager gets about 7.5 hours. Activities such as sports and jobs often leads to excessive daytime sleepiness which leads to risks such as bad academics, mood changes, substance abuse.

Failure to maintain a persons usual sleep-wake cycle can

Negatively influence his or her overall health

Nocturia

Nighttime urination that disrupts sleep and the sleep cycle.

Normal sleep involves 2 phases called

Non-rapid eye movement (NREM) and Rapid eye movement (REM)

The 3 types of sleep apnea

Obstructive, central, mixed apnea

What to include in a sleep history

Obtain a brief sleep history from patients on admission. Include usual bedtime, bedtime rituals, preferred environment for sleeping, and what time the patient usually rises.

Sleep deprivation

Occurs from insufficient or disrupted sleep with decrease in quantity and quality or inconsistency in timing. Causes include illness, emotional stress, medications, environmental disturbances

Central sleep apnea (CSA)

Originates in the CNS. Pauses in breathing happen in the respiratory and pulmonary systems at the same time. The brain stops sending signals to the muscles that control breathing. Frequently seen in patients with congestive heart failure.

What is the best source for sleep assessment?

Patients are your best resource for describing a sleep problem and any change from their usual sleep and waking patterns. For children it is best to obtain a sleep history from a parent.

Factors that can affect sleep are

Physical illness, drugs and substances, lifestyle, unusual sleep patterns, daytime napping, national stress, environment, exercise and fatigue,and food and calorie intake,

Sleep in pregnant women

Pregnancy increases the need to sleep. Common problems during the 3rd trimester include restless leg syndrome, insomnia, periodic limb movements, and sleep-disordered breathing.

The reticular activating system (RAS) does what

Receives visual, auditory, pain, and tactile sensory stimuli. It is stimulated by the cerebral cortex resulting in arousal, wakefulness, and maintenance of consciousness.

Circadian Rythm

Referred to as the "body clock" it tells our bodies when to sleep, rise, eat, and regulates many physiological processes such as heart rate and blood pressure.

Process-S

Regulates the length and depth of sleep and circadian rythms

Sleep allows the body to?

Restore biological processes such as release human growth hormones for repair and renewal of epithelial and specialized cells such as brain cells, tissue renewal occurs, and energy conservation.

Treatments for narcolepsy include

Stimulants, antidepressants, short day time naps no longer than 20 mins, regular exercise, eating light meals high in protein, deep breathing, chewing gum, and taking vitamins.

Cataplexy

Sudden muscle weakness during intense emotions such as anger or laughter that occurs at any time during the day. In severe attacks a person loses voluntary muscle control and falls to the floor.

The national "Back to Sleep" campaign

Teaches parents and infant caregivers to place infants on their backs for sleeping to reduce the incidence of SID's

Nature of the problem

Tell me what type of problem you have with your sleep. Tell me why you think you are not getting enough sleep. Describe a typical nights sleep. How is this sleep different from your usual sleep?

Predisposing factors

Tell me what you do just before going to bed. Have you recently had any changes in work school or home? Any mood changes? What medications do you take? What do you eat or drink before bed (spicy foods, caffeine, liquid right before bed etc)

Pre-sleep cycle

The person is aware only of a gradually developing sleepiness. This period normally lasts 10-30mins. People having difficulty falling asleep can remain in this stage for an hour or more.

What controls the rhythm of the sleep-wake cycle and coordinates it with other circadian rythms

The suprachiasmatic nucleus in the hypothalamus

Obstructive sleep apnea (OSA)

This is the most common form. It is a cessation or stopping of airflow despite the effort to breath. Occurs when muscles or soft structures of the oral cavity or throat relax during sleep causing the upper airway to become blocked and nasal airflow diminishes or stops. Causes the person to snore and then to awaken when they can't breath.

Middle adults

Total time of sleeping at night begins to decline. The amount of stage 4 sleep begins to fall. Sleep disturbances are usually diagnosed among people in this age range. Because of stress experienced in middle age insomnia is common and often experienced more in menopausal women.

Neonates

Up to 3 months average about 16 hours of sleep a day. About 50% of sleep is REM sleep.

School-age children

Usually does not require a nap. A 6 year old averages 11-12 hours of sleep nightly. An 11 year old averages 9-10 hours of sleep nightly. The older child usually resists sleeping because of an unawareness of fatigue or a need to be independent.

Onset and duration

When did you notice this problem? How long has this problem lasted?

How do the sleep cycles work?

You go through stages 1-4, followed by a reversal from stages 4, to 3, to 2, ending in a period of REM sleep. With each successive cycle, stage 3 and 4 shorten, and the period of REM lengthens. REM lasts up to 60 minutes during the last cycle of sleep.

Prostaglandin D2, L-tryptophan, and growth factors in the hypothalamus do what?

control sleeping

The major sleep center in the body is the

hypothalamus