Ch.34: Sleep-Wake Disorder

Rhythm

Movement with a cadence, a measured flow that occurs at regular intervals, with a cycle of coming and going, ebbing and rising, to return at the start point and begin again

Monitoring for Drug-to-Drug Interactions

-Sleep medications generally have increased depressive effects when given with other CNS depressants -Sleep medications can interact with oral contraceptives, isoniazid (an antibiotic), fluvoxamine (a serotonin reuptake inhibitor \[SSRI\]), and verapamil (a calcium channel blocker) -Grapefruit juice should be avoided when taking these drugs -Ramelteon should not be given with fluvoxamine

Hypnotics: Benzodiazepine Receptor Agonists

Estazolam Flurazepam Temazepam (Restoril) Triazolam (Halcion) Quazepam (Doral) Zolpidem (Ambien) Zolpidem ER (Ambien) Zaleplon (Sonata) Eszopiclone (Lunesta)

Insomnia in Children and Adolescents

-Sleep issues in children can occur in the presence of attention deficit hyperactivity disorder (ADHD), epilepsy, and autism spectrum disorder or independently of a neurologic or psychiatric diagnosis -Up to 66% of children are experiencing anxiety disorders, such as separation anxiety disorder or specific phobias, including social anxiety disorder, and experience insomnia -Not unlike adults, cognition and emotional regulation are impacted when sleep quality and/or sleep quantity are impacted

Etiology of Insomnia

-Many factors affect sleep, but one of the major reasons for insomnia is depression, which accounts for most cases -However, most people with insomnia do not have a psychiatric diagnosis

Psychosocial Theories

-Sleep is also related to psychosocial factors, such as lifestyle, stress, and work- and school-related factors -Underrepresented groups have short sleep duration -Short sleep duration is associated with lower socioeconomic groups and the unemployed

Sleep

-A recurrent, altered state of consciousness that occupies nearly one third of our lives and occurs for sustained periods -Is necessary for human survival, is a state of decreased awareness of environmental stimuli and a relative state of unconsciousness with no memory of the state -Unlike a coma, sleep can be disrupted and reversed quite easily -Is usually preceded by a period of sleepiness or the urge to fall asleep -Sleep is important to our development, functioning, and health -Sleep has identifiable cycles and a variety of cognitive experiences, ranging from memory recall to feeling energetic -The consequences of disturbed sleep include impaired alertness and performance

Sleep and Wellness

-Adequate sleep is a critical aspect of wellness -Sleeping less than the recommended 7 hours per night is associated with obesity, diabetes, high blood pressure, coronary heart disease, stroke, and mental distress -More than one third of Americans report sleeping less than 7 hours per night, with the average sleep duration of U.S. adults being between 6 and 6.5 hours from a high of 8.5 hours in 1960 -Sleepiness has been linked to catastrophic disasters, such as the Exxon Valdez oil spill, the nuclear meltdown at Chernobyl in Ukraine, the space shuttle Challenger accident, and the Three Mile Island disaster in the United States

Age on Onset for Insomnia

-Age of onset for insomnia varies and may be impacted by physical health issues and psychological and environmental experiences that impact sleep -Older adults and those with health problems are reportedly more likely to experience insomnia

Evidence-Based Nursing Practice for the Persons with Parasomnias

-Although polysomnography may be used to diagnose or confirm a sleep disorder, the evaluation of a response to an NREM disorder involves a careful sleep history -Episodes of sleep terrors or sleepwalking are often unrealized by the patient but can be described in detail by the parent or partner -Support persons should be advised to avoid attempting to wake the person/child and ensure a safe environment surrounds the individual -Safety features may include a sleep space absent of stairs, as well as securing windows and doors with locks -Sleep diaries should focus on the person's bedtime activities, time of sleep onset and wake up, time to prepare for bed and fall asleep, use of medications, number of awakenings, subjective assessment of quality of sleep, and daytime naps -Sleep hygiene and a routine, to avoid insufficient sleep, should be promoted -Nursing interventions range from referring to sleep specialists to patient education about the disorder and strategies in dealing with the disorder -In some instances, nurses care for patients in the inpatient setting who have arousal disorders -In these instances, nurses should develop care plans that address the individual patient's needs -In instances of sleepwalking, staff should be alert to the safety issues and protect the patient from injury

Sleep-Wake Cycle

-An endogenously generated rhythm close to 24 to 25 hours synchronized with the day-night cycle -The sleep-wake cycle is regulated by circadian rhythms and sleep homeostasis

Etiology of Obstructive Sleep Apnea

-An obstruction or collapse of the airway causes apnea, or cessation of breathing -In most cases, the site of obstruction is in the pharyngeal area -Vibrations of the soft, pliable tissues found in the pharyngeal airway cause the snoring sounds that occur during breathing

Clinical Course of Obstructive Sleep Apnea

-Apneic episodes, which last from 10 seconds up to several minutes, cause disrupted sleep and abrupt awakenings with feelings of choking or falling out of bed; some people even leap out of bed to restore breathing -The person may not later recall the awakening -These brief awakenings deprive essential sleep, resulting in excessive daytime sleepiness that may reach the same degree of pathologic sleepiness found in narcolepsy -Unlike narcolepsy, naps tend to be unrefreshing -Esophageal reflux, or heartburn, is a common complaint -Genitourinary symptoms include nocturia (three to seven trips to the bathroom), nocturnal enuresis, and erectile dysfunction -Bradycardia, in association with tachycardia, is often seen with apneic events -Other cardiac arrhythmias are also seen, including sinus arrest -The onset of symptoms and sleepiness may coincide with weight gain -Obesity is a major risk factor for apnea and predictor across populations

Mental Health Nursing Assessment

-Assessment of a patient's sleep pattern is a part of every psychiatric nursing assessment -If a patient has a sleep disorder, a detailed sleep history should be included in the assessment process

Insomnia in Older Adults

-Cognitive impairment, depression, anxiety, and increased risk of falls are linked to insomnia in those 65 years and older -Increased rates of insomnia are seen in those residing in institutions versus those in a community setting -Older adults should be educated about the impact of poor quality sleep on daily functioning as well as vital organs, including cardiovascular, neurologic, and mental health implications

Enhancing Cognitive Functioning

-Cognitive-behavioral therapy (CBT) is useful in changing negative learned responses that perpetuate insomnia -This approach is especially helpful for those who also have comorbid depression or anxiety -The objective of CBT is to change the belief system that results in improvement of the self-efficacy of the individual

Stages of Sleep

-Sleep is biphasic, cycling between NREM and REM -During an 8-hour sleep period, the cycle of NREM and REM repeats itself -This duration of the cycles may change as the night progresses -In the first cycle, the amount of REM sleep is brief -With each succeeding cycle, the amount of time spent in REM lengthens -Conversely, NREM is most prominent during the initial cycle but declines as total sleep time progresses

Physical Health and Functioning

-During the patient interview, the description, duration (when problem began), stability (every night?), and intensity (how bad is it?) should be determined -A sleep history includes current sleeping patterns, medical problems, current medications (including OTC and dietary supplements), current life events, use of alcohol and caffeine, and emotional and mental status that might be affecting sleep -A sleep diary is a person's subjective written account of their sleep experience -The diary may cover a few days to several weeks -A simple diary is a record of the patient's daily, estimated bedtime, rise time, total sleep time, estimated time to fall asleep, number and length of awakenings, and naps -More complicated sleep diaries involve recording the amount and time of alcohol and caffeine ingestion, activity level, ratings of fatigue, medication, and stressful events

Teaching Strategies

-Education regarding interventions is crucial for patients with sleep disorders -An explanation of the sleep cycle and the factors that influence sleep are important for these patients -For those with insomnia, teaching about avoiding foods and beverages that might interfere with sleep should be highlighted

Psychosocial Interventions

-Enhancing cognitive functioning -Using behavioral interventions

Mental Health Nursing Interventions

-Establishing recovery and wellness goals -Wellness challenges -Medication interventions -Psychosocial interventions -Psychoeducation -Evaluation and treatment outcomes -Integration with primary care

Diagnosis of Narcolepsy

-Excessive daytime sleepiness and the presence of cataplexy are diagnostic of narcolepsy -It is possible to have narcolepsy without cataplexy -The diagnosis should be confirmed by an in-lab polysomnogram demonstrating at least 6 hours of sleep, followed by the MSLT showing a sleep latency of less than or equal to 8 minutes and two or more SOREM periods -The diagnosis can also be confirmed by a cerebrospinal fluid hypocretin-1 level less than or equal to 110 mg/mL

Providing Family Education

-Family and friends should be encouraged to support the new habits the patient is trying to establish -Patients, spouses, and friends must understand that activities engaged in just before sleep can greatly affect sleep patterns and sleep difficulties, such as socializing, alcohol consumption, use of caffeine, and engaging in stimulating activities -Relaxing activities before bedtime are vital contributors to establishing a routine conducive to sleep -Family and friends can help create a positive environment with an emphasis on sleep as a priority

Familial Differences and Insomnia

-Fatal familial insomnia is characterized by not only insomnia but also dysautonomia, changes to motor function, neuropsychiatric disorders, and myoclonic limb activity -Rarely does clinical onset occur before the age 32, with the average at 51 years of age, with the majority of cases reported from Italy, Spain, and Germany -Genetically, the disorder is of autosomal dominant pattern -The most widely regarded predictor of a familial risk for insomnia is a maternal history -It is challenging to distinguish differences among families and support systems due to the web of intricacies that can impact sleep, specifically insomnia -Known medical disorders and treatment regimens can impact sleep architecture whereby making it challenging to determine if insomnia is idiopathic or a consequence of another component of overall health wellness management or treatment -Of all sleep-related problems, insomnia is the most prevalent -Thirty percent to 50% of the population experiences short-term, occasional insomnia -The prevalence of chronic or severe insomnia (occurring for at least 3 months and a minimum of three times per week) is estimated to range from 10% to 15% -Insomnia is one of the most prevalent complaints in primary health care -Insomnia has a greater prevalence among older people and among divorced, separated, and widowed adults -Increasing age, female sex, and comorbid disorders (e.g., medical, mental disorders, and substance use) are all risks for developing insomnia disorder

Clinical Course for Insomnia

-Few studies describe the course of insomnia disorder, which can last for short periods in some patients and for decades in others -Since ancient times, physicians noted individuals having difficulty falling asleep, staying asleep, and early morning awakenings -Acute insomnia is described as 3 or more nights per week with symptoms occurring in a 2- to 12-week timeframe, whereas chronic insomnia has a longer duration

Quality of Life

-Health-related quality of life is decreased in adults who experience insomnia -There are numerous studies showing the quality of life is negatively impacted in people with insomnia -While insomnia has a negative effect on quality of life in both genders, women report a lower quality of life than men

Other Disorders

-Hypersomnolence disorder -Narcolepsy -Breathing related disorders -Obstructive sleep apnea syndrome -Circadian rhythm sleep disorder -Parasomnias -Sleep terrors and sleepwalking -Nightmare disorder -Restless legs syndrome

Sleep Terrors and Sleepwalking

-In sleep terrors (also called night terrors or pavor nocturnes), there are episodes of screaming, fear, and panic, causing clinical distress or impairing social, occupational, or other areas of functioning -Sleep terrors usually last 1 to 10 minutes, are frightening to the person and to anyone witnessing them -Often, individuals abruptly sit up in bed screaming; others have been known to jump out of bed and run across the room -Other symptoms include a rapid heart rate and breathing, dilated pupils, and flushed skin -Usually, the person having a sleep terror is inconsolable and difficult to awaken completely -Efforts to awaken the individual may prolong the episode -Once awake, most are unable to recall the dream or event that precipitated such a response -A few report a fragmentary image -Often, the individual does not fully awaken and cannot recall the episode the next morning -In sleepwalking or somnambulism, there are repeated episodes of complex motor behavior during sleep that may involve getting out of bed and walking around -While sleepwalking, people typically have a blank stare and are difficult to awaken -Often, they awaken to find themselves in a different place from where they went to sleep -If awakened during the episode, there is a brief period of confusion

Insomnia

-Latin for "no sleep," refers to difficulty falling asleep or maintaining sleep when opportunity and circumstances are adequate for sleep -Dissatisfaction with sleep quantity or quality may also be present

Family Response to Insomnia

-Living with a family member with insomnia disorder is challenging -Irritability, complaints of sleeplessness, and chronic fatigue interfere with quality of interpersonal relationships -Family members become "exhausted" by living with someone who never sleeps

Lifestyles and Sleep Pattern and Quality

-Many factors can cause disrupted sleep patterns, such as travel across time zones, stress or anxiety, and changes in the sleep-wake pattern because of shift work -When traveling across time zones or working night shifts (and sleeping during the day), one's regular sleepiness-alertness rhythm may persist for several days -Even when daytime sleep is improved with a pharmacologic agent, sleepiness in the early morning hours usually continues for the first 2 to 3 nights -This extreme sleepiness often decreases after a 4- to 6-day reversal of the sleep-wake cycle

Melatonin Receptor Agonist

-Melatonin is a hormone, released from the pineal gland that aids in the regulation of the sleep-wake cycle through activation of MT1 and MT2 receptors -Melatonin has been shown to shift circadian rhythm, decrease body temperature, alter reproductive rhythm, enhance immune function, and decrease alertness -Normally, levels of melatonin increase with decreasing exposure to light -Ramelteon (Rozerem), indicated for insomnia, is a melatonin receptor agonist with high affinity for melatonin receptors MT1 and MT2 -This pharmacologic activity is believed to be related to its sleep-promoting properties -Ramelteon has a low abuse potential and is not a controlled substance

Non-Rapid Eye Movement Sleep

-NREM sleep occurs about 90 minutes after falling asleep and consists of four substages -Light sleep is characteristic of stages 1 and 2, in which the person is easily aroused -A person aroused from stage 1 sleep may even deny having been asleep, such as dozing while watching television and awakening minutes later during a loud commercial -Stage 1 accounts for only 2% to 5% of a night's sleep and is a transition between relaxed wakefulness and sleep -Stage 2 comprises about 45% to 55% of sleep -During phases 1 and 2, an electroencephalogram (EEG) shows an alpha rhythm gradually being replaced by a theta rhythm -Sleep spindles or "k complexes" occur in stage 2 -Slow-wave sleep, or the deepest state of sleep, characterizes stages 3 and 4 -Slow-wave sleep is believed to have a restorative function, although the exact mechanism for this is unclear -It may serve to conserve energy because metabolism and body temperature decrease during this part of sleep -These stages make up 10% to 23% of sleep -EEG findings show high-amplitude waves, slow waves, or delta waves -The difference between stages 3 and 4 is the amount of delta waves seen, with stage 3 demonstrating 20% to 50% of delta waves and stage 4 showing more than 50% of delta waves

Clinical Course for Narcolepsy

-Narcolepsy is a chronic disorder that usually begins in young adulthood between the ages of 15 and 35 years -Excessive sleepiness is the first symptom to appear -The severity of sleepiness may remain stable over the lifetime -Narcolepsy has no cure -Treatment is designed to control symptoms based on clinical presentation and severity -A secondary sleep disorder should be considered if the level of sleepiness changes -Narcolepsy is distinguished by a group of symptoms, including daytime sleepiness, cataplexy, hypnagogic hallucinations, and sleep paralysis -The symptom of daytime sleepiness is found in all individuals with narcolepsy, but existence of the other three symptoms varies -Cataplexy is the bilateral loss of muscle tone, triggered by a strong emotion, such as anger or laughter -This muscle atonia can range from subtle (drooping eyelids) to dramatic (buckling knees) -Respiratory muscles are not affected -Cataplexy usually lasts for seconds -Individuals are fully conscious, oriented, and alert during the episode -Prolonged episodes of cataplexy may lead to unintentional sleep episodes -The frequency and severity of events generally increase when the individual is sleep deprived -Hypnagogic hallucinations are intense dreamlike images that occur at sleep onset and usually involve the current environment -Hallucinations can be visual or auditory, such as hearing one's name called or a door slammed -Sleep paralysis, the inability to move or speak when falling asleep or waking up, is often described as terrifying and is accompanied by a sensation of struggling to move or speak -Although the diaphragm is not involved, patients may also complain of not being able to breathe or feeling suffocated -These episodes are typically brief in duration and usually terminate spontaneously or when the individual is touched

Circadian Rhythms

-Nearly all physiologic and psychological functions fluctuate in a pattern that repeats itself in a 24-hour cycle, called circadian rhythms -The biologic clock that regulates our circadian rhythms is located in the suprachiasmatic nucleus, an area of the hypothalamus that lies on top of the optic chiasm -However, it is now recognized that almost all cells and tissues in the body are circadian clocks -When two or more rhythms reach their peak at the same time, they are synchronized; if they reach their peak at different times, they are desynchronized -Most physiologic functions reach their lowest levels during the middle of the sleep period -For example, body temperature follows a predictable pattern from lowest, in the early morning, to highest, in the mid-evening -Manual dexterity, reaction time, and simple recognition appear to coincide with the circadian rhythm of body temperature -Most circadian rhythms continue even when humans are unaware of the time of day -Natural age-related changes in circadian sleep rhythms generally regulate people as they get older, toward morning alertness and productivity and sleepiness at night

Changes in Normal Sleep

-Normal sleep is sensitive to changes, and the body responds when deprived of certain phases of sleep, particularly REM sleep and slow-wave sleep -Certain activities, such as early rising, alcohol intake before bedtime, or consumption of certain medications, can suppress REM sleep -One example is the use of central nervous system (CNS)-acting medications -Fragmented sleep interrupts the restorative function of a good night's sleep -Not only does insufficient sleep cause daytime sleepiness, but disturbed sleep also affects daytime alertness and performance -A sleep debt occurs when there is recurrent long-term sleep deprivation -When individuals are deprived of REM sleep, there is a subsequent "rebound effect," wherein the lost REM sleep is made up during the next sleep period -The body makes up for this lost REM sleep by earlier occurrence of REM sleep during the next night -The presence of REM at sleep onset implies REM deprivation -Slow-wave sleep does not appear to have a circadian determinant, but it is more sensitive to the amount of previous sleep obtained -When one is deprived of both REM and slow-wave sleep, the body prefers to make up the slow-wave before the REM sleep

Nursing Implications on Nurses' Sleep, Fatigue, and Sleepiness Impact on Cognitive Performance

-Nurses are at high risk for sleep deprivation and fatigue -Self-care and patient can be negatively impacted by fatigue associated with variable shifts, long work hours, and chaotic environments

Evidence-Based Nursing Care of Persons with Hypersomnolence Disorder

-Nursing assessment for the patient with hypersomnolence focuses on excessive sleepiness -The following are examples of assessment questions 1. Have you ever nodded off unintentionally? 2. When did your sleepiness begin? 3. Does anyone in your family experience the same sleepiness symptoms? 4. Do you suddenly find yourself awakening feeling refreshed? -Interventions stress the importance of sleep hygiene and helping the patient establish normal sleep patterns -If medications are given, the most commonly prescribed stimulants for treating excessive daytime sleepiness are dextroamphetamine and amphetamine mixtures (Adderall), modafinil (Provigil), methylphenidate (Ritalin, Concerta), and pemoline (Cylert) -These agents increase the patient's ability to stay awake and perform -Abuse of these medications should be assessed -In some cases, serotonin antagonists are used off-label -Sleepy people often self-medicate with caffeine -A cup of brewed coffee contains about 100 to 150 mg of caffeine -A 12-oz can of Mountain Dew contains 54 mg of caffeine -Caffeine contents of popular "energy" drinks range from 80 to 300 mg -Peak plasma concentration is reached 30 to 60 minutes after consumption, and the duration of effect is 3 to 5 hours in adults -Caffeine improves psychomotor performance, particularly tasks involving endurance, vigilance, and attention -High doses, especially in people who are not habitual users, may exhibit side effects such as irritability and anxiety

Evidence-Based Nursing Care for Persons with Insomnia

-Nursing assessment for the patient with insomnia focuses on difficulty falling asleep, staying asleep, and/or early morning awakenings -The following are examples of assessment questions 1. What time do you go to bed? In your estimation, how long does it take you to fall asleep? 2. When did your symptoms begin? Did anything unusual or stressful precipitate the sleep disturbance pattern? 3. Does anyone in your family experience the same symptoms? 4. Do you find yourself awakening feeling sluggish or refreshed? 5. Does your reported sleep issue impact your daily activities or ability to function? 6. Do you nap? If so, what time and for how long? -Interventions stress the importance of sleep hygiene and helping the patient establish normal sleep patterns -If medications are given, the commonly prescribed over-the-counter (OTC) medications and supplements include diphenhydramine and melatonin -Prescription medications used for insomnia include Benzodiazepine Receptor Agonists (BzRAs), Melatonin Receptor Agonist, and Orexin Receptor Antagonist

Evidence-based Nursing Care of Persons with Narcolepsy

-Nursing assessment is similar to that for insomnia -In general, sleepiness is treated with CNS stimulants -Methylphenidate, dextroamphetamine, modafinil, and pemoline are the most frequently prescribed stimulants -Cataplexy may be treated with tricyclic antidepressants because these drugs suppress REM -Sodium oxybate (Xyrem), classified as a Schedule II drug, is indicated for excessive sleepiness and cataplexy -Because of its high abuse potential, patients who are prescribed this medication are closely monitored -Patient education focuses on factors that can make symptoms worse, such as sleep deprivation -Patients need to develop strategies to manage symptoms -Naps can be integrated into their daily routines such as during work breaks or before engaging in activities that require sustaining alertness

Obstructive Sleep Apnea

-OSA syndrome, the most commonly diagnosed breathing-related sleep disorder, OSA is characterized by snoring during sleep and episodes of sleep apnea (cessation of breathing) that fragments sleep and contribute to daytime sleepiness -The hallmark symptoms are snoring and daytime sleepiness -Often, snoring is so loud and disturbing that partners choose separate bedrooms for sleeping -On physical examination, an enlarged, elongated uvula is associated with increased severity of snoring and apneic events -Snoring affects 57% of men, 40% of women, and 27% of children

Over-the-Counter Medications and Dietary Supplements

-OTC sleeping pills are usually antihistamines -The most common agents are doxylamine and diphenhydramine -These histamine-1 antagonists have a CNS effect that includes sedation, diminished alertness, and slowing of reaction time -These drugs also produce anticholinergic side effects, such as dry mouth, accelerated heart rate, urinary retention, and dilated pupils -Drowsiness lasts from 3 to 6 hours after a single dose -Next-morning hangover can be a problem -Diphenhydramine decreases sleep latency and improves quality of sleep for those with occasional sleep problems but is not as effective as benzodiazepines for chronic sleep disturbances -Melatonin has long been an available OTC and has been shown to have mild sleep-promoting properties when given outside the period of usual secretion -That is, melatonin can advance the sleep-wake cycle by making it easier to fall asleep earlier than usual -Some evidence suggests that in young and older individuals with insomnia, melatonin can be beneficial in ameliorating the symptoms -Valerian, a dietary supplement, is used as a medicinal herb in many cultures -The mechanism of action is not fully understood and is believed to inhibit GABA reuptake -Valerian may be useful for sleeplessness, but not enough evidence from double-blind studies exists to confirm this -The American Academy of Sleep Medicine recommended against using valerian for chronic insomnia in adults -Mild side effects include headaches, dizziness, upset stomach, and tiredness the morning after its use

Diagnosis of Hypersomnolence Disorder

-On the day after overnight polysomnography, a multiple sleep latency test (MSLT) may be used -The MSLT is a standardized procedure that measures sleep variables during a 20-minute period -The process is repeated every 2 hours, occurring approximately five times during the day -The faster a person falls asleep during testing, the greater the physiologic sleep tendency -The presence of sleep-onset REM (SOREM) during the MSLT and a report of cataplexy assist providers in determining a sleep diagnosis -Polysomnography shows short sleep latency, a normal-to-long sleep duration, and normal sleep architecture -Subjective symptoms of sleepiness are recognized as heavy eyelids, loss of initiative, reluctance to move, and yawning or slowed speech -Sleepiness is unique to the person and situation, varying from mild to severe

Orexin Receptor Antagonist

-Orexins (also known as hypocretins) are neurotransmitters produced in the hypothalamus that trigger wakefulness, while low levels result in sleep -A deficiency is associated with narcolepsy -Suvorexant (Belsomra) is an orexin receptor antagonist approved for the treatment of insomnia -Blocking the binding of orexins to receptors is thought to suppress the wake drive -This antagonism may also trigger signs of narcolepsy/cataplexy -There is emerging evidence that this group of medications is effective for other psychiatric disorders

Parasomnias

-Parasomnias are sleep-wake disorders that occur in association with sleep, specific sleep stages, or sleep-wake transitions -The person experiences abnormal behavioral, experiential, or physiologic events -Parasomnias are divided into two primary categories: NREM-related and rapid eye movement (REM)-related NREM sleep arousal disorders, including sleepwalking and sleep terror types, which usually occur during the first third of the major sleep episode -Nightmare disorder is a REM disorder that generally occurs during the second half of the major sleep episode -RLS is considered a sleep disorder and is classified as a sleep-related movement disorder

Clinical Course for Hypersomnolence Disorder

-People with hypersomnolence typically sleep 8 to 12 hours per night -They fall asleep easily and sleep through the night, often having difficulty awakening in the morning -They often have difficulty meeting morning obligations -They exhibit poor concentration and memory -Excessive sleepiness may not be impacted by napping because they may awaken from a nap feeling unrefreshed -They may even describe dangerous situations, such as being sleepy while driving or operating heavy machinery

Sleep History

-Perception of sleep problem -Sleep schedule (bedtime and rise time) -Difficulty falling asleep or maintaining sleep -Quality of sleep -Daytime sleepiness and impact of the sleep disorder on daytime functioning -General emotional and physical problems (e.g., stress) -Sleep hygiene (e.g., consuming caffeine immediately before bed) -Sleep environment (e.g., room temperature, noise, light)

Teaching Points

-Pharmacologic agents should complement sleep hygiene practices -These medications can be useful on a short-term basis -Alcohol use should be avoided when taking sleeping medications -Patients should use these medications when time for sleeping is adequate (at least 8 hours) -Most sleep-related medications should be taken at bedtime -Patients should be instructed about the safe use of these medications and possible side effects

Clinical Course for Sleep Terrors and Sleepwalking

-Polysomnography shows that these disorders usually begin when slow-wave NREM sleep predominates during the first third of the night -They rarely occur during daytime naps

Diagnosis of Obstructive Sleep Apnea

-Polysomnography, usually performed at night during sleep, monitors many body functions, including brain wave activity, eye movements, muscle activity, heart rhythm, breathing function, and respiratory effort -Polysomnography may show poor sleep continuity, increased stage 1 and decreased slow-wave and REM sleep, and an increased amount of EEG alpha wave activity while the individual is asleep -Clinical evaluation includes oral and nasal airflow, respiratory effort, oxyhemoglobin saturation, and electromyogram of limb muscle activity -Typically, patients with OSA demonstrate numerous respiratory events per night, resulting in intermittent hypoxemia and changes in intrathoracic pressure during polysomnographic measurement

Rapid-Eye Movement Sleep

-Rapid eye movement (REM) sleep is a state characterized by bursts of rapid eye movements -REM sleep occurs in four to six separate episodes and makes up about 20% to 25% of a night's sleep -Although REM sleep is a deep sleep and muscles seem to be at rest, EEG findings demonstrate an active brain -Brain waves resemble a mixture of wakeful and drowsy patterns -Although vivid dreaming is the outstanding feature reported by adults when awakened out of REM sleep, people also report dreams when they awaken from NREM sleep -During REM sleep, nerve impulses are blocked within the spinal cord -Muscle tone diminishes to the point of paralysis -Only stronger impulses are relayed, producing muscular twitches, eye movements, and impulses controlling heart rate and respiration -Breathing and heart rate may become irregular -This type of sleep has a circadian rhythm that closely coincides with the body temperature rhythm -The greatest amount of REM sleep is seen when the body temperature cycle is at its lowest -People do not sweat or shiver during REM sleep because temperature regulation is impaired -Patterns of hormone release, kidney function, and reflexes change -Women have clitoral engorgement and an increase in blood flow to the vagina -Men have penile erections

Safety Issues of Insomnia

-Safety is a priority for people with insomnia disorder -Sleep deprivation can lead to accidents, falls, and injuries, especially in older patients -Sedating medication could potentially increase falls

Ramelteon (Rozerem)

-Sedative-hypnotic -It is readily absorbed -Melatonin receptor agonist with high affinity for MT1 and MT2 -No appreciable affinity for the GABA receptor complex -Treatment of insomnia characterized by difficulty with sleep onset -Should be taken 30 minutes before bedtime -It should not be taken with or immediately after a high fat meal -Patients should be advised to use caution if they consume alcohol in combination with ramelteon

Zaleplon (Sonata)

-Sedative-hypnotic (pyrazolopyrimidine nonbenzodiazepine hypnotic) -It is readily absorbed and metabolized with only about 1% of zaleplon eliminated in urine -Acts at the GABA-benzodiazepine receptor complex -Treatment of onset or maintenance insomnia -It should be taken at bedtime or after a nocturnal awakening with difficulty falling back to sleep (but at least 4 hours before the desired rise time)

Zaleplon (Sonata) Warnings

-Should not be administered to patients with severe hepatic impairment -Potentiates the psychomotor impairments of ethanol consumption

Ramelteon (Rozerem) Warnings

-Should not be used by patients with severe hepatic impairment -It should not be used in combination with fluvoxamine

Teamwork and Collaboration: Working Toward Recovery for Insomnia

-Sleep disorders are best treated by clinicians specializing in this area, but primary and mental health care professionals should be able to identify sleep disturbances and provide education and interventions for normalizing sleep -However, because sleep disorders are common in individuals with mental health problems, psychiatric-mental health nurses should be prepared to provide care for those with sleep disorders -Optimal management and treatment of insomnia have been linked to improved outcomes in those with coexisting psychiatric disorders

Pattern of Sleep

-Sleep is a patterned activity and is one component of the biphasic 24-hour sleep-wake cycle -Sleep latency, the amount of time it takes to fall asleep, is measured from "lights out," or bedtime, to initiation of sleep -Sleep architecture is the pattern of non-rapid eye movement (NREM) and rapid eye movement (REM) that are in about a 90- to 110-minute cycle -Sleep occurs in stages, and the timing of sleep is regulated by circadian rhythms -Sleep efficiency is the ratio of total sleep time to time in bed

Age and Sleep Pattern and Quality

-Sleep patterns change dramatically over the course of the life span -Newborns need 17 to 18 hours of sleep each day, which occurs in 3- to 4-hour episodes throughout the day -By age 6 months, 12 hours of sleep at night and two 1- to 2-hour naps each day are needed -After age 5 years, children gradually need less sleep -Preadolescents need about 10 hours of sleep each night, and napping is rare -A teenager's sleep need is only slightly less, at about 9 hours -During young adulthood, about 8 hours of sleep is needed -The amount of sleep required and sleep architecture typically remain unchanged during the middle-aged years -Poor sleep in women is associated with hormonal changes, such as during the menstrual cycle, pregnancy, and menopause -For older adults, the need for sleep does not decrease, but the ability to sustain sleep changes -Older people spend more time in bed, sleep less, wake more often during the night, and take longer to fall asleep than younger adults -For some, sleep requirements are met by daytime napping -Furthermore, temperature rhythm in older people peaks earlier; early morning arousals may reflect early rise of body temperature -Older people are at higher risk for sleep disorders

Gender and Sleep Pattern and Quality

-Sleep problems and poorer quality sleep are reported more often by women than men -Disturbed sleep and daytime sleepiness have a cumulative effect on mental health -Women are at greater risk for insomnia and other sleep problems -Sleep in women is influenced by the sex hormones, which vary throughout the life cycle -Socioeconomic factors contribute to poor sleep quality and daytime sleepiness in American women -Sleep deprivation and sleep quality in transgender and gender nonconforming adults (TGNC) have been reported and are compounded when TGNC individuals experience sexual victimization

Integration with Primary Care

-Sleep problems are usually treated in the primary care setting -Cardiovascular and metabolic disorders are associated with sleep disturbances -Sleep deprivation is associated with obesity and hypertension -If a sleep disorder is being treated by a mental health specialist, it is important that the mental health specialists communicate with the primary care provider

Establishing Recovery and Wellness Goals

-Sleep problems impact all aspects of health and wellness -Helping a person examine current sleep patterns and their impact on any mental health issues is a beginning step in establishing wellness goals -Depending on the sleep problem, the nurse and patient should collaborate on establishing realistic goals -For example, going to bed at a regular hour each night or omitting caffeine after a set time of day could be a realistic goal

Environment and Sleep Pattern and Quality

-Sleep-related problems have multiple factors that make up the clinical picture -Whereas some are external, such as the noise and temperature, others are internal (e.g., stress and pain) -A person can be sleepy but may stay awake if in a stimulating environment with bright lights or a lot of activity -In contrast, a sleepy person in a quiet place or engaged in sedentary activity cannot resist the urge to fall asleep -Sleepiness is a physiologic state, and although a stimulating environment can temporarily forestall it, when these stimuli are removed, the urge to sleep will persist -Even when someone who is chronically sleep deprived does not feel sleepy, the tendency to fall asleep is much greater and may manifest by causing the person to doze off while sitting in lectures or during the monotonous operation of machinery or driving

Sleep-Wake Disorders

-Sleep-wake disorders are diagnosed when an individual is dissatisfied about the quality, timing, and amount of their sleep, which is causing daytime distress and impairment -Sleep problems are more common in women, and prevalence increases with age in both genders -Sleep-wake disorders occur independently of the diagnosis of other mental disorders, but they are also seen in people with mental disorders -For example, a core feature of posttraumatic stress disorder (PTSD) is sleep disturbance -An occasional change in sleep pattern becomes a sleep disorder when mental and physical health is compromised as a result of problems in the sleep-wake cycle -Sleep-wake disorders include insomnia, hypersomnolence, and narcolepsy -Other disorders include breathing-related sleep disorders (such as obstructive sleep apnea \[OSA\] and circadian rhythm disorders) and parasomnias

Comorbidity of Insomnia

-Sleep-wake disorders occur independently of the diagnosis of other mental disorders, but they are also seen in people with mental disorders, such as PTSD and depression -Insomnia often increases the risk for relapse of the mental disorder -Documented comorbid conditions include cardiovascular disorders, diabetes, musculoskeletal disorders (e.g., arthritis, chronic back/neck pain), respiratory disorders (e.g., chronic obstructive pulmonary disease \[COPD\], seasonal allergies, chronic bronchitis, emphysema), digestive disorders (e.g., gastroesophageal reflux disease, irritable bowel syndrome), pain conditions, and mental disorders including depression, PTSD, and other sleep disorders such as sleep apnea, and restless legs syndrome (RLS)

Administering and Monitoring Medication

-Sleeping medications are commonly used in all settings -They are usually given nightly for a short period of time to establish a wake-sleep pattern -Rebound insomnia can occur if a drug is abruptly discontinued -This side effect can be minimized or prevented by giving the lowest effective dose and tapering before discontinuing -Nurses should assess for confusion, memory problems, excessive sedation, and risk of falls

Using Behavioral Interventions

-Stimulus control is a technique used when the bedroom environment no longer provides cues for sleep but has become the cue for wakefulness -Patients are instructed to avoid behaviors in the bedroom incompatible with sleep, including watching television, doing homework, and eating -This allows the bedroom to be reestablished as a stimulus for sleep -Another behavioral intervention is sleep restriction -Patients often increase their time in bed to provide more opportunity for sleep, resulting in fragmented sleep and irregular sleep schedules -Patients are instructed to spend less time in bed and avoid napping -Relaxation training is used when patients complain of difficulty relaxing, especially if these patients are physically tense or emotionally distressed -Various procedures to reduce somatic arousal can be used, including progressive muscle relaxation, autogenic training, and biofeedback -Imagery training, meditation, and thought stopping are attention-focusing techniques that center on cognitive arousal

Psychoeducation

-Teaching strategies -Wellness strategies -Providing family education

Recovery-Oriented Care for Persons with Insomnia

-Teamwork and collaboration: working toward recovery -Safety issues

Benzodiazepine Receptor Agonists

-The BzRA hypnotics have U.S. Food and Drug Administration (FDA) approval for insomnia -They include the benzodiazepines (e.g., triazolam, temazepam, estazolam, quazepam, and flurazepam) and the nonbenzodiazepines (e.g., zolpidem, zolpidem extended release, zaleplon, and eszopiclone) -All these medications bind to benzodiazepine receptors and exert their effects by facilitating GABA effects -GABA, the most common inhibitory neurotransmitter, must be present at the benzodiazepine receptor for the BzRA to exert its effect -These medications are all absorbed rapidly and reduce sleep latency (the amount of time it takes to fall asleep after the lights have been turned off) with medication at recommended doses -Nonbenzodiazepine hypnotics, which provide immediate relief, are often used for short-term treatment of insomnia -The most common side effects are headache, dizziness, and residual sleepiness -The BzRAs are Schedule IV-controlled substances by federal regulation, have abuse and dependence potential, and produce withdrawal signs and symptoms after abrupt discontinuation -The risk for residual sedation on the day after using hypnotic medication is determined by the dose and rate of elimination -The recommended therapeutic dose for using zolpidem (immediate release) is 5 mg and zolpidem CR is 6.25 mg

Breathing-Related Disorders

-The DSM-5 identifies three breathing disorders, including OSA-hypopnea, central sleep apnea, and sleep-related hypoventilation -The term obstructive sleep apnea syndrome is more commonly used in nonpsychiatric areas

Psychosocial Assessment

-The assessment also includes evaluating the behavioral and social factors related to sleep problems -Though we each respond differently, stressful life events impact the quality and quantity of our sleep -Factors to consider include gender, coping skills, timing and perception of the stressor, and substance use or misuse -Recent changes in relationships, particularly a divorce or death of a loved one, can interfere with sleep significantly -A recent move, travel, and addition of a new family member can impact sleep -Fatigue and stress increase when individuals assume the role of a caregiver in their personal lives and in those with occupations as professional health care providers -A rotating or variable work schedule compromises the circadian rhythm and contributes to insomnia

Substance Use and Medication

-The bidirectionality of insomnia and substances must be acknowledged as substances impact the receptors and neurotransmitters directly involved with sleep-wake regulation -The development of sleep-related issues can be associated with the use of OTC products, such as nicotine and caffeine -Those who use products that are stimulating need to be informed about not only the effects on overall health but also the timing of consumption as it relates to initiating sleep and maintaining sleep and the impact on sleep quality -OTC and prescription medications that have a stimulating effect need to be avoided within 4 hours of sleep initiation -Though alcohol consumption may initially assist in helping individuals fall asleep, ultimately alcohol use impacts sleep architecture and leads to disrupted, poor sleep quality; increases the likelihood of snoring or sleep apnea; and due to the diuretic effects increases restroom visits

Biologic Theories

-The biology of sleep appears to involve dopamine, gamma-aminobutyric acid (GABA), adenosine, histamine, hypocretin, melatonin, and cortisol, which play roles in changing sleep states -Wakefulness is maintained by the reticular activating system in the brain -As the cycle of the reticular activating system dwindles, neurotransmitters that promote sleep take over

Circadian Rhythm Sleep Disorder

-The chief feature of a circadian rhythm sleep disorder is the mismatch between the individual's internal sleep-wake circadian rhythm and the timing and duration of sleep -People with these disorders complain of insomnia at particular times during the day and excessive sleepiness at others -This diagnosis is reserved for those individuals who present with marked sleep disturbance or significant social or occupational impairment

Sleep Homeostasis

-The circadian rhythms are not the only processes that regulate sleep -Sleep homeostasis is an internal biochemical system that operates as a timer or counter that generates pressure to sleep and regulates sleep intensity -This process reminds the body to sleep after a certain time -The longer we have been awake, the stronger the desire and need for sleep becomes and the likelihood of falling asleep increases -The longer we sleep, the pressure to sleep decreases and we are more likely to wake

Hypersomnolence Disorder

-The essential characteristic of hypersomnolence disorder is excessive sleepiness at least three times a week for at least 3 months -Sleepiness occurs on an almost daily basis and causes significant impairment in social and occupational functioning -They have an excessive quantity of sleep, deteriorated quality of wakefulness, and sleep inertia (a period of impaired performance occurring during the sleep-wake transition characterized by confusion, ataxia, or combativeness) -This diagnosis is reserved for individuals who have no other causes of daytime sleepiness (e.g., narcolepsy, OSA syndrome)

Teamwork and Collaboration: Working Toward Recovery for Circadian Rhythm Sleep Disorder

-The goals of treatment of circadian rhythm disorder are to strengthen timed clues (when to go to sleep), timed bright or blue light (stay awake during the day), and timed exogenous melatonin (initiate melatonin secretion at bedtime) -Melatonin is often helpful in initiating sleep -Chronotherapy, timed interventions, manipulates the sleep schedule by progressively delaying bedtime until an acceptable bedtime is attained -Chronopharmacotherapy resets the biologic clock by using medications to induce sleep -Tasimelteon (Hetlioz) is a melatonin receptor agonist that is approved for the treatment of this disorder -Small amounts of hypnotics can also produce high-quality sleep in people who wish to reset their circadian schedules after long transmeridian flights -Conversely, for night shift workers, caffeine taken while working at night improves alertness and performance -However, caffeine should be used judiciously by night shift workers because they become quickly tolerant to the effects after a few nights -Luminotherapy (light therapy) is used to manipulate the circadian system -Timing, wavelength intensity and prior light exposure are key factors when considering light therapy -Commercially prepared light boxes produce therapeutic light at 2500 to 10,000 lux -In contrast, indoor light is about 150 lux

Narcolepsy

-The overwhelming urge to sleep is the primary symptom of narcolepsy -This irresistible urge to sleep occurs at any time of the day, regardless of the amount of sleep -Falling asleep often occurs in inappropriate situations, such as while driving a car or reading a newspaper -These sleep episodes are usually short, lasting 5 to 20 minutes, but may last up to an hour if sleep is not interrupted -Individuals with narcolepsy may experience sleep attacks and report frequent dreaming -They usually feel alert after a sleep attack, only to fall asleep unintentionally again several hours later

Epidemiology and Risk Factors for Obstructive Sleep Apnea

-The prevalence of OSA is worldwide and is said to impact up to one billion adults globally, between the ages of 30 and 69 years, affecting both men and women -OSA is most common in men aged 45 to 65 who are overweight -The female-to-male ratio is estimated to be 1:8, with women becoming more likely to develop this syndrome after menopause -Men are twice as likely to snore as women -Research supports ethnic and racial differences in sleep disturbances -African American individuals and Hispanic individuals have an increased frequency of snoring as compared with White individuals, but the increase may be related to poorer physical health -Lost workplace productivity, motor vehicle accidents, workplace injuries, and increased use of health care services account for some of the societal consequences of untreated OSA -OSA is a risk factor for cardiac events and is commonly associated with metabolic syndrome disorders -OSA is more prevalent in people with mental health disorders than in the general population -Depression, anxiety, PTSD, and bipolar disorder are associated with OSA -The symptoms of depression, such as fatigue, irritability, depressed mood, and poor concentration, are similar to the symptoms of OSA -Evidence suggests that the successfully treated OSA may improve depressive symptoms

Epidemiology and Etiology of Narcolepsy

-The prevalence of narcolepsy is between 20 and 50 per 100,000 people in the United States -The etiology of most cases of narcolepsy is unknown, but it is thought that there are many triggers such as head trauma, viral illness, exposure to toxins, and development factors -In some patients, there is a deficiency of hypocretin, a hypothalamic peptide that may be linked to chromosome 6 in class II human leukocyte antigen -Hypocretin neurons are part of the neurologic system that wakes and maintains wakefulness

Epidemiology and Etiology for Sleep Terrors and Sleepwalking

-The prevalence of sleep terrors is estimated at 6.5% in children and 2.2% in adults -Males and females are affected equally -The prevalence of sleepwalking is 30% in children and 4% in adults -Sleepwalking peaks between 8 and 12 years of age and is more common in males -Fever, stress, and sleep deprivation can increase the frequency of episodes -There appears to be some genetic predisposition for disorders of arousal, and they tend to run in families

Clinical Judgment

-The primary concern is sleep deprivation or insomnia, which can result in depression, cognitive dysfunction, and suicide ideation -It is important to help the patient learn about sleep hygiene and the role that sleeps plays in maintaining health and well-being

Evaluation and Treatment Outcomes

-The primary treatment outcome is establishing a normal sleep cycle -Changes in diet and behavior (e.g., initiation of an exercise program) should be evaluated for their impact on the individual's sleep -Environmental modifications, such as a change in the level of lighting in the bedroom, decreased stimulation (e.g., turning off cell phone or moving the television out of the bedroom), or modification in room temperature, can be monitored for any changes affecting the sleep cycle

Epidemiology and Etiology for Circadian Rhythm Sleep Disorder

-There are no data regarding the prevalence of circadian rhythm disorders in the general population -The prevalence of circadian rhythm disorders among patients diagnosed at sleep disorder centers accounts for 2% or less of the total patients diagnosed -However, this is a gross underestimate, given that jet lag, a circadian rhythm disorder, affects nearly everyone traveling over three time zones -Circadian rhythm disorders are caused by the dissociation of the internal circadian pacemaker and conventional time -The cause might be intrinsic, such as genetic factors called "clock genes" or extrinsic, as in jet lag and shift work -Each result is overwhelming daytime sleepiness and overflowing wakefulness at night

Teamwork and Collaboration: Working Toward Recovery for Obstructive Sleep Apnea

-There are nonsurgical and surgical options for the treatment of patients with OSA -Nonsurgical options vary based on the severity of the obstructive breathing -For obese patients with less severe OSA, weight loss may help -For others, whose apnea is mild, changing sleeping position from supine to lateral can help control the severity of OSA -There has also been some effort in devising an oral appliance to reduce snoring and the occurrence of apnea -Currently, the most effective nonsurgical treatment is continuous positive airway pressure -This treatment takes place during sleep and involves wearing a nose mask that is connected by a long tube to an air compressor -Airway patency is maintained with air pressure -Although this method of treatment is highly effective, compliance can be a problem -Individuals who have severe OSA symptoms and daytime sleepiness are more compliant with CPAP (continuous positive airway pressure) treatment and report an improved quality of life -The most commonly performed surgical procedure to treat patients with OSA is uvulopalatopharyngoplasty -This procedure involves the removal of redundant soft palate tissue, uvula, and tonsillar pillars -The surgery usually eliminates snoring and is judged to be about 50% effective in reducing the amount of sleep apnea -Severity of OSA, body mass index, and pharyngeal anatomic features are factors that impact surgical outcomes

Wellness Strategies

-There are sleep hygiene strategies that specifically promote sleep, but there are many other activities associated with physical and psychological well-being that should also be considered -Eating a healthy diet, avoiding excessive weight gain, and identifying and managing psychological and physical stressors are examples of wellness strategies that promote sleep -Yoga is associated with improvement in sleep quality -Other strategies include relaxation, massage therapy, and meditation

Ethnicity and Culture and Insomnia

-There is not an equal distribution of sleep disorders among race and ethnicity -Underrepresented groups experience less optimal sleep compared to those populations less impacted by health disparities -In addition to poor sleep quality and quantity, underrepresented groups are at increased risk for adverse mental and physical health outcomes, such as diabetes, hypertension, cardiovascular disease, mood disorders, and occupational accidents

Wellness Challenges

-Wellness activities are especially challenging because of the negative impact lack of sleep has on daily life -Wellness can be severely compromised because the person is tired and irritable from lack of sleep -The lack of energy can lead to poor nutrition and inadequate performance at work or school -Coping with everyday stress can be difficult -The nurse can help the patient develop bedtime rituals and good sleep hygiene -Bedtime should be at a regular hour, and the bedroom environment should be conducive to sleep -Preferably, the bedroom should not be where the individual watches television or does work-related activities -The bedroom should be viewed as a room for either resting or sleep -Nonpharmacologic health-promoting interventions are the first choice before administering pharmacologic agents -Sleep hygiene strategies can be effective and should be encouraged -The goal is to normalize sleep patterns to improve well-being

Activity, Exercise, Nutrition, and Thermoregulation Interventions

-With the emergence of smartphones and other portable devices, limiting screen time to within 1 hour of bedtime has been found to improve sleep quality and positively impact daytime vigilance -Exercise promotes sleep, but regular exercise should be planned to end 3 hours before bedtime -Routines are important, especially when preparing your body to sleep -Engaging in a quiet relaxing activity, such as listening to soft music or reading nonstimulating material, is often suggested -Additional interventions include avoiding eating a heavy meal, and avoiding drinking alcohol or caffeinated beverages -Patients should be encouraged to evaluate the temperature of the room -Generally, a cooler environment enhances sleep

Zaleplon (Sonata) Side Effects

Abdominal pain, headache, dizziness, depression, nervousness, difficulty concentrating, back pain, chest pain, migraine, conjunctivitis, bronchitis, pruritus, rash, arthritis, constipation, and dry mouth

Medications and Other Substances and their Effect on Sleep

Alcohol -Increases TST (total sleep time) during the first half of the night -Decreases TST during the second half -Decreases REM sleep during the first half of the night -Withdrawal from long-term use of alcohol decreases TST, increased wakefulness after sleep onset, and REM rebound Amphetamines -Disrupt sleep-wake cycle during acute use -Decrease TST -Decrease REM sleep -Withdrawal may cause REM rebound Antidepressants (Tricyclics and MAOIS) -Sleep effects vary with sedative potential -Increase slow-wave sleep (i.e., a recurrent period of very deep sleep, typically totaling 5 or 6 hours a night) -Decrease REM sleep Barbiturates -Increase TST -Decrease WASO -Decrease REM sleep -Withdrawal may cause a decrease in TST and REM rebound Benzodiazepines -Drugs vary in onset and duration of action -Decrease SL -Increase TST -Decrease WASO -Decrease REM sleep -Daytime sedation may occur with long-acting drugs Beta-Adrenergic Blockers -Decrease REM sleep -Increase WASO, nightmares -Daytime sedation may occur Caffeine -Increases SL -Decreases TST -Decreases REM sleep L-Dopa -Vivid dreams and nightmares Lithium -Increases slow-wave sleep -Decreases REM sleep Opiods -Effects vary with specific agents -Increase WASO -Decrease REM sleep -Decrease slow-wave sleep Phenothiazines -Increase TST -Increase slow-wave sleep Steroids -Increase WASO -MAOI, monoamine oxidase inhibitor; REM, rapid eye movement; SL, sleep latency; TST, total sleep time; WASO, wake after sleep onset.

Medication Interventions

Types of drugs used to treat symptoms of insomnia include benzodiazepine receptor agonists, melatonin receptor agonists, sedating antidepressants, and OTC medications and dietary supplements

Wellness Challenges and Strategies

Coping effectively with daily stresses when not getting adequate sleep -Strategies: Reduce number of activities that require intense concentration Seeking pleasant environments that support well-being -Strategies: Arrange for short periods of "quiet time" throughout the day Recognizing the need for physical activity, healthy foods, and sleep -Strategies: Encourage regular physical activity, discuss healthy diets, encourage establishing healthy sleep hygiene routines Developing a sense of connection, belong, and a support system -Strategies: Seek positive relationships and reduce number of unpleasant interactions

Diagnosis and Clinical Course for Circadian Rhythm Sleep Disorder

Delayed sleep phase type -Individuals with delayed sleep phase type, or "night owls," tend to be unable to fall asleep before 2 AM to 6 AM; hence, their whole sleep patterns shift, and they have difficulty rising in the morning Advanced sleep phase type -Opposite of the night owls, these individuals are "larks" or earlier risers -They are unable to stay awake in the evening and consistently wake up early Irregular sleep-wake type -People with this type have a temporarily disorganized sleep pattern that varies in a 24-hour period Non-24-hour sleep-wake type -Individuals with this type have an abnormal synchronization between the 24-hour light-dark cycle and their endogenous circadian rhythm, which leads to periods of insomnia, excessive sleepiness, or both -This type is most common among blind or visually impaired individuals Shift work type -The endogenous sleep-wake cycle is normal but is mismatched to the imposed hours of shift work -Rotating shift schedules are disruptive because any consistent adjustment is prevented -Compared with day and evening shift workers, night and rotating shift workers have a shorter sleep duration and poorer quality of sleep -They may also be sleepier while performing their jobs -This disorder is further exacerbated by insufficient daytime sleep resulting from social and family demands and environmental disturbances (i.e., traffic noise, telephone) -Because of the job requirements of the profession, nurses often experience this disorder -Furthermore, 20% of the U.S. workforce is engaged in shift work and thereby at risk for circadian rhythm disorders Jet lag type -This type of sleep disturbance occurs after travel across time zones, particularly in coast-to-coast and international travel -The normal endogenous circadian sleep-wake cycle does not match the desired hours of sleep and wakefulness in a new time zone -Individuals traveling eastward are more prone to jet lag because it involves resetting one's circadian clock to an earlier time—it is easier to delay the endogenous clock to a later time period than adjust it to an earlier one

Factors Affecting Sleep Pattern and Quality

Gender, age, environment, and lifestyles

Diagnostic Criteria for Insomnia

Insomnia disorder is characterized by dissatisfaction with sleep quantity or quality and difficulty initiating or maintaining sleep, or in waking early in the morning, and being unable to return to sleep

Sleep Hygiene Tips

Nurses are often involved in helping patients develop and maintain good sleep habits. Teaching tips include the following: 1. The most important healthy sleep habit is to establish and maintain a regular bedtime and rising time. Even if you awaken feeling unrefreshed, get up and out of bed at a regular, consistent time. "Sleeping in" can disturb sleep on the subsequent night. For most, time in bed should be limited to 8 hours 2. Avoid naps 3. Abstain from alcohol. Although alcohol may assist with sleep onset, there is an alerting effect when it wears off 4. Refrain from caffeine after midafternoon. Avoid nicotine before bedtime and during the night. Caffeine and nicotine are strong stimulants and fragment sleep 5. Exercise regularly, avoiding the 3 hours before bedtime. Exercising 6 hours before bedtime tends to strengthen the circadian rhythms of body temperature and sleepiness 6. Use the bedroom only for sleep and sex. Promote the bedroom as a stimulus for sleep, not for studying, watching television, or socializing on the telephone 7. Set a relaxing routine to prepare for sleep. Avoid frustrating or provoking activities before bedtime 8. Provide for a comfortable environment. A cool room temperature, minimal light, and limiting noise are suggested

Ramelteon (Rozerem) Adverse Reactions

Somnolence, dizziness, nausea, fatigue, headache, and insomnia

Gender Differences in Insomnia

Women report a higher prevalence of insomnia as compared to men within the United States and across countries in Europe and Asia