Sleep - Chapter 45

Circadian Regularity

begins to develop by the sixth week of life, and by 3-6 months most infants have a regular sleep/wake cycle.

Psychological Functions of Sleep

being is best noticed by the deterioration in mental functioning related to sleep loss. Individuals with inadequate amounts of sleep tend to become emotionally irritable, have poor concentration, and experience difficulty making decisions.

Elevated body temperatures

can cause some reduction in delta sleep and REM sleep.

Respiratory Conditions

can disturb an individual's sleep. Shortness of breath often makes sleep difficult, and people who have nasal congestion or sinus drainage may have trouble breathing and hence may find it difficult to sleep.

Intervention to promote sleep and rest

can help enhance the rejuvenation and renewal that sleep provides. The following interventions can help promote sleep: • Reduce or eliminate the consumption of caffeine and nicotine. • Be sure their environment is warm and safe, especially if they get out of bed during the night. • Provide comfort measures, such as analgesics if indicated, and proper positioning. • Enhance the sense of safety and security by checking on clients frequently and making sure that the call light is within reach. Answer the call light promptly. • If lack of sleep is caused by medications or certain health conditions, intervention should focus on resolving the underlying problem. • Evaluate the situation and find out what the rest and sleep disturbances mean to the client. They may not perceive sleeplessness to be a serious problem, but will just do other activities and sleep when tired.

Darkness and preparing for sleep

causes a decrease in stimulation of the RAS. During this time, the pineal gland in the brain begins to actively secrete the natural hormone melatonin, and the person feels less alert

The cyclic nature of sleep is controlled by

centers located in the lower part of the brain.

Sleep enhances daytime functioning and is vital for

cognitive, physiological, and psychosocial function

Stimulus Control

creating a sleep environment that promotes sleep

Antihistamines

diphenhydramine (Benadryl) is thought to be safer for older clients, there side effects (atropine-like effects, dizziness, sedation, and hypotension) make them extremely hazardous. In fact, anti-histamines should not be recommended for any client with a history of asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease, or hypertension.

Endocrine disturbances

disturbances can also affect sleep. Hyperthyroidism lengthens presleep time making it difficult for a client to fall asleep. Hypothyroidism decreases stage III sleep.

Sleep-onset REM period

dreaming sleep that occurs within the first 15 minutes of falling asleep happens in patients with narcolepsy

Urination

during the night also disrupts sleep, and people who awaken at night to urinate sometimes have difficulty getting back to sleep

After surgery,

establishing the sleep/wake rhythm is important daytime napping should be allowed and encouraged in hospitalized clients

Sleep Restriction

following a program that limits time in bed in order to get to sleep and stay asleep throughout the night

Quality of Sleep

is a subjective characteristic and is often determined by whether a person wakes up feeling energetic or not

Sundown Syndrome

is not a sleep disorder directly; it refers to a pattern of symptoms (agitation, anxiety, aggression, and sometimes delusions) that occur in the late afternoon. They can last through the night and disturb sleep.

Noradrenaline

is release in the pons

Dopamine

is released in the midbrain

Acetylcholine

is released in the reticular formation

During sleep, the growth hormone

is secreted and cortisol is inhibited.

Quantity of Sleep

is the total time the individual sleeps.

Cognitive Theory

learning to develop positive thoughts and beliefs about sleep

Serotonin

lessens the response to sensory stimulation and GABA to shut off the activity in the neurons of the reticular activating system

Neurons within the reticular formation,

located in the brainstem, integrate sensory information from the cerebral cortex.

People who have gastric or duodenal ulcers

may find their sleep disturbed because of pain, often a result of the increase gastric secretions that occur during REM sleep.

Individual's respond to

meaningful stimuli when sleeping and selectively disregard non-meaningful stimuli.

Within the beginning of daylight,

melatonin is at its lowest level in the body and the stimulating hormone, cortisol, is at its highest

Circadian Synchronization

when a person's biologic clock coincides with the sleep/wake cycles the person is awake when the body temperature is highest, and asleep when the body temperature is the lowest

Adults

• 7-8 hours but individual needs vary • Signs that may indicate that a person is not getting enough sleep include falling asleep or becoming drowsy during a task that is not fatiguing, not able to concentrate or remember information, and being unreasonable irritable with others. It contributes to short-term memory loss and inadequate performance on newly learned tasks. • Multiple jobs sleep pattern of children, pregnancy, menses, and perimenopausal period can also affect sleep patterns.

Drugs that May Cause Excessive Daytime Sleepiness

• Antidepressants • Antihistamines • Beta-blockers • Narcotics

Physiological Changes During NREM Sleep

• Arterial blood pressure falls • Pulse rate decreases • Peripheral blood vessels dilate • Cardiac output decreases • Skeletal muscles relax • Basal metabolic rate decreases 10-30% • Growth hormone levels peak • Intracranial pressure decreases

Infants

• At first, infants awaken every 3-4 hours, eat, and return to sleep. • Periods of wakefulness increase. • By 6 months, most infants sleep through the night (midnite-5am) and begin to establish a pattern of daytime naps. • At the end of the first year, an infant usually takes 2 naps per day and should get about 14-15 hours of sleep in 24 hours. • ½ is light sleep, exhibits a great deal of activity, such as movement, gurgles, coughing. For this reason, parents need to make sure infants are truly awake before feeding or changing. • Putting infants to bed when they are drowsy, helps them to become "self-soothers" and put themselves back to sleep.

Clinical Manifestations of Insomnia

• Difficulty falling asleep • Waking up frequently during the night • Difficult returning to sleep • Waking up too early in the morning • Unrefreshing sleep • Daytime sleepiness • Difficulty concentrating • Irritability

Older Adults

• Earlier bedtime and wake times • Older adults (65-75) usually awaken 1.3 hours earlier and go to bed 1 hour earlier than younger adults • Increase in disturbed sleep that can create a negative impact on QOL, mood, and alertness. • Awaken on average 6 times per night. • Ability becomes more difficult, but need does not decrease. • Circadian rhythm is flattened (advanced sleep phase syndrome) • Have a harder time falling back to sleep and have a diminished amount of REM. • Medical conditions and pain interrupt sleep. Older adults with several medical conditions should speak to their PCP. • They may have a major sleep disorder that is complicating treatment of other conditions. • It is important for the nurse to teach about the connection between sleep, health and aging. • Some older clients may experience sundown syndrome

If awakened,

begin anew at stage 1 NREM sleep and proceeds through all stages to REM

Sleep is characterized by

* minimal physical activity, * variable levels of consciousness, *changes in the body's physiological processes, *decreased responsiveness to external stimuli

Stage 3 of NREM

* the deepest stage of sleep, * different only in the percentage of delta waves recoded during a 30-second period. * During deep sleep or delta sleep, the sleeper's heart and respiratory rate from 20% to 30% below those exhibited during waking hours. *difficult to arouse. *not disturbed by sensory stimuli, *skeletal muscles are very relaxed, *reflexes are diminished, and *snoring is most likely to occur. *is essential for restoring energy and releasing important growth hormones

Stimulants and Alcohol

*Caffeine containing beverages act as stimulants of the CNS. Drinking beverages containing caffeine in the afternoon or evening may interfere with sleep. *People who drink an excessive amount of alcohol often find their sleep disturbed. Alcohol disrupts REM sleep, although it may hasten the onset of sleep. *While making up for lost REM sleep after some of the effects of the alcohol have worn off, people often experience nightmares. The alcohol-tolerant person may be unable to sleep well and become irritable as a result.

Lifestyle

*Following an irregular morning and nighttime schedule can affect sleep. *Moderate exercise in the morning or early afternoon usually is conducive to sleep, but exercise late in the day can delay sleep. *The person's ability to relax before retiring is an important factor affecting the ability to fall asleep. It is best to avoid doing homework or office work before or after getting into bed. *Night shift workers frequently obtain less sleep than other workers and have difficulty falling asleep after getting off work. Wearing dark wraparound sunglasses during the drive home and light blocking shades can minimize the alerting effects of exposure to daylight, thus making it easier to fall asleep when body temperature is rising.

Hospital environments

*Hospital environments can be quite noisy, and special care needs to be taken to reduce noise in the hallways and nursing care units. Some hospitals have instituted quiet times in the afternoon where the lights are lowered and activity and noise is purposefully decreased so clients can rest or nap.

Medications

*Most hypnotics can interfere with deep sleep and suppress REM sleep. *Beta-blockers have been known to cause insomnia and nightmares. *Narcotics, such as morphine, are known to suppress REM sleep and to cause frequent awakenings and drowsiness. *Tranquilizers interfere with REM sleep. *Antidepressants suppress REM sleep, this effect is considered a therapeutic action. In fact, selectively depriving a depressed client of REM sleep will result in immediate but transient improvement in mood. *Clients accustomed to taking hypnotic medications and antidepressants may experience a REM rebound (increased REM sleep) when the medications are discontinued. *Warning clients to expect a period of more intense dreams when these medications are discontinued may reduce their anxiety about this symptom.

Smoking

*Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than non-smokers. *Smokers are usually easily aroused and often describe themselves as light sleepers. *By refraining from smoking after the evening meal, the person usually sleeps better; moreover, many former smokers report that their sleeping patterns improve once they stopped smoking.

Functions of Sleep

*Sleep exerts physiological effect on both the nervous system and other body structures. *It restores normal levels of activity and normal balance among parts of the nervous system. *Sleep is also necessary for protein synthesis, which allows repair processes to occur.

Emotional Stress

*Stress is considered to be one of the greatest causes of difficulties in falling asleep or staying asleep. *A constant exposure to stress will increase the activation of the HPA axis leading to sleep disorders. *A person who becomes preoccupied with personal problems may be unable to relax sufficiently to get to sleep. *Anxiety increases the norepinephrine blood levels through stimulation of the sympathetic nervous system. This chemical change results in less deep and REM sleep and more stage changes and awakenings.

Diet

*Weight gain has been associated with reduced total sleep time as well as broken sleep and earlier awakening. *Weight loss seems to be associated with an increase in total sleep time and less broken sleep. *Dietary L tryptophan - found in cheese and milk - may induce sleep

Neurotransmitters

*are located in the neurons in the brain * affect the sleep/wake smile *are localized within the reticular formation and influence cerebral cortical arousal.

Environment

*can promote or hinder sleep *the absence of usual stimuli or the presence of unfamiliar stimuli can prevent people from sleeping. *Environmental temperature, lack of ventilation, light levels, comfort and size of the bed, and a partner's sleep habits can affect sleep.

REM sleep

*recurs about every 90 minutes and lasts 5 to 30 minutes. *Most dreams take place here but usually will not be remembered unless the person arouses briefly at the end of the REM period. *the brain is highly active, and brain metabolism may increases as much as 20%. *Levels of acetylcholine and dopamine increase, with the highest levels of acetylcholine release occurring during REM sleep. *The type of sleep is also called paradoxical sleep because EEG activity resembles that of wakefulness. *Distinctive eye movements occur, *voluntary muscle tone is dramatically decreased, *deep tendon reflexes are absent. *difficult to arouse or may wake spontaneously, *gastric secretions increase, *heart and respiratory rates often are irregular. *It is thought that the regions of the brain that are used in learning, thinking, and organizing information are stimulated during REM sleep.

Insomnia

*the inability to fall sleep or remain asleep. *do not awaken feeling rested. *most common sleep complaint in America. *Acute insomnia lasts one to several nights and is often caused by personal stressors or worry. *If the insomnia persists for longer than a month, it is considered chronic insomnia. *More often, people experience chronic intermittent insomnia, which means difficulty sleeping for a few nights, followed by few nights of adequate sleep before the problem returns.

Time spent sleeping

1/3 of lives

The health adult usually experiences

4-6 cycles of sleep during 7-8 hours of sleep

A complete sleep cycle usually lasts

90-110 minutes

Sleep is considered

an altered state of consciousness in which the individual's perception of and reaction to the environment are decreased

Common Sleep Disorders

Although sleep disorders are typically categorized for the purpose of research as dyssomnias, parasomnias, and disorders associated with medical or psychiatric illness, it is usually more appropriate for clinicians to focus on the clients symptoms (insomnia, excessive sleepiness, and abnormal events) that occur during sleep (parasomnias).

Factors Affecting Sleep

Illness Environment Lifestyle Emotional Distress Stimulants and Alcohol Diet Smoking Motivation Medications

Excessive Daytime Sleepiness

Clients may experience daytime sleepiness as a result of hypersomnia, narcolepsy, sleep apnea, and insufficient sleep.

Illness

Illness that causes pain or physical distress can result in sleep problems. People who are ill require more sleep than normal, and the normal rhythm of sleep and wakefulness is often disturbed. People deprived of REM sleep subsequently spend more sleep time than normal in this stage.

What is necessary for the regulation of sleep and waking states?

an intact cerebral cortex and reticular formation are necessary for the regulation of sleep and waking states.

Sleep deprivation in hospitalized clients contributes to

anxiety, fear, immunosuppression, inglammation, alteration of sympathetic and parasympathetic equilibrium, and increases insulin resistance.

Hypersomnia

Hypersomnia refers to conditions where the affected individual obtains sufficient sleep at night but still cannot stay awake during the day. Hypersomnia can be caused by medical conditions, for example, CNS damage and certain kidney, liver, or metabolic disorders, such as diabetic acidosis and hypothyroidism. Rarely does hypersomnia have a psychological origin.

Trained Night Feeders

Infants who are fed during the night, or fed until they fall asleep and then put into bed, or who have a bottle left with them in their bed learn to expect and demand middle of the night feedings. Infants who are growing well do not need night feedings after about four months of age. Infants should never be put to bed with a bottle. This practice increases the risk of otitis media. Infants who are diagnosed with failure to thrive may need to be fed at night.

Sleep Disturbances in Children

Learning to sleep alone without the parents help is a skill that all children need to master. Regular bedtime routines and rituals such as reading book help children learn this skill and could prevent sleep disturbance. Trained Night Feeder Sleep Refusal Night Terrors

Sleep Refusal

Many toddlers and young children are resistant to settling down to sleep. This sleep refusal may be due to not being tired, anxiety about separation from the parents, stress, lack of regular sleep routine, the child's temperament, or changes in sleep arrangements.

Motivation

Motivation can increase alertness in some situations. Motivation alone however is usually not sufficient to overcome the normal circadian drive to sleep during the night. Nor is motivation sufficient to overcome sleepiness due to insufficient sleep. A combination of boredom and lack of sleep can contribute to feeling tired.

Sleep Disturbances in Adults

New jobs, pregnancy, and babies are common examples that often disrupt the sleep of a young adult. The sleep patterns of middle-aged adults can be disrupted by the need to take care of older parents and/or chronically ill partners in the home.

Night Terrors

Night terrors are partial awakenings from NREM stage III sleep. They are usually seen in children 3 to 6 years of age. The child may sleep walk, or may sit up in bed screaming and thrashing about. They usually cannot be awakened, but should be protected from injury, helped back to bed, and soothed back to sleep. Babysitters should be alerted to the possibility of a night terror occurring. Children do not remember the incident the next day, and there is no indication of a neurologic or emotional problem. Excessive fatigue and a full bladder may contribute to the problem. Having the child take an afternoon nap and empty the bladder before going to sleep at night may be helpful.

Sleep Disturbances in Older Adults

Some of the leading factors that often are influential in sleep disturbances include the following: • Side effects of medication, • Gastric reflux disease, • Respiratory and circulatory disorders which may cause breathing problems or discomfort, • Pain from arthritis, increased stiffness, or impaired immobility, • Nocturia, • Depression, • Loss of life partner and their close friends. • Confusion related to delirium or dementia.

The first cycle

Stage 1 and 2 of NREM = 20-30 Stage 3 = 50-60 Stage 1 and 2 = 20 REM = 10 minutes or less

Stage 1 of NREM

Stage 1 is the stage of very light sleep and lasts only a few minutes. The person feels drowsy and relaxed, the eyes roll from side to side, and the heart and respiratory rates drop slightly. The sleeper can be readily awakened and may deny having been asleep. Low voltage brain waves are noted.

Stage 2 of NREM

Stage 2 is the stage of sleep during which body processes continue to slow down. The eyes are generally still, the heart and respiratory rates decrees slightly, and body temperature falls. An individual in stage 2 requires more intense stimuli to awaken such as touching or shaking.

Who are vulnerable to not getting enough sleep?

Students, shift workers, travelers, and those with acute stress, depression, or chronic pain

Hypnotic Medications

The long-term efficacy of hypnotic medications is questionable. Such medications do not deal with the cause of the problem, and their prolonged use can create drug dependencies

Two Types of Sleep

are NREM (non rapid eye movement) sleep and REM (rapid eye movements) sleep. During sleep, NREM and REM sleep alternate in cycles.

Drugs that Disrupt Sleep

These drugs may disrupt REM sleep, delay onset of sleep, or decrease sleep time: • Alcohol • Amphetamines • Antidepressants • Beta-blockers • Bronchodilators • Caffeine • Decongestants • Narcotics • Steroids

Treatment for Insomnia

Treatment for insomnia frequently requires client to develop new behavior patterns that induce sleep and maintain it. Stimulus Control Cognitive Theory Sleep Restriction

Wakefulness is also associated with high levels of

acetylcholine, dopamine, and noradrenaline

Circadian Rhythm

a 24-hour internal biologic clock. Sleep and waking cycles, body temperature, blood pressure, and may other physiological functions also follow a circadian pattern

The upper part of the reticular formation consists of

a network of ascending nerve fibers called the reticular activating system (RAS), which is involved with the sleep/wake cycle.

NREM Sleep

occurs when activity in the RAS is inhibited. About 75-80% of sleep during a night is NREM sleep. It is divided into three stages

Women with low estrogen levels

often report excessive fatigue. In addition, they may experience sleep disruptions due to the discomfort associated with hot flashes or night sweats that can occur with reduced estrogen levels.

The two main risk factors for insomnia are

older age and female gender. Women suffer sleeplessness in connection with hormonal changes. The incidence of insomnia increases with age, but it is thought that this is caused by some other medical condition.

Cataplexy

or the sudden onset of muscle weakness or paralysis in association with strong emotion

Sleep Architecture

refers to the basic organization of normal sleep. Changes in the architecture of one's sleep can be linked to physiological or psychosocial changes. i.e. Williams's syndrome is disorder of neurodevelopment that causes cognitive changes and decreased sleep efficacy.

Consequences of chronic sleep loss include

risk of hypertension, diabetes, obesity, depression, heart attack, and stroke.

During the earlier part of the night,

the deep sleep periods are longer.

We require sleep for many reasons

to cope with daily stresses, to prevent fatigue, to conserve energy, to restore the mind and body to enjoy life more fully

School-Age Children

• Need 10-11 hours from 5-12 years but most receive less because of increasing demands. • TV, caffeine, computer, can lead to difficulty falling asleep and fewer hours • Regular and consistent sleep schedule and bedtime routine need to be continued.

Toddlers

• Need 12-14 hours between 1-3 years of age • Still need an afternoon nap but not midmorning naps • May resist going to bed and awaken during the night. • Fears and nightmares common • Security objects helpful • Parents need assurance that if the child has had adequate attention from them during the day, maintaining a daily sleep schedule and consistent bedtime routine will promote good sleep habits for the entire family.

Adolescents

• Need 9-10 hours of sleep from 12-18 years but typically get less • Nurses can teach parents to recognize signs and symptoms that indicate their teen is not getting enough sleep. • Circadian rhythms shift to where they stay up later and wake up later (caused by need for greater independence) • Blue-spectrum light exposure: Internet, TV, and cell phone disrupt ability to fall asleep • Nocturnal emissions in boys several times a month

Preschoolers

• Require 11-13 hours between 3-5 years • Sleep needs fluctuate in relation to activity and growth spurts. • Resist and prolong bedtime • The 4-5 year older may become irritable and restless • Maintain consistent schedule. • Limiting or eliminating TV will reduce the number of nightmares

Newborns

• Sleep 12-18 hours a day, on an irregular schedule with 1-3 hours spent awake. • They enter REM (active) sleep immediately. Rapid eye movements are observable, and body movements and irregular respirations are observed. • NREM (quiet) sleep is characterized by regular resperations, closed eyes, and the absence of body and eye movements. • They spend 50% of their time in each state, and the sleep cycle is about 50 minutes. • They need to be put to bed when they are sleepy but not asleep. • Light and play decreases daytime sleep.