sleep disorders Chapter 20

treatment of primary insomnia

•use of medications such as alprazolam (Xanax), •chlordiazepoxide (Librium or Novapam), •triazolam (Halcion) Increasingly, melatonin is being used by the elderly to deal with insomnia. Long-term use of the above hypnotics is not encouraged due to the potential addiction.

Primary Hypersomnia (dyssomnias)

*Excessive sleepiness for at least 1 month, evidenced by either prolonged sleep episodes or daytime sleep episodes that occur almost daily and cause significant distress and social and vocational impairment*. Key diagnostic features to this diagnosis are a report of *continuous yet unrefreshing and non-restorative sleep and difficulty waking up, either in the morning or at the end of a nap*. Some patients with this disorder can sleep up to 20 hours a day. Diagnosis is determined by clinical evaluation and PSG and MSLT. *Treatment is through lifestyle modification and stimulant medication*.

Restless Legs Syndrome (RLS) (dyssomnias)

A sensory and movement disorder characterized by an unpleasant, uncomfortable sensation in the legs (occasionally the arms and trunk are affected) accompanied by an urge to move. Symptoms begin or worsen during periods of inactivity and are relieved or reduced by physical activity such as walking, stretching, or flexing. Symptoms are worse in the evening and at bedtime and can have a significant impact on the individual's ability to fall asleep and stay asleep. Symptoms may be induced or exacerbated by serotonergic agents such as SSRIs or SNRIs. Diagnosis is determined by clinical evaluation. Many patients with RLS also have periodic limb movements of sleep that are observed during PSG. *Treatment is through lifestyle modification and dopamine agonist therapy, such as pramipexole and ropinirole*.

sleep walking (parasmonias)

Also referred to as somnambulism. Consists of a sequence of complex behaviors that begin in the first third of the night during deep NREM sleep (stages 3 and 4) and usually progress (without full consciousness or later memory) to leaving bed and walking about (may include dressing, going to the bathroom, screaming, and even driving). Because of the possibility of accident or injury, somnambulism in adults should be evaluated by a sleep specialist. PSG is sometimes indicated to rule out the possibility of an underlying disorder of sleep fragmentation. *Treatment consists of instructing the patient and family regarding safety measures such as alarms or locks on windows and doors and gating stairways. Attention to sleep hygiene, limiting alcohol prior to bed, obtaining adequate amounts of sleep, and stress reduction is helpful*.

primary insomnia

Behavioral therapies - There are nonpharmacological interventions, including various relaxation therapies. Cognitive-behavioral therapy for insomnia or CBT-I which includes educational, behavioral, and cognitive components. Educational components - include providing education related to sleep and sleep needs and helping the individual set realistic expectations about sleep. The individual needs to be asked questions about the understanding of what is healthy sleep and any misconceptions found need to be clarified. This is also how you as a nurse are able to get information regarding the individual's quality of sleep rather than the number of hours spent sleeping. Behavioral components - with this there is a need to modify poor sleep habits and establish a regular sleep/wake schedule. Having the individual keep a sleep diary for approximately a 2 week period will assist in establishing overall sleep patterns and determining overall sleep efficacy. We defined sleep efficacy before as the ratio of sleep duration to time spent in bed or as total sleep time/total time in bed x 100. Sleep restriction and stimulus control are a couple of behavior modifications used. Sleep restriction is limiting the total sleep time thus creating a temporary, mild state of sleep deprivation and strengthening the sleep homeostatic drive. It is important to not to reduce sleep to below f hours regardless of sleep efficiency. Stimulus control is the adherence to five basic principles in order to decrease the negative associations between the bed and bedroom and strengthen the stimulus for sleep. Cognitive components - this is an important component in that it is aimed at identifying and correcting maladaptive attitudes and beliefs regarding sleep that perpetuates insomnia. Many times individuals will rationalize maladaptive coping behaviors like spending excessive time in bed to "catch up" on lost sleep and then exhibit unrealistic expectations about sleep. It is the therapist's duty to offer alternative interpretations regarding the individuals' sleep complaints in order to get them to think in a different way about their insomnia, thus empowering them to be in control of their sleep.

REM Sleep Behavior Disorder (RSBD) (parasomnias)

Characterized by absence of muscle atonia during sleep. Patients with this disorder display elaborate motor activity associated with dream mentation. These patients are actually acting out their dreams. RSBD is most frequently seen in elderly men but can be seen as the heralding symptom of neurological pathology such as Parkinson's disease. Serotonergic medications (such as SSRIs or SNRIs) can induce or exacerbate episodes. Diagnosis is determined by clinical evaluation and PSG with video recording. *Treatment focuses on patient and sleep partner safety. Placing the mattress on the floor is sometimes necessary to prevent injury as a result of falling out of bed. The use of intermediate-acting benzodiazepine can be helpful, especially in cases of severe disruption to the sleep partner and concerns about safety*.

nightmare disorder (parasomina)

Characterized by long, frightening dreams from which people awaken scared. They almost always occur during rapid eye movement (REM) sleep and usually after a long REM period late in the night. For some people, this is a lifetime condition; for others nightmares occur at times of stress and illness. Diagnosis is determined by clinical evaluation. PSG is sometimes necessary to rule out the possibility of an underlying disorder of sleep fragmentation such as obstructive sleep apnea. Treatment is dependent on the frequency and severity of the symptoms, as well as the underlying cause. *Treatment with hypnotic therapy is sometimes indicated. Many patients do well with lifestyle modification measures, attention to sleep hygiene, and stress reduction*.

sleep disorders due to medical conditions

For instance, conditions accompanied by pain and discomfort, such as arthritis and cardiovascular and pulmonary disease, are frequently associated with insomnia. Insomnia is also associated with neoplasms, vascular lesions, infections, and degenerative and traumatic conditions. Chronic fatigue syndrome and hypothyroidism have been associated with hypersomnia. The relationship between chronic medical disorders and sleep disturbance highlights the importance of screening patients with medical disorders for sleep complaints. The treatment is directed at the underlying medical condition

primary insomnia

Most common sleep complaint Difficulty with sleep initiation Sleep maintenance Early awakening Non-refreshing, non restorative sleep these individuals have *difficulty falling asleep and staying asleep*. It is considered the most common types of complaints about sleep. This type of sleep is also *non-restorative and non-refreshing*. This condition must last for 1 month and not be related to any known physical or medical condition. It is known as a state of constant hyperarousal which involves biological, psychological, and social factors. It is important for a complete medical, psychiatric, and substance use history be done. There is a specific model that is used to access the causes of insomnia, suggest interventions and provide the rationale for treatment. This is called Spielman's 3P Model of insomnia. The 3Ps are predisposing, precipitating, and perpetuating factors.

Sleep Disorders Related to Other Mental Disorders

Insomnia related to another mental disorder Hypersomnia related to another mental disorder Major depressive disorder Anxiety disorders Schizophrenia There are sleep disorders related to other mental disorders. They are: Insomnia related to another mental Axis 1 or Axis 2 disorder and Hypersomnia related to another mental Axis 1 or Axis 2 disorder. These disorders produce significant functional problems in social, occupational, and other important areas. These individuals can be so preoccupied with a sleep disorder that they tend to ignore the symptoms of the related mental health disorder or completely deny having a mental health disorder. Insomnia related to another mental disorder - Individuals with major depressive disorder and anxiety disorder may frequently experience insomnia. Those individuals with schizophrenia often have prolonged sleep latencies and other sleep difficulties. Hypersomnia related to another mental disorder - occurs in many mental conditions including mood disorders. Daytime sleepiness is seen in individuals with depression, bipolar 1 disorder, and uncomplicated grief can be temporarily connected to hypersomnia. Personality disorders, dissociative disorders, somatoform disorders, and others can be associated with hypersomnia. The treatment is focused on treating the primary mental health disorder.

Circadian Rhythm Sleep Disorder (dyssomnias)

Persistent or recurrent pattern-of-sleep disruption resulting from altered function of the circadian timing system or from a mismatch between the individual's natural circadian sleep/wake cycle and external demands regarding the timing and duration of sleep, such as in those who do shift work or experience jet lag. Diagnosis is determined by clinical evaluation, sleep diaries, and actigraphy. Treatment is with aggressive lifestyle management strategies aimed at adapting to or modifying the required sleep schedule.

primary sleep disorders (Dyssomnias)

Primary insomnia Primary hypersomnia Narcolepsy Breathing-related sleep disorders Circadian rhythm disorders Dyssomnias not otherwise specified Restless legs syndrome

Precipitating factors (primary insomnia)

are external events that trigger insomnia. They may be personal and vocational difficulties, medical and psychiatric disorders, grief, and changes in role or identity such as that seen in retirement.

Other Sleep Disorders

Sleep disorders due to a general medical condition Substance-induced sleep disorders In both sleep disorders, sleep disturbance may be Insomnia Hypersomnia Parasomnia Combination The last two sleep disorders are: sleep disorders due to a general medical condition and substance-induced sleep disorders. These individuals report sleep disturbances for example insomnia, hypersomnia, parasomnia, or a combination of the disturbances. Sleep disorders due to a general medical condition - medical conditions such as those that are related to pain and discomfort can be complicated by the presence of insomnia. Some of these medical conditions include arthritis, angina, neoplasms, vascular lesions, infections, and degenerative and traumatic conditions just to name a few. The treatment consists of addressing the underlying medical condition. Substance-induced sleep disorders - a substance-induced sleep disorder can result from the use or recent discontinued use of a substance whether it is drugs or alcohol. Alcohol, nicotine, and caffeine all have an effect on the quality and quantity of sleep. There can be insomnia, hypersomnia, parasomnia, or a combination of the sleep disturbances.

Interventions for Primary Insomnia

Sleep hygiene - conditions and practices that promote continuous and effective sleep Behavioral therapies Educational components Behavioral components Cognitive components Some instances - hypnotic medication •Maintain a regular sleep/wake schedule. •Develop a pre-sleep routine that signals the end of the day. •Reserve the bedroom for sleep and a place for intimacy. •Create an environment that is conducive to sleep remember to take into consideration light, temperature, and clothing. •Avoid clock watching. •Limit caffeinated beverages to 1 or 2 a day and none in the evening. •Avoid heavy meals before bedtime. •Use alcohol cautiously, and avoid use for several hours before going to bed. There could be the inclusion of not smoking for several hours before bed also. •Avoid daytime napping. •Exercise daily, but not right before bed. You will find that the first week of exercise one is very tired, but as the routine develops, it actually invigorates you.

consequences of sleep

The major consequence of acute or chronic sleep curtailment is *excessive sleepiness* (ES). ES is a subjective report of difficulty staying awake that is serious enough to impact social and vocational functioning and increase the risk for accident or injury. While self-imposed sleep restriction is a common cause of ES, disruption of the normal sleep cycle (as seen in shift work), underlying sleep disorders, medications, alcohol, and many medical disorders are important causes of excessive sleepiness. After a poor night's sleep, *we feel tired, lethargic, and out of synch*. The effects of chronic sleep deprivation may be less obvious but may have a greater overall impact on health and well-being. A discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning is responsible for a state of sleep deprivation, which has widespread implications for health, safety, and quality of life. Adults who sleep less than 6 hours a night are more likely to *report fair to poor general health, frequent physical distress, frequent mental distress, limitations in activities of daily living, depressive symptoms, anxiety, and pain* Sleep loss *diminishes safety and results in the loss of lives and property*. Sleepiness while driving has become a national epidemic, with almost 20% of all *serious car accidents* being associated with driver sleepiness Sleep deprivation can produce psychomotor impairments equivalent to those induced by alcohol consumption at or above the legal limit. Daytime wakefulness in excess of 17 to 19 hours can produce psychomotor deficits equivalent to blood alcohol concentrations (BACs) between 0.05% and 0.1% (the legal limit in most states is 0.08%)

sleep paralysis (parasmonias)

The sensation of paralysis at sleep onset or upon awakening. The patient describes a complete awareness of their surroundings but is unable to move. For many patients, sleep paralysis is associated with extreme anxiety and even panic. For a number of patients, these events are rare or isolated and do not require any long-term treatment. Reassurance that the sensation is harmless and temporary is helpful. For those individuals with more frequent or severe episodes, further evaluation and treatment by a sleep specialist is warranted. Because sleep paralysis can be seen in patients with narcolepsy, screening for this sleep disorder is indicated.

sleep requirements

Varies from individual to individual Long sleepers Require more than 10 hours of sleep each night Short sleepers Can function effectively on fewer than 5 hours of sleep per night

parasomnias

are sleep disorders that are characterized by *unusual or undesirable behaviors or events that occur during sleep/wake transitions, certain stages of sleep, or during arousal from sleep*. These individuals *do not complain about insomnia or daytime sleepiness*. Many times these individuals may not even be aware of the condition and it is another individual such as a family member or friend that report it.

dyssomnias

are sleep disturbances associated with the initiation and maintenance of sleep or of excessive sleepiness.

Perpetuating factors (primary insomnia)

are sleep practices and attributes that maintain the sleep complaint for example excessive caffeine or alcohol use, spending excessive amounts of time in bed or napping, and worry about the consequences of insomnia.

Predisposing factors (primary insomnia)

are those individual factors that create a vulnerability to insomnia such as prior history of poor-quality sleep, history of depression and anxiety, or a state of hyperarousal. The patients that are at risk to develop insomnia may describe themselves as light sleepers and night owls.

substance-induced sleep disorders

can result from the use or recent discontinuance of a substance or medication. While it is quite obvious that many prescriptions and over the counter medications may affect sleep, there is less appreciation for the effects of commonly used substances on sleep. Alcohol, nicotine, and caffeine all have an impact on sleep quantity and quality. Alcohol—despite its great soporific effects—decreases deep sleep (stage 3 and 4) and REM sleep and is responsible for middle-of-the-night awakenings with difficulty returning to sleep. Nicotine is a central nervous system stimulant, increasing heart rate, blood pressure, and respiratory rate. As nicotine levels decline through the night, patients wake in response to mild withdrawal symptoms. Caffeine blocks the neurotransmitter adenosine, promoting wakefulness. It increases sleep latency, reduces slow wave sleep, and acts as a diuretic, causing middle-of-the-night awakening for urination

Narcolepsy (dyssomnias)

includes *episodes of irresistible attacks of refreshing sleep, cataplexy (muscle weakness), sleep paralysis, and hypnagogic hallucinations*. impairing degrees of excessive sleepiness, not all patients experience cataplexy, sleep paralysis, and hypnagogic hallucinations, making diagnosis sometimes difficult. is distinguished from primary hypersomnia in that patients with narcolepsy generally *feel refreshed upon awakening*. Associated symptoms include disturbed nighttime sleep with multiple middle-of-the-night awakenings and automatic behaviors characterized by memory lapses. Diagnosis is determined by clinical evaluation and PSG and MSLT. *Treatment is through lifestyle modifications and stimulant medication*.

Breathing-Related Sleep Disorder (dyssomnias)

obstructive sleep apnea, which is characterized by repeated episodes of *upper airway collapse and obstruction that result in sleep fragmentation*. Essentially, patients with obstructive sleep apnea are not able to sleep and breathe at the same time. *Typical symptoms include loud, disruptive snoring, witnessed apnea episodes, and excessive daytime sleepiness*. Obesity is an important risk factor for obstructive sleep apnea. Diagnosis is determined by clinical evaluation and PSG. *Treatment is with continuous positive airway pressure (CPAP) therapy*.

Sleep Disorders Related to Other Mental Disorders

there are two distinct classifications of sleep disorders associated with major mental disorders: insomnia related to another mental disorder (axis I or axis II) and hypersomnia related to another mental disorder (axis 1 or axis II). An additional diagnosis of a sleep disorder is made when the sleep disturbance is sufficiently severe to warrant independent clinical attention . Patients with this type of insomnia or hypersomnia tend to focus on their sleep and ignore the symptoms of the related mental disorder, even to the point of denying that they have a mental disorder. It is not unusual for patients to present to a sleep disorders center for a sleep evaluation and later be diagnosed with a primary psychiatric disorder. For example, patients with major depressive disorder frequently experience insomnia that involves relatively normal sleep onset followed by repeated awakenings during the second half of the night and early-morning awakening. This is usually followed by a difficult mood in the morning. Patients point to the sleep disruption as the cause of the mood disturbance and report that if they could just get a good night's sleep, the mood symptoms would improve. Difficulty with sleep latency is common with all anxiety disorders, and it is not usual for patients with a previously undiagnosed anxiety disorder to present for treatment of an insomnia complaint of lifelong duration. Management of the underlying anxiety diagnosis in conjunction with the insomnia complaint results in the best clinical outcome. Finally, patients with schizophrenia have prolonged sleep latencies, sleep fragmentation, and multiple middle-of-the-night awakenings. Poor health habits such as excessive caffeine use, smoking, and inattention to a regular sleep schedule contribute to sleep complaints. As a result of many of the medications used to treat schizophrenia, these patients are at increased risk for the development of obstructive sleep apnea due to weight gain. Hypersomnia related to another mental disorder is seen in many mental conditions, including mood disorders. Many patients report excessive daytime sleepiness in the beginning stages of a mild depressive disorder. A similar complaint is characteristic of the depressed phase of bipolar I disorder. Uncomplicated grief may temporarily be associated with hypersomnia. Personality disorders, dissociative disorders, somatoform disorders, and dissociative fugue are all associated with hypersomnia. Generally speaking, treatment is directed at the primary disorder

sleep hygiene

• Maintain a regular sleep/wake schedule. • Develop a pre-sleep routine that signals the end of the day. • Reserve the bedroom for sleep and a place for intimacy. • Create an environment that is conducive to sleep (taking into consideration light, temperature, and clothing). • Avoid clock watching. • Limit caffeinated beverages to 1 or 2 a day and none in the evening. • Avoid heavy meals before bedtime. • Use alcohol cautiously, and avoid use for several hours before bed. • Avoid daytime napping. • Exercise daily but not right before bed.

Parasomnias

•Unusual or undesirable behaviors or events •Occur during Sleep/wake transitions Certain stages of sleep Arousal from sleep Categories of parasomnias •Nightmare disorder •Sleep walking •REM sleep behavior disorder •Sleep paralysis