Chapter 8: Sleep and Sleep Disorders PDF

Chapter 8 Sleep and Sleep Disorders  Sleep  State in which a person lacks conscious awareness of environmental surroundings but can be easily aroused  Basic, dynamic, highly organized, complex behavior  Essential for healthy mood, behavior, physical...

Chapter 8 Sleep and Sleep Disorders  Sleep  State in which a person lacks conscious awareness of environmental surroundings but can be easily aroused  Basic, dynamic, highly organized, complex behavior  Essential for healthy mood, behavior, physical functioning and survival  Sleep insufficiency- does not support optimal alertness, functioning, and health  Sleep deprivation – too little sleep to meet needs  Sleep fragmentation – frequent awakenings or arousal (almost wakes) 2 Sleep Disturbances and Disorders  Sleep disturbance  Conditions of poor sleep quality  Caused by health-related or environmental factors  Sleep disorders  Abnormalities unique to sleep Insomnia, OSA, periodic limb movements, circadian sleep disorders, narcolepsy, parasomnias  Often missed or unreported  Cause considerable health, safety, economic consequences 3  Sleep–Wake Cycle (1 of 2)  Controlled by the brain  Cerebral cortex, hypothalamus, thalamus and brainstem interact to regulate the complex sleep-wake cycle  Wake behavior  ARAS and various neurotransmitters activate the cerebral cortex which influences alertness and attention  Negatively affected by some illnesses and certain medications  Decreased orexin (hypocretin) – neuropeptide found in the hypothalamus – leads to narcolepsy 4  Sleep–Wake Cycle (2 of 2)  Sleep behavior  Sleep-promoting neurons in the hypothalamus inhibit the ARAS and promote sleep  Melatonin Hormone made by the pineal gland Linked to the environmental light-dark cycle Turns off the mechanisms that promote wakefulness Light exposure at night can suppress melatonin secretion 5  Circadian Rhythms  24-hour biologic rhythm fluctuations  Regulated by the suprachiasmatic nucleus (SCN) in hypothalamus  Master clock  Synchronizes genetic clocks in individual cells  Regulates the 24-hour sleep-wake cycle  Synchronized through light detectors in retina  Light is the strongest time cue  Light therapy can shift the timing of the sleep-wake rhythm 6  Sleep Architecture  Pattern of nighttime sleep  Recorded with polysomnography (PSG)  EMG (electromyogram) measures muscle tone  EOG (electrooculogram) records eye movements  EEG (electroencephalograph) measures brain activity  Two sleep states  Rapid eye movement (REM)  Non–rapid eye movement (NREM)  4-6 NREM and REM sleep cycles, lasting 60 – 110 minutes, occur once a person falls asleep 7  NREM Sleep  75% to 80% of sleep time  Divided into three stages  N 1—beginning transition from wakefulness to sleep, slow eye movements, easily awakened  N 2—most of night’s sleep, HR and temperature decrease, EEG depicts specific brain wave forms  N 3—deep or slow wave sleep (SWS); EEG shows delta waves that measure sleep intensity 8  REM Sleep  20% to 25% of sleep  Follows NREM  Brain waves resemble wakefulness  Postural muscles inhibited – patient cannot initiate muscle movement  Most vivid dreams occur 9 Effects of Sleep Deprivation and Sleep Disorders Fig. 8.3 10 Sleep Disturbances in the Hospital  Hospitalization  Decreased total sleep time  Disrupted normal sleep stages  Disordered circadian rhythms  Sleep problems can cause delirium, pain intolerance and delayed recovery  Opioids alter sleep quality and place patients at risk for sleep-disordered breathing  Nurses  Create environment to promote sleep  Consider sleep-aid medications 11  Insomnia (1 of 13)  Most common sleep disorder  Affects 1 in 3 adults  Characterized by:  Difficulty falling asleep  Difficulty staying asleep  Waking up too early  Waking up feeling unrefreshed 12  Insomnia (2 of 13) Short-term insomnia disorder  Problems falling asleep or remaining asleep for at least 3 nights/wk for less than 3 months Chronic insomnia disorder  Difficulty falling asleep or remaining asleep for at least 3 nights/wk for 3 months or more  Occurs in 10% of Americans – more common in Women Divorced, widowed and separated than married people Low socioeconomic, less educated individuals 13  Insomnia (3 of 13)  Etiology and pathophysiology  Behaviors  Lifestyle  Diet  Physical and mental conditions  Medications  Once insomnia becomes chronic, symptoms are likely to persist 14  Insomnia (4 of 13)  Manifestations  Difficulty falling asleep (long sleep latency)  Difficulty maintaining sleep (prolonged nighttime awakenings or awakening too early and not being able to fall back to sleep)  Awakening earlier than desired  Avoidance or resistance to scheduled bedtime  Inability to sleep without intervention 15  Insomnia (5 of 13)  Diagnostic studies  Self-Report  Subjective information  1-2 week sleep diary Number and times of naps Times of going to bed, awakening, getting up Number of awakenings Overall sleep quality ratings  Comprehensive sleep history  Actigraphy 16  Audience Response Question (1 of 2) A patient at the outpatient clinic reports insomnia and anxiety. He tells you that he recently lost his job and is not able to pay the bills. Which response would the nurse provide? a. “You are healthy and will be able to find another job.” b. “Can you tell me more about what is happening in your life?” c. “If you stop focusing on your problems, you will sleep better.” d. “Did you receive a severance package from your employer?” 17  Audience Response Question (2 of 2) Answer: B “Can you tell me more about what is happening in your life?” 18  Insomnia (6 of 13)  Interprofessional care  Prevent short-term insomnia from becoming chronic  Treat chronic insomnia  Education on sleep and behavioral strategies  Sleep hygiene – variety of practices important to normal, quality nighttime sleep and daytime alertness  Cognitive-behavioral therapy for insomnia (CBT-I) Avoid or limit naps to 15-20 minutes, once a day, only within 7-9 hours of waking in the morning Regular exercise but not within several hours of bedtime 19  Insomnia (7 of 13)  Interprofessional care  Drug therapy  Individualized for specific patterns of insomnia  Generally recommended for short-term treatment  Can cause day-time impairment  OTC medications can cause dependence  Rebound insomnia – worsening of sleep from abruptly stopping certain sleep medications 20  Insomnia (8 of 13)  Interprofessional care  Drug therapy  Benzodiazepine-receptor agonists Recommended for intermittent, not daily, use for sleep onset and sleep maintenance insomnia Alert – tell patients to stop drug immediately if they experience sleepwalking, sleep driving, or engaging in other activities while not fully awake  Orexin-receptor antagonist Blocks effects of orexin Used for sleep onset or sleep maintenance insomnia 21  Insomnia (9 of 13)  Interprofessional care  Drug therapy  Melatonin receptor agonists Rapid onset medication for insomnia with difficulty falling asleep; not for waking during the night Not always effective  Antidepressants Some tricyclic antidepressants have sedation side effects  Benzodiazepine Hypnotics are not first-line therapy Can cause dangerous sedation with alcohol or other CNS depressants Recommended for 2-3 weeks duration only 22  Insomnia (10 of 13)  Interprofessional care  Complementary and alternative therapies Melatonin—effective for circadian rhythm disorders (jet lag, shift work); not recommended for insomnia; purity concerns in OTC products Herbal remedies need further testing in clinical trials 23  Insomnia (11 of 13)  Assessment  Personal habits and environmental factors contributing to poor sleep  Be sure to ask patients – many don’t tell their HCP about sleep problems  Assess diet and caffeine intake  Identify sleep aids being used – OTC and prescription  Sleep diary  Medical history and mental health problems  Shift work and travel 24  Insomnia (12 of 13)  Clinical Problems  Impaired sleep  Fatigue 25  Insomnia (13 of 13)  Implementation  Care depends on severity and duration of sleep problems  Patient education on sleep hygiene may be helpful but is inadequate for chronic insomnia  CBT-I for chronic insomnia  Decrease caffeine intake  Reduce light and noise; avoid looking at the clock; keep bedroom temperatures cooler  Teach safe use of sleep medications/aids 26 Sleep-Disordered Breathing (SDB)  Abnormal respiratory patterns associated with sleep  Snoring  Apnea – absent respiratory airflow  Hypopnea – reduced respiratory airflow  Causes frequent sleep disruptions and changes in sleep stages  Obstructive sleep apnea (OSA)  Most diagnosed SDB problem  Occurs in about 25% of US adults 27  Obstructive Sleep Apnea (1 of 4)  Also called obstructive sleep apnea-hypopnea syndrome (OSAHS)  Partial or complete upper airway obstruction during sleep Usually occur during REM cycle (airway muscle tone is lowest) Occur repeatedly throughout the night  Apnea >90% cessation of respiratory airflow lasting >10 seconds  Hypopnea 30-90% decrease in airflow 28  How Sleep Apnea Occurs How sleep apnea occurs. A, The patient predisposed to obstructive sleep apnea (OSA) has a small pharyngeal airway. B, During sleep, the pharyngeal muscles relax, allowing the airway to close. Lack of airflow results in repeated apneic episodes. C, Continuous positive airway pressure (CPAP) splints the airway open, preventing airflow obstruction. (Modified from LaFleur Brooks M: Exploring medical language: a student-directed approach, ed 8, St Louis, 2012, Mosby.) Figure 8.4 29  Obstructive Sleep Apnea (2 of 4)  No single cause for OSA  Multiple factors affect airway patency and muscle tone  Risk factors Obesity - [BMI] greater than 30 kg/m2 Older than age 65 Neck circumference >16 inches Male Postmenopausal women 30  Case Study (1 of 4)  52-year-old man enters his provider’s office with his wife.  She is concerned because he seems to stop breathing in his sleep.  He weighs 280 pounds and drinks alcohol regularly. 31  Obstructive Sleep Apnea (3 of 4)  Manifestations  Frequent arousals during sleep  Insomnia  Excessive daytime sleepiness  Witnessed apneic episodes  Snoring  Morning headache  Irritability  Personality changes 32  Case Study (2 of 4)  What risk factors does the patient have for sleep apnea?  Can he decrease his risk factors? 33  Obstructive Sleep Apnea (4 of 4)  Serious health consequences if untreated  Hypertension  Type 2 diabetes  Dysrhythmias  CHD  Arteriosclerosis  Heart failure  Mortality  Impact on ADLs 34  Case Study (3 of 4) 1. Based on potential complications of sleep apnea, what assessment data will you obtain on this patient? 2. What patient teaching could be beneficial to this patient at this time? 35  Diagnostic Studies  Sleep and medical history  Manifestations highly suspicious of OSA  Berlin questionnaire  STOP-BANG questionnaire  Sleepiness associated with OSA  Epworth Sleepiness Scale 36  Clinical Sleep Laboratory  PSG study  Electrodes measure sleep stages and wakefulness Chest and abdominal movement Oral and nasal airflow SpO2 Limb movements EEG HR 37  Apnea-Hypopnea Index  AHI  Hourly average of apneic events or hypopneas of at least 10 seconds’ duration  OSA Diagnosis  AHI > 5 events/hour with 3-4% decrease in O2 saturation  Severe apnea can have > 30-50 apneic events per hour of sleep 38  Nursing and Interprofessional Management: Sleep Apnea (1 of 6)  Behavioral Treatment  Mild sleep apnea (AHI of 5-10) Positional therapy: Sleeping on one’s side Elevating head of bed Weight loss Avoiding sedatives and alcohol 3 to 4 hours before sleep  Teach safety  Suggest support group  Refer for insomnia treatment when indicated 39  Nursing and Interprofessional Management: Sleep Apnea (2 of 6)  Medical Devices  Severe sleep apnea (>15 apnea/hypopnea events/hr) Continuous Positive Airway Pressure (CPAP) Nasal or oral-nasal mask attached to a high-flow blower Benefits are dose-dependent based on length of use Effective, but poor adherence  2/3 users have nasal stuffiness  Adherence = 5 days or more/week with at least 4 hours of use/night 40  Devices for Sleep Apnea Examples of positive airway pressure devices for sleep apnea. A, Patient wearing a nasal mask and headgear (positive pressure only through nose). B, Patient wearing nasal pillows (positive pressure only through nose). C, Patient wearing a full face mask (positive pressure to nose and mouth). 41  Nursing and Interprofessional Management: Sleep Apnea (3 of 6)  Medical Devices  Bilevel positive airway pressure (BiPAP)  Delivers higher inspiration pressure and lower expiration pressure  May be better tolerated 42  Nursing and Interprofessional Management: Sleep Apnea (4 of 6)  Medical Devices  Assess patient knowledge  Involve bed partner in teaching  Assess nasal resistance  Involve patient in choices  During hospitalization Be aware of treatments that worsen OSA symptoms (sedatives, opioid analgesics) Determine if device is needed during stay and if patient can bring their own  Consider use of oral appliances as an alternative 43  Nursing and Interprofessional Management: Sleep Apnea (5 of 6)  Surgical treatment is done to reduce collapsibility and increase patency of upper airway  Uvulopalatopharyngoplasty (UPPP or UP3) Removal of obstructing tissue from tonsillar pillars, uvula and posterior soft palate  Genioglossal advancement and hyoid myotomy (GAHM) Advances the attachment of muscular part of tongue on the mandible UPPP is usually done with GAHM 44  Nursing and Interprofessional Management: Sleep Apnea (6 of 6)  Surgical treatment  Radiofrequency ablation (RFA) Least invasive Done alone or in combination with other surgical techniques  New: Neurostimulators Effectiveness and safety are still being tested More expensive option  Postop complications Airway obstruction and hemorrhage Teaching is important – usually discharged within 1 day Follow-up includes repeat PSG in 3-4 months 45  Case Study (4 of 4)  The provider orders a sleep study.  After the study, the patient is diagnosed with sleep apnea.  He returns to the office to learn his results, where he is given a CPAP machine. 46  Audience Response Question (1 of 2) An older adult patient in the hospital has sleep deprivation. Which intervention may improve sleep patterns for this patient? a. Decrease noise and dim the lights at bedtime. b. Administer an opioid pain medication to induce sleep. c. Set the room temperature at 78°F to induce drowsiness. d. Offer to give the patient a back massage until he falls asleep. 47  Audience Response Question (2 of 2) Answer: A Decrease noise and dim the lights at bedtime. 48 Periodic Limb Movement Disorder (PLMD) (1 of 2)  PLMS – periodic limb movements in sleep  Involuntary, repetitive  Usually involves legs; rarely involves arms  May involve abdominal, oral and nasal movement  Typically occur for 0.5-10 seconds in intervals separated by 5-90 seconds  Results in poor-quality sleep and excessive daytime sleepiness  Unknown cause 49 Periodic Limb Movement Disorder (PLMD) (2 of 2)  Diagnosed with detailed history and PSG  Medications are used to reduce or eliminate limb movements or arousals  Benzodiazepines (clonazepam) – improve sleep quality  Valproic acid – reduces muscle activity  Selegiline – dopaminergic agent  Dopamine agonists are often used but their effectiveness for PLMD is less understood than their usefulness in treatment RLS 50  Circadian Rhythm Disorders  Circadian time-keeping system loses synchrony with environment  Disrupts sleep-wake cycle and quality of sleep  Jet lag disorder Most commonly when crossing at least 3 time zones Severity and recovery time increased with number of zones Melatonin and daylight exposure help to resynchronize the body’s rhythm  Shift work sleep disorder  Common symptoms  Insomnia, excessive sleepiness 51  Narcolepsy (1 of 3)  Chronic neurologic disorder  Brain unable to regulate sleep–wake cycles normally  Causes uncontrollable urges to sleep  Often go directly into REM sleep; have fragmented and disturbed nighttime sleep  Cause unknown  Associated with destruction of neurons that produce orexin (thought to be an autoimmune process)  Onset usually in adolescence or early 20’s 52  Narcolepsy (2 of 3)  Two types:  Type 1—with cataplexy  Type 2—without cataplexy  Cataplexy  Brief and sudden loss of skeletal muscle tone  Can manifest as a brief episode of muscle weakness or complete postural collapse and falling  Often triggered by laughter, anger, or surprise  Treated with antidepressants (tricyclics and SSRIs)  Diagnosed by: history, PSG, multiple sleep latency tests (MSLTs) 53  Narcolepsy (3 of 3)  No cure  Management focuses on excessive daytime sleepiness, nighttime sleep disturbance, cataplexy  Teach sleep and sleep hygiene Take 2-3 short (15-20 minutes) naps throughout day  Patient safety precautions  Prescribed medication plan Modafinil (Provigil) and armodafinil (Nuvigil) – nonamphetamine wake-promotion drugs are 1st-line choices Wakix (histamine receptor) and Sunosi (inhibits norepinephrine and dopamine reuptake) are new Sodium oxybate (Xyrem) - daytime sleepiness and cataplexy 54  Parasomnias (1 of 3)  Unusual and often undesirable behaviors that occur while falling asleep, transitioning between sleep stages, or during arousal from sleep  Due to CNS activation  Involve complex behaviors  Generally goal directed yet patient not aware or conscious of the act(s)  Fragmented sleep and fatigue 55  Parasomnias (2 of 3)  Arousal parasomnias – occur during NREM sleep  Sleepwalking—sit up in bed, move objects, walk around, drive car May not speak Limited or no awareness of event No memory of event upon wakening Can be misinterpreted as ICU psychosis  Sleep terrors (night terrors)—sudden awakening; loud cry and signs of panic Increased HR and respirations; diaphoresis ICU related sleep disruption and deprivation, fever, stress, exposure to noise and light can contribute 56  Parasomnias (3 of 3)  Nightmare—recurrent awakening with recall of frightful or disturbing dream  Usually occur during REM in final third of sleep  Medications used to treat critically ill Sedative-hypnotics β-adrenergic antagonists Dopamine agonists Amphetamines 57 Gerontologic Considerations: Sleep (1 of 3)  Older age is associated with  Overall shorter total sleep time  Decreased sleep efficiency  More awakenings  Amount of needed sleep does not change with age  Some sleep disorders increase with age  Circadian sleep timing can shift with age  Sleepy earlier in evening; awaken earlier in morning 58 Gerontologic Considerations: Sleep (2 of 3)  Increased symptoms of insomnia occur with  Depression, CV disease, pain, cognitive problems  Chronic conditions common in older adults COPD, diabetes, dementia, chronic pain, cancer  Prescribed and OTC medications Cough and cold remedies (pseudoephedrine) Caffeine-containing drugs Drugs with nicotine 59 Gerontologic Considerations: Sleep (3 of 3)  Increased fall risk and injury  Increased cognitive disturbances  Under-reporting and under-diagnosing  Sleep assessment is important  Great caution with use of sleep medications  Metabolism of hypnotic drugs decreases with aging  Avoid long-acting benzodiazepines  Diphenhydramine is sedating Note OTC medications labeled “PM” 60  Special Sleep Needs of Nurses  Alternating and rotating day/night shifts can be associated with  Decreased job satisfaction  Less social engagement  More job related stress  Permanent night or rapidly rotating shifts  Increased risk for shift work sleep disorder Insomnia, sleepiness, fatigue  Sleep debt grows with repeated inadequate sleep  Chronic fatigue has implications for nurse’s health and patient safety 61  Altered Synchrony  Disruption of synchrony between circadian rhythms and the environment - increased  Morbidity and mortality risks from CV problems  Mood disorders  Nursing mistakes and accidents  Distortion of perceptual skills, judgment and decision- making abilities  Patient errors  Decreased coping skills 62  What Can We Do?  Be aware of potential problems & use sleep hygiene  Brief periods of napping  Maintain a consistent sleep-wake schedule (even on days off)  Sleep just before working night shift Increases alertness and vigilance Improves reaction times Decreases accidents during work  Be involved in setting work schedules 63