Rest and Sleep Needs PDF

NURS 3000 - Professional Nursing Rest and Sleep Needs Rest and Sleep Needs Harding University - Active Learning Guide, Module 8 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respo...

NURS 3000 - Professional Nursing Rest and Sleep Needs Rest and Sleep Needs Harding University - Active Learning Guide, Module 8 Name: Sean Whitfield Instructions Complete the module active learning guide as you work through the module content. Take notes, answer the questions on the guide, and respond to any case studies and client scenarios. All of these activities will assist in your preparation for exams, help you plan and implement care in the clinical setting, and facilitate your development as a Christian nurse servant. You will submit your completed guide to the instructor at the end of the week. The completed learning guide will be worth a maximum of 10 points. If you have questions or are unsure about your answers; or you may email your instructor for clarification. Note: The Active Learning Guide provides a general outline of topics covered in this module; it is not all inclusive of all information needed for the exam. You are responsible for all content in readings and activities throughout the module. I. Rest and Sleep Needs: Chapter 45: Sleep 1. Describe the physiology of sleep-in terms you understand. Sleep is the reduced level of consciousness and reaction to external stimuli and environment. This is enabled due to the change in the physiological process. Neurotransmitter activity is reduced, the pineal gland secretes melatonin, growth hormone is secreted and cortisol is inhibited. Box 45.1 Physiologic 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% to 30%. Growth hormone levels peak. Intracranial pressure decreases. 2. What is the role of the circadian rhythm in regulation of sleep? Circadian Rhythms Biological rhythms exist in plants, animals, and humans. In humans, these are controlled from within the body and synchronized with environmental factors, such as light and darkness. The NURS 3000 - Professional Nursing Rest and Sleep Needs most familiar biological rhythm is the circadian rhythm. It is a sort of 24-hour internal biological clock. The term circadian is from the Latin circa dies, meaning “about a day.” Although sleep and waking cycles are the best known of the circadian rhythms, body temperature, blood pressure, and many other physiologic functions also follow a circadian pattern and are affected by changes in sleep patterns. Chronic sleep loss can lead to cardiovascular morbidity, obesity, and metabolic dysfunction (Morgenthaler et al., 2016). 3. Describe the two types of sleep, comparing purpose and what occurs during each type. NREM: NREM Sleep NREM sleep occurs when activity in the RAS is inhibited. About 75% of sleep during a night is NREM sleep. NREM sleep was previously divided into four stages. It is now divided into three stages. Each of the stages is associated with distinct brain activity and physiology. Stage 1 is the stage of very light sleep and lasts only a few minutes. During this stage, the individual 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 that he or she was sleeping. Lowvoltage brain waves are noted in stage 1 (National Sleep Foundation, 2018). 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 decrease slightly, and body temperature falls. An individual in stage 2 requires more intense stimuli than in stage 1 to awaken, such as touching or shaking. Stage 3 is the deepest stage of sleep, differing only in the percentage of delta waves recorded during a 30 second period. During deep sleep or delta sleep, the sleeper’s heart and respiratory rates drop 20% to 30% below those exhibited during waking hours. The sleeper is difficult to arouse. The individual is not disturbed by sensory stimuli, the skeletal muscles are very relaxed, reflexes are diminished, and snoring is most likely to occur. This stage is essential for restoring energy and releasing important growth hormones (Box 45.1). REM: REM Sleep REM sleep usually recurs about every 90 minutes and lasts 5 to 30 minutes. Most dreams take place during REM sleep but usually will not be remembered unless the individual arouses briefly at the end of the REM period. During REM sleep, the brain is highly active, and brain metabolism may increase as much as 20%. For example, during REM sleep, levels of acetylcholine and dopamine increase, with the highest levels of acetylcholine release occurring during REM sleep. Because both of these neurotransmitters are associated with cortical activation, it makes sense that their levels would be high during dreaming sleep. This type of sleep is also called paradoxical sleep because electroencephalogram (EEG) activity resembles that of wakefulness. Distinctive eye movements occur, voluntary muscle tone is dramatically decreased, and deep tendon reflexes are absent. In NURS 3000 - Professional Nursing Rest and Sleep Needs this phase, the sleeper may be difficult to arouse or may wake spontaneously, gastric secretions increase, and 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. 4. What happens during a normal sleep cycle? Sleep Cycles During a sleep cycle, individuals typically pass through NREM and REM sleep, the complete cycle usually lasting about 90 to 110 minutes in adults. In the first sleep cycle, a sleeper usually passes through the first two stages of NREM sleep in a total of about 20 to 30 minutes. Stage 3 lasts about 50 to 60 minutes. After stage 3 NREM, the sleep passes back through stages 2 and 1 over about 20 minutes. Thereafter, the first REM stage occurs, lasting about 10 minutes, completing the first sleep cycle. It is not unusual for the first REM period to be very brief or even skipped entirely. How many cycles does a person usually experience during a sleep period? The healthy adult sleeper usually experiences four to six cycles of sleep during 7 to 8 hours (Figure 45.1). What happens if a person is awakened during a period of sleep? The sleeper who is awakened during any stage must begin anew at stage 1 NREM sleep and proceed through all stages to REM sleep. 5. What is the effect of smartphones on sleep quality? Smartphones are just like computers. Parents and adolescents should be instructed to leave the phone in another area of the home to enhance sleep outcomes. 6. What factors affect sleep in the older adult? The quality of sleep is often diminished in older adults. Some of the leading factors that often are influential in sleep disturbances include the following: Side effects of medications Gastric reflux disease Respiratory and circulatory disorders, which may cause breathing problems or discomfort Pain from arthritis, increased stiffness, or impaired mobility Nocturia Depression Loss of life partner or close friends Confusion related to delirium or dementia. Discuss interventions to promote more effective sleep-in older adults. See Lifespan Considerations: Sleep Disturbances p. 1145 Interventions to promote sleep and rest can help enhance the rejuvenation and renewal that sleep provides. The following interventions can help promote sleep: NURS 3000 - Professional Nursing Rest and Sleep Needs Reduce or eliminate the consumption of caffeine and nicotine. Be sure the environment is warm and safe, especially if clients 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, interventions should focus on resolving the underlying problem. Evaluate the situation and find out what the rest and sleep disturbances mean to the client. The client may not perceive nighttime sleeplessness to be a serious problem, and will just do other activities and sleep when tired. 7. List and discuss factors which affect sleep: Illness: Illness that causes pain or physical distress (e.g., arthritis, back pain) can result in sleep problems. Individuals who are ill require more sleep than normal, and the normal rhythm of sleep and wakefulness is often disturbed. Individuals deprived of REM sleep subsequently spend more sleep time than normal in this stage. Respiratory conditions can disturb an individual’s sleep. Shortness of breath often makes sleep difficult, and individuals who have nasal congestion or sinus drainage may have trouble breathing and hence may find it difficult to sleep. Individuals who have gastric or duodenal ulcers may find their sleep disturbed because of pain, often a result of the increased gastric secretions that occur during REM sleep. Certain endocrine disturbances can also affect sleep. Hyperthyroidism lengthens presleep time, making it difficult for a client to fall asleep. Hypothyroidism, conversely, decreases stage 3 sleep. Women with low levels of estrogen often report excessive fatigue. In addition, they may experience sleep disruptions due, in part, to the discomfort associated with hot flashes or night sweats that can occur with reduced estrogen levels. Elevated body temperatures can cause some reduction in delta sleep and REM sleep. The need to urinate during the night also disrupts sleep, and individuals who awaken at night to urinate sometimes have difficulty getting back to sleep. Environment: Environment can promote or hinder sleep. The individual must be able to achieve a state of relaxation prior to entering a period of sleep. Any change, such as noise in the environment, can inhibit sleep. The absence of usual stimuli or the presence of unfamiliar stimuli can prevent individuals from sleeping. Hospital environments can be quite noisy, and special care needs to be taken to reduce noise in the hallways and nursing care units. In fact, some hospitals have NURS 3000 - Professional Nursing Rest and Sleep Needs instituted “quiet times” in the afternoon on nursing units where the lights are lowered and activity and noise are purposefully decreased so clients can rest or nap. Discomfort from environmental temperature (e.g., too hot or cold) and lack of ventilation can affect sleep. Light levels can be another factor. An individual accustomed to darkness while sleeping may find it difficult to sleep in the light. Another influence includes the comfort and size of the bed. An individual’s partner who has different sleep habits, snores, or has other sleep difficulties may become a problem for the individual also. Lifestyle: Following an irregular morning and nighttime schedule can affect sleep. Moderate exercise in the morning or early afternoon is usually conducive to sleep, but exercise late in the day can delay sleep. The individual’s ability to relax before retiring is an important factor affecting the ability to fall asleep. It is best, therefore, 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 in the bedroom can minimize the alerting effects of exposure to daylight, thus making it easier to fall asleep when body temperature is rising. Emotional stress: Stress is considered by most sleep experts to be the one of the greatest causes of difficulties in falling asleep or staying asleep. Clients who are consistently exposed to stress will increase the activation of the hypothalamic–pituitary–adrenal (HPA) axis leading to sleep disorders. An individual who becomes preoccupied with personal problems (e.g., school- or job-related pressures, family or marriage 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. Stimulants: Caffeine-containing beverages act as stimulants of the central nervous system (CNS). Drinking beverages containing caffeine in the afternoon or evening may interfere with sleep. Individuals 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, individuals often experience nightmares. The alcoholtolerant individual may be unable to sleep well and become irritable as a result. Diet: Weight gain has been associated with reduced total sleep time as well as broken sleep and earlier awakening. Weight loss, on the other hand, seems to be associated with an increase in total sleep time and less broken sleep. Dietary L-tryptophan—found, for example, in cheese and NURS 3000 - Professional Nursing Rest and Sleep Needs milk—may induce sleep, a fact that might explain why warm milk helps some individuals get to sleep. Smoking: Nicotine has a stimulating effect on the body, and smokers often have more difficulty falling asleep than nonsmokers. Smokers are usually easily aroused and often describe themselves as light sleepers. By refraining from smoking after the evening meal, the individual usually sleeps better; moreover, many former smokers report that their sleeping patterns improved once they stopped smoking. Motivation: Motivation can increase alertness in some situations (e.g., a tired individual can probably stay alert while attending an interesting concert or surfing the web late at night). 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. Medications: Main effects of medications, including alcohol and caffeine, on the sleep cycle: Some medications affect the quality of sleep. 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. Although antidepressants suppress REM sleep, this effect is considered a therapeutic action. In fact, selectively depriving a depressed client of REM sleep will result in an immediate but transient improvement in mood. Clients accustomed to taking hypnotic medications and antidepressants may experience a REM rebound (increased REM sleep) when these 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. Boxes 45.3 and 45.4, respectively, list drugs that can disrupt sleep or cause excessive daytime sleepiness. Box 45.3, Drugs That Disrupt Sleep These drugs may disrupt REM sleep, delay onset of sleep, or decrease sleep time: Alcohol - 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, individuals often experience nightmares. The alcohol-tolerant individual may be unable to sleep well and become irritable as a result. Amphetamines - amphetamines have been used to reduce excessive daytime sleepiness. Xanthines, such as caffeine, stimulate the cerebral cortex to increase alertness. Antidepressants - suppress REM sleep, this effect is considered a therapeutic action. In fact, selectively depriving a depressed client of REM sleep will result in an immediate but transient improvement in mood. Antidepressants, both older monoamine oxidase inhibitors (MAOIs) and NURS 3000 - Professional Nursing Rest and Sleep Needs the newer serotonergic antidepressants, are usually quite effective for controlling cataplexy. Modafinil (Provigil) has psychoactive effects to alter mood, perception, and thinking to control excessive daytime sleepiness in narcoleptic clients. Clients accustomed to taking hypnotic medications and antidepressants may experience a REM rebound (increased REM sleep) when these 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. Beta-blockers - Beta blockers have been known to cause insomnia and nightmares. Bronchodilators – help open up your airways or cough suppressants to reduce nighttime coughing. Caffeine - stimulate the cerebral cortex to increase alertness. Decongestants - can cause restlessness and insomnia. Narcotics - such as morphine, are known to suppress REM sleep and to cause frequent awakenings and drowsiness. Tranquilizers interfere with REM sleep. Steroids - Sleep disruption caused by exogenous administration of steroids is thought to trigger other psychostimulant effects, such as mood swings, nervousness, psychoses, and delirium. Box 45.4 Drugs That May Cause Excessive Daytime Sleepiness These drugs may be associated with excessive daytime sleepiness: Antidepressants – See definition above Antihistamines – Antihistamines that make you sleepy can be useful as a sleep aid once in a while. But tolerance to the effects of these antihistamines develops quickly. Beta blockers – See definition above. Narcotics – See definition above. 8. Common Sleep Disorders: Insomnia - is described as the inability to fall asleep or remain asleep. Individuals with insomnia do not awaken feeling rested. Insomnia is the 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, individuals experience chronic-intermittent insomnia, which means difficulty sleeping for a few nights, followed by a few nights of adequate sleep before the problem returns (National Sleep Foundation, n.d.i). See Box 45.5 for symptoms of insomnia. The two main risk factors for insomnia are older age and female gender (National Sleep Foundation, n.d.e). Women suffer sleep loss in connection with hormonal changes (e.g., menstruation, pregnancy, and menopause). The incidence of insomnia increases with age, but it is thought that this is caused by some other medical condition. Excessive Daytime Sleepiness - Clients may experience excessive daytime sleepiness as a result of hypersomnia, narcolepsy, sleep apnea, and insufficient sleep. 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 psychologic origin. NURS 3000 - Professional Nursing Rest and Sleep Needs Narcolepsy - is a disorder of excessive daytime sleepiness caused by the lack of the chemical hypocretin in the area of the CNS that regulates sleep. Clients with narcolepsy have sleep attacks or excessive daytime sleepiness, and their sleep at night usually begins with a sleep-onset REM period (dreaming sleep occurs within the first 15 minutes of falling asleep). The majority of clients also have cataplexy or the sudden onset of muscle weakness or paralysis in association with strong emotion, sleep paralysis (transient paralysis when falling asleep or waking up), hypnagogic hallucinations (visual, auditory, or tactile hallucinations at sleep onset or when waking up), and/or fragmented nighttime sleep. Their fragmented nocturnal sleep is not the cause of their excessive daytime sleepiness; many clients, particularly younger clients, have sound restorative nocturnal sleep but still cannot stay awake during the daytime. Onset of symptoms tends to occur between ages 15 and 30, and symptom severity usually stabilizes within the first 5 years of onset. Sleep Apnea - is characterized by frequent short breathing pauses during sleep. Although all individuals have occasional periods of apnea during sleep, more than five apneic episodes or five breathing pauses longer than 10 seconds per hour is considered abnormal and should be evaluated by a sleep medicine specialist. Symptoms suggestive of sleep apnea include loud snoring, frequent nocturnal awakenings, excessive daytime sleepiness, difficulties falling asleep at night, morning headaches, memory and cognitive problems, and irritability. Although sleep apnea is most frequently diagnosed in men and postmenopausal women, it may occur during childhood. The periods of apnea, which last from 10 seconds to 2 minutes, occur during REM or NREM sleep. Frequency of episodes ranges from 50 to 600 per night. Because these apneic pauses are usually associated with an arousal, clients frequently report that their sleep is nonrestorative and that they regularly fall asleep when engaging in sedentary activities during the day. Insufficient sleep - Healthy individuals who obtain less sleep than they need will experience sleepiness and fatigue during the daytime hours. Depending on the severity and chronicity of this voluntary, albeit unintentional sleep deprivation, individuals may develop attention and concentration deficits, reduced vigilance, distractibility, reduced motivation, fatigue, malaise, and occasionally diplopia and dry mouth. The cause of these symptoms may or may not be attributed to insufficient sleep, because many Americans believe that 6.8 hours of sleep is sufficient to maintain optimal daytime performance. In fact, the sleep times of Americans have decreased dramatically during the past decade, with adults averaging only 6.8 hours of sleep on weekdays and 7.4 hours on weekends. All age groups, not just adults and adolescents, are getting less than the recommended amounts of sleep. Even 4- to 5-year-old children now average less than 9.5 hours of sleep, approximately 1.5 to 2.5 hours less than recommended. Parasomnias - is behavior that may interfere with sleep and may even occur during sleep. It is characterized by physical events such as movements or experiences that are displayed as emotions, perceptions, or dreams. The International Classification of Sleep Disorders subdivides parasomnias into three classes: non–rapid eye movement, rapid eye movement, and miscellaneous with no specific stage of sleep (Judd & Sateia, 2019). Parasomnias with non–rapid NURS 3000 - Professional Nursing Rest and Sleep Needs eye movement are associated with confusion upon arousal, sleep tremors, and sleep walking. Parasomnias with rapid eye movement are associated with arousal disorders such as sleep paralysis. This may be a nightmare disorder with exaggerated features of REM sleep. Miscellaneous parasomnias are not associated with any stage of sleep and may produce nocturnal enuresis or hallucinations. The miscellaneous parasomnias are often related to a medication, substance abuse, or a medical disorder. Box 45.6 describes examples of parasomnias. 9. Sleep History: What should be included? When do you usually go to sleep? And when do you wake up? Do you nap? If so, when? If the client is a child, it is also important to ask about bedtime rituals. This information provides the nurse with information about the client’s usual sleep duration and preferred sleep times, and allows for the incorporation of the client’s preferences in the plan of care. Do you have any problems with your sleep? Has anyone ever told you that you snore loudly or thrash around a lot at night? Are you able to stay awake at work, when driving, or engaging in your usual activities? These questions elicit information about sleep complaints including the possibility of excessive daytime sleepiness. Loud snoring suggests the possibility of obstructive sleep apnea, and any client replying yes to this question should be referred to a specialist in sleep disorders medicine. Referrals should also be made if clients indicate they have difficulty staying awake during the day or that their movements disturb the sleep of their bed partners. Do you take any prescribed medications, over-the-counter (OTC) medications, or herbal remedies to help you sleep? Or to stay awake? This information alerts the nurse to the use of prescription hypnotics and stimulants as well as the use of OTC sleep aids and herbal remedies. Is there anything else I need to know about your sleep? This allows the client to voice any concerns or bring up topics that the nurse may not have asked about. 10. Nursing Interventions to promote sleep: Bedtime Rituals - Most individuals are accustomed to bedtime rituals or presleep routines that are conducive to comfort and relaxation. Altering or eliminating such routines can affect a client’s sleep. Common prebedtime activities of adults include listening to music, reading, taking a soothing bath, and praying. Children need to be socialized into a presleep routine such as a bedtime story, holding onto a favorite toy or blanket, and kissing everyone goodnight. Sleep is also usually preceded by hygienic routines, such as washing the face and hands (or bathing), brushing the teeth, and voiding. Environment: Box 45.7 Reducing Environmental Distractions in Hospitals ◦ Close window curtains if street lights shine through. NURS 3000 - Professional Nursing Rest and Sleep Needs ◦ Close curtains between clients in semiprivate and larger rooms. ◦ Reduce or eliminate overhead lighting; provide a night light at the bedside or in the bathroom. ◦ Use a flashlight to check drainage bags, the client’s identification, dressings, and IV infusions, without turning on the overhead lights. ◦ Ensure a clear pathway around the bed to avoid bumping the bed and jarring the client during sleeping hours. ◦ Close the door of the client’s room. ◦ Adhere to agency policy about times to turn off communal televisions or radios. ◦ Lower the ringtone of nearby telephones. ◦ Discontinue use of the paging system after a certain hour (e.g., 2100 hours) or reduce its volume. ◦ Keep required staff conversations at low levels; conduct nursing reports or other discussions in a separate area away from client rooms. Wear rubber-soled shoes. Ensure that all cart wheels are well oiled. Perform only essential noisy activities during sleeping hours. Make sure the bed linen is smooth, clean, and dry. Assist or encourage the client to void before bedtime. Offer to provide a back massage before sleep. Position dependent clients appropriately to aid muscle relaxation, and provide supportive devices to protect pressure areas. ◦ Schedule medications, especially diuretics, to prevent nocturnal awakenings. ◦ For clients who have pain, administer analgesics 30 minutes before sleep. ◦ Listen to the client’s concerns and deal with problems as they arise. ◦ ◦ ◦ ◦ ◦ ◦ ◦ Promoting Comfort and Relaxation - Comfort measures are essential to help the client fall asleep and stay asleep, especially if the effects of the client’s illness interfere with sleep. A concerned, caring attitude, along with the following interventions, can significantly promote client comfort and sleep: ◦ Provide loose-fitting nightwear. ◦ Assist clients with hygienic routines. Client Teaching: Promoting Sleep p. 1152 Medications - Enhancing Sleep with Medications Sleep medications often prescribed on a prn (as-needed) basis for clients include the sedative– hypnotics, which induce sleep, and antianxiety drugs or tranquilizers, which decrease anxiety and tension. When prn sleep medications are ordered in institutional settings, the nurse is responsible for making decisions with the client about when to administer them. These medications should be administered only with complete knowledge of their actions and effects and only when indicated. NURS 3000 - Professional Nursing Rest and Sleep Needs Both nurses and clients need to be aware of the actions, effects, and risks of the specific medication prescribed. Although medications vary in their activity and effects, considerations include the following: ◦ Sedative-hypnotic medications produce a general CNS depression and an unnatural sleep; REM or NREM sleep is altered to some extent, and daytime drowsiness and a morning hangover effect may occur. Some of the new hypnotics, such as zolpidem (Ambien), do not alter REM sleep or produce rebound insomnia when discontinued. ◦ Antianxiety medications decrease levels of arousal by facilitating the action of neurons in the CNS that suppress responsiveness to stimulation. These medications are contraindicated in pregnant women because of their associated risk of congenital anomalies, and in breastfeeding mothers because the medication is excreted in breast milk. ◦ Sleep medications vary in their onset and duration of action and will impair waking function as long as they are chemically active. Some medication effects can last many hours beyond the time that the client’s perception of daytime drowsiness and impaired psychomotor skills have disappeared. Clients need to be cautioned about such effects and about driving or handling machinery while the drug is in their system. ◦ Sleep medications affect REM sleep more than NREM sleep. Clients need to be informed that one or two nights of increased dreaming (REM rebound) are usual after the drug is discontinued after long-term use. ◦ Initial doses of medications should be low and increases added gradually, depending on the client’s response. Older adults, in particular, are susceptible to side effects because of their metabolic changes; they need to be closely monitored for changes in mental alertness and coordination. Clients need to be instructed to take the smallest effective dose and then only for a few nights or intermittently as required. ◦ Regular use of any sleep medication can lead to tolerance over time (e.g., 4 to 6 weeks) and rebound insomnia. In some instances, this may lead clients to increase the dosage. Clients must be cautioned about developing a pattern of drug dependency. ◦ Abrupt cessation of barbiturate sedative-hypnotics can create withdrawal symptoms such as restlessness, tremors, weakness, insomnia, increased heart rate, seizures, convulsions, and even death. Long-term users need to taper their medications under the supervision of a specialist.