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Sleep Disorders

A 45-year-old man presented with sleep disturbances including heavy snoring, difficulty sleeping, and sleep talking, compounded by a high caffeine intake. His BMI of 30.24 suggests possible obesity-related sleep apnea, and the assessment indicates a need for further examination of his sleep patterns and possible insomnia or hypersomnia. Recommendations for management include a thorough medical history, sleep hygiene education, and potential lifestyle modifications.

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A 45-years old gentleman visited the OPD clinic with c/o heavy snoring in the night, difficulty in sleeping, disturbed sleep timings, sleeping late and waking late in the morning, sleep talking, sudden jerky movements while asleep and occasional sleepless nights. O/E, BMI was 30.24 and had a shorter neck. He looked tired and sleepy. On subjective assessment, he mentioned his tea intake was 10cups across the day and the last cup was around 8pm in the night. He did not have any relevant medical history
What history needs to be taken? What are the points should be assessed during examination? What is the possible diagnosis? What is your action as a Nurse?
Nearly one third of human life is spent in sleep!
Sleep Disorders
Sleep: It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
Purpose of sleep Energy conservation : Decreased metabolism to allocate limited energy resources Restorative function : Tissue repair and protien synthesis Immune function regulation : Sleep boosts immunity Memory consolida tion Synaptic hemostasis
The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases: 1.D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep. 2. S-sleep (synchronised sleep), also called as NREM-sleep (non- REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person first passes through these stages of NREM-sleep.
Brain waves Stages Type of brainwave Frequency of brainwave Time Spent Type of sleep 0 Alpha Rhythm 8 to 12 cycles per second 2-5% Awake 1 Beta rhythm 18 to 25 cycles per second 5 to 10 minutes (5%) Non – REM 2 Theta Rhythm 4 to 7 cycles per second Almost half of sleep cycle (50%) 30-60 min Non – REM 3 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 20 to 40 min Non – REM 4 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 15 to 30 min Non – REM 5 Beta rhythm 18 to 25 cycles per second 20% REM
Circadian Rhythms (Biological Clock)
Circadian Rhythms (Biological Clock)
Circadian Rhythms (Biological Clock)
Neuro-chemical influences on circadian rhythm [sleep – wake cycle]: Serotonin • Induction of sleep Serotonin & Norepinephrine • Non-REM Sleep Acetylcholine • REM GABA • Regulation of sleep & arousal Histamine • Prolongs REM Sleep
Sleep Need and Age
Age group Sleeping Time REM Sleep Percentage Miscellaneous Neonates 16 hours of sleep a day, sleeping almost constantly during 1st week, sleep cycle is generally 40 to 50 min 50% as it stimulates higher brain function Awakening occurs after 1 or 2 sleep cycles. Infants [after 3 months] Several naps during day, sleeps 8 to 10 hours at night with total 15 hours sleep. 30% Awakening commonly occurs early in the morning but can awake at night also. Toddlers By age 2, children usually sleep through night and take daily naps. After 3 years, usually give up daytime naps. Total sleep almost 12 hours a day. 20% Common to awaken at night. Toddler may unwilling to go to bed at night due to a need for autonomy or a fear of separation from their parents. Pre – schoolers 12 hours 20% The pre-schoolers usually have difficulty relaxing or quieting down after long, active days and has problem with bedtime fears, waking during the night or nightmares. Partial awakening followed by normal return to sleep is common. In waking period, the child exhibit crying, walking around, unintelligible speech, sleep walking or bed wetting.
Age group Sleeping Time REM Sleep Percentage Miscellaneous School age children 6 years - 11 years 11 to 12 hours 9 to 10 hours 20% They go to bed doing some quiet activities. They resist sleeping because of an unawareness of fatigue or a need to be independent. Adolescents 7 hours 30 mins 20% Shortened sleep time due to busy schedule leads to EDS. Young adults 6 hours to 8 hours and 30 min of sleep 20% Insomnia and use of drugs to sleep is common. Middle adults Sleeping time declines. Stage 4 sleep falls. 20% Insomnia is common because of stress or changes, anxiety, depression, menopause can cause sleep disturbances. Older adults Decrease in stage 3 and stage 4 / no stage 4 20-10% Awakens more often at night and it takes more time to fall asleep, tendency for nap increases.
Sleep Patterns Long Sleepers >9 Hours Short sleepers <6 Hours
ICD-10 Classification F51 Non-organic sleep disorders F51.0 Non-organic insomnia F51.1 Non-organic hypersomnia F51.2 Non-organic disorder of the sleep-wake cycle F51.3 Sleep walking F51.4 Sleep terrors F51.5 Nightmares F51.8 Other non-organic sleep disorders F51.9 Non-organic sleep disorders, unspecified
Dyssomnias Dyssomnias are sleep disorders that are characterized by disturbances in the amount, quality or timing of sleep. These are the commonest disorders of sleep.
Dyssomnias Insomnia Hypersomnia Disorders of sleep-wake schedule Parasomnias Stage IV disorders Other disorders
Prevalence of Insomnia • More than 33% of adults experience insomnia intermittently • 10-22% suffer chronic sleep difficulties • Prescriptions for sleep aids increased by nearly 300% during same period
Insomnia Insomnia is also known as the Disorder of Initiation and/or Maintenance of Sleep ( DIMS). This includes frequent awakening during the night and early morning awakening. Insomnia means one or more of the following: 1. Difficulty in initiating sleep (going-off to sleep). 2. Difficulty in maintaining sleep (remaining asleep). This can include both: a. Frequent awakenings during the night, and b. Early morning awakening. 3. Non-restorative sleep where despite an adequate duration of sleep, there is a feeling of not having rested fully (poor quality sleep).
Causes Medical illnesses • Any painful or uncomfortable illness • Heart disease • Respiratory diseases • Brain stem or hypothalamic lesions • Delirium • Rheumatic and other musculoskeletal diseases • Periodic movements in sleep • Oldage • Rheumatic and musculo-skeletal disease • PMS ( Periodic movements in sleep)
Alcohol and drug use • Delirium tremens • Amphetamines or other stimulants • Chronic alcoholism • Drug or alcohol withdrawal syndrome Current medication • e.g. fluoxetine, steroids, theophylline, propranolol
Psychiatric disorders • Mania (due to decreased need for sleep,(may not complain of decrease in sleep, as there is often a decreased need for sleep) • Major depression (early morning awakening or late insomnia,difficulty in maintenance of sleep is more prominent, although diffifi culty in initiating sleep is also present) • Dysthymia or neurotic depression (difficulty in initiating sleep or early insomnia) • Schizophrenia and other psychoses (due to psychotic symptoms) • Anxiety disorder (difficulty in initiating sleep due to worrying thoughts)
Social causes • Financial loss • Separation or divorce • Death of spouse or a close relative • Retirement • Stressful life situations (may cause temporary insomnia).
Behavioral causes • Naps during the day • Irregular sleeping hours • Lack of physical exercise • Excessive intake of beverages in the evening, e.g. coffee • Disturbing environment (heat, cold, noise) Idiopathic insomnia One cause of insomnia, PMS ( periodic movements in sleep) needs further mention. PMS actually consists of two different syndromes, which often occur together: 1. Periodic Limb Movement Disorder (PLMD), and 2. ‘ Restless Legs’ Syndrome (RLS or Ekbom syndrome).
Treatment of Insomnia A person suffering from insomnia should be differentiated from a short-sleeper, who needs less than 6 hours of sleep per night and has no symptoms or dysfunction. A short- sleeper does not need any treatment. 1. A thorough medical and psychiatric assessment. 2. Treatment of the underlying physical and/or sychiatric disorder, if present. 3.Withdrawal of current medications, if any.
Sleep Hygiene 1. Regular, daily physical exercises (preferably not in the evening). 2. Minimise daytime napping. 3. Avoid fluid intake and heavy meals just before bedtime. 4. Avoid caffeine intake (e.g. tea, coffee, cola drinks) before sleeping hours. 5. Avoid regular use of alcohol (especially avoid use of alcohol as a hypnotic for promoting sleep). 6. Avoid reading or watching television while in bed. 7. Sleep in a dark, quiet, and comfortable environment. 8. Regular times for going to sleep and waking-up 9. Try relaxation techniques 10. Backrubs, warm milk and relaxation exercises.
Sleep hygiene to maintain sleep – wake cycle: Sleep – wake pattern Environment Medications Diet Physiological / Illness Factors
Medications for treatment of insomnia
Sleep Diary It is a record of a patient’s sleepand wake patterns is meant to capture sleep wake information over several weeks. Patients can be instructed to record the information by themselves or it can be recorded by a caregiver. It aims to measure the pattern and quality of sleep, and factors that may affect patient’s sleep. General Instruction for the Patient • Fill the diary every day for minimum two weeks • Generally, fill the diary after one hour of getting up from the bed in the morning • Be as specific as you can • If you forget to fill the diary on a particular day, leave it blank for that day • Make brief notes of anything unusual which has affected your sleep in the diary
Sleep Diary • Each row corresponds to 24 hours (from noon today to noon tomorrow) • Each column corresponds to 1 hour • Shade in the time you are actually sleeping • Arrow down ( ↓ ) when you get in bed • Arrow up ( ↑ ) when you get out of bed
Non-drug treatment for insomnia • Progressive relaxation. • Autosuggestion. • Meditation, yoga. • Stimulus control therapy: do not use the bed for reading or chatting - go to bed for sleep only.
Hypersomnia Hypersomnia is also known as Dis order of excessive somnolence ( DOES). Hypersomnia means one or more of the following: 1. Excessive day time sleepiness. 2. ‘ Sleep attacks’ during day time (falling asleep unintentionally). 3. ‘ Sleep drunkenness’ (person needs much more time to awaken; and during this period is confused or disoriented).
Causes of hypersomnia 1. Medical illnesses i. Narcolepsy (in about 25% of all patients with hypersomnia) ii. Sleep apnoea (in about 50% of all patients with hypersomnia) iii. Kleine-Levin syndrome iv. Menstrual-associated somnolence v. Sleep deprivation vi. Following or with insomnia vii. Encephalitis viii. Hypothyroidism ix. Head Injury x. Cerebral tumours in the region of mid-brain xi. Hypothalamic lesions xii. Trypanosomiasis xiii. PMS ( Periodic movements in sleep); in about 10% of all patients with hypersomnia. 2. Alcohol and drug use i. Stimulant withdrawal ii. Alcohol intoxication iii. Use of CNS depressant medications. 3. Psychiatric disorders i. Dysthymia ii. Atypical depression iii. Seasonal mood disorder. 4. Idiopathic hypersomnia
Treatment 1. A thorough physical and psychiatric assessment. 2. Treatment of the underlying cause is the most important method. 3. Associated or underlying insomnia should be looked for and treated. 4. Withdrawal of current medication causing hypersomnia, especially depressant medication. 5. Benzodiazepines at night may paradoxi cally decrease hypersomnia by correcting night time insomnia.
Disorders of Sleep-wake Schedule(F51.2) The person with this disorder is not able to sleep when he wishes to, although at other time he is able to sleep adequately. Causes • Work shifts • Jet Lag • Unusual sleep phases • Unspecified
Treatment No specific treatment is usually needed. Benzodiazepines may be needed for short-term correc tion of insomnia. Changes in ‘work-shifts’ may be needed for persons with unusual sleep phases. Exposure to sunlight during outdoor activity (instead of staying indoors) and adopting the local (new) hours for sleeping (and working) can help in combating jet lag.
Classification of Stage IV Sleep Disorders • Sleep walking (somnambulism) • Night terrors • Sleep-related enuresis • Bruxism (tooth-grinding) • Sleep talking (somniloquy) • REM sleep behaviour disorders • Sleep related head banging
Treatment Since benzodiazepines suppress stage 4 of NREM- sleep, a single dose at bedtime usually provides relief from stage 4 parasomnias.
Other Sleep Disorders  Nocturnal angina  Nocturnal asthma  Nocturnal seizures Sleep related cluster headaches and chronic paraxysmal hemicranias Sleep related abnormal swallowing syndrome Sleep related gastroesophageal reflex  Sleep paralysis Nightmares ( dream anxiety disorder) Paraxysmal nocturnal hemoglobinuria Substance induced sleep disorders
Examination in sleep apnea • Obesity • Body mass index (height/weight) • Neck circumference • Enlarged tonsils • Elongated soft palate • Larger tongue • High-arched hard palate • Enlarged uvula • Facial abnormalities (retrognathia or micrognathia) • Large degree of overjet • Medical conditions: High blood pressure, metabolic disease, cardiovascular disease, stroke. Obesity is a major concern in obstructive sleep apnea (OSA). It is estimated that 45% obese individuals may have OSA. What simply happens in obesity is the fat deposition in the tissues surrounding the upper airways leading to smaller lumen and increased chances of collapsibility during sleep leading to sleep apnea.
Treatment There is no specific treatment. Treatment of the underlying condition is the most impor tant step. The treatment of nightmares is by suppression of REMsleep, e.g. by bedtime dose of a benzo diazepine. However, on stopping the drug, arebound increase in symptoms may occur.
METHODS OF SLEEP STUDY 1.Observation of a sleeping person for exter nally visible changes. 2.EEG. 3.Polysomnography (This is usually the preferred method in the sleep research centers). It consists of: i.Continuous EEG recording, parti cularly from occipital and parietal leads. ii.EOG (electro-oculography) to record the eye movements. iii.EMG (electromyography) for muscle potential and activities. iv.ECG for changes in cardiac status. v.In certain cases, respiratory tracings of various kinds are used, such as oxymetry, expired CO2 , O2 saturation. vi.MSLT (Multiple sleep latency test): It involves repeated measures of the sleep latency (i.e. time to onset of sleep). vii.Penile tumescence, body temperature, GSR (galvanic skin response), and body movements are also sometimes studied. The recordings are made throughout the night sleep
Detailed Sleep History Questionnaire Sleep Timings • How many hours do you generally sleep? (do not include the hours you spend awake on bed) • How many hours does it take for you to feel well rested? • Do you take daytime naps and for how long (weekdays and weekends)? Normal Sleeping Habits • What time do you go to bed on a normal day? • What time do you get out of bed on a normal day? • What is the time required for you to fall asleep once you go to bed? • Do you get up in middle of the night? If yes, how many times and what is it that wakes you up? • How quickly are you able to get back to sleep? (Address these questions separately for weekdays as well as weekends)
Sleep Quality • Do you feel refreshed in the morning? • How long does it take for you to feel refreshed after awakening? • During the day, are you chronically fatigued, sleepy or tired?Snoring • Do you think, you snore in the night? • Are your snores heard outside the bedroom? • Do you think your snoring is worse while lying on back or on either side? • Can you suggest, how many nights per weeks do you snore? • Does it awaken the bed partner? • Is this worse on the night you have stuffed nose or consume alcohol. Apneic Event • Has your bed partner noticed that you transiently stop breathing while asleep? • Have you ever witnessed that while you sleep there is a silent period with no snoring followed by a loud snort or a body jerk which awakens you? • Have you experienced episodes of choking or waking up in the night shortness of breath? This history is often elicited by the bed partners.
Abnormal Behavior During Sleep • Do you have an urge to move your limbs in early part of night? • Has anyone noticed any abnormal movements/behavior in the night? Daytime Functioning • Do you wake up with a headache or heaviness in head? • Have you felt that you are mostly tired/fatigued during the day? • Have you ever dozed of in meeting or while driving? • What time do you get home from your work place? • What time do you have your dinner?
Personal Habits • Any history of alcohol consumption? – How many drinks? per day/per week/per month – What time of day is your last drink? • Any history of tobacco consumption? – If yes, how many per day and for how many years? – If yes, what time of day is your last use? • History of consumption of tea/coffee – How many time and what time of the day/night – Any consumption of hyper caffeinated drinks.
Medical History A detailed medical history needs to be taken and specific details need to asked regarding • Heart diseases/skipped heart beats/ heart failure/ high blood pressure • Thyroid problems/ • Diabetes • Stroke/epilepsy/headaches • Asthma/emphysema/sinusitis/nasal congestion/deviated nasal septum/enlarged tonsils allergies • Depression/anxiety/bipolar disorder
Drug History • All medications need to be noted with special emphasis on • Any sedatives/antidepressants/anxiolytics. Any Established Comorbidities State/Condition • Cardiovascular disease • Cerebrovascular disease • Metabolic syndrome • Gastroesophageal reflux • Obesity. Occupational History • Does your job involve a lot of stress? • Is your work timing out of 9 AM–5 PM? (if not everyday/ but mostly) • Does your job demand regular flight travel to the western countries? Social History • General quality of life should be evaluated • General attitude of the patient and his family/colleagues.
Nursing diagnosis: • Disturbed sleep pattern related to, use or, withdrawal from substances: anxiety or depression: circadian rhythm disturbance: familial pattern: or specific medical condition. • Risk for injury related to excessive sleepiness, sleep terrors or sleep walking. • Ineffective breathing pattern related to obstructive sleep apnea, obesity and decreased ventilation
Planned interventions • Monitor the client's sleep pattern and identify the risks ( sleep walking, breathing related sleep disorders etc) to prevent the harm and injury to the client • Activate the client to keep a sleep diary, so that he/she will be identify the patterns that promote sleep pattern disturbances • Develop a sleep hygiene plan and educate the client about sleep hygiene practices to promote rest and sleep in the sleep deprived client. Teach the client about useful strategies for symptoms management to promote a sense of control over the problem Help the patient to structure and maintain a quiet, comfortable environment that is conducive to sleep to promote sleep and rest during designated period through out the day/night • Help the client to identify specific structures that effects his or her ability to obtain restorative sleep to help the client avoid or reduce stressors and obtain restorative sleep . • Promote the development of adaptive coping skills, such as relaxation tequeniques, through, client and family educaton to assess the client in managing, the psycho social stressors that negatively affect his/her ability to obtain restorative sleep • Identify the persons social support system to foster use of this resource, in the clients adaptation to perceived psychosocial stressors • Promote the compliance with prescribed medication plans in the treatment of a co-occurring psychiatric illness or in the short term treatment of primary sleep disorder. The use of medication is an effective intervention in the treatment of primary or secondary sleep pattern disturbances.
• Teach the client the importance of limiting the intake of substance that causes a substance induced sleep disorder. Use of prescription medications such as opioids, sedatives, hypnotics, and anxiolytics also affect sleep quality, and the client should only use them when directed by the client's health care provider. Some substances negatively affect a client's ability to attain restorative sleep. • Educate the client regarding the effect that circadian rhythm disturbances have on restorative sleep patterns, and explore ways to establish regular sleep patterns when sleep routines and are disrupted. Knowledge will inform and empower the client to accept help and initiate learned strategies to restore regular sleep patterns. • Refer the client to a sleep disorder specialist as needed to determine if advanced practice interventions are necessary. Further testing, such as polysomnography, is sometimes necessary to arrive at a differential diagnosis for the client.
Expected outcome • The client will - • Identify the primary causes of the sleep pattern alteration • Demonstrate significant reduction of sleep pattern through self report Participate actively in the discharge planning .
BIBLIOGRAPHY: 1.Townsend C. Mary. Psychiatric Mental Health Nursing. Eighth Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd: 2018 2.Basavanthappa BT. Psychiatric Mental Health Nursing. 1st Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd: 2007 3.Sreevani, R. A Guide to Mental Health and psychiatric Nursing ; Jaypee Brothers, Medical Publishers Pvt. Ltd, 2010 4.Kapoor, Dr. Bimla , Textbook of Psychiatric Nursing, Volume I, Kumar Publishing house, 2013 5.Ahuja N. A short textbook of psychiatry. New Delhi, India: Jaypee Brothers Medical; 2011.
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Sleep Disorders

  • 1.
    A 45-years oldgentleman visited the OPD clinic with c/o heavy snoring in the night, difficulty in sleeping, disturbed sleep timings, sleeping late and waking late in the morning, sleep talking, sudden jerky movements while asleep and occasional sleepless nights. O/E, BMI was 30.24 and had a shorter neck. He looked tired and sleepy. On subjective assessment, he mentioned his tea intake was 10cups across the day and the last cup was around 8pm in the night. He did not have any relevant medical history
  • 2.
    What history needsto be taken? What are the points should be assessed during examination? What is the possible diagnosis? What is your action as a Nurse?
  • 3.
    Nearly one thirdof human life is spent in sleep!
  • 4.
  • 5.
    Sleep: It is aneasily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
  • 6.
    Purpose of sleep Energy conservation : Decreased metabolismto allocate limited energy resources Restorative function : Tissue repair and protien synthesis Immune function regulation : Sleep boosts immunity Memory consolida tion Synaptic hemostasis
  • 7.
    The EEG recordingsshow typical features of sleep which is broadly divided into two broadly different phases: 1.D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep. 2. S-sleep (synchronised sleep), also called as NREM-sleep (non- REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person first passes through these stages of NREM-sleep.
  • 10.
    Brain waves Stages Typeof brainwave Frequency of brainwave Time Spent Type of sleep 0 Alpha Rhythm 8 to 12 cycles per second 2-5% Awake 1 Beta rhythm 18 to 25 cycles per second 5 to 10 minutes (5%) Non – REM 2 Theta Rhythm 4 to 7 cycles per second Almost half of sleep cycle (50%) 30-60 min Non – REM 3 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 20 to 40 min Non – REM 4 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 15 to 30 min Non – REM 5 Beta rhythm 18 to 25 cycles per second 20% REM
  • 12.
  • 13.
  • 14.
  • 15.
    Neuro-chemical influences oncircadian rhythm [sleep – wake cycle]: Serotonin • Induction of sleep Serotonin & Norepinephrine • Non-REM Sleep Acetylcholine • REM GABA • Regulation of sleep & arousal Histamine • Prolongs REM Sleep
  • 16.
  • 17.
    Age group SleepingTime REM Sleep Percentage Miscellaneous Neonates 16 hours of sleep a day, sleeping almost constantly during 1st week, sleep cycle is generally 40 to 50 min 50% as it stimulates higher brain function Awakening occurs after 1 or 2 sleep cycles. Infants [after 3 months] Several naps during day, sleeps 8 to 10 hours at night with total 15 hours sleep. 30% Awakening commonly occurs early in the morning but can awake at night also. Toddlers By age 2, children usually sleep through night and take daily naps. After 3 years, usually give up daytime naps. Total sleep almost 12 hours a day. 20% Common to awaken at night. Toddler may unwilling to go to bed at night due to a need for autonomy or a fear of separation from their parents. Pre – schoolers 12 hours 20% The pre-schoolers usually have difficulty relaxing or quieting down after long, active days and has problem with bedtime fears, waking during the night or nightmares. Partial awakening followed by normal return to sleep is common. In waking period, the child exhibit crying, walking around, unintelligible speech, sleep walking or bed wetting.
  • 18.
    Age group SleepingTime REM Sleep Percentage Miscellaneous School age children 6 years - 11 years 11 to 12 hours 9 to 10 hours 20% They go to bed doing some quiet activities. They resist sleeping because of an unawareness of fatigue or a need to be independent. Adolescents 7 hours 30 mins 20% Shortened sleep time due to busy schedule leads to EDS. Young adults 6 hours to 8 hours and 30 min of sleep 20% Insomnia and use of drugs to sleep is common. Middle adults Sleeping time declines. Stage 4 sleep falls. 20% Insomnia is common because of stress or changes, anxiety, depression, menopause can cause sleep disturbances. Older adults Decrease in stage 3 and stage 4 / no stage 4 20-10% Awakens more often at night and it takes more time to fall asleep, tendency for nap increases.
  • 19.
    Sleep Patterns Long Sleepers>9 Hours Short sleepers <6 Hours
  • 20.
    ICD-10 Classification F51 Non-organicsleep disorders F51.0 Non-organic insomnia F51.1 Non-organic hypersomnia F51.2 Non-organic disorder of the sleep-wake cycle F51.3 Sleep walking F51.4 Sleep terrors F51.5 Nightmares F51.8 Other non-organic sleep disorders F51.9 Non-organic sleep disorders, unspecified
  • 21.
    Dyssomnias Dyssomnias are sleepdisorders that are characterized by disturbances in the amount, quality or timing of sleep. These are the commonest disorders of sleep.
  • 22.
  • 23.
    Prevalence of Insomnia •More than 33% of adults experience insomnia intermittently • 10-22% suffer chronic sleep difficulties • Prescriptions for sleep aids increased by nearly 300% during same period
  • 24.
    Insomnia Insomnia is alsoknown as the Disorder of Initiation and/or Maintenance of Sleep ( DIMS). This includes frequent awakening during the night and early morning awakening. Insomnia means one or more of the following: 1. Difficulty in initiating sleep (going-off to sleep). 2. Difficulty in maintaining sleep (remaining asleep). This can include both: a. Frequent awakenings during the night, and b. Early morning awakening. 3. Non-restorative sleep where despite an adequate duration of sleep, there is a feeling of not having rested fully (poor quality sleep).
  • 25.
    Causes Medical illnesses • Anypainful or uncomfortable illness • Heart disease • Respiratory diseases • Brain stem or hypothalamic lesions • Delirium • Rheumatic and other musculoskeletal diseases • Periodic movements in sleep • Oldage • Rheumatic and musculo-skeletal disease • PMS ( Periodic movements in sleep)
  • 26.
    Alcohol and druguse • Delirium tremens • Amphetamines or other stimulants • Chronic alcoholism • Drug or alcohol withdrawal syndrome Current medication • e.g. fluoxetine, steroids, theophylline, propranolol
  • 27.
    Psychiatric disorders • Mania(due to decreased need for sleep,(may not complain of decrease in sleep, as there is often a decreased need for sleep) • Major depression (early morning awakening or late insomnia,difficulty in maintenance of sleep is more prominent, although diffifi culty in initiating sleep is also present) • Dysthymia or neurotic depression (difficulty in initiating sleep or early insomnia) • Schizophrenia and other psychoses (due to psychotic symptoms) • Anxiety disorder (difficulty in initiating sleep due to worrying thoughts)
  • 28.
    Social causes • Financialloss • Separation or divorce • Death of spouse or a close relative • Retirement • Stressful life situations (may cause temporary insomnia).
  • 29.
    Behavioral causes • Napsduring the day • Irregular sleeping hours • Lack of physical exercise • Excessive intake of beverages in the evening, e.g. coffee • Disturbing environment (heat, cold, noise) Idiopathic insomnia One cause of insomnia, PMS ( periodic movements in sleep) needs further mention. PMS actually consists of two different syndromes, which often occur together: 1. Periodic Limb Movement Disorder (PLMD), and 2. ‘ Restless Legs’ Syndrome (RLS or Ekbom syndrome).
  • 30.
    Treatment of Insomnia Aperson suffering from insomnia should be differentiated from a short-sleeper, who needs less than 6 hours of sleep per night and has no symptoms or dysfunction. A short- sleeper does not need any treatment. 1. A thorough medical and psychiatric assessment. 2. Treatment of the underlying physical and/or sychiatric disorder, if present. 3.Withdrawal of current medications, if any.
  • 31.
    Sleep Hygiene 1. Regular,daily physical exercises (preferably not in the evening). 2. Minimise daytime napping. 3. Avoid fluid intake and heavy meals just before bedtime. 4. Avoid caffeine intake (e.g. tea, coffee, cola drinks) before sleeping hours. 5. Avoid regular use of alcohol (especially avoid use of alcohol as a hypnotic for promoting sleep). 6. Avoid reading or watching television while in bed. 7. Sleep in a dark, quiet, and comfortable environment. 8. Regular times for going to sleep and waking-up 9. Try relaxation techniques 10. Backrubs, warm milk and relaxation exercises.
  • 32.
    Sleep hygiene tomaintain sleep – wake cycle: Sleep – wake pattern Environment Medications Diet Physiological / Illness Factors
  • 33.
  • 34.
    Sleep Diary It isa record of a patient’s sleepand wake patterns is meant to capture sleep wake information over several weeks. Patients can be instructed to record the information by themselves or it can be recorded by a caregiver. It aims to measure the pattern and quality of sleep, and factors that may affect patient’s sleep. General Instruction for the Patient • Fill the diary every day for minimum two weeks • Generally, fill the diary after one hour of getting up from the bed in the morning • Be as specific as you can • If you forget to fill the diary on a particular day, leave it blank for that day • Make brief notes of anything unusual which has affected your sleep in the diary
  • 35.
    Sleep Diary • Eachrow corresponds to 24 hours (from noon today to noon tomorrow) • Each column corresponds to 1 hour • Shade in the time you are actually sleeping • Arrow down ( ↓ ) when you get in bed • Arrow up ( ↑ ) when you get out of bed
  • 36.
    Non-drug treatment forinsomnia • Progressive relaxation. • Autosuggestion. • Meditation, yoga. • Stimulus control therapy: do not use the bed for reading or chatting - go to bed for sleep only.
  • 37.
    Hypersomnia Hypersomnia is alsoknown as Dis order of excessive somnolence ( DOES). Hypersomnia means one or more of the following: 1. Excessive day time sleepiness. 2. ‘ Sleep attacks’ during day time (falling asleep unintentionally). 3. ‘ Sleep drunkenness’ (person needs much more time to awaken; and during this period is confused or disoriented).
  • 38.
    Causes of hypersomnia 1.Medical illnesses i. Narcolepsy (in about 25% of all patients with hypersomnia) ii. Sleep apnoea (in about 50% of all patients with hypersomnia) iii. Kleine-Levin syndrome iv. Menstrual-associated somnolence v. Sleep deprivation vi. Following or with insomnia vii. Encephalitis viii. Hypothyroidism ix. Head Injury x. Cerebral tumours in the region of mid-brain xi. Hypothalamic lesions xii. Trypanosomiasis xiii. PMS ( Periodic movements in sleep); in about 10% of all patients with hypersomnia. 2. Alcohol and drug use i. Stimulant withdrawal ii. Alcohol intoxication iii. Use of CNS depressant medications. 3. Psychiatric disorders i. Dysthymia ii. Atypical depression iii. Seasonal mood disorder. 4. Idiopathic hypersomnia
  • 39.
    Treatment 1. A thoroughphysical and psychiatric assessment. 2. Treatment of the underlying cause is the most important method. 3. Associated or underlying insomnia should be looked for and treated. 4. Withdrawal of current medication causing hypersomnia, especially depressant medication. 5. Benzodiazepines at night may paradoxi cally decrease hypersomnia by correcting night time insomnia.
  • 40.
    Disorders of Sleep-wakeSchedule(F51.2) The person with this disorder is not able to sleep when he wishes to, although at other time he is able to sleep adequately. Causes • Work shifts • Jet Lag • Unusual sleep phases • Unspecified
  • 41.
    Treatment No specific treatmentis usually needed. Benzodiazepines may be needed for short-term correc tion of insomnia. Changes in ‘work-shifts’ may be needed for persons with unusual sleep phases. Exposure to sunlight during outdoor activity (instead of staying indoors) and adopting the local (new) hours for sleeping (and working) can help in combating jet lag.
  • 42.
    Classification of StageIV Sleep Disorders • Sleep walking (somnambulism) • Night terrors • Sleep-related enuresis • Bruxism (tooth-grinding) • Sleep talking (somniloquy) • REM sleep behaviour disorders • Sleep related head banging
  • 43.
    Treatment Since benzodiazepines suppressstage 4 of NREM- sleep, a single dose at bedtime usually provides relief from stage 4 parasomnias.
  • 44.
    Other Sleep Disorders Nocturnal angina  Nocturnal asthma  Nocturnal seizures Sleep related cluster headaches and chronic paraxysmal hemicranias Sleep related abnormal swallowing syndrome Sleep related gastroesophageal reflex  Sleep paralysis Nightmares ( dream anxiety disorder) Paraxysmal nocturnal hemoglobinuria Substance induced sleep disorders
  • 45.
    Examination in sleepapnea • Obesity • Body mass index (height/weight) • Neck circumference • Enlarged tonsils • Elongated soft palate • Larger tongue • High-arched hard palate • Enlarged uvula • Facial abnormalities (retrognathia or micrognathia) • Large degree of overjet • Medical conditions: High blood pressure, metabolic disease, cardiovascular disease, stroke. Obesity is a major concern in obstructive sleep apnea (OSA). It is estimated that 45% obese individuals may have OSA. What simply happens in obesity is the fat deposition in the tissues surrounding the upper airways leading to smaller lumen and increased chances of collapsibility during sleep leading to sleep apnea.
  • 46.
    Treatment There is nospecific treatment. Treatment of the underlying condition is the most impor tant step. The treatment of nightmares is by suppression of REMsleep, e.g. by bedtime dose of a benzo diazepine. However, on stopping the drug, arebound increase in symptoms may occur.
  • 47.
    METHODS OF SLEEPSTUDY 1.Observation of a sleeping person for exter nally visible changes. 2.EEG. 3.Polysomnography (This is usually the preferred method in the sleep research centers). It consists of: i.Continuous EEG recording, parti cularly from occipital and parietal leads. ii.EOG (electro-oculography) to record the eye movements. iii.EMG (electromyography) for muscle potential and activities. iv.ECG for changes in cardiac status. v.In certain cases, respiratory tracings of various kinds are used, such as oxymetry, expired CO2 , O2 saturation. vi.MSLT (Multiple sleep latency test): It involves repeated measures of the sleep latency (i.e. time to onset of sleep). vii.Penile tumescence, body temperature, GSR (galvanic skin response), and body movements are also sometimes studied. The recordings are made throughout the night sleep
  • 48.
    Detailed Sleep HistoryQuestionnaire Sleep Timings • How many hours do you generally sleep? (do not include the hours you spend awake on bed) • How many hours does it take for you to feel well rested? • Do you take daytime naps and for how long (weekdays and weekends)? Normal Sleeping Habits • What time do you go to bed on a normal day? • What time do you get out of bed on a normal day? • What is the time required for you to fall asleep once you go to bed? • Do you get up in middle of the night? If yes, how many times and what is it that wakes you up? • How quickly are you able to get back to sleep? (Address these questions separately for weekdays as well as weekends)
  • 49.
    Sleep Quality • Doyou feel refreshed in the morning? • How long does it take for you to feel refreshed after awakening? • During the day, are you chronically fatigued, sleepy or tired?Snoring • Do you think, you snore in the night? • Are your snores heard outside the bedroom? • Do you think your snoring is worse while lying on back or on either side? • Can you suggest, how many nights per weeks do you snore? • Does it awaken the bed partner? • Is this worse on the night you have stuffed nose or consume alcohol. Apneic Event • Has your bed partner noticed that you transiently stop breathing while asleep? • Have you ever witnessed that while you sleep there is a silent period with no snoring followed by a loud snort or a body jerk which awakens you? • Have you experienced episodes of choking or waking up in the night shortness of breath? This history is often elicited by the bed partners.
  • 50.
    Abnormal Behavior DuringSleep • Do you have an urge to move your limbs in early part of night? • Has anyone noticed any abnormal movements/behavior in the night? Daytime Functioning • Do you wake up with a headache or heaviness in head? • Have you felt that you are mostly tired/fatigued during the day? • Have you ever dozed of in meeting or while driving? • What time do you get home from your work place? • What time do you have your dinner?
  • 51.
    Personal Habits • Anyhistory of alcohol consumption? – How many drinks? per day/per week/per month – What time of day is your last drink? • Any history of tobacco consumption? – If yes, how many per day and for how many years? – If yes, what time of day is your last use? • History of consumption of tea/coffee – How many time and what time of the day/night – Any consumption of hyper caffeinated drinks.
  • 52.
    Medical History A detailedmedical history needs to be taken and specific details need to asked regarding • Heart diseases/skipped heart beats/ heart failure/ high blood pressure • Thyroid problems/ • Diabetes • Stroke/epilepsy/headaches • Asthma/emphysema/sinusitis/nasal congestion/deviated nasal septum/enlarged tonsils allergies • Depression/anxiety/bipolar disorder
  • 53.
    Drug History • Allmedications need to be noted with special emphasis on • Any sedatives/antidepressants/anxiolytics. Any Established Comorbidities State/Condition • Cardiovascular disease • Cerebrovascular disease • Metabolic syndrome • Gastroesophageal reflux • Obesity. Occupational History • Does your job involve a lot of stress? • Is your work timing out of 9 AM–5 PM? (if not everyday/ but mostly) • Does your job demand regular flight travel to the western countries? Social History • General quality of life should be evaluated • General attitude of the patient and his family/colleagues.
  • 55.
    Nursing diagnosis: • Disturbedsleep pattern related to, use or, withdrawal from substances: anxiety or depression: circadian rhythm disturbance: familial pattern: or specific medical condition. • Risk for injury related to excessive sleepiness, sleep terrors or sleep walking. • Ineffective breathing pattern related to obstructive sleep apnea, obesity and decreased ventilation
  • 56.
    Planned interventions • Monitorthe client's sleep pattern and identify the risks ( sleep walking, breathing related sleep disorders etc) to prevent the harm and injury to the client • Activate the client to keep a sleep diary, so that he/she will be identify the patterns that promote sleep pattern disturbances • Develop a sleep hygiene plan and educate the client about sleep hygiene practices to promote rest and sleep in the sleep deprived client. Teach the client about useful strategies for symptoms management to promote a sense of control over the problem Help the patient to structure and maintain a quiet, comfortable environment that is conducive to sleep to promote sleep and rest during designated period through out the day/night • Help the client to identify specific structures that effects his or her ability to obtain restorative sleep to help the client avoid or reduce stressors and obtain restorative sleep . • Promote the development of adaptive coping skills, such as relaxation tequeniques, through, client and family educaton to assess the client in managing, the psycho social stressors that negatively affect his/her ability to obtain restorative sleep • Identify the persons social support system to foster use of this resource, in the clients adaptation to perceived psychosocial stressors • Promote the compliance with prescribed medication plans in the treatment of a co-occurring psychiatric illness or in the short term treatment of primary sleep disorder. The use of medication is an effective intervention in the treatment of primary or secondary sleep pattern disturbances.
  • 57.
    • Teach theclient the importance of limiting the intake of substance that causes a substance induced sleep disorder. Use of prescription medications such as opioids, sedatives, hypnotics, and anxiolytics also affect sleep quality, and the client should only use them when directed by the client's health care provider. Some substances negatively affect a client's ability to attain restorative sleep. • Educate the client regarding the effect that circadian rhythm disturbances have on restorative sleep patterns, and explore ways to establish regular sleep patterns when sleep routines and are disrupted. Knowledge will inform and empower the client to accept help and initiate learned strategies to restore regular sleep patterns. • Refer the client to a sleep disorder specialist as needed to determine if advanced practice interventions are necessary. Further testing, such as polysomnography, is sometimes necessary to arrive at a differential diagnosis for the client.
  • 58.
    Expected outcome • Theclient will - • Identify the primary causes of the sleep pattern alteration • Demonstrate significant reduction of sleep pattern through self report Participate actively in the discharge planning .
  • 59.
    BIBLIOGRAPHY: 1.Townsend C. Mary.Psychiatric Mental Health Nursing. Eighth Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd: 2018 2.Basavanthappa BT. Psychiatric Mental Health Nursing. 1st Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd: 2007 3.Sreevani, R. A Guide to Mental Health and psychiatric Nursing ; Jaypee Brothers, Medical Publishers Pvt. Ltd, 2010 4.Kapoor, Dr. Bimla , Textbook of Psychiatric Nursing, Volume I, Kumar Publishing house, 2013 5.Ahuja N. A short textbook of psychiatry. New Delhi, India: Jaypee Brothers Medical; 2011.
  • 60.