Psychiatric / Mental Health Nursing Sleep Disorders Chapter 20

Sleep Disorders Sleep deprivation – discrepancy between hours of sleep obtained and hours of sleep required for optimal functioning Implications for ◦ Health ◦ Safety ◦ Quality of life

Theories of Sleep Disorders - continued  Studies show those with chronic insomnia have physiological differences.  Studies suggest that gene variations are involved in human circadian activity.  There is predisposition to sleep disorders based on genetic susceptibility and familial pattern.

Theories of Sleep Disorders - continued  Any emotional or cognitive arousal can precipitate or perpetuate insomnia.  Environmental conditions, including associating the sleeping room with lying awake, cause distress and are a powerful perpetuating factor to sleep problems.

Normal Sleep Cycle Complex interaction between CNS and environment Non-REM (NREM) sleep ◦ Composed of four stages REM sleep ◦ Reduction and absence of skeletal muscle tone ◦ Bursts of rapid eye movement ◦ Myoclonic twitches of facial and limb muscles ◦ Dreaming ◦ Autonomic nervous system variability

Regulation of Sleep Complex interaction between two processes ◦ Homeostatic process or sleep drive – promotes sleep ◦ Circadian process or circadian drive – promotes wakefulness  Influenced by  Endogenous factors  Exogenous factors

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

Primary Sleep Disorders Dyssomnias ◦ Primary insomnia ◦ Primary hypersomnia ◦ Narcolepsy ◦ Breathing-related sleep disorders ◦ Circadian rhythm disorders ◦ Dyssomnias not otherwise specified  Restless legs syndrome  (Box 20-1)

Primary Insomnia Most common sleep complaint Difficulty with sleep initiation Sleep maintenance Early awakening Non-refreshing, nonrestorative sleep

Interventions for Primary Insomnia Sleep hygiene – conditions and practices that promote continuous and effective sleep Behavioral therapies ◦ Educational components ◦ Behavioral components ◦ Cognitive components Some instances – hypnotic medication (Table 20-1)

Parasomnias Unusual or undesirable behaviors or events Occur during ◦ Sleep/wake transitions ◦ Certain stages of sleep ◦ Arousal from sleep

Sleep Disorders Related to Other Mental Disorders Insomnia related to another mental disorder Hypersomnia related to another mental disorder ◦ Major depressive disorder ◦ Anxiety disorders ◦ Schizophrenia

Sleep Patterns in Major Depressive Disorder  Insomnia of maintenance or early wakening type most common  Insomnia is the most commonly reported residual symptom after remission  Sleep pattern disturbance may respond to antidepressant treatment sooner than other symptoms

Sleep Patterns in Schizophrenia  Exacerbation of illness causes significant sleep disruption  Extreme sleep difficulty can accompany severe anxiety  Heightened concern of delusions and hallucinations  Circadian cycle disrupted

Sleep Patterns in Schizophrenia - continued  Reduction in REM sleep  Do not experience REM rebound  Deficits in slow-wave sleep found in clients with acute and chronic schizophrenia

Sleep Patterns in Manic Episodes of Bipolar Disorder  Sleep time significantly reduced  Clients don’t complain of insomnia and can go without sleep  Reduced slow-wave sleep  Reduced REM latency

Other Sleep Disorders Sleep disorders due to a general medical condition Substance-induced sleep disorders ◦ In both sleep disorders, sleep disturbance may be  Insomnia  Hypersomnia  Parasomnia  Combination

Sleep Patterns in Substance Abuse  Severe sleep disorder during intoxication or withdrawal periods  Persists even after prolonged abstinence of some substances

Sleep Patterns in Substance Abuse - continued  Substance-induced mood disorder characterized by sustained use of stimulants to stay awake or alcohol to induce sleep  Examples of substances

Key Assessments Assessment ◦ General assessment – sleep patterns ◦ Identifying sleep disorders ◦ Functioning and safety

Key Assessments - continued Self-defined - say they get enough sleep to feel refreshed, have energy, fall asleep quickly

Key Assessments - continued Behaviorally defined - observe alertness during sedentary, repetitive activity; note ability to fall asleep and final wakening at habitual rising time; utilize photographic serializing of movement during sleep

Key Assessments - continued  Comprehensive sleep studies are conducted in sleep labs: - polysomnogram - multiple sleep latency test

Nursing Diagnosis ◦ Sleep deprivation related to inadequate quality and quantity of sleep ◦ Insomnia related to medical, psychiatric, or sleep disorder, substance use/abuse, or inadequate sleep hygiene ◦ Readiness for enhanced sleep ◦ Risk for injury related to inadequate sleep

Nursing Outcome Identification Outcomes Identification ◦ Sleep ◦ Rest ◦ Risk control ◦ Personal well-being ◦ (Table 20-2) Planning

Implementation Basic Level Interventions ◦ Counseling ◦ Health teaching and health promotion ◦ Pharmacological interventions Advanced Practice Interventions ◦ Cognitive-behavioral therapy

Guidelines for Good Sleep Hygiene  Maintain regular sleep–wake schedule  Rise at the same time each day  Go to bed when sleepy and relaxed  Maintain rituals in preparation for sleep  Control for temperature, lighting, noise  Avoid stimulants before bed  Focus on enjoying sleep that is achieved

Guidelines for Insomnia  Treatment for sleep disorders is complex  Follow guidelines for good sleep hygiene  Utilize good sleep hygiene before taking sedative hypnotic medications  Instill a sense of hope that insomnia will improve, client can manage it effectively

Guidelines for Insomnia - continued  Facilitate setting realistic goals.  Teach normal developmental changes in sleep patterns.  See treatment provider for continued insomnia.  Differentiate between myths and evidence-based practice.

Evaluation ◦ Based on whether or not patient experiences improved sleep quality as evidenced by  Decreased sleep latency  Fewer nighttime awakenings  Shorter time to get back to sleep after awakening

Pharmacology

Sleep and Wakefulness Goal: Improve quantity and quality of sleep May prevent worsening of mood, anxiety and pain if sleep improves Many choices: evaluate lifestyle Do not underestimate the POWER of sleep

Sleep Agents: NT Nearly all hypnotics work on at least one of these neurotransmitters: ◦ GABA ◦ Histamine

Rx Sleep agents Barbiturates Benzodiazepines Non-benzos Melatonin Receptors Agonists

Sleep agents Barbituturates – first used in 1860s named after St Barbara Nembutal (pentobarbital) Seconal (secobarbital)

Sleep agents Benzodiazepines ◦ Short Acting  Halcion (triazolam) ◦ Intermediate  Restoril (temazepam)  Prosom (estazolam) ◦ Long Acting  Dalmane (flurazepam)

Sleep Agents Non-Benzos ◦ Zolpidem - Ambien ( mg/night) ◦ Ambien CR ◦ Zaleplon - Sonata (10 mg/night) ◦ Eszopiclone -Lunesta (1-3 mg/night) ◦ Cholral Hydrate – Noctec, Aquachloral Supprettes, Somnote ( mg/d) ◦ Diphenhydramine - Benadryl, Sominex, Nytol ( mg/d)

Sleep Agents Melatonin Receptor Agonist ◦ Rameltoeon - Rozerem (8mg/d) ◦ Valdoxan (agomelatine) also works on 5-HT2c so is antidepressant

Sleep Agents Over the Counter OTC ◦ Benadryl (diphenhydramine) ◦ Atarax/Vistaril (hydroxyzine Kava Caution: may cause liver toxicity Valerian

Side Effects Hangover Amnesia Headache

When Starting on Sleepers Sleep hygiene first – remember caffeine Cool, quiet, dark room without dogs and kids Don’t mix with Alcohol Go straight to bed and lay down

Wake Agents: NT Nearly all wake promoting agents work on at least one of these neurotransmitters: ◦ Norepinephrine ◦ Dopamine

Wake Agents Provigil = Nuvigil FDA Indication ◦ Excessive sleepiness due to narcolepsy ◦ Obstructive sleep apnea ◦ Shift work sleep disorder Treat fatigue and sleepiness due to other conditions – depression and MS

Wake Agents Stimulants Provigil (modafinil) Nuvigil (armodafinil)

When Starting on Wakers Sleep hygiene first – not a replacement for sleep