Sleep-Wake Disorders

quality of sleep now recognized as …

key determinant of health and well being

average adult needs ______ hrs of sleep a night

7-9

sleep disturbance increases risk for…

accidents, injuries, poor communication

many of the neurocognitive symptoms of sleep deprivation can mimic _________ symptoms 

psychiatric

• most psych disorders are associated with sleep disturbance

• psych meds cause sleep disturbance

• sleep disturbance can worsen progression of alzheimers and prakinsons

  • depressed pts who experience sleep disturbance have greater degrees of…

suicidal ideation

sleep has become an expendable commodity due to

schedules that disrupt normal sleep physiology

explain consequences of sleep loss

•  Excessive sleepiness – high risk for accidents and injuries

   Sleep deprivation – hours of sleep obtained vs. requirements for optimal

  functioning, effects quality of life, health and safety

   Mental & physical problems – poor health, mood disorders,

  somatic pain, emotional distress; cognitive, memory, and performance

  deficits; reduced quality of life, increased stress responsivity, safety risks,

  cardiovascular disease, weight-related issues, metabolic syndrome, type 2

  diabetes mellitus, colorectal cancer, all-cause mortality

   Psychomotor impairment – similar to substance abuse, intoxication

  symptoms

   Increased risk for errors

 Sleep loss diminishes safety and results in loss of lives and property, can produce psychomotor impairments equivalent to _________________

those induced by alcohol consumption at or above the legal limit 

explain the normal sleep cycle

 Complex interaction between CNS and environment, measured by EEG

 Non-REM (NREM) sleep (75-80% of total sleep)

 Composed of 3 stages (body temp decreases, muscles relax, RR

declines, response to external stimuli continues to decline, through the 3

stages) Restorative sleep happens here.

 REM sleep (20-25% of all sleep time)

 Reduction and absence of skeletal muscle tone (ATONIA) – a

protective mechanism to prevent physical response to dreams

 Bursts of Rapid Eye Movement (REM)

 Myoclonic twitches of facial and limb muscles

 Dreaming

 Autonomic nervous system variability

__________: Distribution of sleep and wakefulness across the sleep period 

• Sleep continuity

•__________: Disruption of sleep stages 

Sleep fragmentation

•_________: Ratio of sleep duration to time spent in bed 

Sleep efficiency

__________: the time it takes to fall asleep (associated with N1 stage) 

Sleep latency

explain the 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 – light, darkness, timing of social events, work, etc

• Neurotransmitters – any med that effects neurotransmitters

can alter sleep (adenosine and GABA promote sleep)

explain 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

explain basal sleep requirement

 Establish a routine bedtime and allow sleep to be undisturbed by an alarm for several days during a leisure time such as a vacation 

explain insomnia disorder:

• difficulty with sleep initiation, maintenace, or early awakening

• nonrefreshing sleep, nonrestorative sleep

• sleep disturbance causes distress in social, occupational, educational, academic, behavioral, or other areas of fxn

• symptoms 3x a week for at least 3 months

• will also have a daytime consequence like impaired fxn, decreased concentration, somatic complaints, or mood disturbance

• usually due to anxiety, depression, daily stressors, and life events

explain the 3P model of insomnia:

• predisoposing factors: h/o poor sleep quality, depression, anxiety, or hyperarousal

• preciptating factors: external events, life situations, greif, can be medical or psych disorders (whats happening in life)

• perpetuating factors: poor sleep practices, habits, excess caffiene, napping, alcohol, too much time in bed

explain hypersomolence disorders

• excessive daytime sleepiness

• unintended lapses into sleep, frequent naps, prolonged sleep more than 9 hrs

• excessive sleepiness impairs social and vocational fxn

• nonrefreshing/ nonrestorative sleep no matter how long slept

• tx: maintains regular sleep wake schedules, pharmacotherapy (methylpenidate and provigil- stimulants)

• high risk for accidents and injury

explain narcolepsy:

• uncontrollable need to sleep

• s/s:

  • irresistable attacks of refreshing sleep, cataplexy (atonia in wakefulness), sleep paralysis, hypnagogic hallucinations

  • disturbed nighttime sleep and memory lapses at night

  • feel refreshed upon wakening but sleepy 2-3 hrs later

  • diagnosis by measuring hypocretin levels from CSF fluid

  • tx: lifestyle modifications and long acting stimulant meds, naps, exercise, balanced diet

what is cataplexy?

 Brief loss of bilateral muscle tone while maintaining

consciousness

 Usually triggered by a strong emotion such as anger, frustration,

or laughter

 Can last for several minutes and recovery is immediate and

complete

 Likely the occurrence of REM sleep paralysis during

wakefulness

 Occurs in about 50% of people with narcolepsy and can happen

1-2 times in life or 20 times/day

**safety issue

expain circadian rhythm sleep disorder

• misalignment between timing of normal circadian rhythm and external factors that affect timing or duration of sleep

• shift working and jet lag

• types:

  • delayed sleep phase

  • advanced sleep phase

  • irregular sleep type

  • non- 24 hr sleep wake type: blind individuals

  • shift work type

• dx by clinical eval, sleep diary, and actigraphy; and tx with lifestyle changes

____________– sleepwalking,sleep terrors, treatment is aimed at SAFETY measures such as locking doors, gating stairways, hiding keys, bed alarms 

Non-rapid eye movement sleep arousel disorders

 ____________– treated with stress reduction and hypnotic therapy 

Nightmare disorder

___________– absence of muscle atonia, act out their dreams, symptom of Parkinson’s, may be induced by SSRI’s (kick, scream, and attack in sleep)

Rapid eye movement sleep behavior disorder

___________ – uncomfortable sensation in the legs accompanied by an urge to move legs, can be induced by SSRI’s or SNRI’s  (low mag levels)

Restless leg syndrome

______________ – alcohol, nicotine and caffeine all inhibit successful sleep 

Substance-induced sleep disorders

explain obstructive sleep apnea or hypopnea syndrome

 Repeated episodes of upper airway collapse and obstruction

 Results in sleep fragmentation

 Cannot breathe and sleep at the same time

 Loud, disruptive snoring, witnessed apnea by another person,

excessive daytime sleepiness

 Obesity is biggest risk factor

 Diagnosis

 Clinical evaluation and polysomnography

 Treatment

 Continuous positive airway pressure (CPAP) therapy

explain central sleep apnea

 Cessation of breathing during sleep

 Instability of respiratory control system

 Related to aging, advanced cardiac or pulmonary disease,

neurological disorders

explain sleep related hypoventilation

 Sustained oxygen desaturation in sleep

 No apnea or respiratory events

 Associated with morbid obesity, lung parenchymal disease, or

pulmonary vascular pathology

___________ – most common test, all night testing with electrodes, used to diagnose and evaluate patients with sleep related breathing and nocturnal seizure disorders ex) Sleep Apnea, nocturnal seizures 

Polysomnography (PSG)

_____________ – daytime nap test, measures sleepiness in a sleep-conducive setting, often used to detect narcolepsy 

Multiple Sleep Latency Test (MSLT)

_____________ – used to document ability to stay alert in individuals whos sleepiness would pose risk to public safety, ex) CDL’s, truck drivers 

Maintenance of Wakefulness Test (MWT)

___________– uses a wristwatch type device that evaluates sleep patterns and helps evaluate circadian rhythm disorders and insomnia 

Actigraphy

Less than __________ per night: increases risks to cardiovascular, endocrine, immune, and neurological function 

6 hours

what are some psych disorders that have comorbidity with sleep disorders

MDD or bipolar

increased SI

what to assess with sleep disorders

 Identify sleep patterns – Quality of sleep

 Identify sleep-wake disorders

 Functioning and safety

list possible questions to ask for sleep assessment:

 Always consider Quality of sleep over Quantity of sleep due

to individual sleep requirements

 When did you begin having trouble with sleep? History of sleep

problems?

 Describe your bedtime routine. What activities do you

engage in before sleep?

 Describe your sleeping environment. Noise, light, temperature,

comfort, safe?

 Do you use your bedroom for things other than sleep or sex?

 What time do you go to bed? How long does it take to fall

asleep?

 Middle of the night awakening? Able to return to sleep?

 What do you do if you are unable to sleep?

 What time do you wake up? Get out of bed?

 Do you feel like you are sleeping enough for your

requirements?

 Do you nap? How long? Refreshed afterwards?

 Any stressors?

 Daily habits, diet, exercise, medications

 Any changes made to improve sleep?

▪ Fall asleep too early?

 Awaken frequently/sleep too much?

 Snore or get complaints about snoring? What does

spouse or parents think?

 Restless - legs twitch?

 Walk or talk in sleep?

 Eat during night, but don’t remember?

 Do you wake up feeling refreshed?

 Nightmares?

 Awakened gasping for breath or unable to breathe?

 Feel unable to move when falling asleep or waking?

 Vivid, dreamlike hallucinations, even when you know

you’re awake?

 Are you drowsy during the day? Fatigued?

 Do you feel productive during the day?

 Decreased concentration?

 Mood disturbances?

 Sleep Scales (Epworth Sleepiness Scale)

list sleep hygeine behavior strategies for insomnia

• room comfort, temp, darkness, and noise

• limit TV/ radio

• reserve bedroom for sleep and intimacy

• avoid clock watching

• avoid heavy dinners

• maintain regular sleep wake schedule w set hours

• bedtime relaxation techniques

• activities before bedtime

• exercise during day not 3 hrs before bed

• bath

• avoid alcohol and limit caffiene to 2 drinks per day and not in evening

• bedtime routine, downtime

• avoid daily naps

what are some implementations for sleep disturbance pts

 Counseling

 Health teaching and promotion

 Hospitalized patients – minimize disturbances, safety if taking sleep

meds

 Encourage necessary lifestyle changes and behavior modifications

that are conducive to successful sleep

 Teach relaxation techniques such as meditation, guided imagery,

controlled breathing exercises, PMR, counting backwards from 100

 Modifying poor sleep habits

 ID factors which create sleep disturbances

 Sleep Diaries – can refer to 2 week sleep diaries for evaluation

what are treatment modalities for sleep wake disorders

Biological: Pharmacotherapy

 In insomnia: used mostly with comorbidities

Somatic Interventions

 Cerêve Sleep System (insomnia)- body focused mindfullness

Psychological Therapies

 CBT-I

 Stimulus control

meds for insomnia

Benzodizepines – 5 drugs but only 1 is common, monitor

for ataxia

 Restoril (temazepam) most common

Z-drugs

 Ambien (zolpidem)

 Sonata (zaleplon)

 Lunesta (eszopiclone)

Melatonin Receptor Agnoist

 Rozerem (ramelteon)

Anti-depressants

▪ Doxepin (silenor)

▪ Trazodone

Anti-histamines

 Benadryl

what are some sleep medication safety concerns

• sleepiness during day

• rebound insomnia

• poor concentration

• act strangely, confused, or upset

• sleep walking or doing other activities while sleep like eating, talking, having sex, driving

• amnesia effects

explain Ambien/ Ambien CR (zolpidem)

 acts on GABA-benzodiazepine receptor complex

 nonaddictive

 no resp. depression

 few rebound symptoms (e.g., insomnia, anxiety)

 Can have an amnesia effect

 Ambien CR form is bi-layered tablet (first layer

works quickly to induce sleep, 2nd layer longer acting

explain lunesta (eszopiclone)

Enhances GABA activity

 Unlike some other sleep aids, Lunesta helps you sleep

all through the night with fewer interruptions.

 Has bitter taste in 30%, copper type taste

 Does not lose its effectiveness over time as shown in

a 6-month study.

 First and only prescription sleep aid approved for

long-term use

explain resotil (temazepam)

 1 of the 5 approved Benzodiazepines for insomnia

 Worry about ataxia in the elderly