Sleep and fatigue

what are the 2 stages of sleep?

non rapid eye movement (NREM)

and rapid eye movement (REM)

physiological changes in REM sleep?

\-heart rate fluctuates

\-body temp fluctuates

\-muscle twitches

\-respirations fluctuate

\-blood pressure fluctuates

\-dreams happen

\-penile erection in men and clitoral engorgement in women.

\-cerebral blood flow increases

melatonin

regulated by the pineal gland, works in a circadian manner to help regulate sleep patterns. it peaking at night is what makes us feel drowsy.

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when it becomes dark out is when the pineal gland secretes melatonin.

adenosine

builds up in the body while someone is awake, signals us to sleep. while sleeping the body breaks adenosine down again

REM

fluctuations and dreams, intense brain activity

temp. muscle paralysis, brain wave activity similar to being awake

NREM

body restoration, separated into 3 stages

accounts for 75 to 80% of sleep time in adults.

parasympathetic activity increases.

reduced activity

what are the 3 stages of NREM?

N1: light sleep, pre sleep stage, transition of being awake to being asleep. lasting few min to 30min. could be longer for those that have difficulty falling asleep

N2: normal sleep, can be awoken easily generally,

N3: slow delta brain waves, no eye movement, less responsive to stimuli, snoring might happen

what is sleep architecture?

the right proportions of REM and NREM sleep stages, the patterns of sleep

when do you become at risk for sleep deprivation?

less than 6h of quality sleep

sleep and GERD

often have issues with sleep as they are awoken from the heartburn from stomach acid coming into esophagus.

what are the classes of sleep disorders?

\-sleep disturbances

\-parasominas

\-sleep pattern disruptions, associated with mental illness.

sleep disturbances

insomnia, narcolepsy, hyperaemia, sleep apnea, restless leg syndrome, parasomina.

insomnia

inadequate quantity or quality of sleep that interferes with normal daytime functioning. may happen due to difficulty falling asleep, staying asleep, or waking up early. can be caused by physiological conditions, neurotransmitter conditions, cardiac disorders, stomach upset,

can’t fall or stay asleep

hypersomnia

excessive sleepiness, person falls asleep randomly even though they slept uninterrupted the previous night.

different then narcolepsy because sleepiness is more gradual. and there is paralysis, the sleep is not refreshing.

may fall asleep while driving, talking, working etc. it can be dangerous

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narcolepsy

falling asleep at any given time. sleep quickly moves to REM sleep. may experience Hallucinations or paralysis while awaking or falling asleep.

may experience cataplexy ( loss of muscle control)

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sleep apnea

one of most common sleep disorders, more than 5 repetitive intermittent periods where breathing stops.

when this happens the person wakes up as the brain realizes it needs to make the person breathe.

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one type is obstructive sleep apnea. where airways are obstructed by things such as the tongue, soft palate, tonsils. this kind is the most diagnosed sleep disorder.

what factors make someone prone to sleep apnea?

family history

relaxed throat and tongue while sleeping

enlarged tonsils and adenoids (tissue at back of nasal passage)

being overweight

anatomy (small airway)

congestion from allergies

restless leg syndrome

tingling, pain, burning, cramping, crawling sensations in lower legs or feet.

what are the associated factors of restless leg syndrome?

family history

anemia

hypertension

gastritis

neuro disorders

pregnancy

parasomnia

unusual movements, behaviours, emotions and dreams when they start to fall asleep, during sleep and between sleep stages.

ex: may sit up, start talking, sleep walking, night terrors, bedwetting.

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important to take precautions to keep them safe if they sleep walk, such as locking doors.

caffeine

should be avoided after 6pm to prevent sleep disturbance.

having more than the recommended amount can result in rapid heart rate, anxiety, irritability, nervousness.

caffeine works by inhibiting adenosine’s sleep signal by binding the adenosine to neuron receptors.

what are inhibitors of sleep?

caffeine

alcohol and drugs

stress

environment

medications

shift work

pain or discomfort

what meds are known to cause sleep issues?

B-blockers, A-blockers, antidepressants, albuterol, diuretics, amphetamine and corticosteroids

what is our circadian rhythm?

our physical, mental and behavioural changes that roughly follow a 24h cycle, responding to light and darkness. it is our biologic clock regulated by our brain and hormones.

healthy sleep hygiene practices

developing a sleep routine

healthy eating patterns

exercising regularly

using relaxation practices

(adapting the environment)

what time of day is not recommended to exercise and why?

3 hours before bedtime as it can cause you to have more energy/ being more awake, preventing sleep

prone position

laying on your stomach

supine position

laying on your back

sims

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fowler

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semi fowler

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dorsal recumbent

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lithotomy

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trendelenburg

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what parts of the brain control the sleep wake cycle?

thalamus, hypothalamus, brain stem, and cortex.

which stage of sleep is shorter?

REM sleep, 20-25%

NREM takes up the most of the time sleeping

how many cycles of REM and non REM sleep happen each night?

4-6 cycles

what neuropeptides are secreted by the hypothalamus to promote wakefulness?

hypocretins (orexins), acetylcholine, and glutamate.

what factors promote sleep?

prostaglandin D2, adenosine, melatonin, serotonin, 1-tryptophan, GABA, and growth factors.

what creates REM sleep?

the pontine reticular formation

rem sleep is started by on and off neurons in the pons ans mesencephalon.

what creates NREM sleep?

projections from the thalamocortical network.

when does REM sleep occur?

every 90min starting 1-2h after non rem sleep begins.

the periods of REM lengthen and NREM becomes shorter closer to the morning.

sleep in infants

they sleep 10-16h a day 50% REM sleep, 25% NREM

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their sleep cycles are 50-60min long 10 to 45 min of REM sleep with 20min of NREM

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at 1 year old, REM and NREM sleep cycles are about equal in length and they sleep through the night with about 2 naps during the day.

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(they sleep longer, have longer periods of REM sleep, shorter sleep cycles)

sleep in older persons

time asleep is lessened

takes longer to fall asleep

poorer quality of sleep

tend to go to bed earlier in the evening and wake up earlier due to advanced normal circadian rhythm

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sleep patterns occur about 10 years later in women than in men.

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they are more likely to have sleep disorders.

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what is somnambulism?

sleepwalking

sedatives and hypnotics

they are drugs that calm people, by depressing the CNS. it gets classified as either depending on the degree that it inhibits the transmission of nerve impulses to the CNS.

sedatives vs hypnotics effects

sedatives reduce nervousness, excitability, and irritability, without causing sleep, and can become a hypnotic if given in large doses.

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hypnotics do cause sleep and have a much more potent effect on the CNS than sedatives.

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drugs can act as either depending on the dosage, this is why some are called sedative-hynotics.

the 3 main groups ofsedative-hypnotics are barbiturates, benzodiazepines and nonbenzdiazepines.

prolonged use of sedative hypnotic drugs can lead to what?

it can lead to REM interference resulting in daytime fatigue, when the drugs are stopped REM rebound can happen which is where someone has large amounts of REM sleep causing frequent and vivid dreams.

melatonin interactions and contraindications

should not take with anticoagulants, immunosuppressants, antihyperglycemics, or birth control.

it is contraindicated with people with depression, hypertension, reduced liver function and seizure disorder.

common drugs prescribed for sleep:

benzodiazepines,

antihistamine: diphenhydramine hydrochloride

antidepressants: trazodone hydrochloride and

amitriptyline hydrochloride.

anxiolytic drugs

benzodiazepines are classified as either anxiolytic drugs or sedative-hyponotics.

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anxiolytic drugs are used to reduce the intensity of feelings of anxiety.

benzodiazepines mechanism of action

depress the CNS, regions specifically being hypothalamic, thalamic, and lymbic systems of the brain.

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is it thought there is receptors in the brain for benzos. thought to be GABA or other closer receptors.

Gaba is the main inhibitory neurotransmitter in the CNS. it modulates activity by inhibiting overstimulation.

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benzos are often combined with anesthetics, analgesics, and neuromuscular blocking drugs in anesthesia and procedural sedations as they reduce memory of painful procedures.

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benzos receptors are in the same area as those that play a role in alcohol addiction. because of this, they are used in the treatment of symptoms of alcohol withdrawal.

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if benzos are being used for the treatment of insomnia it’s recommended to use shorterm to avoid dependency.

contraindications of benzos

drug allergy, narrow angle glaucoma, pregnancy (leads to preterm birth and low birth weight)

adverse effects of benzos

confusion, amnesia, drowsiness, headache, nervousness, dizziness or vertigo.

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more pronounced effects in the older adult. cause a fall risk in older adults.

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“hangover” effect is sometimes reported with benzos

what is the antidote for benzodiazepine overdose?

flumazenil.

if competes with them for binding at receptors.

interactions of benzos

other CNS depressants like alcohol or opioids,

grapefruit

natural health products to promote sleep

kava and valerian

barbiturates

few in clinical use today as benzos are safe and work well.

they produce many adverse effects and have a low therapeutic index. (narrow range where the drug is effective but not toxic)

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they are CNS depressants that act on the brain stem.

they also raise seizure threshold and can be used to treat seizures.

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contraindications: allergry, pregnancy, respiratory difficulties, severe kidney or liver disease, caution in older adults as it increases fall risk

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in overdose: support in oxygen and fluids, charcoal

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can’t take birth control with them as they alter metabolism of the birth control, which can cause unplanned pregnancy

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phenobarbital

most commonly prescribed barbiturate, long acting