Untitled Flashcards Set

OVERVIEW

sleep is a dynamic process, with behavioral and biological aspects that both stimulate and respond to changes in health.

The science of sleep is relatively new. Polysomnography (PSG), developed in the 1970s, revolutionized sleep science by allowing the documentation of actual electroencephalographic changes during sleep with distinction between normal and abnormal sleep patterns and events

SLEEP PHYSIOLOGY

Sleep Architecture

Sleep architecture refers to the basic stages and structure of normal sleep. The two types of sleep, non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep, alternate in four to six 90-minute cycles per night. NREM sleep is divided into stages N1-3, representing a continuum of sleep depth and unique variations in brain wave patterns, eye movements, and muscle tone. NREM sleep consists of progressively deepening sleep, decreasing responsiveness to stimuli, and intact muscle tone. NREM Stages N1 and N2 are considered light sleep, and Stages N3 refers to as slow wave or deep sleep.

NREM deep sleep is more dominant during the first third of the night, whereas REM sleep dominates the final third of the night

Sleep Regulation

The underlying mechanisms that coordinate sleep are complex and include circadian, homeostatic, neurological, neurochemical, and hormonal processes. The sleep-wake cycle is regulated by a circadian system that controls wakefulness (Process C) and sleep-wake homeostasis that promotes sleep (Process S;

Process C is driven by the suprachiasmatic nucleus (SCN) of the hypothalamus (master body clock) in nearly 24-hour patterns and are synchronized to environmental light exposure received via the retina

The SCN is the circadian pacemaker and receives innervation from the retinohypothalamic tract to entrain sleep. There are circadian rhythms for the sleep-wake cycle, as well as physical activity, food consumption, and body temperature, heart rate, muscle tone, and hormone secretion.

Sleep-wake homeostasis (Process S) involves the accumulation of sleep-inducing substances in the brain, which generates the need for sleep, known as the homeostatic sleep drive.

homeostatic sleep drive accumulates during the day, peaks before bedtime and dissipates throughout the night.

Neurotransmitters such as glutamate and GABA interact with modulatory systems of cell groups to regulate sleep. Hormones, including cortisol and melatonin further influence the circadian system. Cortisol is associated with arousal, rises during wake time, and is inhibited by sleep. Melatonin levels rise during the day in response to sunlight exposure, peak near the onset of sleep, promote sleep initiation and maintenance, and reach a nadir near the onset of waking.

SLEEP ACROSS THE LIFE SPAN

considered within cultural and social contexts, such as usual sleep–wake times, family sleeping arrangements, meal patterns, disruptive influences, and infant feeding practices

Newborn Period

Newborn infants sleep 16 to 20 hours daily.

do not have an established circadian rhythm - A circadian rhythm may begin by 10 to 12 weeks

REM (Stage R) sleep, infants may exhibit fluttering eyelids, body movements, irregular respirations, and at times grunting or other vocalizations.

Infancy

“periodic breathing,” periods of deep, rapid breathing with alternating apneic periods

Toddlerhood

average sleep time in 3- to 5-year-olds of 10 to 13 hours

School Age

During the school-age years, total sleep time and slow wave sleep appear to decrease, whereas REM (Stage R) sleep may slightly increase until adolescence.

Adolescence

Adolescents experience a decrease in total sleep time to a range of 7 to 8 hours including a change in sleep/wake homeostasis and circadian rhythms

Getting the recommended amount of sleep is associated with better health outcomes such as improved attention, improved emotional regulation, better learning abilities. While poor sleep is associated with health problems in adolescents and adults such as depression, anxiety, obesity, hypertension, and increased risk of suicide or injuries

Young, Middle-Aged, and Older Adulthood

Younger adults sleep about 7.5 hours a night (Li et al., 2018) and experience slow wave sleep for the first one-third of the NREM cycle

Total sleep time decreases by 10 to 12 minutes for every decade of life, but stays the same after age 60

FAMILIAL AND GENETIC IMPLICATIONS

Sleep traits are hereditable including timing of sleep, daily sleep requirements, response to sleep deprivation, and EEG variations. Genetic mutations have been associated with human sleep disorders, including fatal familial insomnia, seasonal affective disorder (SAD), natural short sleepers (NSS), and familial advanced sleep phase syndrome.

restless legs syndrome (RLS) which is a disorder with a strong familial inheritance pattern. Narcolepsy is associated with complex genetic mutations and variations primarily found on DQB1. Given the heritable aspects of many sleep disorders, a family sleep pedigree (genogram) should be routine when taking the sleep history of a client with complaints of sleep disturbance.

SLEEP ASSESSMENT

sleep assessment including routine screening, sleep and health history, physical exam, and general and specialized sleep measures.

Routine Screening

Simple questions about difficulties falling asleep or staying asleep, experience of excessive daytime sleepiness, and snoring bring to light common sleep disorders.

Sleep and Health History

A review of the client’s sleep, general health, and dental history is important to identify sleep disorders. Knowledge of relevant medical, surgical, and psychiatric conditions and interventions provides evidence of risk factors associated with impaired sleep.

Sleep disturbances are broadly grouped in one or more of the following: (a) symptoms of insomnia, (b) symptoms experienced during sleep or nighttime awakenings, or (c) symptoms of excessive daytime sleepiness (EDS).

asked about recent life stresses such as relocation, bereavement, or loss of employment. Environmental factors such as home and job demands

ask about excessive hours of sleep, including daytime napping. Sleep diaries are a customary tool to determine sleep-wake patterns, sleep hygiene habits, and lifestyle practices as well as identify circadian rhythm disorders

keep a 2-week sleep diary

promotes a client’s self-awareness of sleep habits, and it can boost motivation to make sleep-related behavior changes.

Physical Assessment

Physical exams provide needed data about medical factors contributing to sleep problems.

Signs- dark circles under the eyes, difficulty staying awake, and rubbing the face suggest daytime sleepiness, which is often associated with sleep fragmentation and disorders such as OSA or RLS (also referred to as Willis-Ekbom Disease).

A neck circumference of 48 cm (19.2 inches) or greater has also been associated with OSA. Obesity is a significant risk factor for OSA, therefore, BMI should be calculated

upper airway structures should be examined for narrowing of the airway or nasal obstruction, with the client in seated and supine positions. Abnormal posterior positioning of the mandible, large tongue (macroglossia), and overcrowding of the teeth suggest a small oral cavity with potential crowding at the base of the tongue, which predispose an individual to OSA.

The nose should be inspected for septal deviation, enlarged nasal turbinates, or other anatomic abnormalities that contribute to nasal obstruction.

Sleep Measures

Standardized sleep assessment tools provide helpful frameworks for collecting sleep information systematically, which supports diagnostic reasoning and is conducive to evaluating treatment outcomes.

The Epworth Sleepiness Scale (ESS), an 8-item Likert-type scale, assesses daytime sleepiness by rating the likelihood of falling asleep in certain situations. High scores on the Epworth suggest, but are not diagnostic of, OSA or narcolepsy (Johns, 1991). Sleep diaries identify circadian rhythm disorders and contributing factors in insomnia development. The Pittsburgh Sleep Quality Index (PSQI) is a well-established but lengthy measure of sleep disturbance, sleep medication use, and daytime dysfunction in the past month. The Sleep Hygiene Awareness and Practices Scale (SHAPS) assesses understanding and practice of factors that may influence sleep. The 11-item Global Sleep Assessment Questionnaire (GSAQ) elicits information about symptoms of sleep disorders (insomnia, EDS, OSA, RLS, REM behavior disorder [RBD]), daytime function, and causes of sleep disturbance.

Pediatric assessment tools include the BEARS framework (bedtime problems, excessive sleepiness, awakenings, regularity of sleep, and sleep-disordered breathing) for general sleep assessment.

Children’s Sleep Habits Questionnaire assesses sleep disturbance and mood in school-age children.

Specialized Sleep Assessments

specialized sleep assessments may be indicated if specific sleep disorders are suspected. Referrals for specialized evaluation such as polysomnography and actigraphy may also be required. Early identification of OSA, RLS, or circadian rhythm disorders allows for timely referral to a sleep specialists for diagnostic studies and treatment.

Berlin questions, STOP (snoring, tiredness, observed apnea, and high blood pressure), and BANG (BMI, age, neck circumference, and gender) questionnaires.

If OSA is suspected, referral to a sleep specialist and a laboratory-based polysomnogram (overnight sleep study) or portable home study may be arranged. If a client describes uncomfortable sensations in the legs at rest or a positive family history of RLS, screening for RLS with the Cambridge-Hopkins Restless Legs Syndrome Questionnaire.

other possible underlying causes of sleep disturbance should first be considered and ruled out. Once this is done, the severity of insomnia could be assessed with the ISI to determine if referral to a behavioral sleep medicine specialist

Technology for Sleep Assessment

Actigraphy (ACTG), usually worn on the wrist, detects motion, and the absence of motion is measured as a proxy of sleep

ACTG allows monitoring of sleep in the client’s home environment over an extended period of time.

better measure of total sleep time than of other sleep variables

used to spot circadian rhythm disorders and sleep–wake patterns in adults with insomnia. It is also used to estimate total sleep time in adults with OSA and in populations intolerant of PSG, such as children and elderly adults. Ankle ACTG can also be used to assess periodic limb movements (PLMs) of sleep

SLEEP AND PSYCHIATRIC DISORDERS

COMMON PSYCHIATRIC DISORDERS, ASSOCIATED SLEEP DISORDERS, AND THEORIZED PATHOPHYSIOLOGY

SLEEP AND MEDICAL DISORDERS

medical disorders may precipitate or exacerbate sleep disturbance.

NURSING DECISION TREES

SHARED DECISION-MAKING AND COLLABORATIVE TREATMENT PLANNING

Addressing client and family learning needs about sleep regulation, factors that can negatively impact sleep, and practices that can promote healthy sleep support shared decision-making and responsibility for sleep intervention.

NONPHARMACOLOGICAL AND PHARMACOLOGICAL TREATMENTS

Nonpharmacological Treatment

cognitive and behavioral therapies as first-line therapy for insomnia. Cognitive behavioral therapy for insomnia (CBTI) is an effective treatment option for those with or without comorbidities or psychiatric disorders, using or not using medications and for any age group; nevertheless CBTI is underused. Multicomponent cognitive behavioral therapy for insomnia (CBTI) is an approach aimed at reducing perpetuating factors of insomnia by modifying sleep schedules, habits, and misconceptions about sleep that are responsible for chronic insomnia. The most common, empirically supported, and standard components of cognitive behavioral interventions or approaches are sleep restriction, stimulus control, sleep hygiene education, and cognitive therapy, with or without relaxation in adults with persistent insomnia. The 2006 AASM insomnia practice parameters appraised psychological and behavioral interventions as effective, and recommended three “standard” therapies for treatment of chronic insomnia: multicomponent CBTI, stimulus control, and relaxation for treating chronic insomnia. A recent meta-analysis of CBTI for insomnia with mental health and/or medical conditions suggests that it is highly effective for improving insomnia symptoms and sleep parameters, with larger effects on mental health conditions compared with medical conditions

COMMON MEDICAL & ASSOCIATED SLEEP DISORDERS

Circadian rhythm sleep disorder

Obstructive sleep apnea syndrome

•Can occur with Alzheimer’s disease or dementias

Insomnia

•Can occur with asthma, nocturnal

•Cardiovascular disease

•Congestive heart failure

•Cerebrovascular accident

•Can occur with COPD

Insomnia, excessive daytime sleepiness

•Cancer (anxiety, depression, QOL)

Sleeping disorders in acute lung injury

Acute respiratory distress syndrome

Post-stroke insomnia Cheyne–Stokes respirations

•Can occur with cardiovascular accident

Severe OSA and arousals; RLS

Hypersomnia associated with MDD

•Sleep variability

•Diabetes Type 1

Sleep duration

•Diabetes Type 2

REM behavior disorder (RBD)

•Parkinson’s disease

Cognitive Therapy

Cognitive therapy for insomnia is based on the premise that people with insomnia have sleep-related fears and worry, which arises from maladaptive cognitions and beliefs (such as catastrophic thinking) about the devastating consequences of poor sleep. This method assists the patient to identify these cognitions and beliefs, critically analyze them, recognize that they may not be factual, and restructure them in a more realistic light

Stimulus Control Therapy

instructions that discourage sleep-incompatible behaviors and attempt to limit stimuli in the bedroom linked with sleep-related anxiety that is associated with wakefulness and arousal. The purpose of stimulus control is to re-associate the bed/bedroom with feeling sleepy and develop positive associations between pre-sleep rituals and the sleep environment

Relaxation Therapy

approaches that focus on decreasing elevated levels of arousal. For example, progressive muscle relaxation is aimed at reducing somatic arousal, and it consists of systematic tension and relaxation of muscle groups. Guided imagery is aimed at reducing cognitive arousal and includes visualization of relaxing settings or activities.

Paradoxical Intention and Biofeedback

Paradoxical intention aims at eliminating performance anxiety by having the patient avoid any intentional effort to fall asleep. Biofeedback focuses on reducing somatic arousal by training the patient to control physiological variables using visual or auditory feedback.

Sleep Restriction

based on the premise that persons with insomnia spend excessive time in bed attempting to sleep. The purpose of sleep restriction is to strengthen homeostatic and circadian processes, consolidate sleep, reduce time to fall asleep, and establish sleep–wake patterns. For example, if the reported sleep time is 6 hours, the sleep restriction prescription limits time in bed to 6 to 6.5 hours.

contraindicated in persons who require maximal vigilance to prevent accidents such as operators of heavy machinery, and in those with conditions exacerbated by sleepiness such as epilepsy, parasomnias, obstructive sleep apnea, psychotic disorders or bipolar disorder.

Sleep Compression

Sleep compression is similar to sleep restriction, except that sleep is restricted gradually. This technique is an alternative approach for patients who have anxiety about prescribing sleep and need relaxed limitations or who cannot tolerate the sudden reduction associated with sleep restriction.

Multicomponent Therapy

combinations of stimulus control, relaxation, and sleep restriction therapies, with or without cognitive therapy

intensive therapy, is delivered for 6 to 8 weeks at weekly visits and is administered by a behavioral sleep medicine specialist.

BBTI is designed to be delivered over a shorter time period in fewer visits and/or in a small group format and can be administered by master’s level clinicians including nurses. BBTI is contraindicated in those for whom sleep restriction therapy is not recommended, as well as for persons with bipolar or psychotic disorders due to potential exacerbation of symptoms

Sleep Hygiene Education

combination with other CBTs to address problems with sleep initiation and maintenance.

purpose of sleep hygiene education is to increase knowledge of homeostatic and circadian processes and encourage sleep-promoting behaviors.

behavioral factors (sleep schedule, stimulants, environment, etc.) that may potentially influence sleep

Pharmacological Treatment

sleep and psychiatric disorders share some pathophysiological relationships, pharmacological therapies may target neurotransmitters associated with both. In general, pharmacological therapies for sleep disorders act by enhancing sleep-promoting systems, blocking wake-promoting systems, or enhancing wake-promoting systems.

Selection of sleep agents should depend not only on the sleep problem or disorder identified, but also on the acuity of the disorder in addition to individual risks.

recommends alternative to benzodiazepines and nonbenzodiazepines for older adults with insomnia due to motor vehicle accidents, falls, fractures, cognitive and other side effects. Trazodone, the most frequently used off-label insomnia agent, has low potential for abuse and is a preferred agent for management of insomnia in patients with substance abuse disorder.

MANAGEMENT OF SLEEP DISORDERS

Insomnia

Psychological and behavioral therapies are recommended for first-line management of both primary and chronic insomnia. Nonbenzodiazepines should also be used

Melatonin agonists have fewer adverse effects but have been suggested to be more effective in phase shifting than in managing insomnia. The orexin receptor antagonists, suvorexant and lemborexant, are among the newest pharmacological therapies available for insomnia, and appear promising in the management of insomnia with fewer adverse effects.

Central and Mixed Sleep Apneas

Adaptive sero-ventilation (ASV) provides expiratory positive airway pressure (EPAP) to treat central sleep apnea by adjusting to control central events. An ASV device is similar to bilevel positive airway pressure (BPAP) and continuous positive airway pressure (CAP). Central sleep apnea occurs with neuromuscular disorders due to diaphragm weakness. Indications of central sleep disordered breathing include sawtooth desaturation, hypoventilation, desaturation and hypocarbia

ASV to treat central sleep apnea and heart failure

Obstructive Sleep Apnea

Effective long-term management of OSA includes client education and reduction of risk factors. Characteristics of OSA include loud snoring, gasping at the end of an apneic episode, choking and excessive daytime sleepiness. Obesity, large neck size, morning headaches, gastroesophageal reflux at night and comorbid conditions are very common in OSA. Continuous positive airway pressure (CPAP) is used to manage moderate to severe OSA

Education, cognitive behavioral therapy, peer support and telemedicine are strategies to promote adherence

RLS and PLM of Sleep

Management of RLS includes correction and monitoring of underlying risk factors for RLS, such as low serum ferritin (less than 45–50 mcg/L). Oral iron administered with vitamin C to enhance absorption, is recommended to correct deficiencies. Pharmacological therapy with dopamine agonists has become preferred therapy for the long-term management of RLS, due to augmentation of symptoms with levodopa.

For clients who do not respond to nonpharmacological therapy and correction of existing iron deficiency, first-line medications to treat chronic RLS/PLM include dopamine agonists (pramipexole, ropinirole or rotigotine) or an alpha-2-delta calcium channel ligand such as gabapentin or pregabalin.

recommended to use the lowest effective dose of these agents. For mild cases of RLS in younger patients, the benzodiazepine clonazepam, has been shown to be helpful; however, the short-acting products such as zolpidem should be avoided as they have been associated with a high incidence of sleepwalking and sleep-related eating disorders in RLS.

Alcohol use has also been associated with increased PLMs, and alcoholism with both PLMs and RLS in the presence of iron, ferritin, magnesium, and vitamin B12 deficiencies.

Circadian Rhythm Disorders

aimed at the maintenance of the dark–light entrained sleep cycles established in initial therapy. Continued resolution of delayed sleep-phase disorder (DSPD) depends upon adherence to good sleep hygiene practices including a set sleep–wake schedule. Light therapy (early morning exposure and evening avoidance) and melatonin may be incorporated into the plan of care. Long-term management of advanced sleep phase disorder (ASPD) requires maintenance of the established later bedtime schedule.

Melatonin is used for management of free-running disorder (FRD) in blind or sighted persons, and light therapy may be used in sighted persons. Irregular sleep–wake rhythm (ISWR) is managed with mixed modalities, including light therapy, and scheduled physical and social activities. Management of shift work disorder may include the use of a hypnotic such as zolpidem to promote daytime sleep and use of stimulant medications such as modafinil to promote alertness during night work. Bright light therapy may be used to promote adjustment to night work, with use of a portable light box (bright blue or white) at the workstation until 4 a.m. if possible.

Bright light or light box exposure after 12 noon may be helpful on days off to promote wakefulness. Bright light therapy is contraindicated in persons with eye disease or on photosensitizing medications. Bright lights can also induce migraines and mania.

Narcolepsy

based on the presence of EDS as a single symptom, or with REM sleep and other symptoms. Stimulants such as modafinil or armodafinil are used to treat EDS without other symptoms. Two new medications, solriamfetol and pitolisant

Solriamfetol is a dopamine and norepinephrine receptor inhibitor while pitolisant is believed to be an antagonist of the histamine-3 receptor. Sodium oxybate is approved for adults with or without cataplexy plus REM sleep and/or other symptoms such as disturbed nighttime sleep, frequent unpleasant dreams, hypnagogic hallucinations, and/or sleep paralysis. Oxybate salts (calcium, magnesium, potassium and sodium) are available in a product that can be used to treat narcolepsy in both adults and children.

adverse side effects, including severe cardiovascular and psychiatric effects. Drug tolerance, addiction, hypertension, impaired hepatic function, and psychosis may occur. Regular sleep times and two short scheduled naps per day can be helpful adjunct therapy to reduce day sleepiness and sleep episodes.

symptomatic for years before receiving a narcolepsy diagnosis, depressive symptoms are common.

support groups such as the Narcolepsy Network

collaborate with sleep specialists

Age-Related Sleep Disturbances

Pregnancy, Childbirth, and Postpartum

The first trimester of pregnancy is characterized by daytime sleepiness due to increased progesterone. Fragmentation of sleep in the first and third trimesters is also common due to pregnancy-related changes and discomforts. Sleep change is most significant in the third trimester with increased wakening, poor sleep efficiency and possible changes in slow wave sleep and REM sleep.  Sleep-disturbed breathing during pregnancy can contribute to complications such as increased maternal blood pressure, decreased uteroplacental blood flow, gestational diabetes, fetal growth restriction, stillbirth or poor neonatal condition. Pregnancy-associated insomnia symptoms are extremely common in pregnancy and may be related to increased metabolism and body temperature, restless leg syndrome, ongoing pain, discomfort, and breathing disturbance. Gastroesophageal reflux and nocturnal micturition, often disrupts sleep and limits positions for sleep.

altered circadian rhythm related to infant care and feeding

cognizant of how sleep deprivation may precipitate or exacerbate depressive symptoms

Newborn Implications

born prematurely, had low Apgar scores, or have experienced illnesses such as sepsis are at greater risk for primary sleep apnea of infancy.

described as obstructive, central, or mixed. Obstructive apnea, characterized by thoracic movement but little or no nasal airflow, may occur with gastroesophageal reflux disease. Central apnea is caused by immature control of the respiratory system and is more common in preterm infants

characterized by the absence of both thoracic movement and nasal airflow. Mixed apnea describes events that begin with either central apnea or obstructive apnea and then change to the other type.

experienced illness such as sepsis or hyperbilirubinemia

infants are free of apneic symptoms by 40 weeks

Parents who are frequently up at night and deprived of sleep on an ongoing basis are not only very tired but may also become anxious and depressed

new parents with a current or past history of depression, and may require psychological support to prevent induction or exacerbation of mood disturbance.

Infancy and Childhood

sleep disruption in childhood may adversely impact mood, behavior, and learning

Menopause

cessation of the menstrual cycle with accompanying changes in gonadal hormones.

“hot flashes,” also referred to as “hot flushes” and “night sweats,” which are symptoms of a nocturnal thermoregulatory phenomenon characterized by vasodilation.

increased nocturnal awakenings and are present in peri-menopausal women who develop insomnia.

transitioning to menopause who develop insomnia has been further characterized as having a prolonged and variable wake-after-sleep onset and by an overall sleep deficit

OSA is higher in perimenopausal women as a result of decreased hormone production, the prevalence of sleep disordered breathing including OSA is higher in postmenopausal women. Sleep-disordered breathing should be considered in post-menopausal women with sleep complaints, hypertension, and obesity.

Older Adults

Sleep complaints correlate with health complaints, depression and mortality in older adults. For example, desynchronized circadian rhythm in older adults results in a greater risk for mild cognitive disorder, dementia, and cardiovascular disease.

adults with hypertension, breathing problems, urinary problems, chronic pain, and gastrointestinal complaints had higher levels of insomnia

Sleep disturbances are common with psychiatric comorbidities

With access to appropriate treatment, the symptoms associated with severe and persistent mental health conditions such as schizophrenia or bipolar disorder may sometimes diminish in older age. Mental health conditions such as depression, bipolar disorder, and schizophrenia may also worsen with chronic conditions or when superimposed on dementia.

Due to antipsychotic medications, sudden cardiac death is a cause of higher mortality and obstructive sleep apnea is an underestimated risk factor for sudden cardiac death in persons with schizophrenia.

sleep quality was associated with symptoms of increased anxiety and depression. Symptoms of anxiety, but not depression was related to increased daytime sleepiness

depression is more common when the severity of restless legs syndrome worsens.

Dementia is one of the most common geropsychiatric disorders and is associated with neurodegenerative changes resulting in fragmented sleep. Older adults with dementia are at high risk for severely disturbed sleep due to damage in the neuronal pathways that interfere with homeostatic and circadian rhythm processes.

nighttime wandering and daytime sleepiness, and their sleep architecture is characterized by decreased slow wave sleep and less REM

Sleep disturbances in older adults are associated with Parkinson’s disease. Insufficient amounts of dopamine produced in the substantial nigra of the brain causes Parkinson’s disease.

nonmotor symptoms such as depression, decreased olfactory sensitivity and sleep disorders that may herald this movement disorder. Sleep disturbances such as insomnia, fragmented sleep, sleep apnea, daytime sleepiness, periodic limb movements during sleep and Idiopathic Rapid Eye Movement Sleep Behavior Disorder (RBD) are common in older adults with Parkinson’s disease.

RBD awaken suddenly and act out their dreams, demonstrating a loss of REM sleep atonia and an increase in motor activity. Studies reveal that RBD may be an early predictor of Parkinson’s disease.

Nonpharmacological management focused on safety is recommended because pharmacological therapy can worsen associated sleep apnea and dementia.

adverse side effects of these medications such as orthostatic hypotension, cognitive impairment, EDS, and interactions due to polypharmacy. Consequently, nonpharmacological interventions are first-line treatments for older adults with and without mental health conditions.

SUMMARY

PEDIATRIC POINTERS

result from improper sleep training (reliance on specific conditions or objects to initiate sleep) or limit setting by parents or caretakers (bedtime refusal behaviors)

beginning in infancy with a focus on routine and parenting skills In infancy

prevention strategies include limiting screen time at bedtime, no bed-sharing, allowing infants and children to fall asleep on their own, allowing self-consoling behaviors, and promoting sleep hygiene measures such as light and noise reduction.

EDS may go unrecognized in children and adolescents, who demonstrate hyperactivity, impulsivity, or aggressiveness rather than classic adult symptoms and poor school performance.

narcolepsy is difficult to diagnose in preschool children, habitual afternoon napping beyond preschool age is a red flag. Such naps (attacks of sleepiness) are characteristically associated with sedentary activities, autonomic activities of which the child is unaware, occur regardless of nighttime sleep quantity, and may result in learning problems

OSA are generally less likely than adults to have a history of EDS, although obese children and adolescents may report EDS

hypertrophy of the adenoids and tonsils.

history of choking on food and speaking as if holding a “hot potato” in the mouth.

surgical removal of adenoids and tonsils, although nasal CPAP.

RLS, narcolepsy, and sleep disorders should be treated with a multi-disciplinary approach including behavioral therapies and potentially pharmacological or mechanical interventions. Childhood parasomnias arise from NREM slow wave sleep, include sleep terrors and sleep walking, are characterized by amnesia of the episode, and typically resolve by early school age.

nightmares, also common, which arise from REM sleep and are remembered by children. Management recommendations for sleepwalking and sleep terrors include identifying and limiting triggers and awakening the child 30 minutes prior to the anticipated episode nightly for a week to interrupt the pattern.

children demonstrating stereotypical behaviors such as lip-smacking or hand hitting the head during episodes of sleepwalking, as these may be symptoms of nocturnal seizures and require further evaluation. Children with pervasive developmental delays may demonstrate a variety of sleep disorders, such as head-banging by those with autism. Children with attention deficit hyperactivity disorder have increased rates of PLMs of sleep and sleep-disordered breathing. Bedtime fading may be used in children with and without developmental disabilities and includes putting the child to bed later than the typical onset of sleep, eliminating daytime naps, and establishing a set sleep–wake pattern. It also includes removing the child from bed if sleep does not occur within 15 minutes and allowing engagement in regular evening activity, as well as only allowing the child to remain in bed when sleep is highly likely. This protocol is based on similar principles as stimulus control and sleep restriction therapies, and pairs bedtime stimuli with sleepiness and sleep-related behaviors.

OVERVIEW

• Sleep is a dynamic process with both behavioral and biological aspects stimulating and responding to changes in health.

• The science of sleep is relatively new, with Polysomnography (PSG) developed in the 1970s revolutionizing sleep science by documenting electroencephalographic changes during sleep.

SLEEP PHYSIOLOGY
Sleep Architecture

• Sleep architecture involves NREM and REM sleep alternating in 90-minute cycles.

• NREM sleep consists of stages N1-3: N1 and N2 are light sleep; N3 is deep sleep or slow wave sleep.

• NREM deep sleep is more dominant during the first third of the night, while REM sleep dominates the final third.

Sleep Regulation

• Circadian rhythms and homeostatic processes regulate sleep.

  • Process C (circadian system) is driven by the suprachiasmatic nucleus (SCN) in nearly 24-hour patterns.

  • Process S (sleep-wake homeostasis) accumulates sleep-inducing substances during the day.

• Hormones and neurotransmitters, including cortisol and melatonin, influence sleep.

SLEEP ACROSS THE LIFE SPAN

• Newborn Period: Infants sleep 16-20 hours daily, with the circadian rhythm developing around 10-12 weeks.

• Infancy: Characterized by periodic breathing with alternating apneic periods.

• Toddlerhood: Average sleep for 3-5-year-olds is 10-13 hours.

• School Age: Total sleep decreases; REM sleep may increase until adolescence.

• Adolescence: Sleep time decreases to 7-8 hours; good sleep is linked to health outcomes.

• Young, Middle-Aged, and Older Adulthood: Sleep duration decreases with age; about 7.5 hours for younger adults.

FAMILIAL AND GENETIC IMPLICATIONS

• Sleep traits are hereditable; genetic mutations can lead to sleep disorders.

SLEEP ASSESSMENT

• Routine Screening: Identifies common sleep disorders via screening questions.

• Sleep and Health History: Reviews sleep patterns and health conditions.

• Physical Assessment: Identifies signs of sleepiness and associated disorders, such as OSA.

Sleep Measures

• Standardized tools like the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI) help assess sleep quality and disorders.

SLEEP AND PSYCHIATRIC DISORDERS

• Sleep disturbances are common with psychiatric disorders and can exacerbate symptoms.

MANAGEMENT OF SLEEP DISORDERS

• Nonpharmacological Treatments: Cognitive behavioral therapy, stimulus control, sleep hygiene education.

• Pharmacological Treatments: Emphasis on alternatives to benzodiazepines, use of melatonin agonists, and newer drugs for insomnia (e.g., suvorexant).

AGE-RELATED SLEEP DISTURBANCES

• Sleep changes during pregnancy include nighttime awakenings and insomnia.

• In older adults, sleep complaints are associated with various health issues including depression and cognitive decline.

PEDIATRIC POINTERS

• Proper sleep training and limiting screen time can prevent sleep issues in children.

SUMMARY

• Understanding sleep's complexity and its impact on health is crucial for managing sleep disorders effectively.