Study Notes on Sleep and Sleep Disorders

Sara Adams (Case Study)
- 51-year-old female, small business owner, faced bankruptcy 6 years ago.
- Supplemented income by substitute teaching; business recovery, continued teaching due to financial insecurity concerns.
- Tried various sleep medications, discontinued due to side effects or perceived ineffectiveness.
- Father's death 3 months prior created significant stress affecting her ability to cope with responsibilities (care for two teenage daughters, support her mother, settle father's estate).
- Currently isolated from friends and hobbies (painting, gardening).
- Consuming 5-6 cups of coffee daily and 2-3 glasses of wine nightly to aid sleep.
- Referred to sleep disorders clinic for chronic severe insomnia affecting daily function.
Assessment Data
- Appears older than stated age, pale skin, puffy eyes, frequent yawning.
- Height: 165 cm (65 in), Weight: 52.1 kg (115 lb), Body Mass Index (BMI): 19.1.
- Vital signs:
- Temperature: 36.3° C (97.4° F)
- Pulse: 84 bpm (regular)
- Respiration: 20 breaths/min (nonlabored)
- Blood Pressure: 160/90 mmHg
- Pulse oximetry: 95% on room air.
- No significant physical complaints; psychiatric assessment indicated high stress without depression or anxiety.
- Reports:
- Daytime sleepiness and difficulty concentrating.
- 60-90 minutes to fall asleep at night (bedtime: 11 p.m.).
- Wakes 3-4 times with at least 30 minutes to fall back asleep, sometimes longer.
- 4-5 hours of sleep per night.

Physiologic and Psychological Changes
- Sleep cycle includes alterations in physiological states that affect overall health.
- Physiological Effects of Lack of Sleep:
- Decreased immune function
- Negative impacts on cognition and emotional health
- Increased risk for chronic diseases.
Types of Sleep:
- Non-Rapid Eye Movement (NREM) Sleep (75-80% of sleep):
- Stages:
  - N1: Light sleep, slow eye movements, easily awakened.
  - N2: True sleep, longest stage, no eye movement, slow brain activity for memory protection.
  - N3: Deep sleep (slow-wave), essential for growth and repair (tissue healing).
- Physiological changes: Decreased heart rate, blood pressure, respiratory rate, body temperature, increased growth hormone.
- Rapid Eye Movement (REM) Sleep (20-25% of sleep):
- Involves the most vivid dreaming.
- Both BP, heart rate, and temperature are irregular during REM.
- Increases creativity, emotional regulation, and memory consolidation.
- Cycles lengthen with time throughout the night.

Key Neurotransmitters and Their Roles:
- Acetylcholine: Activates cortex, plays a role in REM sleep.
- Norepinephrine: Increases alertness.
- Serotonin: Supports sleep onset, precursor to melatonin.
- Gamma-Aminobutyric Acid (GABA): Calms the central nervous system (CNS).
- Melatonin: Signals the body that it is time to sleep.
- Adenosine: Accumulates and promotes sleep, can be blocked by caffeine.

Circadian Rhythms: Controlled by hypothalamus, regulating the 24-hour day-night cycle.
Sleep Patterns:
- Newborns: Require most sleep.
- Elderly: Typically require the least sleep.
Polysomnography: Used to analyze sleep cycles, including stages N1, N2, N3, and R.
Sleep Cycle Duration: Approximately 90-110 minutes, with 3-6 cycles occurring per night.

Abnormal behaviors or experiences associated with sleep, including:
- Somnambulism (Sleepwalking)
- Nocturnal Enuresis (Bedwetting)
- Sleep Terrors and Nightmares
- Bruxism (Teeth Grinding)

Sleep disturbances resulting from medical or psychiatric conditions:
- Heart failure, COPD, pain, gastric reflux.
- 90% of depression patients report sleep disturbances.

Health History: Inquire about sleep patterns, quality, environment, sleep aids, and disturbances.
- Instruments to assess:
- Epworth Sleepiness Scale
- Pittsburgh Sleep Quality Index (PSQI)
Physical Assessment: Evaluate sleep-related physical conditions and symptoms, including energy levels, physical endurance, obesity indicators.
Diagnostic Tests:
- Polysomnography: Monitors various parameters during sleep.
- Multiple Sleep Latency Test: Assesses daytime sleepiness.

Sleep Deprivation:
- Evidence includes trouble falling/staying asleep, excessive daytime sleepiness, physical signs (pale skin, frequent yawning).
Impaired Sleep: Environmental factors causing sleep disruption within healthcare settings.
Fatigue: Daytime tiredness stemming from sleep impairments.

Example Goals:
- Patient will achieve 6-7 hours of sleep for at least 5 nights per week within 1 month.
- Patient will maintain sleep durations of at least 90 minutes at a time during hospital stays.
- Patient will incorporate two 20-minute naps daily.

For Insomnia:
- Establish good sleep hygiene practices, maintain regular sleep schedules, create conducive sleep environments, limit caffeine/alcohol intake.
- Recommend relaxation techniques (e.g., yoga, meditation).
- Medication considerations:
- Melatonin, short-term sedatives, avoiding long-term use.
For Narcolepsy and Obstructive Sleep Apnea (OSA):
- Use CPAP devices, consider pharmacological treatments as necessary.
- Address RLS through movement therapies and dietary adjustments.

Encourage self-care and education on:
- Variations in sleep patterns
- Techniques to promote relaxation and improve sleep hygiene
- Keeping a sleep diary.

Outcomes include the patient effectively sleeping in supportive environments with adequate rituals and energy levels to complete daily tasks, actively identifying sleep-interrupting factors and employing strategies to enhance sleep.

Example goal::
- Patient will report achieving 6-7 hours of restful sleep within one month.

Sleep hygiene practices, coping mechanisms for stress, dietary considerations, establishing a routine exercise schedule, resuming hobbies.

Patient reports sleep duration improvement, decreased caffeine and wine consumption, initiated journaling, resumed painting as a form of relaxation, adopted a dog for companionship and physical activity.
Educational reinforcement includes optimizing walking duration, maintaining a sleep schedule, and continuing self-care activities (journaling, painting).