Sleep

• Definition: Sleep is a natural, necessary shift in physiologic and neurologic activity that is intended to be restorative.

Rest and Sleep

• Sleep and rest are often used interchangeably, but:

  • One can rest without sleeping.

  • One can sleep and not feel rested.

• Rest: A condition with decreased activity and a feeling of refreshment.

• Sleep: A state of rest with altered consciousness and inactivity; it's a cyclical process.

• Wakefulness: Time of mental activity and energy expenditure.

Functions of Sleep

• Sleep serves several essential functions:

  • Maintains healthy brain function.

  • Promotes emotional well-being.

  • Supports physical health.

  • Facilitates daytime functioning.

• Getting quality sleep can help mental and physical health

• Our body is working to support healthy brain function

• Children and teens need sleep for growth and development

• Sleep deficiency increases risk of heart issues (high bp, diabetes, heart failure)

• Helps us function throughout the day

Physiology of Sleep

• Sleep regulation:

  • biological mechanisms that regulate

  • Includes Circadian Rhythms and the Reticular Activating System (RAS).

Circadian Rhythm

• Refers to predictable fluctuations in biological processes repeating every 24 hours.

• Regulates when we wake up and go to sleep

• Full cycle every 24 hours

  • Circadian Synchronization: When sleep-wake patterns align with the inner biological clock.

  • Night shift jobs effect the circadian synchronization.

  • High rhythms correspond to awakening, while low rhythms indicate sleep.

• Located in the hypothalamus

  • Responds to light and darkness through messages from the retinas

• Controls production of melatonin

• EX. moving time zones, jet lag, night shift, seasons, etc.

Reticular Activating System (RAS)

• Situated in the anterior brainstem, extending up through the medulla, pons, and midbrain into the hypothalamus.

• Relays impulses to the cerebral cortex

• Maintains alertness and wakefulness

• Contributes to muscle tone in different stages of sleep

• Contains the reticular formation crucial for maintaining alertness and wakefulness.

• RAS filters sensory stimuli, ignoring most input, and is sensitive to drugs.

Neurotransmitters and Hormones

• Neurotransmitters:

  • Excitation: Norepinephrine. (Awake/Alert)

  • Inhibitory: Gamma-aminobutyric acid (GABA). (Inhibits wakefulness)

• Hormones:

  • Melatonin: Regulates the sleep-wake cycle; its production increases in darkness.

Stages of Sleep

• Two major phases: NREM sleep (3 stages) and REM sleep.

• Sleep study: polysomnogram. It can be used to show when you are in REM sleep

  • EEG- brain frequencies

  • EOG- eye movements

  • EMG- muscle movements

Sleep Cycle Characteristics

• Normal adults sleep 7-9 hours (varies from 5-10 hours)

• The sleep stages remain fixed, but duration may vary.

• Generally characterized by:

  • Initial predominance of NREM.

  • Increasing duration of REM sleep happens as each cycle is repeated

• Each cycle is 90-100 minutes and we go through each cycle 4-5 times

• Sometimes it is common to wake up each cycle

NREM Sleep Stages *

• STAGE 1: transition stage between wakefulness and sleep. Around 5% of total sleep time.

  • Can be woken easily during this stage

  • Involuntary muscle jerking

  • HR & RR will slow

• STAGE 2: Initiation of the sleep phase. Light sleep is around 50% of total sleep time.

  • Vitals slow even more

• STAGE 3: Deep Sleep. Around 20% of total sleep time

  • HR & RR slowest of all stages

  • Hardest to wake someone up

REM Sleep

• 25% of sleep

• People typically experience more REM sleep as the night progresses

• The brain is active- eye twitch occurs, and HR & RR increase

• Dreaming occurs

• End of the sleep cycle

Sleep Needs Across Lifespan

• Varies across development stages

• Standard 8 hours for adults: not necessarily what your body needs (Sleep needs are different for everybody)

• No rigid formula, each person should follow a pattern of rest that maintains one’s own well-being

  • Newborns: More REM sleep. Need the most sleep

  • Age two: Sleep-wake cycle fully develops.

  • Slow-wave sleep peaks in early childhood and then drops sharply in the teenage years

  • Adolescents: Increased sleep needs due to growth spurts and activity levels.

  • Slow-wave sleep decreases through adulthood, and older people may not have any at all

  • The older you get, LESS sleep you need

Factors Affecting Sleep

• Age- Older adults report difficulty sleeping more often. Make sure they do not take diuretics at night.

• Motivation- Lack of motivation to be awake

• Chronic illnesses/sleep disorders

• Environment- Cars

• Lifestyle choices

• Physical activity/exercise- Can make you have better sleep

• Diet- High caffeine, alcohol, etc.

• Psychological stress- Less sleep

• Illness

• Substance use and medications

• Shift work

• Smoking

• Stress

Assessing Client Sleep

• Physical Assessment:

  • Energy Level

  • Facial Characteristics

  • Behavior

  • Physical data

  • Observation from nurse or bed partner

• Patient sleep health history:

  • Sleep-wakefulness pattern and any recent changes? (difficulty falling/staying asleep, how long have you been sleeping, environment, stressors, etc.)

  • Satisfaction

  • Effect of sleep pattern on everyday functioning

  • Sleep aids (Medication or rituals)

  • Sleep disturbances and contributing factors

• Sleep diary (14 day recall)- time of sleep, time of awakening, sleep pattern, etc.

Physical and Psychological Effects of Insufficient Sleep

• 25% of US adults report insufficient sleep 15 days of each month.

• Obesity risk (hormones leptin and ghrelin).

• Night shift workers: Increased anxiety, depression, GI symptoms, increased type 2 diabetes, hypertension, higher rates of cardiovascular disease like strokes, and substance abuse.

• Higher Car accident rates due to sleep deprivation.

Sleep Health

• Refers to a multidimensional pattern of sleep-wakefulness adapted to individual, social, and environmental demands, that promote physical and mental well-being

• When evaluating sleep health, you want to look at measurable characteristics (quality & satisfaction)

• Good sleep health = subjective satisfaction, appropriate timing, adequate duration, high efficiency, and sustained alertness during waking hours

Common Sleep Disorders (ICSD-3-TR)

1. Insomnia Disorders

2. Sleep-Related Breathing Disorders

3. Central Disorders of Hypersomnolence

4. Circadian Rhythm Sleep-Wake Disorders

5. Parasomnias

6. Sleep-Related Movement Disorders

Insomnia Characteristics and Treatment

• Prevalent in 30-35% of adults.

• Cant FALL/STAY asleep sleep

• Short-term or Chronic

• Can lead to sleep deprivation

• Symptoms: difficulty falling asleep, intermittent sleep, daytime lethargy, irritability, difficulty concentrating, delirium in an acute care setting

• Treatment should prioritize non-pharmacological approaches first.

Sleep-Related Breathing Disorders

• Include obstructive, central, and mixed sleep apneas.

• Obstructive Sleep Apnea (OSA) The throat muscles intermittency relax and block/narrowed airway during sleep, causing breathing to repeatedly stop and start

• Characterized by 5 or more obstructive respiratory events during sleep

• Accompanied by sleepiness, fatigue, snoring, insomnia, and observed apnea

• Sleep study confirms diagnosis

• Treatment includes continuous positive airway pressure (CPAP)

• Obesity causes it

Central Disorders of Hypersomnolence

• Characterized by inability to stay awake during daytime

• Narcolepsy:

  • Type 1: sudden episode of falling asleep with muscle weakness

  • Type 2: Sudden episodes of sleepiness and sleeping

• Treatment: stimulant drugs, symptomatic management.

Circadian Rhythm Sleep-Wake Disorders

• Result from disruptions in the internal circadian timing system.

• Common forms: shift work disorder and jet lag.

• Treatment involves behavioral interventions, sleep hygiene, exercise, and melatonin.

Parasomnias Characteristics and Treatment

• Patterns of waking behavior that appear during REM or NREM stages of sleep

• Abnormal behavioral phenomena during sleep (e.g., sleepwalking, nightmares).

• Head bangs, jaw clenching/teeth grinding, nightmares, night terrors, sleep paralysis, REM sleep disorder, sleep talking, somnambulism

• Improvement in habits or medications may be necessary.

Restless Leg Syndrome (RLS)

• Leg movements worse at night

• Cramps in legs can be painful

• Sleep disruption due to movement

• No diagnostic test and no cure

• Treatment: symptomatic with lifestyle changes and medication.

Sleep Deprivation

• Decrease in sleep Consistency, quality, or quantity; effects emerge after 30 hours of wakefulness.

• Increases Risk for diseases

• Can cause irreversible damage to body tissue from chronic sleep deprivation

• AFTERMATH of not enough sleep

• Loss of concentration and inattention

Good Sleep Hygiene Interventions

• Fix lifestyle/ environmental risk factors

• Get a schedule

• Create the most optimal sleep environment

• Minimize light and noise

• Avoid naps

• Avoid alcohol, nicotine, caffeine

• Avoid drinking a lot of liquid before bed

• Do rituals

• Relax techniques

Promoting Sleep in Hospitalized Patients

• CLUSTER CARE

• Limit daytime naps

• Quiet time

• Minimize environmental stimulation

• Find out the patient’s sleep routine and habits to plan individualized care

• Promote comfort and relaxation

Sedative-Hypnotics

• Drugs that depress or slow down the body’s functions

• Often referred as tranquilizers and sleeping pills

• Their effects range from calming down anxious people to promoting sleep

• FOR SHORT-TERM USE ONLY

• Can cause withdrawal symptoms

  • Tremors, muscle twitches, delusions, dizzy, light headed, induce delirium in some

Barbiturates

• pentobarbital (Nembutal)

• secibaribital (Seconal)

• phenobarbital (Luminal)

• Use for two weeks or less

Benzodiazepines

• Can be used 2-4 weeks or less

• flurazepam (Dalmane)

• temazepam (Restoril)

• triazolam (Halcoin)

• lorazepam (Ativan)

• diazepam (Valium)

Nonbenzodiazepines

Eszopiclone (Lunesta)

• Sometimes used long term as it is indicated for chronic insomnia

• its peak action is in about 1 hour

• common side effects: next day drowsiness, unpleasant taste, dry mouth, headache, and dizziness

Zaleplon (Sonata)

• Helpful in sleep initiation, due to the short half-life

• Least likely to be associated with daytime drowsiness

• Common Side effects: Headache, malaise, bloody nose, and altered color perception

Zolpidem (Ambien and Ambien CR)

• Helps with falling asleep

• CR helps with falling asleep and staying asleep

• Has been associated with sleepwalking and doing nighttime activities with no memory of doing them in the morning, less tolerance is noted with Ambien CR

• DO NOT TAKE IT WITH ALCOHOL & MAKE SURE YOU SWALLOW THE WHOLE THING AT ONCE (DO NOT BREAK), STAY IN BED FOR A PERIOD OF TIME (6 HOURS)

Melatonin Receptor Agonists

• A newer class of medications used in the management of insomnia

• Ramelteon (Rozerem) works through a unique mechanism and is not linked to dependence

• DOES NOT CAUSE DEPENDENCE SAFEST OPTION

• Good for long-term use

• Side effects

Orexin Receptor Antagonists

• Suvorexant (Belsomra) is used to help with sleep initiation and maintenance by blocking alertness-inducing orexin receptors.

• Can cause sleepiness during the day and confusion

Antihistamines

• Benedryl

• Hydroxyzine (Atarax, Vistaril)

• Has no dependence; usually a trial

Complementary Health Approaches

• Include herbal therapies, meditation, and other relaxation techniques to enhance sleep quality.

Implementation Strategies for Sleep Promotion

• Focus on creating a restful environment and implementing restful rituals for patients.