Sleep can be defined as a normal state of altered consciousness during which the body rests; it is characterized by decreased responsiveness to the environment, and a person can be aroused from it by external stimuli.

Or Sleep is a cyclical physiological

process that alternates with longer periods of wakefulness

Sleep is generally characterized by :•A reduction in voluntary body movement.•Temporary blindness.•Decreased reaction to external stimuli.•Loss of consciousness.•A reduction in audio receptivity.

An increased rate of anabolism (the synthesis of cell structures), and a decreased rate of catabolism (the breakdown of cell structures

Almost a third of the general population has some problems with sleep during any given year. More than half of the 9000 participants in a study of sleep in elderly persons (65 years or older) reported the following as sleep pattern disturbance that they experience most of the time:• Trouble falling asleep• Frequent awakening• Waking too early• Needing to nap• Not feeling rested

Circadian Rhythms:-• When physiologic & psychological rhythms are high or most active, the person is awake; when these rhythms are low, the person & asleep.

• Although light & dark appear to be powerful regulators of the sleep wake circadian rhythm.

• Fluctuations in a person’s heart rate, blood pressure, body temperature, hormone secretions, metabolism & performance & mood depend in part on circadian rhythms.

• Circadian rhythms complete a full cycle every 24 hour.

• “Circa” in Latin means “approximately” & “diem” is stands for “day”, circadian represents approximately one day.

Sleep involves a sequence of physiological states maintained by highly integrated central nervous system activity; this is associated with changes in the peripheral nervous, endocrine, cardiovascular, respiratory and muscular systems.

Current theory suggests that sleep is an active multiphase process. 

The major sleep centre in the body is the hypothalamus. 

The hypothalamus secretes hypocreatins (orexines) that promotes wakefulness & rapid eye movement sleep.

Prostaglandin d2, L-tryptophan and growth factors control sleep.

Researchers believe that the ascending Reticular Activating System (RAS) located in the upper brain stem that contains special cells that maintain alertness & wakefulness.

The (RAS) receives visual, auditory, pain & tactile sensory stimuli. 

Arousal, wakefulness and maintenance of consciousness results from neurons in the RAS that release catecholamine such as nor epinephrine.

Researches hypothesize that the release of serotonin from specialized cells in the raphe nuclei sleep system of the Pons & Medulla produce sleep ,this area of sleep is also called the Bulbar Synchronizing Region (BRR)

Whether a person remain awake or falls asleep depends on a balance of impulses received from higher canters (e.g. thoughts), peripheral sensory receptors (e.g. sound or light stimuli), & the limbic system (emotions). 

As people try to fall sleep, they close their eyes & assumed relaxed positions stimuli to the RAS decline, if the room is dark and quite, activation of the RAS further declines. At some point the BSR takes over, causing sleep.

Normal sleep involves two phases   1. NREM: N0N RAPID EYE MOVEMENT 2. REM: RAPID EYE MOVEMENT 

• This stage have been studies and analyzed with the help of the electroencephalograph (EEG) which receives & records electrical currents from the brain .EOG – electrooculogram, which records eye muscle tone movements, and the electromyography (EMG), which records muscle tone.

Restoration

Ontogenesis

Memory processing

Dreaming

Preservation

Infants Toddlers Preschoolers School age children Adolescents Older adults Middle age adults Young adults

Developmental considerations: Psychological stress: Motivation: Culture: Diet: Alcohol intake: Caffeine containing beverages: Smoking: Environmental factors: Lifestyle: Exercises: Medications: Illness:

DYSSOMNIAS

PARASOMNIAS

MEDICAL OR PSYCHIATRIC CONDITIONS THAT MAY PRODUCE SLEEP DISORDERS

HOSPITAL ACQUIRED SLEEP DISTURBANCES

A broad category of sleep disorders. The three major subcategories include intrinsic (i.e., arising from within the body), extrinsic (secondary to environmental conditions or various pathologic conditions), and disturbances of circadian rhythm.

Insomnia Narcolepsy Obstructive sleep apnea Restless leg syndrome Periodic limb movement disorder Hypersomnia Circadian rhythm sleep disorders

DEFINITION:DEFINITION: - insomnia is "difficulties in initiating and/or maintaining sleep, or nonrestorative sleep, associated with impairments of daytime functioning or marked distress for more than 1 month.“

INCIDENCE:INCIDENCE: - Insomnia is 41% more common in women than in men.

Psychoactive drugs or stimulants Fluoroquinolone antibiotic drugs Restless Legs Syndrome Pain Hormone shifts Life problems Mental disorders Disturbances of the circadian rhythm Certain neurological disorders Medical conditions Poor sleep hygiene Parasomnia elevated night-time levels of circulating

cortisol and adrenocorticotropic hormone

Physical exercise genetic condition

Types of insomnia • Transient insomnia• Acute insomnia: • Chronic insomnia l

Patterns of insomnia• Onset insomnia • Middle-of-the-Night Insomnia• Middle insomnia • Terminal (or late) insomnia

Subjective insomnia Insomnia versus poor sleep

quality

Assessment of sleep.

It can be confirmed by polysomnographic recording, which usually shows the same pattern of long sleep latency or fragmentation that the client describes

Non-pharmacological Cognitive behavior therapy Medications

• Benzodiazepines:-temazepam, flunitrazepam, triazolam, flurazepam, midazolam, nitrazepam and quazepam.

• Non-benzodiazepines:-zopiclone and eszopiclone

• Opioids:-hydrocodone, oxycodone, and morphine

• Antidepressants:-amitriptyline, doxepin, mirtazapine, and trazodone and Mirtazapine

• Antihistamines:-Cyproheptadine and

diphenhydramine

• Atypical antipsychotics:-quetiapine, olanzapine and risperidone

DEFINITION: -  Narcolepsy is one of the disorders

characterized by excessive daytime sleepiness. The client also experiences disturbed nocturnal sleep and repeated episodes of almost irresistible daytime drowsiness followed by brief periods of sleep, especially when engaged in monotonous activities

•A depiction of the neuropeptide Orexin A. People with narcolepsy often have a reduced number of neurons that produce this protein.

• One factor that seemed to predispose an individual to narcolepsy involved an area of Chromosome 6 known as the HLA complex. There appeared to be a correlation between narcoleptic individuals and certain variations in HLA genes,

Excessive daytime sleepiness (EDS), Daytime naps may occur with little

warning and may be physically irresistible

Four of the other classic symptoms of the disorder, often referred to as the "tetrad of narcolepsy," are cataplexy, sleep paralysis, hypnagogic hallucinations, and automatic behaviour. These symptoms may not occur in all patients.

Drowsiness may persist for prolonged periods of time. In addition, nighttime sleep may be fragmented with frequent awakenings

Multiple sleep latency test (MSLT)

Polysomnogram Diagnosis is relatively easy when

all the symptoms of narcolepsy are present, but if the sleep attacks are isolated and cataplexy is mild or absent, diagnosis is more difficult

Treatment is based on symptoms and therapeutic response. • The main treatment of excessive daytime sleepiness in narcolepsy is with central nervous system stimulant drugs such as methylphenidate, racemic - amphetamine, dextroamphetamine, and methamphetamine, or modafinil (Provigil), a new stimulant with a different pharmacologic mechanism, and more recently, armodafinil (Nuvigil).

• Cataplexy and other REM-sleep symptoms are frequently treated with tricyclic antidepressants such as clomipramine, imipramine, or protriptyline, as well as other drugs that suppress REM sleep. Venlafaxine, an antidepressant.

Another treatment option for narcolepsy is Xyrem (sodium oxybate) oral solution for the treatment of cataplexy associated with narcolepsy and Excessive Daytime Sleepiness (EDS) associated with narcolepsy.

Lifestyle changes Scheduling short naps (10 to 15

minutes) two to three times per day Transplantation of hypocretin neurons

into the pontine reticular formation

DEFINITION Sleep apnea is characterized by

cessation of breathing for 10 seconds or longer occurring at least 5 times / hour.

As air flow stops during a sleep apnea episode, the oxygen level in blood drops. Brain responds by briefly disturbing sleep enough to kick start breathing—which often resumes with a gasp or a choking sound. In obstructive sleep apnea, the person probably won’t remember these awakenings. Most of the time, patient stirs just enough to tighten throat muscles and open the windpipe. In central sleep apnea, patient may be conscious of his awakenings

Obstructive sleep apnea

Central sleep apnea

Complex sleep apnea

• RISK FACTORS FOR OBSTRUCTIVE RISK FACTORS FOR OBSTRUCTIVE SLEEP APNEASLEEP APNEA Overweight Male Over the age of 65 Black, Hispanic, or a pacific islander Related to someone who has sleep apnea A smoker Physical attributes, such as having a thick neck, deviated septum, receding chin, or enlarged tonsils or adenoids.

Allergies or other medical conditions that cause to nasal congestion and blockage can also contribute to sleep apnea.

• RISK FACTORS FOR CENTRAL SLEEP RISK FACTORS FOR CENTRAL SLEEP APNEAAPNEA

More common in males and people over the age of 65.

Central sleep apnea is often associated with serious illness, such as heart disease, stroke, neurological disease, or spinal or brainstem injury.

• Major signs and symptoms of sleep Major signs and symptoms of sleep apneaapnea

Loud and chronic snoring Choking, snorting, or gasping during sleep

Long pauses in breathing Daytime sleepiness, no matter how much time you spend in bed

• Other common signs and symptoms Other common signs and symptoms of sleep apnea include:of sleep apnea include: Waking up with a dry mouth or sore throat Morning headaches Restless or fitful sleep Insomnia or nighttime awakenings. Going to the bathroom frequently during the night

Waking up feeling out of breath Forgetfulness and difficulty concentrating Moodiness, irritability, or depression

Self-help treatment for sleep apnea Lifestyle changes that can help sleep

apnea Bedtime tips for preventing sleep

apnea Throat exercises to reduce sleep

apnea Medical treatment for sleep apnea Continuous Positive Airflow Pressure

(CPAP) for sleep apnea Dental devices and surgery for sleep

apnea

DEFINITIONDEFINITION  Restless leg syndrome involves

anything “crawling”, itching or tingling sensations of the leg while at rest and causes an almost irresistible urge to move. The syndrome is often most severe before sleep onset.

Imbalance of dopamine, a chemical that transmits signals between nerve cells in the brain.

Usually genetic. It is more common in women. In

fact, about 40% of mothers experience temporary restless legs syndrome during pregnancy.

Health conditions such as diabetes, iron deficiency, rheumatoid arthritis, and kidney failure can also trigger restless legs syndrome.

Not only are the signs and symptoms of restless legs syndrome (RLS) different from person to person, they can be tricky to explain. Some describe the leg sensations as “creeping,” “prickling,” “burning,” “tingling,” or “tugging.” Others say it feels as if bugs are crawling up their legs, a fizzy soda is bubbling through their veins, or they have a “deep bone itch.”

Leg discomfort and strong urge to move

Nighttime leg twitching Symptoms get worse night Symptoms improve when you

walk or move your legs Rest triggers the symptoms

No laboratory tests that can determine

A complete medical history A blood test for low iron levels

•A survey to see if anyone else in family has similar symptoms.

•A diagnostic interview,

Self-help tips for managing Self-help tips for managing restless legs syndrome (RLS)restless legs syndrome (RLS)

Wrap the legs in ace bandages, or wear compression socks or stockings.

Try to find or create a work setting where the person can be active.

Give yourself stretch breaks at work and during long car rides.

Stretches for restless legs Calf stretch Front thigh stretch Hip stretch

Tips for relieving restless legs in Tips for relieving restless legs in the momentthe moment

Lifestyle treatments for Lifestyle treatments for restless legs syndrome (RLS)restless legs syndrome (RLS)• Stick to a regular sleep schedule• Exercise in moderation• Cut back on caffeine• Just say “no” to alcohol and cigarettes• Consider vitamin supplements• Lose weight• Give yoga and meditation

• Parkinson’s medication for restless Parkinson’s medication for restless legs syndrome (RLS)legs syndrome (RLS) Pramipexole (Mirapex) Ropinirole (Requip)

•Other common medications for Other common medications for restless legs syndrome (RLS)restless legs syndrome (RLS) Prescription painkillers :-codeine, oxycodone, Vicodin, and Percocet

Sleep medications and muscle relaxants :-Ambien, Sonata, and Klonopin

Anti-seizure medications :-Neurontin, Tegretol, and Epitol

DEFINITIONDEFINITION: - Periodic limb movement disorder (PLMD), previously known as nocturnal myoclonus is a sleep disorder where the patient moves limbs involuntarily during sleep, and has symptoms or problems related to the movement.

 

• Unknown•Medical problems such as parkinson's disease or narcolepsy.

•Shift worker, snoring, coffee drinking, stress, and use of hypnotics, particularly in the case of benzodiazepine withdrawal.

• Being a woman, the presence of musculoskeletal disease, heart disease, obstructive sleep apnea, cataplexy, doing physical activities close to bedtime and the presence of a mental disorder

Excessive daytime sleepiness (EDS). Falling asleep during the day, trouble

falling asleep at night. Staying asleep throughout the night. Patients also display involuntary limb

movements that occur at periodic intervals anywhere from 20-40 seconds apart. They often only last the first half of the night during non-REM sleep stages. Movements do not occur during REM because of muscle atonia.

People with PLMD often do not know the cause of their excessive daytime sleepiness and their limb movements are reported by a spouse or sleep partner.

polysomnogram first PSG, then integrating that

information with a detailed history from the patient and/or bed partner. PLMD can range from a small amount of movement in the ankles and toes, to wild flailing of all four limbs. These movements, which are more common in the legs than arms, occur for between 0.5 and 5 seconds, recurring at intervals of 5 to 90 seconds

Transcutaneous Electrical Nerve Stimulation (TENS) before sleep has been helpful.

Clonazepam, a benzodiazepine, or baclofen, a skeletal muscle relaxant, may be ordered to diminish the magnitude of the movement and frequency of arousals

DEFINITION: - Hypersomnia is a disorder characterized by excessive amounts of sleepiness. There are two main categories of hypersomnia: primary hypersomnia (also called idiopathic hypersomnia) and recurrent hypersomnia (also called primary recurrent hypersomnia). Both have the same symptoms but differ in how often they occur.

Hypersomnia can be caused by brain damage and disorders such as clinical depression, uremia

Infection of mononucleosis Adverse effect of taking certain

medications (i.e. some psychotropics for depression, anxiety, or bipolar disorder), of withdrawal from some medications, or of drug or alcohol abuse.

Genetic predisposition Overweight

Recurring episodes of excessive daytime sleepiness (EDS)

Prolonged sleep at night and have difficulty waking from long sleep, feeling disoriented upon doing so.

Anxiety, increased irritation, decreased energy, restlessness, slow thinking, slow speech, loss of appetite, hallucinations, and memory difficulty. Some patients lose the ability to function in family, social, occupational or other settings.

To be diagnosed with hypersomnia, one must display symptoms for at least a month and the disorder must have a significant impact on the patient's life.

 

Treatment is symptomatic in nature. Stimulants, such as amphetamine, methylphenidate, and modafinil may be prescribed.

Other drugs used to treat hypersomnia include clonidine, levodopa, bromocriptine, antidepressants, and monoamine oxidase inhibitors.

Changes in behaviour (for example avoiding night work and social activities that delay bed time) and diet may offer some relief.

Avoid alcohol and caffeine.

DEFINITIONDEFINITION:- Circadian rhythm sleep disorders are a family of sleep disorders affecting, among other things, the timing of sleep. People with circadian rhythm sleep disorders are unable to sleep and wake at the times required for normal work, school, and social needs.

Extrinsic typeExtrinsic type•Two of these disorders are extrinsic (from Latin extrinsecus, from without, on the outside) or circumstantial:

Jet lag, which affects people who travel across several time zones.

Shift work sleep disorder, which affects people who work nights or rotating shifts.

Intrinsic typeIntrinsic type Delayed sleep phase syndrome (DSPS), characterized by a much later than normal timing of sleep onset and offset and a period of peak alertness in the middle of the night.

Advanced sleep phase syndrome (ASPS), characterized by difficulty staying awake in the evening and staying asleep in the morning.

Non-24-hour sleep-wake syndrome (Non-24), in which the affected individual's sleep occurs later and later each day, with the period of peak alertness also continuously moving around the clock from day to day.

Irregular sleep-wake patternIrregular sleep-wake pattern

Which presents as sleeping at very irregular times, and usually more than once per day (waking frequently during the night and taking naps during the day) but with total time asleep typical for the person's age.

Chronotherapy Bright light therapy Maintenance of regular schedule and exposure to natural sunlight.

Medications such as melatonin Behaviour therapy

DEFINITION: - DEFINITION: - The parasomnias are disorders that occur during sleep but that usually do not produce insomnia or excessive sleepiness. It may be due to partial arousal or abnormalities in sleep-wake transition

NREM ParasomniasNREM Parasomnias• Confusional arousals•Sleepwalking (somnambulism)•Sleep terrors (night terrors)•Bruxism (teeth grinding)

REM ParasomniasREM Parasomnias•REM sleep behavior disorder•Catathrenia

There is no as such treatment for parasomnia.

Relaxation therapy is given to the patient.

NEUROTRANSMITTER IMBALANCES

HEAD INJURY HORMONAL IMBALANCES RESPIRATORY DISORDERS CARDIOVASCULAR DISORDERS GASTROINTESTINAL DISORDERS OTHER DISORDERS

SLEEP ONSET DIFFICULTY SLEEP MAINTENANCE

DISTURBANCE EARLY MORNING AWAKENING SLEEP DEPRIVATION

Diagnostic assessment: physical assent & history collection

Polysomnogram: involves the use of EEG, EMG, and EOG to monitor stages of sleep and wakefulness during night time sleep.

Electroencephalogram Multiple sleep latency test

(MSLT):

Gouped into four categories:Gouped into four categories:

•Behavioural/ psychotherapeutic treatments

•Rehabilitation/management •Medications •Other somatic treatments

Sleep HistorySleep History Assess client’s usual sleep habits and

recent sleep quality as part of the initial nursing history. If sleep quality is reported to be poor, explore :• The nature of the problem• Its cause• The related signs and symptoms• When it first began and how often it occurs

• How it affects everyday living • The severity of the problem and whether it can be referred to another professionals

• How the patient is coping with the problem and the success of any treatments attempted

The diary generally is kept for 14 days and includes the following:

A graph of the total number of hours of sleep per day. Depending on the nature of the problem, graphs may be made of the number of undisturbed hours of sleep, number of awakenings, and so forth.

•A daily record of following : Time patient decided to retire Time patient actually tries to fall asleep Approximate time patient falls asleep Time of awakening during the night and when sleep was resumed

Time of awakening in the morning Presence of any stressors patient believes are affecting his or her sleep

A record of any food, drink, or medication patient believes has positively or negatively influenced his or her sleep (include time of ingestion).

Record of mental activities – type, duration, and time

Record of activities performed 2 to 3 hours before bedtime, bedtime rituals , changes in sleep environment

Presence of any worries or anxieties patient believes are affecting his or her sleep

Diminished energy level Diminished energy level Presence of physical weakness, fatigue Lethargy

Facial characteristics Facial characteristics Narrowing or glazing of eyes swelling of eye lids

Decreased animation Behavioural characteristics Behavioural characteristics

Yawning Rubbing eyes Slow speech Slumped posture

Physical data suggestive of Physical data suggestive of potential sleep problemspotential sleep problems

Obesity Enlarged neck Deviated nasal septum

ObserveObserve•Restlessness •Sleep posture•Sleep activities Snoring Leg jerking, etc

Disturbed sleep pattern related to changes in routine secondary to hospitalization and pain as evidenced by slumped posture and yawning

Altered sleep-wake pattern related to lack of cues for day- night schedule; manifested by erratic sleep schedule, frequent naps and nocturnal wandering.

Difficulty falling asleep related to worries about family and lack of distressing rituals as evidenced by client’s statements such as, “At least four or five nights a week I lay in bed awake for 3 or 4 hours before I finally fall asleep. Sometimes it is 2 or 3 in morning and I’m still awake worrying about the kids.”

Difficulty falling asleep related insufficient meaningful daytime activity

Difficulty remaining asleep related to evening caffeine intake as evidenced by changing the position frequently after going to the bed.

Instruct client to try to exercise daily,

Advise client to establish a bedtime routine and a regular sleep pattern

Not to use the bedroom for intensive studying, snacking, TV watching, or other nonsleep activity,

Caution client against sleeping long hours during weekends.

Try to avoid worrisome thinking when going to bed and to use relaxation exercises.

Avoid heavy meals for 3 hours before bedtime; a light snack may help.

limit caffeine to morning coffee and limit alcohol intake

Instruct that use of earplugs and eyeshades may be helpful.

Advice to get out of bed and do some quiet activity until feeling sleepy enough to go back to back to bed if client does not fall asleep within 30 minutes of going to bed.

SLEEP PATTERNSLEEP PATTERN Definition Incidence and

characteristics Physiology of

sleep Sleep regulation Stages of sleep Characteristics of

NREM & REM Sleep cycle

Functions of sleep Developmental

pattern of sleep Factors affecting

sleep

SLEEP SLEEP DISTURBANCESDISTURBANCES

DYSSOMNIAS PARASOMNIAS MEDICAL OR

PSYCHIATRIC CONDITIONS THAT MAY PRODUCE SLEEP DISORDERS

HOSPITAL ACQUIRED SLEEP DISTURBANCES

Management Diagnostic tests

for sleep disorders