chapter 7: sleep and sleep disorders Flashcards by Caleigh Justen

sleep

state in which a person lacks conscious awareness of environmental surroundings, but can be easily aroused

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physical and mental functions affected by sleep

mood, behavior, memory, hormone secretion, glucose metabolism, immune functions, body temperature

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who’s most likely to have sleep disturbance?
what’s the dif bt sleep disturbance and sleep disorder?

chronically ill ppl

disturbance = broad term for poor sleep quality for whatever reason

disorder = problems unique to sleep: insomnia, sleep apnea, narcolepsy, periodic limb movement, circadian sleep disorders –> often missed or unreported

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Sleep wake cycle - what controls it

controlled by forebrain (cerebral cortex, hypothalamus, thalamus) and brainstem

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wake behavior

integrated network of arousal systems from brainstem and forebrain
–> ARAS (ascending reticular activating system) and other neurotransmitters

Histamines in hypothal

Orexin = imp neuropep in hypothal

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issues with wake bahavior stuff

Alzheimers = lose cholinergic neurons in forebrain –> sleep probs

Parkinsons = loss of dopamine neurons in ARAS –> sleepy

Narcolepsy = lack of orexin

OTC can inhibit histamine sometimes –> sleepy

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sleep behavior

neurons in hypothal inhibit ARAS

neurotransmitters and peptides promote sleep (GABA, GHRH)

infection = proinflammatory cytokines (ILs and tumor necrosis factor) –> sleepy

Postprandial = after food = peptides from GI after eating = sleepy

Melatonin= from pineal –> turns off wakefulness mechanisms when it gets dark

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circadian rhythm

Regulated by suprachiasmatic nucleaus (SCN) in hypothalamus –> master clock
-light from retina –> SCN –> other brain parts

LIGHT IS STRONGEST TIME CUE

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sleep architecture

Nighttime sleep recorded by polysomnography (PSG)
-brain waves
-eye movement
-muscle tone

Two sleep states
-REM and NREM
-go through 4-6 cycles bt them lasting 60 to 110 mins

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NREM

75-80% of sleep

N1 = slow eye movement –> easy to wake
N2 = most time here = HR and temp drop= visible on EEG
N3 = deepes= slow wave sleep = delta waves on EEG = sleep intensity - not as common in old ppl

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REM

20-25%

-brain waves resemble wakefulness
-postural muscles inhibited –> loss of muscle tone
-vivid dreams

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effects of insufficient sleep

Neurologic
-cognitive impairment and behavioral changes (grumpy)

Immune
-worse

Respiratory
-asthma exacerbated

Cardiovascular
-Heart disease
-high BP
-stroke

GI
-higher risk for obesity
-GERD

Endocrine
-risk for type 2 diabetes
-insulin resistance
-low growth hormone

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sleep disturbance in hospital

-noise and light 24/7
-illness keeps you awake
-boredom and daytime napping
-meds –> esp opiods –> can fuck with sleep

*lack of sleep makes you less tolerant to pain though

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Insomnia

most common sleep disorder (1/3 adults)
-difficulty falling asleep/staying asleep –> wake up too early –> wake up not refreshed

Acute = 3 nights a week for less than a month
Chronic = acute symptoms and daytime problems for 3+ months (10-15% Amers)

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insomnia prevelence

women more than men
divorced/widowed more than married
poor and less educted more than alternative

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contributions to insomnia

-irregular sleep schedule
-afternoon naps
-being in bed awake for a long time
-sleeping in late
-exercising near bedtime
-stimulants
-Alc makes you sleepy, but fucks with REM, so you wake up during night
-meds (esp SSRIs)

Onset is usually after stressful life event

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manifestations of insomnia

-difficulty falling asleep
-frequent awakening
-prolonged nighttime awakenings
-feeling unrefreshed in morning

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diagnostic stdies

Self report = diary/log for 1-2 weeks or screening questionairre

Actigraphy = on wrist –>measures gross motor activity –> time awake and asleep

Polysomnography = PSG = muscle tone (EMG), eye movement (EOG), brain activity (EEG) –> all electodes –> only done if there’s symptoms of another sleep disorder (not insomnia)
**can also measure HR, RR, resp effort, airflow, pulse ox

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Intrerprofessional care

-education on sleep hygiene
-CBT-I = stress management, limit non sleepy time in bed, no naps, no pre sleep excersise
-Drugs
-complementary/alt therapies = melatonin and valerian (not for insomnia), relaxation, white noise

Drugs for insomnia

Benzodiazepine hypnotics = Triazolam (sleep onset) and Temazepam (onset and maintenance)
-activate GABA receptors
-only use for 2-3 weeks; don’t use other ones; interact with alc and CNS depressors

Nonbenzodiazepine hypnotics = Zaleplon (onset), Zolpidem and Eszopliclone (onset and maintenance)
-3 months to a year
-act as GABA receptors –> safer than benzos
-shorter half life -> don’t take with food though
-many forms

Orexin-receptor antagonists
-Suvorexant
-1 per night within 30 mins of sleep

Melatonin-receptor agonist
-Ramelteon
-fast, you dont get tolerant, doesn’t work great

Antidepresants
-Tricyclic ones (doxepin and amitriptyline) –> low doses for isomnia
-Trazadone –> sketchy

Antihistamines
-Diphenhydramine, OTC pain meds, doxylamine –> all kinda sketch

Assessment of insomnia

sleep history
ask ab diet, caffeine, and alc intake
ask about sleep aids: OTC, Rx, herbal, supplements (kava is toxic to liver)
Sleep diary for 1-2 weeks
med history, works schedule, travel

Nursing diagnoses

sleep deprivation
impaired sleep

Implementation for insomnia

sleep hygiene and CBTI
-tell to decrease caffeine intake – half life is 6 hrs or up to 9 hrs in old ppl
-keep room dark and cool (avoid clock watching)
-teach ab meds: don’t take with fatty food, alc, or CNS depressants –> don’t plan skilled actiities for morning

Sleep Disordered Breathing

snoring
apnea (90+% reduction in airflow)
hypopnea (30-90% airflow reduction)
obstructive sleep apnea

Obstructive sleep apnea (...hypynea syndrome)

partial or complete upper airway obstruction and reduced tone during sleep; lasts 10-90 secs --> airway narrows due to muscle tone relaxation or tongue goes backwards Can cause hypoxemia and hypercapnia --> ventilatory stimulants which cause arousal Usually during REM when muscle tone is at lowest

Risk factors for OSA

obesity (bmi over 30) age (over 65) neck circumference over 17" craniofacial abnormalities acromegaly smoking

OSA manifestations

frequent arousals insomnia daytime sleepiness witnessed apneic episodes snoring morning headache irritability personality changes

Complications of OSA

HTN cardiac changes poor concentraton/memory impotence depression

link bt CV issues and sleep apnea

apnea = hypoxia and increased intrathoracic pressure ==> SNS activation and increased VR and reduced oxygenation of heart ==> HTN, dysrhythmias, HF

Diagnosis of OSA

-usually use PSG requires documentation of apna or hypopnea of at least 10 s OSA = over 5 episodes an hour with 3-4% decrease in O2 sat

Treatment of mild sleep apnea

sleep on side elevate head avoid sedatives and alc 3-4 hrs b4 sleep weight loss oral appliance --> special mouth guard meds tend to make it worse

Severe sleep apnea treatment

more than 15 apnea events/hr -Continuous Positive Airway Pressure (CPAP) is effective, but poor adherence -Bilevel Positive Airway Pressure (BiPAP) is similar but with lower exhale pressure -need to wear 4 hrs/night to reverse CV risk If in hospital, still should wear CPAP and cautious use of narcotics/sedatives

Surgical treatment for OSA

Uvulopalatopharyngoplasty (UPPP or UP3) = removes tissue Genioglossal advancement and hyoid myotomy (GAHM) tonge/mandible atch Radiofrequency ablation (RFA) = least invasive Neurostimulators = imlants that stimulate hypoglossal nerve to increase muscle tone in airway Post op = risk of airway obstruction and hemorrhage

Periodic limb movement disorder (PLMD)

involuntary repetitive movement of limbs that affects ppl during sleep (usually legs) -causes poor sleep -treated with meds aimed at reducing limb movement/muscle activity and improving sleep quality

Circadian rhythm disorders

Occur when circadian time-keeping system loses synchrony with environment -jet lag -shift work sleep disorder -symptoms = insomnia and excessive sleepiness

Narcolepsy

brain unable to regulate sleep-wake cycles normally -causes uncontrollable urges to sleep --> straight into REM Causes unknown --> assoc w/ destruction of orexin neurons --> happens after head injury, infection, or change in sleep

2 types of narcolepsy

Type 1 = with cataplexy (brief and sudden loss of muscle tone) Type 2 = without cataplexy Symptoms = sleep paralysis, cataplexy, fragmented nighttime sleep

Narcolepsy diagnosis

history PSG Multiple sleep latency test (MSLTs) = PSG and 4-5 naps every 2 hrs next day

Interprofessional management of narcolepsy

uncurable reach ab sleep hygiene take naps avaid heavy meals and alc ensure safety teach ab meds

Narcolepsy drug therapy

Nonamphetamine wake-promoting -modafinil and armodafinil = wake promoting drugs -sodium oxybate (Xyrem) = metabolite of GABA --> for wakefulness and prevents cataplexy SSRIs (fluoxetine and canlafaxine) treat cataplexy

Parasomnias

unusual and often undesirable behaviors that occur while falling asleep, transitioning bt sleep stages, or during arousal from sleep -due to CNS activation -In ICU might be misinterpreted as ICU psychosis

Parasomnia includes:

Sleepwalking - no memory of it Sleep terror = sudden awakening; loud cry and panic Nightmare = frightful or disturbing dream -in critical care, some meds contribute to nightmares (sedative hypnotics, beta adrenergic antagonists, dopamine antagonists, amphetamines)

Gerontologic considerations of sleep

old age assoc w/ -overall shorter total sleep time -decreased sleep efficiency -more awakenings -sleep disordered breathing may manifest with insomnia symptoms -circadian shift

Circumstation stuff that fucks with old ppl's sleep Results of poor sleep in old ppl

medical probs/ chronic conditions/ medications -awakening during night increases fall risk -chronic sleep disturbance = disorientation, delerium, impaired cognition, accidents injury AVOID LONG-ACTING BENZODIAZEPINES --> old ppl are more sensitive

Shift work sleep disorder

insomnia, sleepiness, fatigue -increased stress, health risks, patient safety issues Strategies -on site napping -consistent sleep-wake schedule -sleep hygiene