Psychiatric / Mental Health Nursing

Sleep DisordersChapter 20

Sleep DisordersSleep deprivation – discrepancy

between hours of sleep obtained and hours of sleep required for optimal functioning

Implications for ◦Health ◦Safety◦Quality of life

Theories of Sleep Disorders - continued

Studies show those with chronic insomnia have physiological differences.

Studies suggest that gene variations are involved in human circadian activity.

There is predisposition to sleep disorders based on genetic susceptibility and familial pattern.

Theories of Sleep Disorders - continued

Any emotional or cognitive arousal can precipitate or perpetuate insomnia.

Environmental conditions, including associating the sleeping room with lying awake, cause distress and are a powerful perpetuating factor to sleep problems.

Normal Sleep CycleComplex interaction between CNS

andenvironment Non-REM (NREM) sleep

◦ Composed of four stagesREM sleep

◦ Reduction and absence of skeletal muscle tone

◦ Bursts of rapid eye movement◦ Myoclonic twitches of facial and limb

muscles◦ Dreaming ◦ Autonomic nervous system variability

Regulation of SleepComplex interaction between two

processes◦Homeostatic process or sleep drive –

promotes sleep◦Circadian process or circadian drive –

promotes wakefulness Influenced by

Endogenous factors Exogenous factors

Sleep RequirementsVaries from individual to

individualLong sleepers

◦Require more than 10 hours of sleep each night

Short sleepers◦Can function effectively on fewer

than 5 hours of sleep per night

Primary Sleep DisordersDyssomnias

◦Primary insomnia ◦Primary hypersomnia◦Narcolepsy◦Breathing-related sleep disorders◦Circadian rhythm disorders◦Dyssomnias not otherwise specified

Restless legs syndrome (Box 20-1)

Primary InsomniaMost common sleep complaintDifficulty with sleep initiationSleep maintenanceEarly awakeningNon-refreshing, nonrestorative

sleep

Interventions for Primary InsomniaSleep hygiene – conditions and

practices that promote continuous and effective sleep

Behavioral therapies◦ Educational components◦ Behavioral components◦ Cognitive components

Some instances – hypnotic medication (Table 20-1)

ParasomniasUnusual or undesirable behaviors

or eventsOccur during

◦Sleep/wake transitions◦Certain stages of sleep◦Arousal from sleep

Sleep Disorders Related to Other Mental DisordersInsomnia related to another

mental disorderHypersomnia related to another

mental disorder◦Major depressive disorder◦Anxiety disorders◦Schizophrenia

Sleep Patterns in Major Depressive Disorder

Insomnia of maintenance or early wakening type most common

Insomnia is the most commonly reported residual symptom after remission

Sleep pattern disturbance may respond to antidepressant treatment sooner than other symptoms

Sleep Patterns in Schizophrenia

Exacerbation of illness causes significant sleep disruption

Extreme sleep difficulty can accompany severe anxiety

Heightened concern of delusions and hallucinations

Circadian cycle disrupted

Sleep Patterns in Schizophrenia - continued

Reduction in REM sleep Do not experience REM rebound Deficits in slow-wave sleep found in

clients with acute and chronic schizophrenia

Sleep Patterns in Manic Episodes of Bipolar Disorder

Sleep time significantly reduced Clients don’t complain of insomnia and

can go without sleep Reduced slow-wave sleep Reduced REM latency

Other Sleep DisordersSleep disorders due to a general

medical conditionSubstance-induced sleep

disorders◦In both sleep disorders, sleep

disturbance may be Insomnia Hypersomnia Parasomnia Combination

Sleep Patterns in Substance Abuse

Severe sleep disorder during intoxication or withdrawal periods

Persists even after prolonged abstinence of some substances

Sleep Patterns in Substance Abuse - continued

Substance-induced mood disorder characterized by sustained use of stimulants to stay awake or alcohol to induce sleep

Examples of substances

Key Assessments

Assessment◦General assessment – sleep patterns◦Identifying sleep disorders◦Functioning and safety

Key Assessments - continued

Self-defined - say they get enough sleep to feel refreshed, have energy, fall asleep quickly

Key Assessments - continued

Behaviorally defined - observe alertness during sedentary, repetitive activity; note ability to fall asleep and final wakening at habitual rising time; utilize photographic serializing of movement during sleep

Key Assessments - continued

Comprehensive sleep studies are conducted in sleep labs:

- polysomnogram - multiple sleep latency test

Nursing DiagnosisNursing Diagnosis

◦Sleep deprivation related to inadequate quality and quantity of sleep

◦Insomnia related to medical, psychiatric, or sleep disorder, substance use/abuse, or inadequate sleep hygiene

◦Readiness for enhanced sleep◦Risk for injury related to inadequate

sleep

Nursing Outcome IdentificationOutcomes Identification

◦Sleep◦Rest◦Risk control◦Personal well-being◦(Table 20-2)

Planning

ImplementationBasic Level Interventions◦ Counseling◦ Health teaching and health promotion◦ Pharmacological interventionsAdvanced Practice Interventions◦ Cognitive-behavioral therapy

Guidelines for Good Sleep Hygiene

Maintain regular sleep–wake schedule Rise at the same time each day Go to bed when sleepy and relaxed Maintain rituals in preparation for sleep Control for temperature, lighting, noise Avoid stimulants before bed Focus on enjoying sleep that is

achieved

Guidelines for Insomnia

Treatment for sleep disorders is complex

Follow guidelines for good sleep hygiene

Utilize good sleep hygiene before taking sedative hypnotic medications

Instill a sense of hope that insomnia will improve, client can manage it effectively

Guidelines for Insomnia - continued

Facilitate setting realistic goals. Teach normal developmental changes

in sleep patterns. See treatment provider for continued

insomnia. Differentiate between myths and

evidence-based practice.

Evaluation

◦Based on whether or not patient experiences improved sleep quality as evidenced by Decreased sleep latency Fewer nighttime awakenings Shorter time to get back to sleep after

awakening

Pharmacology

Sleep and WakefulnessGoal: Improve quantity and

quality of sleepMay prevent worsening of mood,

anxiety and pain if sleep improves

Many choices: evaluate lifestyleDo not underestimate the POWER

of sleep

Sleep Agents: NTNearly all hypnotics work on at

least one of these neurotransmitters:

◦GABA◦Histamine

Rx Sleep agentsBarbituratesBenzodiazepines

Non-benzosMelatonin Receptors Agonists

Sleep agentsBarbituturates – first used in

1860s named after St Barbara

Nembutal (pentobarbital)Seconal (secobarbital)

Sleep agentsBenzodiazepines

◦Short Acting Halcion (triazolam)

◦Intermediate Restoril (temazepam) Prosom (estazolam)

◦Long Acting Dalmane (flurazepam)

Sleep AgentsNon-Benzos

◦Zolpidem - Ambien (5 - 10 mg/night)◦Ambien CR◦Zaleplon - Sonata (10 mg/night)◦Eszopiclone -Lunesta (1-3 mg/night)◦Cholral Hydrate – Noctec,

Aquachloral Supprettes, Somnote (500 - 2000 mg/d)

◦Diphenhydramine - Benadryl, Sominex, Nytol (25 - 100 mg/d)

Sleep AgentsMelatonin Receptor Agonist

◦Rameltoeon - Rozerem (8mg/d)◦Valdoxan (agomelatine) also works

on 5-HT2c so is antidepressant

Sleep AgentsOver the Counter OTC

◦Benadryl (diphenhydramine)◦Atarax/Vistaril (hydroxyzine

Kava Kava Caution: may cause liver toxicity

Valerian

Side EffectsHangoverAmnesiaHeadache

When Starting on SleepersSleep hygiene first – remember

caffeineCool, quiet, dark room without

dogs and kidsDon’t mix with AlcoholGo straight to bed and lay down

Wake Agents: NTNearly all wake promoting agents

work on at least one of these neurotransmitters:◦Norepinephrine◦Dopamine

Wake AgentsProvigil = NuvigilFDA Indication

◦Excessive sleepiness due to narcolepsy

◦Obstructive sleep apnea◦Shift work sleep disorder

Treat fatigue and sleepiness due to other conditions – depression and MS

Wake AgentsStimulantsProvigil (modafinil)Nuvigil (armodafinil)

When Starting on WakersSleep hygiene first – not a

replacement for sleep