sleep disorders and its treatment

1. NEELU ARYAL
Msc Nursing 1st year
SLEEP DISORDER

2. SLEEP
 Nearly one third of our life is spent in sleep.
 EEG recording show typical features of sleep.
 It is known that sleep is divided into two
different phases.
1)D-sleep(desynchronized or dreaming sleep)
or REM sleep(rapid eye movement sleep) or
active sleep or paradoxical sleep)
2)S-sleep(synchronized sleep) or NREM-
sleep(non-REM sleep) or quiet sleep or
orthodox sleep.S-sleep or NREM-sleep is
further divided into 4 stages,from stage 1 to
stage 4.

3. CONTINUE…
 As the person falls asleep,the person first
passes through these stages of NREM-sleep.
Depending on the duration of total
sleep,two extremes of normal sleeping
patterns have been described.
1)long-sleepers
These persons regularly and habitually
sleep for more than 9 hours/night and this
pattern of sleep doesnot cause any symptoms
or dysfunctions.

4. CONTINUE…
2)Short-sleepers
These persons regularly and habitually
sleep for less than 6 hours/night and this
pattern of sleep does not cause any
symptoms or dysfunctions.

5. DSM-IV Classification
1) Primary Sleep Disorder
2) Sleep disorder related to another mental disorder
3) Other sleep disorder, most notably those due to a
general medical condition or substance-induced.

6. SLEEP DISORDERS(TYPES)
• Sleep can be regarded as a physiological
reversible reduction of conscious awareness.
• Sleep disorders are divided into subtypes:
1)DYSSOMNIAS
Insomnia
Hypersomnia
Disorders of sleep-wake schedule

7. CONTINUE…
2)PARASOMNIAS
Stage iv disorders
Other disorders

8. DYSSOMNIAS
 Dyssomnias are those sleep disorders which
are characterized by disturbances in the
amount,quality or timing of sleep.These are
the commonest disorders of sleep.

9. INSOMNIA
 Insomnia means one or more of the following:
1)Difficulty in initiating sleep.
2)Difficulty in maintaining sleep
This includes both:
-frequent awakenings during the night,and
-early morning awakening.
3)Non-restorative sleep,i.e.despite adequate
duration of sleep,feeling of not having rested
present(poor quality sleep)

10. DIAGNOSIS
 Sleep disturbances should be at least :
3 times a week
For at least 1 month and
It causes marked distress or interference with
social and occupational functioning.

11. CAUSES
MEDICAL ILLNESS
 Any painful or uncomfortable illness.
 Heart disease
 Respiratory diseases
 Brain stem or hypothalamic lesions
 Delirium
 Rheumatic and other musculoskeletal diseases
 Periodic movements in sleep
 Old age

12. CONTINUE…
ALCOHOL AND DRUG USE
 Delirium tremens
 A mphetamines or other stimulants
 Chronic alcoholism

13. CONTINUE…
CURRENT MEDICATION
 Fluoxetine
 Steroids
 Theophylline
 Propranolol

14. CONTINUE…
PSYCHIATRIC DISORDERS
 Mania(due to decreased need for sleep)
 Major depression(early morning awakening or
late insomnia)
 Dysthymia or neurotic depression(difficulty in
initiating sleep or early insomnia)
 Schizophrenia and other psychoses(due to
psychotic symptoms)
 Anxiety disorder(difficulty in initiating sleep due to
worrying thoughts)

15. CONTINUE…
SOCIAL CAUSES
 Financial loss
 Separation or divorce
 Death of spouse or a close relative
 Retirement
 Stressful life situations

16. CONTINUE…
BEHAVIOURAL CAUSES
 Naps during the day
 Irregular sleeping hours
 Lack of physical exercise
 Excessive intake of beverages in the
evening,for eg:coffee
 Disturbing environment(heat,cold,noise)

17. TREATMENT
 A thorough medical and psychiatric
assessment;polysomnography may be
needed in some cases.
 Treatment of underlying physical or
psychiatric disorder.
 Withdrawal of current medications,if any.

18. CONTINUE…
NON-DRUG TREATMENT
 Progressive relaxation
 Autosuggestion
 Meditation,yoga
 Stimulus control therapy:-do not use the bed
for reading or chatting-go to bed for sleep
only.

19. CONTINUE…
SLEEP HYGIENE
 Regular, daily physical exercises in the
evening.
 Avoid fluid intake and heavy meals just
before bedtime.
 Aviod caffeine intake(for eg:tea,coffee,cola
drinks)before sleeping hours.
 Avoid reading or watching television while in
bed.
 Back rub,warm milk and relaxation exercises.
 Sleep in a comfortable environment.

20. B)HYPERSOMNIA
Hypersomnia means one or more of the
following:
 Excessive day time sleepiness.
 Sleep attacks during day time(falling asleep
unintentionally)
 Sleep drunkenness(person needs much more
time to awaken and during this period is
confused or disoriented)

21. DIAGNOSIS
 Sleep disturbance occurs daily for at least 1
month or for recurrent periods of shorter
duration,and that it causes either marked
disterss or interferes with social and
occupational functioning.

22. CAUSES
1)MEDICAL ILLNESS
 Narcolepsy(in about 25% of all patients with
hypersomnia)
 Sleep apnea(in about 50% of all patients with
hypersomnia)
 Kleine-Levine syndrome
2)ALCOHOL AND DRUG USE
 Stimulant withdrawal
 Alcohol intoxication
 Use of CNS depressant medications

23. CONTINUE…
3)PHYCHIATRIC DISORDERS
 Dysthymia
 Atypical depression
 Avoidance reaction
4)IDIOPATHIC HYPERSOMNIA

24. MEDICAL ILLNESS
1)NARCOLEPSY
Consists of excessive daytime
sleepiness and abnormal manifestation of
REM sleep occuring daily for at least 3
months.

25. SYMPTOMS
 Sleep attacks(most common)
 Cataplexy-sudden decrease or loss of (sleep
paralysis)muscle tone,often generalized and
may lead on to sleep.
 Hypnagogic hallucinations(dream like vivid
perceptions associated with fearfulness)
 Sleep paralysis:
It occurs either at awakening in
morning or at sleep onset.The person is
conscious but unable to move his body.(least
common)

26. TREATMENT
The treatment consists of :-
 Stimulant medication(eg:amphetamines)in
some patients and/or
 Antidepressants(particularly when cataplexy is
a prominent symptoms)

27. CONTINUE…
2)SLEEP APNEA
 It is characterized by repeated episodes of
apnea during sleep.
 Apnea is defined as cessation of airflow at the
nostrils(and mouth)for 10 seconds or longer.
 The apnea can be of central type,obstructive
type or mixed type.
 It is common in elderly and obese(pick-
wickian syndrome)

28. CONTINUE…
 Typically,there are 5 or more apneic episodes
per hour of sleep and the total number of
apneic episodes exceed 30 during one night
sleep.In severe cases,the number of episodes
may be in hundreds.

29. TREATMENT
 Avoidance of alcohol and depressant
medications.
 Use of stimulants like caffeine,regular
exercises and losing excess weight,teaching
correct sleep posture.
 Corrective procedures for obstructive sleep
apnea.(eg:mechanical tongue retaining
device)
 Very severe obstructive sleep apnea may
necessitate tracheostomy(functional only at
night),CPAP through nasal mesh,or even
pharyngoplasty.

30. CONTINUE…
3)KLEINE-LEVIN SYNDROME
This is a rare syndrome characterized
by:-
 Hypersomnia (always present),occuring
recurrently for long periods of time.
 Hyperphagia(usually present),with a
varacious appetite.
 Hypersexuality(associated at
times),consisting of sexual
disinhibition,masturbatory
activity,exhibitionism,and/or inappropriate
sexual advances.

31. CONTINUE…
 A typical episode lasts for one to several
weeks followed usually by a complete
remission.
 Common age of onset is the second decade
of life.
 The disorder is almost always seen in males.
TREATMENT
 No specific treatment is available,although
lithium and occasionally carbamazepine have
been reported to be successful.

32. TREATMENT OF
HYPERSOMNIA
 Through physical and psychiatric
assessment.
 Treatment of underlying cause.
 Associated or underlying insomnia should be
looked for and treated.
 Withdrawal of current medication causing
hypersomnia
 Stimulant drugs like amphetamine given in the
morning or the evening.
 Nonsedative antidepressant drugs such as
serotonin specific reuptake inhibitors.

33. C)DISORDERS OF SLEEP-
WAKE SCHEDULE
 These are characterised by a disturbance in
the timing of sleep.
CAUSES
1)Jet lag type:
Sleepiness and alertness occurs at an
inappropriate time of day relative to local time.
Occuring after repeated travel across more
than one time zone.

34. CONTINUE…
2)Shift work type:
 Insomnia during major sleeping period
or excessive sleepiness during major wake
period associated with night shift work.
3)Delayed sleep phase type:
 A persistent pattern of late sleep onset
and late awakening time.

35. TREATMENT
 No specific treatment needed.
 Benzodiazepines may be needed for short-
term correction of insomnia.
 Changes in’work-shifts’ may be needed for
persons with unusual sleep phases.
 Exposure to sunlight during outdoor
activity(instead of staying indoors) and
adopting the local(new)hours for sleeping
(and working)can help in combacting jet lag.

36. PARASOMNIAS
 Parasomnias are dysfunctions or episodic
nocturnal events occuring with sleep,sleep
stages or partial arousal.
 Most parasomnias are common in childhood
though they may persist into adulthood.

37. TYPES
A)STAGE 4 SLEEP DISORDERS
 These are disorders occuring during deep
sleep.
 The common stage 4 parasomnias are:
1)sleep-walking(somnambulism)
2)sleep-terrors or night terrors(pavor
nocturnus)
3)sleep-related enuresis
4)bruxism
5)sleep-talking(somniloquy)

38. CONTINUE…
1)SLEEP-WALKING(SOMNAMBULISM)
 The patient carries out autonomic motor
activities that range from simple to complex.
 He may leave the bed,walk about or leave the
house.
 Arousal is difficult and accidents may occur
during sleep-walking
2)SLEEP-TERRORS OR NIGHT
TERRORS(PAVOR NOCTURNUS)
 The patient suddenly gets up screaming,with
autonomic arousal(tachycardia,sweating,and
hyperventilation).

39. CONTINUE…
 He may be difficult to arouse and rarely
recalls the episode on awakening.
 In contrast,nightmares(which occur during
REM sleep) are clearly remembered in the
morning.
3)SLEEP-RELATED(BED WETTING)
4)BRUXISM
 The patient has involuntary,and forceful
grinding of teeth during sleep.
 It causes the destruction of the tooth enamel.
 The patient remains completely unaware of
the episode.

40. CONTINUE…
5)SLEEP-TALKING(SOMNILOQUY)
 The patient talks during the stage 3 and 4 of
sleep but doesnot remember anything about it
in the morning on awakening.
TREATMENT
 Since benzodiazepines suppress stage 4 of
NREM sleep,a single dose at bedtime usually
provides relief from stage 4 parasomnias.

41. CONTINUE…
B)OTHER SLEEP DISORDERS
 Nocturnal angina
 Nocturnal asthma
 Nocturnal seizures
 Sleep paralysis

42. SLEEP HYGIENE
 Avoid naps except for a brief 10-15 min nap 8
hrs after rising but check with the physician
first because in some sleep disorders naps
can be beneficial.
 Get regular exercise at least 40 min each day
that causes sweating
 Take a warm bath or warm shower about 2
hrs before bedtime.
 Don’t use bright light even you have to remain
awake for long during nighttime

43. CONTINUE…
 Expose to half an hour of sunlight during 30
min of rising should be useful to prevent
drowsiness in the morning
 Take regular time out of bed for 7 days a week
 Don’t smoke to get sleep
 Give up smoking entirely or don’t smoke after
7 p.m.
 Avoid caffeine entirely or limit no more than 3
cups per day and not after 10 a.m.
 Too much time in bed is not good Remember
that quality of sleep is important.

44. CONTINUE…
 Keep the clock face turned away. Don’t see what
time of night you are awake.
 Don’t eat heavily or drink 3 hrs before bedtime. A
light bedtime snacks is o.k.
 Incase of problem of regurgitation, elevate the
head of bed and prevent spicy as well as oily
meal before bedtime
 Keep your room well ventilated, dark and quiet
during nighttime.
 Reading non-professional materials may be
useful. Perform bedtime rituals.

45. CONTINUE…
 Use stress management technique in
daytime.
 Make sure that mattress isn’t too firm or too
soft. Ensure that the pillow is of appropriate
height and firmness.
 An occasional sleeping pill is alright but use
only after consultation with doctor.
 Use bedroom only for sleep. Avoid activities
that lead to prolonged arousal.

46. FOR PATIENT WITH SLEEP
DISORDER
Assessment
 To promote the restful sleep for clients, nurse can
assess the sleep pattern.
 Usually patients are the best resources for describing
their sleep problem. Some time we can take history
from the partner.
 In case of children, older children or mother can best
describe the pattern of sleep and its problem.

47. CONTINUE…
The tools for sleep assessments are:
 Sleep history including
-Description of client’s sleep problem; nature,
sign/symptoms, onset, duration, predisposing factors,
severity, effects on client.
-Usual sleep pattern prior to sleep problem
-Recent changes in sleep pattern
-Physical illness
-Bedtime routine and sleeping environment
-Use of any medication

48. CONTINUE…
 Pattern of dietary intake or any substance
-symptoms experienced during waking hours
-recent life event
- Current emotional and mental status
 Sleep diary including
-times when patient tries to fall asleep
-approximate time that patient fall asleep
-time of awakening during night
-record of food, physical activity, worries, mental
activity

49. NURSING DIAGNOSIS
Sleep Pattern Disturbance
Related To:
1. Impaired oxygen transport
2. Impaired elimination
3. Immobility
4. Medication
5. Hospitalization
6. Lack of exercise
7. Anxiety response
8. Life-style disruptions

50. CONTINUE…
As evidenced by:
Major:
(Must be present )
 Difficulty falling or remaining asleep
Minor:
(May be present)
 Fatigue on awakening or during the day
 Dozing during the day
 Agitation
 Mood alterations

51. NURSING DIAGNOSIS
 Sleep pattern disturbance
related to decreased physical activity, fear, anxiety,
inability to assume usual sleep position, frequent
assessments or treatments, unfamiliar environment,
and discomfort resulting from current
illness/injury.

52. EXPECTED OUTCOME
 The client will attain optimal amounts of sleep as
evidenced by:
 statements of feeling well rested
 usual mental status
 absence of frequent yawning and dark circles
under eyes

53. INTERVENTION
 Assess for signs and symptoms of a sleep pattern
disturbance. (e.g. statements of difficulty falling
asleep, not feeling well rested, or interrupted sleep;
irritability; disorientation; lethargy; frequent
yawning; dark circles under eyes).
 Determine the client's usual sleep habits.

54. CONTINUE…
 Implement measures to promote sleep:
perform actions to reduce fear and anxiety.
 Discourage long periods of sleep during the day
unless signs and symptoms of sleep deprivation
exist or daytime sleep is usual for client
Perform actions to relieve discomfort if present
(e.g. reposition client; administer prescribed
analgesics, antiemetics, or muscle relaxants

55. CONTINUE…
 discourage intake of foods and fluids high
in caffeine (e.g. chocolate, coffee, tea,
colas) in the evening.
 offer client an evening snack that includes
milk or cheese unless contraindicated (the
L-tryptophan in milk and cheese helps
induce and maintain sleep)

56. CONTINUE…
 allow client to continue usual sleep practices
(e.g. position; time; presleep routines such as
reading, watching television, listening to
music, and meditating) whenever possible.
 satisfy basic needs such as comfort and
warmth before sleep.
 encourage client to urinate just before
bedtime.

57. CONTINUE…
 reduce environmental distractions
(e.g. close door to client's room; use night light rather than
overhead light whenever possible; lower volume of paging
system; keep staff conversations at a low level and away
from client's room; keep beepers and alarms on low
volume; provide client with "white noise" such as a fan,
soft music, or tape-recorded sounds of the ocean or rain;
have sleep mask and earplugs available for client if
needed)
 ensure good room ventilation
 encourage client to avoid drinking alcohol in the evening
(alcohol interferes with REM sleep)

58. CONTINUE…
 if possible, administer medications that can interfere
with sleep (e.g. steroids, diuretics) early in the day
rather than late afternoon or evening
 administer prescribed sedative-hypnotics if
indicated.
 perform actions to reduce interruptions during sleep
(80 - 100 minutes of uninterrupted sleep is usually
needed to complete one sleep cycle)
 restrict visitors
 group care (e.g. medications, treatments, physical care,
assessments) whenever possible.

59. CONTINUE…
 Consult appropriate health care provider if
signs and symptoms of sleep deprivation persist
or worsen.

60. CONTINUE…
 Evaluation
 Reassessment

61. RESEARCH
RESEARCH ARTICLE
 Effect of cognitive behaviour therapy on sleep
disorder in parkinson’s disease in China: A pilot
study
 By:Hualu Yang RN1
 Article first publish on 27 nov 2012
 In this study they evaluated the effect of
cognitive behaviour therapy provided to
individual with parkinson’s disease.
 A single group interupted time series design
was used in this pilot study.

62. CONTINUE…
 Analysis were conducted on 22
participants who provided data on pretest
posttest and 3 months follow up.
 At each time point, participants completed
a sleep diary and parkinson’s disease
sleep scale.
 There was a significant difference between
pre-test and post-test.
 The result suggests that cognitive
behaviour therapy facilitates improvement
of sleep disorders in patient with
parkinson’s disease and provides
important information necessary to design
more definitive studies in the future.

63. THAN
K YOU