15. Sleep Disorders

Sleep is a normal resting state of altered consciousness that occurs periodically. It has restorative effects and is essential to health and survival. Depending on age and physical condition, people require from 4 to 9 hours of sleep out of every 24 to function normally. Sleep disorders can result when a person has difficulty falling asleep or staying asleep or still feels excessively tired on awakening from a long sleep. Sleep disturbances often coexist with physical problems sucr. as pain or with psychological problems such as depression. If sleeping difficulties interiors with activities of daily living and disruptions persist for longer than I month, a sleep disorder may be present. Before diagnosing a sleep disorder, clinicians typically explore whether the sleep problem is related to emotional problems, underlying disease, or physical effects of certain drugs or foods.

Psychological Factors Affecting Medical Condition

DSM-IVCategories
Primary Sleep Disorders
Dyssomnias
307.42 Primary Insomnia
307.44 Primary Hypersomnia, Specify if: Recurrent
347 Narcolepsy
780.59 Breathing-Related Sleep Disorder
307.45 Circadian Rhythm Sleep Disorder
Specify type: Delayed Sleep Phase Type/Jet Lag Type/Shift Work Type/Unspecified Type
307.47 Dyssomnia NOS
Parasomnias
307.47 Nightmare Disorder
307.46 Sleep Terror Disorder
307.46 Sleepwalking Disorder307.47
Parasomnia NOS
Sleep Disorders Related to Another Mental Disorder
307.42 insomnia Related to ... [Indicate the Axis 1or Axis 11 Disorder]
307.44 Hypersomnia Related to ... [Indicate the Axis 1 or Axis 11 Disorder] Other Sleep Disorders
780.xx Sleep Disorder Due to ... [Indicate the General Medical Condition]
780.52 Insomnia Type
780.54 Hypersomnia Type
780.59 Parasomnia Type
780.59 Mixed Type

._ Substance-Induced Sleep Disorder (refer to Substance-Related Disorders for substance-specific codes) Specify type: Insomnia Type/Hypersomnia Type Parasomnia Type/Mixed Type Specify if: With Onset During Intoxication/With Onset During Withdrawal

Sleep disorders are divided into three major groups: dyssomnias. parasomnias, and sleep disorders related to other physiologic or psychological conditions. Dyssomnias are characterized primarily by a change in amount, quality, or timing of sleep. Examples of dyssomnias are primary insomnia, primary hypersomnia, narcolepsy, breathing-related sleep disorder, and circadian rhythm s\eec disorder.

In primary insomnia, the client is restless and complains of a distressing cycle of not being able to fall asleep, becoming upset about the inability to sleep, and then being aroused from sleep by the resulting anxiety. Sometimes people with primary insomnia can sleep better while listening to music or riding in a car than in their own beds. A history of anxiety or depression is common. In primary hypersomnia, the client sleeps for abnormally long hours, is unable to awaken properly, and feels compelled to take naps during the day.

A clientwith narcolepsy experiences episodes of sleepiness in inappropriate circumstances, such as during business meetings or other work tasks and in social situations, A low level of activity or stimulation exacerbates the sleepiness, Typically, periods of inappropriate sleep last for 10 to 20 minutes and occur several times during the day.

A client with a breathing-related sleep disorder experiences either insomnia or hypersomnia related to ventilation difficulties.

Two common examples of breathing difficulties are sleep apnea and severe hypoventilation. Many people are awakened from their sleep by their attempt to breathe normally. Many clients complain of an inability to manage their sleepiness, but they also can fall asleep in many different and inappropriate situations.

In circadian rhythm sleep disorder, a discrepancy arises between the normal sleep-wake pattern and the sleep-wake cycle required by the person's daily environment. Circadian disorders include delayed sleep phase, jet lag, and shift work. The main characteristic of delayed sleep phase is the inability to fall asleep and the difficulty of arising at a desirable time. In jet lag, the person experiences sleepiness and reduced alertness as a result of traveling across more than one time zone. The shift work type results from frequent changes in the designated times a person works.

Parasomnias are characterized by abnormal events that occur during sleep, certain sleep stages, or the sleep-wake cycle. These particular disorders are connected to the autonomic nervous system, the motor system, or cognitive alterations that occur during the sleep-wake cycle, Parasomnias include nightmare disorder, sleep terror disorder, sleepwalking disorder, and parasomnia not otherwise specified. A client with nightmare disorder has been awakened completely by vivid, frightening dreams, which generate anxiety and make it difficult to return to sleep. A client with sleep terror disorder experiences an abrupt awakening accompanied by a scream and physiologic signs of anxiety, such as tachypnea, tachycardia, sweating, and muscle tension. The next day, the client usually has little or no memory of the event. In sleepwalking disorder, the client may get out or bed and walk around, sit up in bed and look around, or simply pick at or rearrange bed covers. Some cases of sleepwalking involve complex behaviors, such as unlocking doors, going outside having something to eat, and using the bathroom. The sleepwalker wears a blank expression and doesn't usually respond to communication attempts by other people. The client may have little or no memory of the event.

For sleep disorders related to another mental disorder, the clinician establishes a relation between the identified mental disorder and the sleep problem. Because sleep disturbances are common symptoms of emotional problems, the diagnosis of a sleep disorder is made only when the sleeping difficulty becomes a major symptom. (See Stages of Sleep in Adults, page 294.)

The biological basis for sleep disorders remains unknown. Conditions such as sleep apnea, narcolepsy, parasomnia, sleepwalking, and night terrors demonstrate a familial predisposition suggesting that a genetic basis may be possible. Disruption of circadian rhythms may help to cause some forms of insomnia.

Communication Strategies

• Talk to the client about sleep patterns. (See Sleep Assessment Questions, page 295.)
• Encourage the client to identify changes or disruptions in sleep habits or patterns.
• Have the client define what "good sleep" is and then ask the client to compare his own experience to that definition.
• Encourage the client to express his feelings about the existence of sleep difficulties.
• Ask the client how many hours of sleep are needed to sustain a comfortable degree of personal, occupational, social, or family functioning. (See Sleep Requirements over the Life Cycle,page 296.)
• Discuss how changes in sleep patterns occur normally throughout the life cycle.
• Identify the client's perception of alertness throughout the day
• Discuss signs and symptoms of sleep deprivation and the impact they have on individuals and families.
• Identify how increased sleep, increased time in bed, and napping can prevent a person from dealing with troublesome issues.
• Talk with the client about stressful situations and how they negatively impact on a person's ability to sleep. e Talk about how increased exercise, intense learning activities, physical work, and exposure to harsh weather conditions may increase the need for sleep.
• Have the client identify concerns about relationships and social or occupational functioning that may influence sleep patterns.
• Discuss the client's coping patterns and ability to tolerate stress. e Address the existence and strength of the client's support system.
• Discuss the client's personal goals for obtaining adequate sleep.

Stages of Sleep in Adults

Sleep Assessment Questions

• What time do you usually go to bed?
• How long does it take you to fall asleep?
• Do you wake up during the night? How many times?
• How long does it take you to fall back to sleep?
• What time do you usually wake up each day?
• When you wake up, how rested do you feel?
• Do you have trouble getting started in the morning?
• Do you have enough energy to get through the day?
• Do you need to push yourself to get things done?
• Do you find yourself falling asleep at inappropriate times (such as during meetings, in school, or while watching TV)?
• Have you changed the usual place where you fall asleep?
• Do you take naps? When? How long do you nap?
• Are there any new situational or environmental factors that may affect your sleeping?
• Do you find yourself in situations where you are fighting sleepiness?
• Do you use caffeine or other substances to stay awake?
• Do you find yourself worrying or being anxious about anything when you are preparing for sleep?
• Do you get by with minimal amounts of sleep all week and try to catch up on sleep during the weekend?
• Do you use prescribed medications, over-the-counter or street drugs, or alcohol to induce sleep?

Nursing Diagnosis: Sleep Pattern Disturbance

Sleep Requirements Over the Life Cycle

Long-Term Goal The client will sleep an appropriate number of hours (based on age and activity level) to feel well rested.

Short-Term Goal #1: The client will identify factors that prevent or disrupt sleep.

Interventions and Rationales

• Have the client record a diary of current sleep-wake patterns, sleep disruptions, and daily stressors or problems. This information helps the nurse identify a particular sleep disturbance.
• Encourage the client to discuss how current stressors impair the ability to sleep normally.Discussing the effects of stressors enables the client to verbalize awareness of difficulties, see the impact of stress on sleep, and begin to make plans for change.
• Discourage the client from napping during the day. Daytime napping can decrease the client's ability to fall asleep at night; the client won't be tired or ready to retire.
• Discuss how changes in the client's environment, such as light, noise, and temperature levels, can affect sleep. Environmental stimulation and disturbances impair the client's ability to sleep.
• Have the client review and make changes in daily activities by performing challenging physical activities early in the day.By performing challenging physical activities early in the day, the client will become physically tired and be better able to sleep at night.
• Have the client monitor food and beverage intake during the day to determine the relation between intake and sleep problems. Identifying certain types of potentially initiating foods; the use of stimulants, such as caffeine, chocolate, and cola products and the time of ingestion provides information about physical Ana chemical stimulants that frequently interfere with sleep.
• Discuss how alcohol impairs sleep pattems. Alcohol, a depressant, initially produces a drowsy feeling, but after a short period. alcohol causes restless, fragmented sleep, and strange dreams.
• Discuss how cigarettes impair sleep pattems; encourage the client who smokes to stop smoking at least 30 minutes before retiring. Nicotine is a stimulant that negatively affects sleep.
• If awaking to use the bathroom is a problem, have the client limit fluid intake for 5 hours before going to bed. Limiting fluid intake prevents the client from being awakened by a full bladder.

Short-Term Goal #2: The client will identify factors that promote sleep.

Interventions and Rationales

• Have the client develop and implement a sleep routine. A sleep preparation routine and a nonstimulating, relaxing period before retiring promotes sleep.
• Encourage the client to prepare a sleep-conducive environment. Constructing a personal environment that contains particular.pillows, quilts, or comforters and even pets or other significant objects can promote a sense of comfort and sleep.
• If not contraindicated, have the client drink milk or a decaffeinated beverage or eat a small, high-protein snack that contains L-tryptophan, such as cheese and nuts. L- Tryptophan is an amino acid that promotes sleep.
• Have the client use sleep-inducing medications appropriately for a limited period. Sleep-inducing medications can lose their effectiveness when taken over long periods. Don t abruptly discontinue sleep medications because the client may have an exacerbation of sleep difficulties.
• Before bedtime, have the client engage in non-stimulating activities, such as reading, listening to music, taking a warm shower or bath, meditating, and performing relaxation exercises. Client's need to develop a repertoire of nonstimulating activities that can be individualized to meet their sleep needs.

Nursing Diagnosis: Anxiety Related to Internal or External Stressors

Long-Term Goal The client will demonstrate effective coping strategies to handle current stressors that affect sleep.

Short-Term Goal #1: The client will review personal behaviors that contribute to sleep difficulties.

Interventions and Rationales

• Have the client assess current sleep problems and verbalize an understanding of them. Each individual has a personal perception of the problem, its causes, and how best to handle it. Effective care can be planned from this valuable client data, and the clients involvement can contribute to goal attainment.
• Encourage the client to evaluate aspects of daily life that present coping difficulties and quickly lead to his feeling overwhelmed. Worrying and feeling like things are chaotic and out of control prevent relaxation and generate internal emotional turmoil that can prevent the client from falling asleep and staying asleep or contribute to bizarre dreams.
• Determine if daily responsibilities cause the client to feel overwhelmed; if so, discuss strategies to share, decrease, or alter these duties. Feeling overwhelmed is stressful. Unrelenting stress contributes to sleep deprivation at a time when more sleep is needed to handle stressors.
• Explore the reasons for feeling overwhelmed, and set adequate limits on the client's workload. Sometimes people don't say no because of unrealistic expectations, fear of not doing an acceptable job, or feeling guilty when someone else s needs aren't being met. Identifying what motivates a person to behave a certain way is essential for helping the person initiate change.
• Explore the fears and feelings that excessive sleep may help the client avoid. Verbalizing feelings or fears permits the client to begin to develop solutions or come to terms with problems. No longer is sleep needed as a form of escape.
• Have the client evaluate the amount of time spent in the bedroom and set appropriate limits on time spent there. Setting nrr.-its on bedroom time liberates the client to engage in activities anc develop a healthy activity routine that promotes sleep.

Short-Term Goal #2: The client will begin to practice coping strategies that decrease anxiety and prepare the client for sleep.

Interventions and Rationales

• Have the client verbalize concerns that may be inhibiting sleep. Discussion of problems can lead to identification of solutions and ways to be proactive about self-care.
• Encourage the client to brainstorm and write down ideas to promote better sleep. Having the client develop a personalized plan for sleep facilitates direct client involvement, increases the client's ownership of the plan, and contributes to the plan's success.
• Have the client implement strategies to promote relaxation and decrease stress. (See chapter 8, Anxiety Disorders, for stress management techniques.) Developing a personal plan to reduce stress gives the client a sense of personal control and the ability to comfort himself
• Encourage the client to use exercise and other recreational activities as a way to prepare during the day for a good night s sleep. Exercise and recreational activities can promote sleep by increasing fatigue and facilitating relaxation.
• Recommend specific treatments to the client when health problems are present. Often, sleep difficulties are influenced by physiologic or psychological problems. Treatment of associated health issues contributes to the promotion of sleep.
• Develop ways to enhance the client's self-esteem. Increasing a client's self-esteem empowers the client to work on overcoming sleep disturbances.
• Promote client participation in family and social activities and in appropriate community events. Enjoyment of social activities can promote relaxation, decrease anxiety, and distract the client from preoccupation with sleep problems.
• If appropriate, discuss the client's spiritual beliefs and incorporate appropriate practices into daily activities. Spiritual interventions may facilitate hope, provide support, and contribute to an improved quality of life.

Therapies

The major goals of therapy are to identify the sleep problem and practice good sleep hygiene. Often, the focus of care is to make lifestyle modifications and strengthen sleep-wake pattems.

Individual Therapy

• Help the client establish healthy lifestyle habits, such as an exercise program, a weight maintenance program, and healthy eating.
• Address variables, such as unrelenting stressors, life changes difficult relationships, and other areas of unhappiness in be inhibiting sleep.
• Have the client consider the use of music as a relaxation strategy and part of preparation for sleep.
• Discuss the need for a referral for polysomnography (an EEG that records several physical variables, such as brain wave activity, respirations, eye movements, and muscle tone. during sleep). Consider the value of a comprehensive sleep evaluation at a diagnostic sleep center.
• Refer the client to appropriate support groups.

Medications

Medications are frequently given to clients with sleep disorders. Before medication administration, a client is evaluated and treated for medical or mental health problems, if appropriate.

• Short-term insomnia is typically treated with benzodiazepines. These drugs can help clients fall asleep and increase the iota. number of hours of sleep. They have few adverse effects and don't tend to promote addiction.
• Nonbenzodiazepine drugs, such as triazolam (Halcion) and zolpidem tartrate (Ambien), are used for clients who have difficulty falling asleep.
• If the client is experiencing symptoms of depression or insomnia, a tricyclic antidepressant (TCA) medication may be  prescribed. Administer the antidepressant medication at bedtime to promote nighttime sleep. A selective serotonin reuptake inhibitor (SSRI) commonly used to treat both depression and insomnia is trazodone (Desyrel). The newer SSRIs must be used with caution because they can actually contribute to insomnia.
• Explain to the client and his family that using substances that decrease rapid-eye-movement sleep, such as short-acting benzodiazepines and TCAs, may increase the incidence of dreaming when the medication is stopped.
• Some clients can benefit from stimulant drugs, such as pemoline (Cylert), dextroamphetamine (Dexedrine), and methylphenidate (Ritalin). These drugs must be used cautiously in a client with a history of substance abuse.
• For clients with high levels of anxiety, an antianxiety medication may be prescribed.
• Sedatives must be used judiciously for sleep disorders because they can worsen some conditions such as sleep apnea.
• Melatonin is sometimes given at night as a treatment for insomnia. People often use it when shift work, jet lag, or other transient situations disrupt their sleep.
• Sometimes clients use over-the-counter medications such as antihistamines to produce sleep. Antihistamines can cause diminished alertness, sedation, and slow reaction time. They also cause dry mouth, urine retention, and tachycardia. (See Appendix D for medication information.)

Major Components of a Sleep Disorder Teaching Plan

• Usefulness of a sleep diary
• Maintenance of a regular sleep schedule 7 days a week
• Establishment of a bedtime routine
• Dietary considerations focusing on foods and fluids that positively or negatively influence sleep
• Principles of adequate sleep hygiene
• Stress-reduction techniques
• A focus on enjoyment of sleep that does occur rather than on sleep problems
• Appropriate use of sleep medications, including monitoring of effects and adverse effects
• Influence of physical and mental health problems on sleep
• Use of any healthy measures the client reports as personally useful
• Elimination of caffeine, alcohol, and cigarettes for 4 to 6 hours before retiring
• Strategies to handle daytime drowsiness
• Strategies to obtain family support

Family Care

• Educate family members about sleep disorders, healthy sleep-wake patterns, the need for a bedtime routine, and environmental variables that impede or enhance sleep. (See Major Components of a Sleep Disorder Teaching Plan.)
• Encourage family members to plan important events around the client's optimal times of alertness.
• Discuss how a decrease of sleep over time affects the client s ability to sustain daily functioning, cope with everyday stressors, make decisions, and feel positive about himself
• Monitor sleep patterns because they may give information about the client's tendency to experience depression, mania, or other health problems.
• Identify how dreams or nightmares are associated with some sleep disorders and how they can negatively impact a person's well being.
• Tell family members how they may assist the client with the evaluation methods used to assess sleep disorders.
• Work with the family to identify stressors and develop ways to cope with or change situations that negatively impact the client's sleep. (See Sleep Hygiene Techniques)
• Help the family effectively communicate about the sleep problems without blaming the person who is experiencing them.
• Discuss the need to prevent the client from vacillating between periods of hyperactivity and periods of under activity.
• Encourage family members to identify how one person's sleeping difficulty may affect each person and inadvertently
• diminish the quantity of sleep for some members of the family.
• Have the family discuss how lifestyle change has a better chance of happening if each family member participates in the change process.
• Help family members identify and build on their strengths and the client's strengths.
• Reinforce the family's use of problem-solving skills.
• Have the family encourage the client to seek help as needed to sleep problems.
• Make referrals to self-help or support groups as needed.

Sleep Hygiene Techniques

• Make the bedroom environment comfortable in terms of aesthetics, noise level, light, and temperature.
• Go to bed and get up at approximately the same tone each day.
• Develop a routine or ritual to prepare for sleep.
• Don't read, eat, watch TV, or perform activities other than sleeping or sex MI bed. Develop the mind-set that the bed is the place where one sleeps.
• Establish a time to stop work or set limits on now much one win do before going to bed.
• Don't engage in serious problem solving, intense discussions, negative ruminations, or troublesome relationship issues before retiring.
• If sleep doesn't occur, get up, perform some simple and nonstimulatmg tasks, and return to bed later.
• Take a warm shower or bath to promote relaxation add enhance steep.
• Limit or avoid daytime naps.
• Do daily exercise. Good times are in the moming ami several hours before retiring.
• Before going to bed, drink a warm decaffeinated beverage or milk. Sometimes a food that contains L-tryptophan may be eaten before retiring. Several good sources of L-tryptophan are wheat, flour, corn, milk. eggs, cheese, nuts, and turkey.
• Avoid caffeine, alcohol, and other stimulating substances.
• Position the alarm clock where it cant be seen If its presence generates anxiety about time or lack of sleep.
• Never go without sleep or become steep-deprived.