NON-ORGANIC SLEEP

DISORDERSPremnath R

THE WORST THINGS;

TO BE IN BED AND SLEEP NOT,

TO WANT FOR ONE WHO COMES

NOT,

TO TRY TO PLEASE AND PLEASE

NOT

PHYSIOLOGY OF SLEEP

Sleep can be regarded as a physiological

reversible reduction of conscious

awareness.

It is observed in all mammals, all birds,

and many reptiles, amphibians, and fish.

SLEEP

Accounts for nearly 1/3rd of our lives

A natural behavioural state

characterized by:

Reduction in voluntary motor

activity

Decreased response to stimulation

(i.e., increased arousal threshold)

Stereotyped posture

SLEEP ARCHITECTURE

There are two types of sleep, non-rapid

eye-movement (NREM) sleep and rapid

eye-movement (REM) sleep.

NREM sleep is divided into stages 1, 2, 3,

and 4, representing a continuum of

relative depth.

Entered through NREM

REM sleep dominates last third of

night

REM sleep: 20-25% total sleep time

NREM

In normal persons, NREM sleep is a

peaceful state relative to waking.

The pulse rate is typically slowed five

to ten beats a minute below the level

of restful waking and is very regular.

Respiration is similarly affected, and

blood pressure also tends to be low,

with few minute-to-minute variations.

NREM

Episodic, involuntary body movements

are present in NREM sleep.

Blood flow through most tissues,

including cerebral blood flow, is

slightly reduced.

REM

Pulse, respiration, and blood pressure in

humans are all high during REM sleep, much

higher than during NREM sleep and often

higher than during waking.

Brain oxygen use increases during REM

sleep.

Thermoregulation is altered during REM

sleep.

REM Sleep v/s Non-REM Sleep

REM SLEEP NON- REM SLEEP

Rapid conjugate eye movement

Absence of eye movement

Fluctuation of vital signs

Stable vital signs

Muscle twitching No muscle twitching

Presence of dreams No dreams

Originate in pontine reticular formation

Originates in midline pontine and medullary nuclei (raphe nuclei)

Mediated by noradrenaline

Mediated by serotonin

SLEEP CYCLE Sleep is divided into a 90 minute cycle of NREM

sleep and REM sleep.

This cycle is repeated 3-6 times during the night.

Generally, a night of sleep begins with about 80

minutes of NREM and 10 minutes of REM sleep.

There is more REM sleep on towards morning,

which explains why when you awaken in the

morning, you generally awaken from a dream.

Wake

Up !!

NON-ORGANIC SLEEP DISORDERS

Sleep disorders are divided into subtypes;

Dyssomnias

Insomnia

Hypersomnia

Disorders of sleep-wake schedule

Parasomnias

Stage IV disorders

Other disorders

Dyssomnias

They are primarily psychogenic

conditions in which the predominant

disturbance is in the amount, quality or

timing of sleep is due to emotional

causes.

Parasomnias

They are abnormal episodic events

occurring during sleep; in childhood,

these are related mainly to the child’s

development, while in adulthood, they

are primarily psychogenic.

DYSSOMNIAS

INSOMNIA

It refer to the disorder of initiation

and maintenance of sleep. This

includes frequent awakening during

night and early morning awakening.

Etiology

Medical illness

Alcohol and drug abuse

Psychiatric disorders

Social causes

Behavioral factors

CLINICAL FEATURES OF INSOMNIA

Individuals describe themselves as

feeling tense, anxious, worried, or

depressed at bedtime and as though

their thoughts are racing

They frequently ruminate over getting

enough sleep, personal problems, health

status and even death.

Use of alcohol and other substances.

In the morning, they frequently report feeling

physically and mentally tired; during the day,

they characteristically feel depressed,

worried, tense and preoccupied with

themselves.

Difficulty in falling asleep at night or getting

back to sleep after waking during night.

Sleep is light, fragmented or

unrefreshing

Need to take something in order to

get sleep

Sleepiness and low energy during

the day.

TREATMENT

Thorough medical and psychiatric assessment

Polysomnography

Treatment of underlying physical/psychiatric

disorder

Withdrawal of current medications

Benzodiazepines for short periods

Non-benzodiazepine hypnotic

Opioids

Melatonin

Low doses of atypical antipsychotics

Non-pharmacologic management

Progressive relaxation

Autosuggestion

Meditation, yoga

Stimulus control therapy

Do not use bed for reading or chatting-go to

bed for sleep only

Sleep hygiene

Sleep as much as needed to feel rested; do

not oversleep

Exercise regularly

Avoid forcing to sleep

Keep a regular sleep and awakening schedule

Avoid caffeinated drink at bedtime

Avoid ‘night caps’

Do not go to bed hungry

Adjust room environment

Do not go to bed with worries

Back rub, warm milk and relaxation exercises.

HYPERSOMNIA

It is also known as Disorder Of

Excessive Somnolence (DOES)

Hypersomnia is characterised

by recurrent episodes of excessive

daytime sleepiness or prolonged night-

time sleep. It includes sleep attacks during

daytime, sleep drunkenness (person needs

much more time to awaken, and during

this period he is confused or disoriented).

Etiology Narcolepsy(Excessive daytime

sleepiness characterized by sleep

attacks, cataplexy, sleep paralysis and

hypnagogic hallucinations)

Sleep apnoea

Kleine –Levin syndrome (Periodic

episodes of hypersomnia)

Dysfunctions in autonomic nervous

system

Drug or alcohol abuse

Certain medications

Medical conditions like multiple

sclerosis, depression, encephalitis,

epilepsy, obesity etc.

Clinical features

Persons are compelled to take nap during day

at inappropriate times

Disoriented sometimes

Anxiety, increased irritation, decreased energy,

restlessness, slow thinking, slow speech,

anorexia, hallucinations and memory difficulty

Poor social, occupational and family functioning

TREATMENT

Symptomatic treatment

Changes in behavior and diet

Avoiding alcohol

Stimulants like amphetamine,

methylphenidate and modafinil

Clonidine, levodopa, bromocriptine

Antidepressants, MAO inhibitors

DISORDERS OF

SLEEP-WAKE

SCHEDULE

It is characterized by a

disturbance in the timing of sleep.

The person with this disorder is not

able to sleep when he wishes to,

although at other times he is able to

sleep adequately.

It is a form of dyssomnia caused by a

conflict between a person’s circadian

rhythm and the socio-economic

demands of society, such as work and

travel schedules.

Causes

Jet lag or rapid change of

time zone

Work shift from day to night

Unusual sleep phases (owls

and larks)

PARASOMNIAS

STAGE IV SLEEP DISORDERS

SOMNAMBULISM

Sleep-walking or

somnambulism is a state of altered

consciousness in which

phenomena of sleep and

wakefulness are combined.

During sleepwalking episode, the

individual arises from bed, usually

during first third of nocturnal sleep, and

walks about, exhibiting low levels of

awareness, reactivity, and motor skill.

Most often he will return quietly to bed,

either unaided or with a gentle

assistance.

Upon awakening, there will be no recall

of event.

NIGHT TERRORS

Night terror or sleep terror or

pavor nocturnus, is a parasomnia

disorder that predominantly affects

children, causing feelings of dread or

terror.

Children usually described the

experience as “bolting upright” with

their eyes wide open, with a look of

fear and panic, and will often scream.

SLEEP-RELATED ENURESIS

Sleep related enuresis or

bedwetting, involves urinating during

sleep and occurs most often during

deep sleep.

It is frequently the result of a failure

of brain to engage in appropriate

“alarming” of bathroom needs during

sleep before urination occurs.

BRUXISM

It is characterized by the grinding of

the teeth and typically includes the

clenching of the jaw.

While bruxism may be a diurnal or

nocturnal activity, it is bruxism during

sleep that causes majority of health issues

and can even occur during short naps.

SLEEP-TALKING (SOMNILOQUY)

It refers to talking aloud in one’s

sleep. It can be quite loud, ranging

from simple sounds to long speeches,

and can occur many times during

sleep.

Listeners may or may not be able to

understand what the person is saying.

OTHER SLEEP DISORDERS

NOCTURNAL ANGINA

NOCTURNAL ASTHMA

NOCTURNAL SEIZURES

SLEEP PARALYSIS

OBSTRUCTIVE SLEEP APNEA SYNDROME

(OSAS)

PERIODIC LIMB MOVEMENT DISORDER

RESTLESS LEG SYNDROME

NURSING MANAGEMENTAssessment Usual activities in the hour before sleep Sleep latency Number and perceived cause of

awakenings Regularity of sleep pattern Consistency of rising time Frequency and duration of naps Ease of falling asleep in places other than

the usual bedroom Daily caffeine intake Use of alcohol, sleeping pills and other

medications

Objective data may include visible

signs of fatigue and lack of sleep,

such as circles under the eyes, lack

of coordination, drowsiness and

irritability.

Diagnosis:- Disturbed sleep pattern related to

(specific medical condition),use of or withdrawal

from substances, anxiety or depression, circadian

rhythm disruptions, familial patterns

Interventions:-

To promote sleep:

Encourage activities that prepare one for sleep:

soft music, relaxation exercise or warm bath

Discourage strenuous exercise within one hour

of bed time

Control intake of caffeine containing substances

within 4 hours of bed time

Provide a high carbohydrate snack before bed time

Keep the temperature of the room between 68-72

degree F

Instruct the client not to use alcoholic beverages to

relax

Discourage smoking and other tobacco products

near sleep time

Discourage day time napping

Individuals with chronic insomnia should use

sleeping medication judiciously

Diagnosis:- Risk of injury related to excessive

sleeping, sleep terrors, or sleep walking

Interventions:-

Keep the side rails of the bed up

Keep the bed in a low position

Equip the bed with a bell that is activated when

the bed is excited

Keep a night light on and arrange the furniture

in the bedroom in a manner that promote safety

Administer drug therapy as ordered.

Diagnosis:- Disturbed sleep pattern related to

enuresis as evidenced by frequent arousal of the

child from bed.

Interventions:-

Assess for anatomical or urinary problems, if any.

lnsist the parents to make the child void before

bedtime

ЕхрІаіn about the availability of bedwetting

alarms

Teach bladder stretching exercises

Administer medications as per physician's order.

Thank you….