Spurthy college of nursing AN ASSIGNMENT ON Sleep

SUBMITTED TO,
Mrs. GUNAVATHY, MSc(N) ASSOCIATE READER

SUBMITTED BY,
MISS. LITHIYA JOSE FIRST YEAR MSC NURSING

SUBMISSION ON,
1

09– 12– 2011

INDEX

SL NO 1. 2. 3. 4. 5. 6. INTRODUCTION DEFINITION PHYSIOLOGY OF SLEEP CICARDIAN RHYTHM STAGES OF SLEEP SLEEP CYCLE

CONTENT

PAGE NO 1 1 1-3 4 4-6 7 - 10

7.

FUNCTIONS OF SLEEP

10 – 15

8. 9.

NORMAL SLEEP PATTERN MYTHS RELATED TO SLEEP

15 - 17 17 – 18

10.

SLEEP PATTERN DISTURBANCES AND MANAGEMENT

18 -25

11.

NURSING IMPLICATIONS

26

2

12.

RESEARCH STUDIES RELATED TO SLEEP

27

13. 14.

CONCLUSION BIBLIOGRAPHY

27 28

Sleep that knits up the ravelled sleave of care The death of each day's life, sore labour's bath Balm of hurt minds, great nature's second course, Chief nourisher in life's feast. ~William Shakespeare, Macbeth

3

4 .

variable levels of consciousness. locus coeruleus. laterodorsal tegmental nucleus. but an active initiation mechanism that facilitates brain withdrawal is also recognized.INTRODUCTION Sleep is a basic human need. The VLPO innervates and can inhibit the wake-promoting regions of the brain including the tuberomammillary nucleus. will usually awaken a sleeper. Currently. lateral hypothalamus. Some environmental stimuli such as smoke detector alarm. where as other noises will not. auditory. The brain gradually becomes less responsive to visual. Historically . sleep was thought to be a passive state that was initiated through withdrawal of sensory input. sleep was considered a state of unconsciousness. withdrawal of sensory awareness is believed to be a factor in sleep. More recently sleep has come to be considered an altered state of consciousness in which the individuals perception of and reaction to the environment are decreased. DEFINITION Sleep is characterized by minimal physical activity. It is a universal biological process common to all people. Historically. It appears that individuals respond to meaningful stimuli while sleeping and selectively disregard un meaningful stimuli. changes in the body’s physiologic process and decreased responsiveness to external stimuli. The "switch" for sleep is considered to be the ventrolateral preoptic nucleus (VLPO) of the anterior hypothalamus. dorsal raphe. and pedunculopontine tegmental 5 . and other environmental stimuli during the transition from wake to sleep. This area becomes active during sleep and uses the inhibitory neurotransmitters GABA and galanin to initiate sleep by inhibiting the arousal regions of the brain. which is considered by some to be stage I of sleep. The predictable cycling of sleep and the reversal of relative external unresponsiveness are features that assist in distinguishing sleep from other states of unconsciousness. PHYSIOLOGY OF SLEEP Sleep is a state of unconsciousness in which the brain is relatively more responsive to internal than external stimuli. Both homeostatic factors (factor S) and circadian factors (factor C) interact to determine the timing and quality of sleep.

which utilizes neuronal plasticity.[5] NREM is an active state that is maintained partly through oscillations between the thalamus and the cortex. Cortical desynchrony (also described as low voltage mixed frequency) is the EEG hallmark of REM sleep.[4] The tubero infundibular region projects rostrally to the intralaminar nuclei of the thalamus and to the cerebral cortex. Another theory. narcolepsy can result. The 3 major oscillation systems are sleep spindles. In addition to inhibiting higher cortical consciousness. A decrease in ascending thalamic cholinergic transmissions occurs in association with decreasing cortical responsiveness. the tuberoinfundibular tract projects caudally into the pontine reticular system and inhibits afferent transmissions from ascending cholinergic tracts. As deafferentation spreads. several theories have been put forth." A pharmacologic offshoot of the cholinergic mediation of REM sleep is stage R increasing with cholinergic agonists and decreasing with anticholinergics. Sleep spindles. delta waves are produced by interactions from both thalamic reticular and cortical pyramidal sources. delta oscillations.nucleus. 6 . The REM-off neurons use norepinephrine. and slow cortical oscillations. The hypocretin (orexin) neurons in the lateral hypothalamus helps stabilize this switch. When the hypocretin neurons are lost. Inhibition of the tubero infundibular region is a critical step toward falling asleep because it results in functional disconnection between the brain stem and the more rostral thalamus and cortex.[6] REM sleep is generated by the cholinergic mediated "REM-on neurons" in the mesencephalic and pontine cholinergic neurons. "REM-off neurons" are the monoadrenergic locus ceruleus and serotonergic raphe neurons. corticothalamic projections back to the thalamus synchronize. Slow cortical oscillations are produced in neocortical networks by cyclic hyperpolarizations and depolarizations. As hyperpolarization of the thalamic reticular neurons progresses. These bursts inhibit thalamocortical projection neurons. suggests that the oscillating depolarizations and hyperpolarizations consolidate memory and remove redundant or excess synapses. The pedunculopontine tegmental nucleus (PPT) and the lateral dorsal tegmental (LDT) neurons use acetylcholine to trigger cortical desynchrony via the thalamus. An additional EEG hallmark of REM sleep is "sawtooth waves. are generated by bursts of hyperpolarizing GABAnergic neurons in the reticular nucleus of the thalamus. a hallmark of stage N2 sleep. One theory proposes that decreased metabolic demand facilitates replenishment of glycogen stores. Although the functions of NREM sleep remain speculative.

Tonic cortical activation with EEG desynchronization is promoted by projections from cholinergic lateral dorsal tegmental and pedunculopontine tegmental neurons to the thalamic nuclei. except for phasic muscle twitches. Medications. REM density is a term used to describe the frequency per minute of the eye movement bursts. Projection of the presumed cholinergic. This is supported by oxygen positron emission tomography (PET) studies. reticular group is through the medullary reticular formation. the metabolic demand of the brain decreases. cortical activation. which show that. During NREM sleep. 7] REM sleep (stage R) is characterized by muscle atonia. such as antidepressants. Glycinergic interneurons produce postsynaptic inhibition and hyperpolarization of the spinal alpha motor neurons. The phasic portion of REM sleep is characterized by skeletal muscle twitches. and rapid eye movements. pupil dilation. These spikes appear to be generated by lateral dorsal tegmental and pedunculopontine tegmental neuronal bursts. but not humans. that increase the amount of norepinephrine or serotonin can cause a pharmacologic suppression of REM sleep. PGO bursts precede rapid eye movements by several seconds. Phasic pontine-geniculate-occipital (PGO) spikes are another neurophysiological feature of REM sleep seen in animals. increased heart rate variability. which are referred to collectively as the dorsolateral small cell reticular group. which projects through the ventrolateral reticulospinal tract to inhibitory spinal and bulbar interneurons. They are projected to the lateral geniculate and other thalamic nuclei.[5. Other projections through brainstem reticular formation neurons are likely to be involved as well. during NREM sleep. and histamine to inhibit the REM-on cholinergic cells and stop REM sleep. Muscle atonia is present throughout REM sleep. Phasic rapid eye movements are composed of lateral saccades generated in the paramedian pontine reticular formation and vertical saccades thought to be generated in the mesencephalic reticular formation. small-cell.serotonin. These REM-off neurons become inactive during REM sleep. REM sleep has a parasympathetically medicated tonic component and sympathetically mediated phasic component. and increased respiratory rate. and then to the occipital cortex. the blood flow throughout the entire brain 7 . It results from inhibition of alpha motor neurons by clusters of peri–locus ceruleus neurons. Increases in PGO bursts are seen after REM sleep deprivation. low-voltage desynchronization of the EEG. dorsolateral.

The morning upswing then facilitates awakening and through the day acts as a counterbalance to the progressive discharge of wake neuronal activity. The increase in blood flow to the primary visual regions of the cortex may explain the vivid nature of REM dreaming. while the continued decrease in blood flow to the prefrontal cortex may explain the unquestioning acceptance of even the most bizarre dream content. during REM sleep. and growth hormone also demonstrate circadian rhythms. with maximal secretion during the night. PET studies also show that. 8 . People who are alert late in the evening (ie. a German word meaning time-giver. The retinohypothalamic tract allows light cues to directly influence the suprachiasmatic nucleus. The nadir of the rhythm is in the early morning. the downswing aids sleep initiation.2-hour cycle. This model explains the relatively steady cognitive function throughout wakefulness. and sensory cortices. The temperature peaks and troughs are thought to mirror the sleep rhythm. A practical purpose has been proposed for the circadian rhythm. Prolactin. testosterone. Light is called a zeitgeber. Melatonin has been implicated as a modulator of light entrainment. while those who find themselves most alert early in the morning (ie. After the circadian apex in the early evening. with both light exposure and schedule clues entraining to the 24. while remaining comparatively decreased in the prefrontal and parietal associational regions. blood flow increases in the thalamus and the primary visual.progressively decreases. An increase in body temperature is seen during the course of the day and a decrease is observed during the night. The downswing in circadian rhythm prior to the nadir is thought to assist the brain to remain asleep overnight for full restoration by preventing premature awakening.2 hours. CIRCARDIAN RHYTHM Circadian sleep rhythm is one of the several intrinsic body rhythms modulated by the hypothalamus. using the analogy of the brain being somewhat like a battery charging during sleep and discharging during the wake period. morning types) have body temperature peaks early in the evening. evening types) have body temperature peaks late in the evening. The suprachiasmatic nucleus sets the body clock to approximately 24. Body temperature cycles are also under hypothalamic control. because it sets the suprachiasmatic clock. It is secreted maximally during the night by the pineal gland. motor.

slow brain waves known as delta waves begin to emerge during stage 3 sleep. these myoclonic jerks are actually quite common. This period of sleep lasts only a brief time (around 5-10 minutes). Common examples of this phenomenon include feeling like you are falling or hearing someone call your name. you are still relatively awake and alert. you may experience strange and extremely vivid sensations known as hypnagogic hallucinations. the brain produces high amplitude theta waves. Stage 1 Stage 1 is the beginning of the sleep cycle. which are small and fast. Stage 2 Stage 2 is the second stage of sleep and lasts for approximately 20 minutes. During this time when you are not quite asleep. As the brain begins to relax and slow down. Stage 3 is a transitional period between light sleep and a very deep sleep. which are very slow brain waves. The brain begins to produce bursts of rapid. Stage 1 can be considered a transition period between wakefulness and sleep. While it may seem unusual. In Stage 1. they might report that they weren't really asleep. Another very common event during this period is known as a myoclonic jerk. The brain produces what are known as beta waves. If you awaken someone during this stage. If you've ever startled suddenly for seemingly no reason at all. Stage 3 Deep. and is a relatively light stage of sleep. slower waves known as alpha waves are produced. rhythmic brain wave activity known as sleep spindles. Body temperature starts to decrease and heart rate begins to slow. then you have experienced this odd phenomenon. 9 .STAGES OF SLEEP The Beginnings of Sleep During the earliest phases of sleep.

however. Once REM sleep is over. we enter the REM stage approximately 90 minutes after falling asleep. the body usually returns to stage 2 sleep. but voluntary muscles become paralyzed. muscles become more relaxed. Dreaming occurs due because of increased brain activity. while other areas are similar to NREM heart rate slows from wakefulness increases and varies compared with NREM 10 . Stage 5 Most dreaming occurs during the fifth stage of sleep. REM sleep is characterized by eye movement. The first cycle of REM sleep might last only a short amount of time.Stage 4 Stage 4 is sometimes referred to as delta sleepbecause of the slow brain waves known as delta waves that occur during this time. stage 3 and then stage 2 sleep are repeated before entering REM sleep. that sleep does not progress through these stages in sequence. After stage 4 sleep. The Sequence of Sleep Stages It is important to realize. known as rapid eye movement (REM) sleep. Stage 4 is a deep sleep that lasts for approximately 30 minutes. 3 and 4. REM sleep can last up to an hour as sleep progresses. Bed-wetting and sleepwalking are most likely to occur at the end of stage 4 sleep. On average. REM sleep is also referred to as paradoxical sleep because while the brain and other body systems become more active. but each cycle becomes longer. Sleep begins in stage 1 and progresses into stages 2. increased respiration rate and increased brain activity. Comparison of Physiological Changes During NREM and REM Sleep Physiological Process brain activity During NREM decreases wakefulness During REM from increases in motor and sensory areas. Sleep cycles through these stages approximately four or five times throughout the night.

shivering initiated at lower temperature than during wakefulness SLEEP CYCLES Sleep proceeds in cycles of REM and NREM.Comparison of Physiological Changes During NREM and REM Sleep Physiological Process blood pressure During NREM decreases wakefulness During REM from increases (up to 30 percent) and varies from NREM blood flow to brain does not change from increases by 50 to wakefulness in most 200 percent from regions NREM. also known as 11 . no shivering or sweating. the order normally being N1 → N2 → N3 → N2 → REM. temperature drifts toward that of the local environment respiration airway resistance body temperature increases wakefulness is regulated at lower set point than wakefulness. coughing suppressed from increases and varies from wakefulness is not regulated. depending on brain region decreases wakefulness from increases and varies from NREM. There is relatively little dreaming in NREM. but may show brief stoppages (apnea). There is a greater amount of deep sleep (stage N3) earlier in the sleep cycle. NREM consists of three stages. Stage N1 refers to the transition of the brain from alpha waves having a frequency of 8–13 Hz(common in the awake state) to theta waves having a frequency of 4–7 Hz. Sudden twitches and hypnic jerks. This stage is sometimes referred to as somnolence or drowsy sleep. NREM sleep (Non-rapid eye movement sleep) According to the 2007 AASM standards. while the proportion of REM sleep increases later in the sleep cycle and just before natural awakening.

as well as the new 2007 AASM guidelines have a range of 0. muscular activity as measured by EMG decreases. or REM sleep. The criteria for REM sleep include rapid eye movements as well as a rapid low-voltage EEG. Such paralysis may be necessary to protect organisms from self-damage through physically acting out scenes from the often-vivid dreams that occur during this stage. but sleep standards in both the original R&K.) This is the stage in which parasomnias such as night terrors. the subject loses some muscle tone and most conscious awareness of the external environment. these have been combined as stage N3. Stage N3 (deep or slow-wave sleep) is characterized by the presence of a minimum of 20% delta waves ranging from 0. Stage N2 is characterized by sleep spindles ranging from 11 to 16 Hz (most commonly 12–14 Hz) and K-complexes. can jerk awake easily. (EEG standards define delta waves to be from 0 to 4 Hz. Some people may also experience hypnagogic hallucinations during this stage.sleepwalking. and have no rapid eye movement. aren't dreaming. Most memorable dreaming occurs in this stage. Many illustrations and descriptions still show a stage N3 with 20–50% delta waves and a stage N4 with greater than 50% delta waves. To put it in simpler form. nocturnal enuresis. and somniloquy occur.5–2 Hz. During this stage.positive myoclonus. Timing 12 . accounts for 20–25% of total sleep time in most human adults. At least in mammals. a descending muscular atonia is seen. REM sleep (Rapid eye movement sleep) Rapid eye movement sleep. may be associated with the onset of sleep during N1. During N1. This stage occupies 45–55% of total sleep in adults. are slightly aware of your surroundings. and conscious awareness of the external environment disappears. you are in a very shallow sleep.5–2 Hz and having a peakto-peak amplitude >75 μV.

temperature-fluctuating. Sleep offset (awakening) is primarily determined by circadian rhythm. sleepiness occurs as the circadian element causes the release of the hormone melatonin and a gradual decrease in core body temperature. Homeostatic sleep propensity (the need for sleep as a function of the amount of time elapsed since the last adequate sleep episode) must be balanced against the circadian element for satisfactory sleep. enzyme-controlling device—works in tandem with adenosine. within certain bounds. 13 . It is the circadian rhythm that determines the ideal timing of a correctly structured and restorative sleep episode.The human biological clock Sleep timing is controlled by the circadian clock. The circadian clock—an inner timekeeping. this tells the body it needs to sleep. The timing is affected by one'schronotype. a neurotransmitter that inhibits many of the bodily processes associated with wakefulness. Along with corresponding messages from the circadian clock. Adenosine is created over the course of the day. A person who regularly awakens at an early hour will generally not be able to sleep much later than his or her normal waking time. In diurnal animals. and in humans. sleepwake homeostasis. willed behavior. high levels of adenosine lead to sleepiness. even if moderately sleep-deprived.

30 am. here with greater than 50% delta waves. Some people have a mutation of this gene. 14 . There is more REM (marked red) before waking. with deep sleep early on. Neurology professor Ying-Hui Fu and her colleagues bred mice that carried the DEC2 mutation and slept less than normal mice. Thirty seconds of deep sleep. EEG highlighted by red box.Sleep duration is affected by the gene DEC2. Hypnogram showing sleep cycles from midnight to 6. Stage N3 sleep. they sleep two hours less than normal.

"[37]) It is likely that sleep evolved to fulfill some primeval function and took on multiple functions over time (analogous to the larynx. it is possible they still sleep one cerebral hemisphere at a time as marine mammals do.REM sleep. (When asked. 15 . but descended over time to develop speech cabilities). [38] While some varieties of shark. eye movements highlighted by red line. answered. really solid is because we get sleepy. EEG highlighted by red box. Thirty seconds of sleep. However it remains to be shown definitively whether any fish is capable of unihemispheric sleep. If sleep were not essential. what he knew about the reason people sleep William Dement. one would expect to find: • • • Animal species that do not sleep at all Animals that do not need recovery sleep when they stay awake longer than usual Animals that suffer no serious consequences as a result of lack of sleep Outside of a few basal animals that have no brain or a very simple one. after 50 years of research. must remain in motion at all times to move oxygenated water over their gills. "As far as I know. such as great whites and hammerheads. no animals have been found to date that satisfy any of these criteria. FUNCTIONS OF SLEEP The multiple theories proposed to explain the function of sleep reflect the as-yet incomplete understanding of the subject. founder of Stanford University's Sleep Research Center. the only reason we need to sleep that is really. which controls the passage of food and air.

A study conducted by Gumustekin et al.FUNCTIONS OF SLEEP Restoration Wound healing has been shown to be affected by sleep. whereas elephants and giraffes with lower BMRs sleep only 3–4 hours per day. 16 . the activity occurring during neonatal REM sleep (or active sleep) seems to be particularly important to the developing organism (Marks et al. inversely related to animal size and directly related to basal metabolic rate. therefore.[44] Ontogenesis According to the ontogenetic hypothesis of REM sleep. and an abnormal amount of neuronal cell death (Morrissey. 1995). the more immature the baby is born. in 2004 shows sleep deprivation hindering the healing of burns on rats. 1983). Energy conservation could as well have been accomplished by resting quiescent without shutting off the organism from the environment. Rats with a very high basal metabolic rate sleep for up to 14 hours a day. Studies investigating the effects of deprivation of active sleep have shown that deprivation early in life can result in behavioral problems. potentially a dangerous situation. The duration of sleep among species is. the more time it spends in REM sleep. but need sleep for something else. yet without any motor consequences that may get the infant in trouble. REM sleep occupies the majority of time of sleep of infants. hibernating animals waking up from hibernation go into rebound sleep because of lack of sleep during the hibernation period. There are multiple arguments supporting the restorative function of sleep. 2004). who spend most of their time sleeping. A sedentary nonsleeping animal is more likely to survive predators. than simply conserving energy. Proponents also suggest that REM-induced muscle inhibition in the presence of brain activation exists to allow for brain development by activating the synapses. hyperphagia. fatal sepsis. They are definitely well-rested and are conserving energy during hibernation. and. decreased brain mass (Mirmiran et al. Duntley & Anch. Sleep. REM deprivation results in developmental abnormalities later in life. or other purposes. seems to serve another purpose. REM sleep appears to be important for development of the brain. Among different species. in general. permanent sleep disruption. for example. anabolic hormones such as growth hormones (as mentioned above) are secreted preferentially during sleep. The metabolic phase during sleep is anabolic.[5] Rats kept awake indefinitely develop skin lesions.. loss of body mass. eventually.. hypothermia. while still preserving energy. Additionally.

From this perspective of adaptation. REM sleep in those animals increases as they age. with the order of nights balanced across participants. Another argument against the theory is that sleep is not simply a passive consequence of removing the animal from the environment. Memory seems to be affected differently by certain stages of sleep such as REM and slow-wave sleep (SWS). and Gais. and Brown. REM became the most active sleep stage at about 24%. Working memory is important because it keeps information active for further processing and supports higher-level cognitive functions such as decision making. cited in Born. (Allison & Cicchetti. 1976. the brain consumes a large proportion of the body's calories at any one time and preservation of energy could only occur by limiting its sensory inputs. Memory processing Scientists have shown numerous ways in which sleep is related to memory. [46] working memory was shown to be affected by sleep deprivation. stronger organisms. However. both on early and late nights.However. In a study conducted by Turner. When the subjects' brains were scanned during sleep. animals alter their behaviors 17 . 1982). and the late-night test group performed 25% better on the procedural memory test than the control group. organisms are safer by staying out of harm's way. They sleep at times that maximize their safety. where potentially they could be prey to other. but is a "drive". and hence roaming around. whereas declarative memory benefits from early. representing around 23% on average for sleep stage activity. Salamat. given their physical capacities and their habitats. hypnograms revealed that SWS was the dominant sleep stage during the early night. REM-rich sleep. and episodic memory. During late-night sleep. In one study. multiple groups of human subjects were used: wake control groups and sleep test groups. Webb. reasoning. Preservation The "Preservation and Protection" theory holds that sleep serves an adaptive function. Drummond. SWS-rich sleep. This indicates that procedural memory benefits from late. would place the individual at greatest risk. Rasch. Aquatic mammal infants do not have REM sleep in infancy. This theory fails to explain why the brain disengages from the external environment during normal sleep. Sleep and wake groups were taught a task and were then tested on it. Organisms do not require 24 hours to feed themselves and meet other necessities. this does not explain why older adults still need REM sleep. It protects the animal during that portion of the 24-hour day in which being awake. The early-night test group performed 16% better on the declarative memory test than the control group.

Freud's work is not ruled out.in order to obtain sleep. Neatly. Sigmund Freud postulated that dreams are the symbolic expression of frustrated desires that had been relegated to the unconscious mind. but the more peculiar specializations of sleep probably serve different and unknown functions. for example. Therefore. the preservation theory needs to explain why carnivores like lions. especially with regard to the organization and consolidation of recent memory. but obviously must occur for a reason. Dreaming Dreaming is the perceived experience of sensory images and sounds during sleep. Recent research claims that sleep has the overall role of consolidation and organization of synaptic connections formed during learning and experience. which does not exclude any physiological role they may have. the forebrain then creates a story in an attempt to reconcile and make sense of the nonsensical sensory information presented to it. In their activation synthesis theory. according to this theory. Certain processes in the cerebral cortex have been studied by John Allan Hobson and Robert McCarley. Ergo. Moreover. this theory helps explain the irrationality of the mind during REM periods. Nevertheless. Dreaming is stimulated by the pons and mostly occurs during the REM phase of sleep. etc. the odd nature of many dreams. not less. As such. and he used dream interpretation in the form of psychoanalysis to uncover these desires. vulnerable to predation. they propose that dreams are caused by the random firing of neurons in the cerebral cortex during the REM period. which are on top of the food chain and thus have little to fear. See Freud: The Interpretation of Dreams. sleep the most. in a sequence which the dreamer usually perceives more as an apparent participant than as an observer. because the animal would still be able to respond to environmental challenges like predators. Sleep rebound that occurs after a sleepless night will be maladaptive. Freud's work concerns the psychological role of dreams. circadian regulation is more than sufficient to explain periods of activity and quiescence that are adaptive to an organism. 18 . A zebra falling asleep the day after it spent the sleeping time running from a lion is more. Freud's research has been expanded on. as. Preservation also does not explain why aquatic mammals sleep while moving. People have proposed many hypotheses about the functions of dreaming. It has been suggested that they need to minimize energy expenditure when not hunting. Quiescence during these vulnerable hours would do the same and would be more advantageous.

Barbiturates cause drowsiness and have actions similar to alcohol in that they have a rebound effect and inhibit REM sleep. the body clock "kicks in. where tryptophan is converted into serotonin and then into melatonin. Antihistamines. Alcohol also reduces REM sleep. since it is a precursor of the neurotransmitter serotonin. and as such. 19 • • • • • • • . However. such as diphenhydramine (Benadryl) and doxylamine (found in various OTC medicines. and 2:00 p.m. Tryptophan – The amino acid tryptophan is a building block of proteins. Melatonin supplementation may be used as a sleep aid. (14:00). it overrides the homeostatic buildup of sleep debt. People naturally feel most sleepy (have the greatest "drive for sleep") at two times of the day about 12 hours apart—for example. it "kicks in" again to ensure a few more hours of sleep. there is strong evidence linking alcoholism and forms of insomnia. PRC). the post-lunch dip is mostly an effect of the biological clock.m. encouraging sleep). Nonbenzodiazepines are the most commonly prescribed and OTC sleep aids used worldwide and have been greatly growing in use since the 1990s. at 2:00 a. being addicted to alcohol can lead to disrupted sleep. so they are not used as a long-term sleep aid. Siesta and the "post-lunch dip" – Many people have a temporary drop in alertness in the early afternoon.Hypnotics • Nonbenzodiazepine hypnotics such as eszopiclone (Lunesta). allowing several more hours of wakefulness. both as a hypnotic and as a chronobiotic (see phase response curve." At about 2 p. such as NyQuil) Alcohol – Often. with the daily sleep debt paid off.m. and zolpidem (Ambien) are commonly used as sleep aids prescribed by doctors to treat forms of insomnia. At about 2 a. As a result." While a large meal can make a person feel sleepy.m. commonly known as the "post-lunch dip. Benzodiazepines target the GABAA receptor also. It is made in the brain. Melatonin is a naturally occurring hormone that regulates sleepiness. They target the GABAA receptor. zaleplon (Sonata). because alcohol has a rebound effect later in the night. (02:00). involved in sleep regulation. they are commonly used sleep aids as well. people start drinking alcohol in order to get to sleep (alcohol is initially a sedative and will cause somnolence. It has been claimed to contribute to sleepiness. though benzodiazepines have been found to decrease REM sleep. which is released at night by the pineal gland to induce and maintain sleep. At those two times.

Cocaine and crack cocaine – Studies on cocaine have shown its effects to be mediated through the circadian rhythm system. etc. shift work sleep disorder. or bk-MDMA – The class of drugs called empathogen-entactogens keep users awake with intense euphoria. Tobacco – Tobacco has been found not only to disrupt but also to reduce total sleep time. Their most common effects are anxiety. stimulation. thereby promoting wakefulness. no solid data have ever linked modest dietary changes in tryptophan to changes in sleep. insomnia. but they have been shown to increase both the release of monoamines and levels of hypothalamic histamine. Effective dosage is individual.) are used to treat narcolepsy. its chemical composition more closely resembles that of cocaine. Stimulants • Amphetamine (dextroamphetamine. including similar drugs like MDA.However. slightly more powerful drug methamphetamine. particularly by acting as an antagonist at adenosine receptors. Caffeine is a stimulant that works by slowing the action of the hormones in the brain that cause somnolence. hypersomnia. Commonly known as "ecstasy." Methylphenidate – Commonly known by the brand names Ritalin and Concerta. In studies. • Marijuana – Some people use marijuana to induce sleepiness. Users often report relaxation and drowsiness. This may be related to the onset of hypersomnia (oversleeping) in regard to "Cocaine-Induced Sleep Disorder. The precise mechanism of these CNS stimulants is not known. and a related. MMDA. It can cause a rapid reduction in alertness as it wears off." MDMA. methylphenidate is similar in action to amphetamine and cocaine. • • • • • • 20 . and other conditions causing Excessive Daytime Sleepiness. increased alertness. in part dependent on prior usage. Other analeptic drugs like Modafinil and Armodafinil are prescribed to treat narcolepsy. users have described more daytime drowsiness than nonsmokers. and decreased hunger.

Newborns Newborn sleep 16 to 18 hours a day. eat. Infants Some infants sleep 22 hours a day.10 7. usually divided in to about seven sleep periods. others 12 to 14 hours a day. Average Sleep Needs Age Newborns (0-2 months) Infants (3 months to 1 year) Toddlers (1 to 3 years) Preschoolers (3 to 5 years) School-aged children (5 to 12 years) Teens and preteens (12 to 18 years) Adults (18+) Hours 12 .5 .15 12 . About 20% to 30 % of sleep is REM sleep. Period of awakens gradually increase during the first months. By 4 months most infants sleep through the night and establish a pattern of daytime naps that 21 .NORMAL SLEEP PATTERNS AND REQUIREMENTS It has been suggested that maintaining a regular sleep wake rhythm is more important than the number of hours actually slept. At first infants awaken every 3 to 4 hours. Nearly 50% of sleep is REM. and irregular respirations. closed eyes.9 1. and then go back to sleep. REM sleep has rapid eye movements that are observable through closed lids. body movements.11 8. and the absence of body and eye movements.5 .13 10 . NREM sleep is characterized by regular respiration.14 11 . 2.18 14 .

Latency to fall asleep and the number and duration of overnight arousal periods increase. Not only is the quantity of sleep important but also the quality of sleep. Sleep fragmentation results from the increase in overnight arousals and may be exacerbated by the increasing number of geriatric medical conditions. At the end of the first year an infant usually takes one or two naps per day and sleeps about 14 of every 24 hours. 3. and cardiopulmonary disease. Myth 4: You can make up for lost sleep during the week by sleeping more on the weekends. 3. 22 . You may not be noticeably sleepy during the day. Furthermore.varies among individuals. Adults Stage N1 is considered a transition between wake and sleep. Stage N3 (delta or slow wave sleep) occurs mostly in the first third of the night and constitutes 515% of total sleep time. It occurs upon falling asleep and during brief arousal periods within sleep and usually accounts for 2-5% of total sleep time. but only by appropriately timed cues—and even then. Myth 2: Your body adjusts quickly to different sleep schedules. it will not completely make up for the lack of sleep. and the time in stage N2 compensatorily increases. musculoskeletal disorders. the time spent in stage N3 sleep decreases. and compromise your cardiovascular health. But even slightly less sleep can affect your ability to think properly and respond quickly. MYTHS AND FACTS ABOUT SLEEP Myth 1: Getting just 1 hour less sleep per night won’t affect your daytime functioning. REM represents 20-25% of total sleep time and occurs in 4-5 episodes throughout the night. Consequently. Some people sleep 8 or 9 hours a night but don’t feel well rested when they wake up because the quality of their sleep is poor. Stage N2 occurs throughout the sleep period and represents 45-55% of total sleep time. and ability to fight infections. Myth 3: Extra sleep at night can cure you of problems with excessive daytime fatigue. by 1–2 hours per day at best. Although this sleeping pattern will help relieve part of a sleep debt. including sleep apnea. Elderly In elderly persons. energy balance. Most people can reset their biological clock. This often causes total time in bed to increase which can lead to complaints of insomnia. it can take more than a week to adjust after traveling across several time zones or switching to the night shift.

restless leg syndrome(RLS). and the circadian rhythm sleep disorders) are treatable.Sleep disorders (including the sleep apneas. Older people are more easily awakened by disturbances in the environment and may to some degree lose the ability to consolidate sleep. For example. narcolepsy. or stress. SYMPTOMS. illness." which then can temporarily make it difficult to fall asleep afterwards. before dying of the disease. is characterized by increasing insomnia as one of its symptoms. TREATMENT. Following sleep hygienic principles may solve problems of physical or emotional discomfort. drugs. or FFI. SLEEP PATERN DISTURBANCES Sleep Disorders and Sleeping Problems There are many reasons for poor sleep. a genetic disease with no known treatment or cure. excessive exposure to bright light within hours of bedtime or simply resisting the urge to fall asleep can trigger a "second wind. periodic limb movement disorder (PLMD). the cause must be treated. primary insomnia. ultimately sufferers of the disease stop sleeping entirely. AND HELP FOR COMMON SLEEP DISORDERS 23 . Fatal familial insomnia. When the culprit is pain.sleeping later on the weekends can affect your sleep-wake cycle so that it is much harder to go to sleep at the right time on Sunday nights and get up early on Monday mornings.

you can identify the underlying causes of your sleeping problem and find ways to improve your sleep and quality of life. efficiency. Poor quality sleep can have a negative impact on your energy. and health. energy. Understanding sleep disorders and sleeping problems Sleep can often be a barometer of your overall health. stay healthy. to have problems getting to sleep at night. However. you can turn to sleep specialists who are trained in sleep medicine. you can learn to sleep better. and perform up to your potential. and then making healthy changes to your daytime habits and bedtime routine. learn about the signs and symptoms of common sleep disorders. Unfortunately. when sleep problems are a regular occurrence—when they get in the way of your daily routine and hamper your ability to function—you may be suffering from a sleep disorder. and when to see a doctor. Signs and symptoms of sleep disorders and sleeping problems 24 . most of us have experienced what it’s like to have trouble falling asleep. and ability to handle stress. even minimal sleep loss can take a toll on your mood. Sleeping well is essential to your physical health and emotional well-being. be it minor or serious. or feel sleepy and fatigued during the day. It’s not normal to feel sleepy during the day. impaired job performance. accidents. If you want to feel your best. If self-help doesn’t do the trick. You can start by tracking your symptoms and sleep patterns. whereas repeated sleeping problems may indicate an underlying medical or mental health problem. If you’re experiencing sleeping problems. sleep is a necessity. productivity. or to wake up feeling unrefreshed. Together. In many cases. what you can do to help yourself. But even if you’ve struggled with sleep problems for so long that it does seem normal. and relationship stress. Ignoring sleep problems and disorders can lead to poor health. not a luxury. to lie awake in the middle of the night.At some time. people in good health tend to sleep well. Sleep disorders and other sleeping problems cause more than just sleepiness. emotional balance.

So how do you tell whether your sleeping problem is just a minor.Everyone experiences occasional sleeping problems. passing annoyance or a sign of a more serious sleep disorder or underlying medical condition? Start by scrutinizing your symptoms. 25 . you may have a sleep disorder.  feel irritable or sleepy during the day?  have difficulty staying awake when sitting still. looking especially for the telltale daytime signs of sleep deprivation. Is it a sleep disorder? Do you . If you are experiencing any of the following symptoms on a regular basis. . watching television or reading?  fall asleep or feel very tired while driving?  have difficulty concentrating?  often get told by others that you look tired?  react slowly?  have trouble controlling your emotions?  feel like you have to take a nap almost every day?  require caffeinated beverages to keep yourself going? If you answered “yes” to any of the previous questions. you may be dealing with a sleep disorder. .

It can also be caused by lifestyle choices. or an underlying health condition. or even the amount of coffee you drink. the inability to get the amount of sleep you need to wake up feeling rested and refreshed.  Sleepiness and low energy during the day. is the most common sleep complaint.Insomnia: The most common type of sleep disorder Insomnia. depression. Common signs and symptoms of insomnia include:  Difficulty falling asleep at night or getting back to sleep after waking during the night. fragmented. nightcap. or unrefreshing.  Waking up frequently during the night. lack of exercise. being mindful of your sleep habits and learning to relax will help you sleep better and feel better. The good 26 . Insomnia is often a symptom of another problem. anxiety. such as stress. Whatever the cause of your insomnia. jet lag.  You need to take something (sleeping pills.  Your sleep feels light. supplements) in order to get to sleep. including the medications you take.

leading to many awakenings each hour. The urge to move occurs when you’re resting or lying down and is usually due to uncomfortable. chronic snoring  Frequent pauses in breathing during sleep  Gasping. Sleep disorder 1: Sleep apnea Sleep apnea is a common sleep disorder in which your breathing temporarily stops during sleep due to blockage of the upper airways. a mask-like device that delivers a stream of air while you sleep. or creeping sensations. elevating the head of the bed. chest pains. tingly. and potentially life-threatening. aching. and sleeping on your side can also help in cases of mild to moderate sleep apnea. or a dry throat. While most people with sleep apnea don’t remember these awakenings. Sleep apnea is a serious. 27 . accompanied by a strong urge to move them. restless legs syndrome (RLS). nasal congestion. they feel the effects in other ways. Symptoms of sleep apnea include:  Loud. such as exhaustion during the day. no matter how much time you spent in bed  Waking up with shortness of breath. These pauses in breathing interrupt your sleep. headaches. Sleep disorder 2: Restless legs syndrome (RLS) Restless legs syndrome (RLS) is a sleep disorder that causes an almost irresistible urge to move your legs (or arms).  The leg sensations are triggered by rest and get worse at night. see a doctor right away.news is that most cases of insomnia can be cured with lifestyle changes you can make on your own—without relying on sleep specialists or turning to prescription or over-the-counter sleeping pills. and narcolepsy. If you suspect that you or a loved one may have sleep apnea. irritability and depression. Losing weight. the most common sleep disorders are sleep apnea. Common signs and symptoms of restless legs syndrome include:  Uncomfortable sensations deep within the legs. or choking during sleep  Feeling unrefreshed after waking and sleepy during the day. sleep disorder. snorting. Other common types of sleep disorders In addition to insomnia. and decreased productivity. Sleep apnea can be successfully treated with Continuous Positive Airway Pressure (CPAP).

Circadian rhythm sleep disorders We all have an internal biological clock that regulates our 24-hour sleep-wake cycle. The symptoms typically appear within a day or two after flying across two or more time zones. Jet lag sleeping problems Jet lag is a temporary disruption in circadian rhythms that occurs when you travel across time zones. It is caused by a dysfunction of the brain mechanism that controls sleeping and waking. or the winter blues. bipolar disorder. The direction of flight also makes a difference. the brain tells the body that it’s time to wake up. fatigue. and shift work sleep difficulties. Light is the primary cue that influences circadian rhythms.  Dreaming right away after going to sleep or having intense dreams  Feeling paralyzed and unable to move when you’re waking up or dozing off. Circadian rhythms have been linked to a variety or sleeping problems and sleep disorders. and seasonal affective disorder. The uncomfortable sensations temporarily get better when you move. stretch. headache. Common signs and symptoms of narcolepsy include:  Seeing or hearing things when you’re drowsy or starting to dream before you’re fully asleep. disoriented. or experiencing other strong emotions. or massage your legs. angry. a hormone that makes you sleepy. When circadian rhythms are disrupted or thrown off. stomach problems.  Suddenly feeling weak or losing control of your muscles when you’re laughing. When the sun comes up in the morning. and insomnia. when there is less light. or even driving. The longer the flight. your brain triggers the release of melatonin. jet lag. you may have “sleep attacks” while in the middle of talking. and sleepy at inconvenient times. At night. working. 28 . also known as ourcircadian rhythms. Abnormal circadian rhythms have also been implicated in depression. Flying east tends to cause worse jet lag than flying west. uncontrollable daytime sleepiness. the more pronounced the symptoms. Symptoms include daytime sleepiness. you may feel groggy. including insomnia. If you have narcolepsy. Sleep disorder 3: Narcolepsy Narcolepsy is a sleep disorder that involves excessive.  Repetitive cramping or jerking of the legs during sleep.

So if you flew from Los Angeles to New York. However.In general. jet lag can be worse if you: 29 . crossing three time zones. it usually takes one day per time zone crossed to adjust to the local time. your jet lag should be gone within three days.

 Naturally regulate your sleep-wake cycle by increasing light exposure at work (use bright lights) and limiting light exposure when it’s time to sleep. 30 . request a shift that’s later. Avoid TV and computer screens. While some people adjust better than others to the demands of shift work. get the kids to school on time. and sleep when your body is signaling you to wake. These schedules force you to work when your body is telling you to go to sleep. This cuts into their productivity and puts them at risk of injury. many shift workers struggle with sleepiness and mental lethargy on the job. In our 24-hour society. As a result of sleep deprivation. rather than earlier as it’s easier to adjust forward in time. or rotating shifts. It’s important to note that this sleeping problem is more than just a preference for staying up late or being a night owl. For example. Delayed sleep phase disorder makes it difficult for you to keep normal hours—to make it to morning classes. most shift workers get less quality sleep than their daytime counterparts. early morning shifts. you go to sleep and wake up much later than other people. or at least you would if your daytime responsibilities didn’t interfere..m. you may not get sleepy until 4 a.Shift work sleeping problems Shift work sleep disorder is a  circadian rhythm sleep disorder that occurs when your work schedule and your biological clock are out of sync. at which time you go to bed and sleep soundly until noon. There are a numbers of things you can do to reduce the impact of shift work on sleep:  Take regular breaks and minimize the frequency of shift changes. As a result. or keep a 9-to-5 job. rather than backward.  Consider taking melatonin when it’s time for you to sleep. Delayed sleep phase disorder Delayed sleep phase disorder is a sleep disorder in which your 24-hour cycle of sleep and wakefulness—your biological clock—is significantly delayed. use black-out shades or heavy curtains to block out daylight in your bedroom. many workers have to work night shifts.  When changing shifts.

Keep a sleep diary A sleep diary is a very useful tool for identifying sleep disorders and sleeping problems and pinpointing both day and nighttime habits that may be contributing to your difficulties. had a glass of milk. and times of consumption  your feelings and moods before bed (e.g. stress.  For those who continue to struggle with a biological clock that is out of sync. treatments such as light therapy and chronotherapy can help. including dose and time of consumption The details can be important. you might notice that when you have more than one glass of wine in the evening.”)  types and amount of food. caffeine. Your sleep diary should include:  what time you went to bed and woke up  total sleep hours and perceived quality of your sleep  a record of time you spent awake and what you did (“stayed in bed with eyes closed. you wake up during the night. for example. Keeping a record of your sleep patterns and problems will also prove helpful if you eventually find it necessary to see a sleep doctor. anxiety)  any drugs or medications taken. or “got up. liquids. no matter how hard they try.m. they fall into a regular sleep schedule. and meditated.  When allowed to keep their own hours (such as during a school break or holiday). Self-help for sleeping problems and sleep disorders The first step to overcoming a sleep problem is identifying and carefully tracking your symptoms and sleep patterns. schedule an appointment with a sleep doctor or local sleep clinic. 31 . and many teens will eventually grow out of it. To learn more. sadness.  Delayed sleep phase disorder is most common in teenagers. revealing how certain behaviors can be ruining your chance for a good night’s sleep. happiness. After keeping the diary for a week. They struggle to go to sleep and get up at socially acceptable times.” for example. People with delayed sleep phase disorder are unable to get to sleep earlier than 2 to 6 a. or alcohol you consumed before bed.

your sleep is much more refreshing. and interfere with your body’s internal clock. The key is to experiment. RESEARCH STUDIES RELATED TO SLEEP A 2010 review of published scientific research suggested that exercise generally improves sleep for most people. and computer a few hours before your bedtime. suppress the production of melatonin. Turn off your TV. These range from returning to sleep on the floor since beds are a relatively recent invention in human history. including the weekends. The optimum time to exercise may be 4 to 8 hours before bedtime. However there is insufficient evidence to draw detailed conclusions about the relationship between exercise and sleep. For example. iPad. which may disturb sleep. Use your sleep diary as a jumping off point. use heavy curtains or shades to block light from windows. The type of light these screens emit can stimulate your brain. Try the following simple changes to your daytime and pre-bedtime routine:        Keep a regular sleep schedule. cool. Make sure your bedroom is dark.Improve your sleep hygiene and daytime habits Learn to recognize & reduce hidden stress Regardless of your sleep problems. smartphone. going to sleep and getting up at the same time each day. White noise appears to be a promising treatment for insomnia  Anthropology of sleep  32 . and quiet. or try an eye mask to shield your eyes. though exercise at any time of day is beneficial. You can address many common sleep problems through lifestyle changes and improved sleep hygiene. Pharmacological treatments Other treatments There are various techniques and products which aim to improve sleep. a consistent sleep routine and improved sleep habits will translate into better sleep over the long term. with the possible exception of heavy exercise taken shortly before bedtime. you may find that when you start exercising regularly and managing your stress more effectively. and helps sleep disorders such as insomnia. Set aside enough time for sleep. to various mattress designs. Cover electrical displays. Most people need at least 7 to 8 hours each night in order to feel good and be productive.

 Research suggests that sleep patterns vary significantly across cultures. Some sleep with blankets. such as a spouse. peers of a certain gender. sleeping partners are strongly regulated by social standards. people will sleep on and off throughout the day or night depending on what is happening. 33 . The most striking differences are between societies that have plentiful sources of artificial light and ones that do not. some with pillows. people might only sleep with their immediate family. people might go to sleep far sooner after the sun sets. children of specific gender. and sleep patterns have changed significantly everywhere that lighting has been introduced. punctuating their sleep with periods of wakefulness. In other cultures. For example. some with simple headrests. perhaps lasting several hours. or with no one at all. Plentiful artificial lighthas been available in the industrialized West since at least the mid-19th century. Sleep may be an actively social time. people sleep in a more concentrated burst through the night. extended family. Some sleep directly on the ground. Some observers believe that nighttime sleep in these societies is most often split into two main periods. For example. the first characterized primarily by deep sleep and the second by REM sleep.  People sleep in a variety of locations. but then wake up several times throughout the night. people rarely sleep with anyone but a most intimate relation.  Some societies display a fragmented sleep pattern in which people sleep at all times of the day and night for shorter periods.The primary difference appears to be that pre-light cultures have more broken-up sleep patterns. In many nomadicor hunter-gatherer societies. The boundaries between sleeping and waking are blurred in these societies. children of a certain age. others on a skin or blanket. others sleep on platforms or beds. although this is not always true. In general. spouses. depending on the sleep groupings. with no constraints on noise or activity. their children. friends. going to sleep much later.  In some societies. In almost all societies. people generally sleep with at least one other person (sometimes many) or with animals. peers of equal social rank.

Here the emphasis is on ensuring the patient can manage the device at home. Any unusual patterns of waking or snoring should be explored with the patient to establish if there might be an underlying problem. These choices are shaped by a variety of factors. though clues may be discernible during the day. A nurse's understanding of the condition. Sleep patterns should be explored on admission and during any subsequent discussion on lifestyle (Kron. 1987). 2000). However. and inactivity of nearly all voluntary muscles. Hospital nurses have a unique opportunity to observe patients sleeping. nurses in the community may become involved if they detect problems during domicilary visits or surgery appointments. For example. where patients may mention unusual sleepiness in themselves or their partners. with people with the condition approaching their GP for advice and treatment. NURSING IMPLICATIONS Sleep apnoea is largely dealt with in primary care. technology. housing type. such as climate.some with no head support. Questions about sleep patterns can also be asked at check-up appointments or during lifestyle discussions. particularly around the nose and ears or conjunctivital oedema. and the incidence of pests. It is distinguished from quiet wakefulness by a 34 . Excessive daytime sleepiness with associated relationship problems or reduced motivation will almost certainly affect the way people act and approach other factors in their lives and nurses need to be sensitive to this. relatively suspended sensory activity. they may be reluctant to bring CPAP equipment to hospital. CONCLUSION Sleep is a naturally recurring state characterized by reduced or absent consciousness. protection from predators. Dehydration or nausea can also cause problems (Mallett and Dougherty. thinking it might disturb other patients or that there will not be room for it by the bed. its diagnosis and treatment may help patients to manage it while in hospital. particularly at night. The nurse role in the use of the CPAP device will differ from that in its use in acute respiratory settings. This would include an explanation and demonstration of how the device works and how to prevent potential problems such as chafing from the mask or nasal cannula.

we recognize changes that have occurred. and fish. a time frame similar to death due to starvation 35 . Nonetheless. Rats deprived of sleep will die within two to three weeks. accentuating the growth and rejuvenation of the immune. It is observed in all mammals. amphibians. sleep is important for normal motor and cognitive function. people generally know little about the importance of this essential activity.decreased ability to react to stimuli. not an option. We all recognize and feel the need to sleep. all birds. Sleep is also a heightened anabolic state. Sleep is not just something to fill time when a person is inactive. and many reptiles. After sleeping. Even though the precise functions of sleep remain a mystery. skeletal and muscular systems. Sleep is a behavioral state that is a natural part of every individual’s life. as we feel rested and more alert. nervous. and is more easily reversible than being in hibernation or a coma. Sleep actually appears to be required for survival. We spend about one-third of our lives asleep. Sleep is a required activity.

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