Unit 6: Sleep Disorder

Sleep

• Sleep is a process required for proper brain function. Sleep is not a single process;
there are several distinct types of sleep. These different types of sleep differ both
qualitatively and quantitatively. Each type of sleep has unique characteristics,
functional importance, and regulatory mechanisms. Selectively depriving one
particular type of sleep produces compensatory rebound.

• Sleep is not a passive process; during sleep, there is a high degree of brain activation
and metabolism.
 Contd…

• Sleep can be regarded as a physiological reversible reduction of conscious

awareness. Sleep is traditionally defined as a behavioral state that encompasses
several essential characteristics used as defining markers, such as immobility or
reduced behavioral responsiveness to external stimuli.

• Nearly 1/3 of human life is spent in sleep, an easily reversible state of relative
unresponsiveness and serenity which occurs more or less regularly and repetitively
each day.
 Phases of sleep

1. D-sleep (desynchronized or dreaming sleep), also called as REM- sleep (rapid eye
movement sleep), active sleep, or paradoxical sleep.

2. S-sleep (synchronized sleep), also called as NREM-sleep (non-REM sleep), quiet

sleep, or orthodox sleep.
S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4.
 Stages of NREM-sleep

Relaxed Wakefulness
This is not a real stage of sleep. It is a state of relaxed wakefulness for comparison. The
alpha waves are at steady series with frequency of 8 to 12 per second.

Stage 1, NREM-sleep is the first and the lightest stage of sleep characterized by an
absence of alpha waves, and low voltage, predominantly theta activity.

During this period, sleep has just begun. The EEG is dominated by irregular, jagged.
Overall brain activity is less than in relaxed wakefulness but higher than other sleep
stages.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterized
by two typical EEG changes. The most prominent characteristics of stage 2 are
sleep spindles and K-complexes.

i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency,

lasting 0.5-2.0 seconds, with a characteristic waxing and waning amplitude. A
sleep spindle consists of 12- to 14-Hz waves during a burst that lasts at least
half a second. Sleep spindles result from oscillating interactions between cells
in the thalamus and the cortex.
ii. K-complexes: High voltage spikes present intermittently. A K-complex is a
sharp high-amplitude wave. Sudden stimuli can evoke K-complexes during
other stages of sleep, but they are most common in stage 2.
 K-complexes: High voltage spikes present intermittently. A K-complex is a sharp
high-amplitude wave. Sudden stimuli can evoke K-complexes during other stages of
sleep, but they are most common in stage 2.

Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0

cycles/sec.

Stage 4, NREM-sleep shows predominant δ-activity in EEG

• In the succeeding stages of sleep, heart rate, breathing rate, and brain
activity decrease, while slow, large-amplitude waves become more
common.
• By stage 4, more than half the record includes large waves of at least a
half-second duration. Stages 3 and 4 together constitute slow wave
sleep (SWS).
• Slow waves indicate that neuronal activity is highly synchronized.
Recommended sleep amounts in children and adolescents
Age Hours

Newborns (0-2 months) 12-18

Infants (3-11 months) 14-15

Toddlers (1-3 years) 12-14

Preschoolers (3-5 years) 11-13

School-age children (6-10 years) 10-11

Teens (10-17 years) 8.5-9.25

Sleep Disorder
• Sleep disorder are conditions that affect the quality, amount and times of sleep.
They can impact a persons overall health, safety, and quality of life.
• Getting plenty of sleep is crucial to the health and development of a young child,
but nearly half of children experience sleep issues at some point in their
childhood. Common sleep disorders in children include sleep apnea and insomnia,
as well as parasomnias, which are disruptive sleep-related behaviors such as
sleepwalking and night terrors.
• Sleep disorders in children, especially parasomnias, are not likely to persist past
adolescence. However, they can be disruptive to a child’s daytime behavior and
overall quality of life.
Sleep problems are relevant to child and adolescent mental health professionals because
there is a complex relationship between sleep disorders and psychiatric disorders:

• Psychiatric disorders can cause sleep problems. For example, difficulties getting to sleep
or staying asleep are common in anxiety and depressive disorders, while nightmares can
be a prominent feature of post-traumatic stress disorder.

• Conversely, sleep disorders may cause, mimic or aggravate psychiatric disorders. For
instance, sleep deprivation in a 6-year-old may result in over-activity, poor concentration,
impulsiveness and irritability, that is, features that are normally part of ADHD and
disruptive behavioural disorders.
• It may be hard to distinguish between sleep disorders and psychiatric disorders, for
example, nocturnal panic attacks can be mistaken for nightmares or night terrors, or
vice versa.

• Psychotropic medication (or its withdrawal) may induce sleep problems, for
example, difficulty getting to sleep when taking methylphenidate, or nightmares
following the abrupt withdrawal of antidepressants.

• A single risk factor may predispose a child to both sleep problems and psychiatric
difficulties. For example, children growing up in chaotic household without routines
or consistently enforced rules are more likely to develop both disruptive behavioural
problems and difficulties getting a regular night’s sleep.
• Notes:
• REM = Rapid Eye Movement: the phase of sleep when most dreaming occurs and
muscle tone is at its lowest. Makes up about 25% of sleep and is commonest
towards the end of the night.
• Non-REM: the deepest non-REM sleep (stages 3 and 4, shown in black) mostly
occurs in the first two cycles. Brief awakenings are normal at all ages, and can
occur from either REM or light non-REM.
• After early infancy, falling asleep is a transition to non-REM sleep. Sleep cycles
last about 50–60 minutes in childhood, increasing to 90–100 minutes in adolescents
and adults.
• Total sleep declines from an average of 12 hours per day in 4-year-olds to an
average of 8 hours per day by late adolescence
Epidemiology of sleep problems
• Very severe sleep disorders are rare, for example, narcolepsy affects fewer than 1
in a thousand children and adolescents, while some degree of obstructive sleep
apnoea affects 2% of children and adolescents.

• Less severe sleep problems are much commoner, for example, about a quarter of
preschool children have significant problems getting to sleep or staying asleep,
while up to 15% of adolescents have an erratic or delayed sleep–wake cycle.

• Sleep problems are particularly common among children and adolescents with
intellectual disability and are also linked to physical disabilities (for example,
cerebral palsy), sensory impairments (for example, blindness), psychiatric
disorders (for example, generalised anxiety), and physical disorders that worsen at
night (for example, asthma) or that cause night-time discomfort (for example,
itching due to eczema.
Specific Sleep Disorders

• Insomnia Insomnia is “a persistent difficulty with sleep initiation, duration,

consolidation, or quality that occurs despite adequate opportunity and
circumstances for sleep, and results in some form of daytime impairment”
(American Academy of Sleep Medicine, 2014).

• DSM-5 integrates pediatric and developmental criteria and replaces primary

insomnia with the diagnosis of insomnia disorder, to avoid the primary/secondary
distinction when this disorder co-occurs with other conditions.
• DSM-5 introduced a duration criterion (more than 3 ‘bad nights’ per week for the
last 3 months).

• Prevalence of pediatric insomnia is estimated at about 1% to 6% in general

pediatric populations, with a much higher prevalence in children with
neurodevelopmental and chronic medical and psychiatric conditions.

• When bedtime resistance and disruptive nighttime awakenings are included, the
prevalence of sleep-disrupted behavior approaches 25% to 50% in preschool
children (Owens & Mindell, 2011).
Parasomnias

• Parasomnias are disruptive physical behaviors that occur during sleep and are
typically classified by the sleep stage (NREM or REM) in which they arise. We
focus here on NREM parasomnias; these include somnambulism, night terrors,
sleep-talking, bruxism, and rhythmic movement disorders (enuresis).

• NREM parasomnias usually occur in the first few hours of the sleep cycle. These
behaviors arise when the cortex incompletely arouses from deep NREM sleep,
often due to comorbid conditions that provoke repeated arousal or promote sleep
inertia (defined as extreme difficulty waking accompanied by confusion or sleep-
drunkenness)
Sleepwalking
Sleepwalking or somnambulism is the combination of ambulation with the
persistence of impaired consciousness after arousal from sleep. Although a large
percentage of children have at least one episode of somnambulism, far fewer
present with recurrent and disruptive episodes.

Children typically have amnesia of the event and the behaviors are often
inappropriate (such as urinating in a wastebasket, moving furniture around
haphazardly or climbing out of a window).

Sleepwalkers are sometimes able to navigate familiar surroundings but are prone to
bumping into objects or to fall down.
Sleep terrors
• Sleep terrors or night terrors are episodes of intense fear initiated by a sudden cry or
loud scream and accompanied by increased autonomic nervous system activity. They
most commonly occur in preadolescent children.

• Parents usually describe the child as being inconsolable during the episode. Several
studies have demonstrated a relationship between anxiety levels and parasomnias in
children, showing that increased anxiety correlates with increased prevalence of
night terrors and awakenings (Kovachy et al, 2013).
Sleep-talking
• Sleep-talking or somniloquy is considered the most common parasomnia, with a
reported prevalence greater than 50% in children between the ages of 3 and 13
(Laberge et al, 2000).

• Somniloquy is often comorbid with sleepwalking and night terrors.

 Differences between sleep terrors and nightmares

Sleep terrors Nightmares

• Children are asleep • Children awaken

• Children have no recall after the episode
• Children are difficult to comfort during
the episode
• Children may sit up, walk around, or
may even talk during the event
• Children can recall details
• Children can be comforted during the
episode and respond to others
communicating with them
• Children have limited movement or
vocalisation until after waking up
 Sleep disordered breathing
Definition
• The spectrum of sleep-disordered breathing includes clinical conditions ranging from
habitual snoring to upper airway resistance syndrome, to obstructive sleep apnea.

• Snoring is one of the cardinal features of sleep-disordered breathing along with

mouth-breathing, restless sleep, episodes of gasping for air during sleep and
breathing pauses in sleep. Snoring may vary in severity from soft, intermittent, to
loud snoring.
 Symptoms
• Snoring
• Mouth breathing
• Restlessness
• Witnessed breathing pauses in sleep
• Diaphoresis in sleep
Frequently associated symptoms:
• Night terrors
• Nocturnal enuresis
• Unusual sleeping position
• Nasal congestion
• Hypertrophy of tonsils and adenoids
• Allergic rhinitis/sinusitis
 Consequences of sleep-disordered breathing
Neurobehavioral:
• Somnolence (state of drowsiness or strong desire to fall aasleep)
• Hyperactivity
• Inattention
• Disruptive behaviors
• Social withdrawal
• Depression, anxiety, low self-esteem
Cardiovascular:
• Systemic hypertension
• Cor pulmonale
• Left ventricular hypertrophy
• Dyslipidaemia
• Insulin resistance
• Neurobehavioral consequences of obstructive sleep apnea
• Neurobehavioral and cognitive dysfunction are well documented in children with
obstructive sleep apnea.

• Behavioral dysregulation is a common feature in children with obstructive sleep

apnea who can present with increased impulsivity, hyperactivity, aggression and
disorders of conduct.

• Memory deficits, inattention, executive dysfunction and poor academic performance

have been also reported (O’Brien, 2009).

• Treatment of obstructive sleep apnea has been shown to be effective in reversing

neurobehavioral deficits and improving academic outcomes.
Treatment
• According to the most recent clinical practice guidelines, adenotonsillectomy is very
effective in treating obstructive sleep apnea in children (Marcus et al, 2012.
• Continuous positive air pressure devices also have sufficient evidence to support their
use in pediatric patients.

• They are recommended in cases that fail to respond to surgical treatment or in whom
adenotonsillectomy is not indicated.
• Other adjunctive strategies include treating nasal allergies, reducing weight, and
avoiding environmental irritants
• Restless legs syndrome and periodic limb movement disorder

• Restless legs syndrome is a sensorimotor disorder characterized by an irresistible

urge to move the legs, often associated with uncomfortable sensations in the legs or,
less frequently other body parts.

• Although the restless legs syndrome has been traditionally considered a disorder of
middle and old age, several studies (summarized in Picchietti & Picchietti, 2008)
have shown that it can occur in childhood .
• Differential diagnoses of restless legs syndrome include (Picchietti & Picchietti
2010):
Positional discomfort
Sore leg muscles
Ligament sprain/tendon strain
Bruises
Orthopaedic disorders
Dermatitis
• Management
• The management of restless legs syndrome/periodic limb movement disorder is
non-pharmacological for mild to moderate cases (i.e., cases with mild to moderate
impact on sleep, cognition, and behavior).

• This includes establishing healthy sleep habits, physical exercise and avoiding
putative exacerbating factors such as insufficient sleep for age, irregular sleep
schedule, low body iron stores, pain, caffeine, nicotine, alcohol, and certain drugs
(e.g., SSRIs, antihistamines, and neuroleptics) (Picchietti & Picchietti 2010).
Narcolepsy
DSM 5

• Recurrent periods of an irrepressible need to sleep, lapsing into sleep , or napping

occurring within the same day. These must have been occurring at least three
times per week over the past 3 months.
Prevalence
• Narcolepsy-cataplexy affects 0.02%-0.04% of the general population in most
countries.
• Narcolepsy affects both genders, with possibly a slight male preponderance.
• Narcolepsy Diagnosis and management of narcolepsy should be carried out by a
sleep specialist.

• However, it is important for child mental health professionals to be aware of its

clinical features since children with narcolepsy are commonly misdiagnosed with
other neurological or psychiatric disorders, such as epilepsy, ADHD, mood
disorders, and psychotic disorders.
• In retrospective case series, about one third of adults with narcolepsy reported
onset prior to 15 years of age and roughly 15% prior to 10 years of age.

• Excessive, uncontrollable daytime sleepiness is the most common presentation of

narcolepsy in school-aged children but, as already highlighted, daytime sleepiness
is also the manifestation of many other sleep problems such as insomnia and
obstructive sleep apnoea. A more specific symptom of narcolepsy is cataplexy (a
sudden weakness of the muscles of the body, especially the legs but also the face
and neck, which is often brought on by a strong emotion, especially laughing).
• Up 50% to 70% of patients with childhood narcolepsy present with cataplexy.
Sleep paralysis and hallucinations can be present but are less common.

• Only 10% to 25% of affected individuals show these four symptoms

(uncontrollable daytime sleepiness, cataplexy, sleep paralysis, and hallucinations)
during the course of their illness.

• These symptoms are the result of a sudden burst of REM sleep in patients who are
awake. Diagnosis of narcolepsy requires sleep laboratory assessment, including
nocturnal polysomnography and multiple sleep latency tests (Guilleminault &
Pelayo, 2000).
• Kleine-Levin syndrome Another uncommon and rare disorder characterized by
recurrent episodes of hypersomnia and to various degrees behavioral or cognitive
disturbances, compulsive eating behaviour, and hypersexuality. Kleine-Levin
syndrome is a rare condition that affects mainly male adolescents; it starts during
the second decade in about 80% of cases, with a male/female ratio of 2:1. Kleine-
Levin syndrome is characterised by periods of extreme somnolence
Management
• Sleep history
Detailed history of the sleep complaint and a typical sleep–wake cycle
Factors that improve or worsen sleep
 Effect on mood and functioning
Past and present treatment
History from bed partner
Sleep diary Systematic 2-week or longer record
Possible investigations
Video recording Actigraphy (wrist-worn)
Polysomnography
Cerebrospinal fluid orexin (hypocretin) levels
Treatments

• Pharmacological treatments Short-acting benzodiazepines (e.g. temazepam) ‘Z

drugs’ (zolpidem, zopiclone) Low-dose sedative antidepressants (e.g. trazodone,
mirtazapine)
• Melatonin or melatonin agonists
• A thorough medical and psychiatric assessment.
• Treatment of underlying physical or psychiatric disorder.
• Withdrawal of current medications, if any.
• Transient insomnia can be treated initially with hypnotics.
Contd…
• Both non-pharmacological and pharmacological approaches can be used to treat
insomnia (Riemann et al., 2015).
• Hypnotic drugs were widely prescribed in the past, but non-pharmacological
approaches are now recommended as first-line treatment.
• Sleep hygiene refers to a series of steps that are useful for all patients with
insomnia and can be applied in primary care.
• For more serious or persistent insomnia, a range of additional specific non-
pharmacological treatments have been shown to be effective .
Non-drug treatment for insomnia
• Progressive relaxation.
• Meditation, yoga.
• Stimulus control therapy: do not use the bed for reading or chatting -
go to bed for sleep only.
• Cognitive and behavioral interventions
• Sleep hygiene
• Sleep restriction
Principles of sleep education (sleep hygiene)
Avoid
• Late-evening exercise
• Caffeine-containing drinks late in the day
• Using mobile devices or watching TV and reading in bed
• Excessive alcohol and smoking, regular use of alcohol (especially avoid use of
alcohol as a hypnotic for promoting sleep).
• Excessive daytime sleep
• Large late meals ,fluid intake and heavy meals just before bedtime.
• Too much time in bed lying awake
Sleep environment Encourage

• Familiar and comfortable • Bedtime routines

• Dark • Consistent time for going to bed
• Quiet and waking up
• Minimize daytime napping. • Going to bed only when tired
• Thinking about problems before
going to bed
• Regular exercise
 Nursing Assessment

The tools for sleep assessments are: Sleep history including -Description of client’s sleep
problem; nature, sign/symptoms, onset, duration, predisposing factors, severity, effects on
client. -Usual sleep pattern prior to sleep problem -Recent changes in sleep pattern -Physical
illness -Bedtime routine and sleeping environment -Use of any medication
Pattern of dietary intake or any substance -symptoms experienced during waking hours -
recent life event - Current emotional and mental status
Sleep diary including -times when patient tries to fall asleep -approximate time that patient
fall asleep -time of awakening during night -record of food, physical activity, worries, mental
activity
Diagnosis

• Sleep deprivation Sleep Disturbance Related To:

• Readiness for enhanced sleep
• Insomnia
• Impaired oxygen transport
• Impaired elimination
• Immobility
• Medication
• Hospitalization
• Lack of exercise
• Anxiety response
• Life-style disruptions
Nursing Diagnosis

• Sleep pattern disturbance related to decreased physical activity, fear, anxiety,

inability to assume usual sleep position, frequent assessments or treatments,
unfamiliar environment, and discomfort resulting from current illness/injury.
Interventions
• Avoids naps except for a brief 10-15 min nap 8 hrs after rising but check with the
physician first because in some sleep disorders naps can be beneficial.

• Get regular exercise at least 40 min each day that causes sweating

• Take a warm bath or warm shower about 2 hrs before bedtime.

• Don’t use bright light even you have to remain awake for long during nighttime

• Expose to half an hour of sunlight during 30 min of rising should be useful to

prevent drowsiness in the morning
• Take regular time out of bed for 7 days a week

• Don’t smoke to get sleep , Give up smoking entirely or don’t smoke after 7 p.m.

• Avoid caffeine entirely or limit no more than 3 cups per day and not after 10 a.m.

• Too much time in bed is not good .Remember that quality of sleep is important.

• Keep the clock face turned away. Don’t see what time of night you are awake.

• Don’t eat heavily or drink 3 hrs before bedtime. A light bedtime snacks is o.k.

• Incase of problem of regurgitation, elevate the head of bed and prevent spicy as
well as oily meal before bedtime
• Keep your room well ventilated, dark and quiet during nighttime.

• Reading non-professional materials may be useful.

• Perform bedtime rituals.

• Use stress management technique in daytime.

• Make sure that mattress isn’t too firm or too soft. Ensure that the pillow is of appropriate
height and firmness.

• An occasional sleeping pill is alright but use only after consultation with doctor.

• Use bedroom only for sleep. Avoid activities that lead to prolonged arousal.
Collaborative Care
• Emphasize the importance of interdisciplinary collaboration in managing sleep
disorders.
• Discuss the involvement of healthcare professionals like physicians,
psychologists, respiratory therapists, and dietitians.
Education and Sleep Hygiene

• Provide education on the importance of sleep hygiene.

• Discuss strategies for maintaining a consistent sleep schedule, creating a sleep-
friendly environment, and promoting relaxation techniques.
• Highlight the need to avoid stimulating activities and substances (e.g., caffeine,
nicotine) close to bedtime.
Behavioral Interventions
• Discuss the role of behavioral interventions in managing sleep disorders.
• Include cognitive behavioral therapy for insomnia (CBT-I) as an effective
approach.
• Highlight the use of sleep restriction, stimulus control, and relaxation techniques.
Continuous Positive Airway Pressure (CPAP)
• Explain the role of CPAP therapy in managing sleep apnea.
• Discuss the nurse's role in educating patients on CPAP equipment use,
maintenance, and adherence.
• Highlight the importance of regular follow-up to assess treatment efficacy and
troubleshoot any issues.
Support and Counseling
• Discuss the role of nursing in providing emotional support and counseling for patients
with sleep disorders.
• Address any concerns or fears related to sleep disorders and their impact on daily life.
• Encourage open communication and the expression of emotions.
Follow-up and Evaluation
• Discuss the importance of follow-up appointments to assess the effectiveness of
interventions.
• Emphasize the need for ongoing evaluation of sleep patterns and symptoms.
• Highlight the nurse's role in monitoring treatment progress and making necessary
adjustments.
Collaboration with Community Resources
• Discuss the availability of community resources and support groups for
individuals with sleep disorders.
• Encourage patients to access these resources for additional support.
• Mention the nurse's role in facilitating referrals and connecting patients to
appropriate resources.
Thank You