Drugs Used for Sleep
Objectives
2 Identify alterations found in the sleep pattern when hypnotics are discontinued.
4 Compare the effects of barbiturates and benzodiazepines on the central nervous system.
5 Identify the antidote drug used for the management of benzodiazepine overdose.
Key Terms
rapid eye movement (REM) sleep (p. 212)
insomnia (
) (p. 213)
hypnotic (
) (p. 213)
sedative (
) (p. 213)
rebound sleep (
) (p. 213)
Sleep and Sleep Pattern Disturbance
http://evolve.elsevier.com/Clayton
Sleep is a state of unconsciousness from which a patient can be aroused by an appropriate stimulus. It is a naturally occurring phenomenon that occupies about one third of an adult’s life.
Adequate sleep that progresses through the normal stages is important to maintain body function, including psychiatric equilibrium and the strengthening of the immune system to ward off disease. A normal sleep duration of 7 to 8 hours per night is thought to be optimal for good health. Studies also show that a reduced amount of sleep is associated with overweight and obesity as well as the development of metabolic syndrome (see Chapter 21). Obesity itself is also detrimental to healthy sleep patterns, and it can contribute to the development of sleep apnea. Other studies show a strong connection between a shortened duration of sleep and cardiovascular disease. Individuals who sleep less than 5 hours per night have a threefold increased risk of heart attacks. The National Health Interview Survey also demonstrates a close relationship between symptoms of insomnia and common adverse physical and mental health conditions, including obesity, diabetes mellitus, hypertension, heart failure, anxiety, and depression. Healthy People 2020 has as one of its objectives the promotion of sleep health, which includes promoting optimal sleep durations and reducing the prevalence and impact of sleep disorders.
Natural sleep rhythmically progresses through phases that provide both physical and mental rest. On the basis of brain-wave activity, muscle activity, and eye movement, normal sleep can be divided into two phases: non–rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. The NREM phase can be further divided into four stages, each of which is characterized by a specific set of brain-wave activities. Stage 1 is a transition phase between wakefulness and sleep that lasts only a few minutes. Some people experience it as wakefulness, whereas others feel it as drowsiness. Approximately 2% to 5% of sleep is stage 1 sleep. Stage 2 sleep comprises about 50% of normal sleep time. People often experience a drifting or floating sensation, and, if they are awakened during this stage, they will often deny being asleep, responding, “I was just resting my eyes.” Stages 1 and 2 are light sleep periods from which a person is easily aroused. Stage 3 is a transition from the lighter to deeper sleep state of stage 4. Stage 4 sleep is dreamless, very restful, and associated with a 10% to 30% decrease in blood pressure, respiratory rate, and basal metabolic rate. Stage 4 sleep is also referred to as delta sleep on the basis of the pattern of brain waves that are observed during this stage. Stage 4 sleep comprises 10% to 15% of sleep time in young, healthy adults. Stage 4 sleep diminishes in length as people age, and many people who are more than 75 years old do not demonstrate any stage 4 sleep patterns. Older adults also take longer to cycle through the relaxation stages of NREM sleep, with an increased frequency and duration of awakenings.
During a normal night of sleep, a person will rhythmically cycle from wakefulness through stages 1, 2, 3, and 4; he or she will then go back to stage 3, then to stage 2, and then to REM sleep over the course of about 90 minutes. The early episodes of REM sleep last only a few minutes. However, as sleep progresses, the amount of REM sleep increases, with REM periods becoming longer and more intense around 5 AM. This type of sleep represents 20% to 25% of sleep time, and it is characterized by REM, dreaming, increased heart rate, irregular breathing, the secretion of stomach acids, and some muscular activity. REM sleep appears to be an important time for the subconscious mind to release anxiety and tension and reestablish a psychiatric equilibrium.
Insomnia is the most common sleep disorder known; 95% of all adults experience insomnia at least once during their lives, and up to 35% of adults will have insomnia during a given year. The term insomnia is defined as the inability to sleep. In general, insomnia is not a disease but rather a symptom of physical or mental stress. It is usually mild and lasts only a few nights. Common causes are changes in lifestyle or environment (e.g., hospitalization), pain, illness, the excess consumption of products that contain caffeine (e.g., coffee, energy drinks) or alcohol, eating large or rich meals shortly before bedtime, and stress. Initial insomnia is the inability to fall asleep when desired, intermittent insomnia is the inability to stay asleep, and terminal insomnia is characterized by early awakening with the inability to fall asleep again. Insomnia is also classified in accordance with its duration. A sleep disturbance that lasts only a few nights is considered to be transient insomnia. A sleep disturbance that lasts less than 3 weeks is referred to as short-term insomnia, and it is usually associated with travel across time zones, illness, or anxiety (e.g., job-related changes, financial stress, examinations, emotional relationships). Chronic insomnia requires at least 1 month of sleep disturbance before the individual is diagnosed with a sleep disorder. About 10% of adults and up to 20% of older people report having chronic insomnia. Women report suffering from insomnia twice as frequently as men. A higher incidence of insomnia is reported by older adults, the unemployed, those of lower socioeconomic status, and the recently separated or widowed. As many as 40% of patients with chronic insomnia also suffer from psychiatric disorders (e.g., anxiety, depression, substance abuse). People with chronic insomnia often develop fatigue or drowsiness that interferes with daytime functioning and employment responsibilities.
Sedative-Hypnotic Therapy
Drugs that are used in conjunction with altered patterns of sleep are known as sedative-hypnotic agents. A hypnotic is a drug that produces sleep; a sedative quiets the patient and gives him or her a feeling of relaxation and rest, but this is not necessarily accompanied by sleep. A good hypnotic should provide the following actions within a short period of time: the onset of restful, natural sleep; a duration of action that allows a patient to awaken at the usual time; a natural awakening with no “hangover” effects; and no danger of habit formation. Unfortunately, the ideal hypnotic is not available; however, for short-term use, benzodiazepines and three benzodiazepine receptor agonists—zolpidem, zaleplon, and eszopiclone—are available. The most commonly used sedative-hypnotic agents increase total sleeping time, especially the time spent in stage 2 sleep (i.e., light sleep); however, they also decrease the number of REM periods and the total time spent in REM sleep. REM sleep is needed to help maintain a mental balance during daytime activities. When REM sleep is decreased, there is a strong physiologic tendency to make it up. Compensatory REM sleep or rebound sleep seems to occur even when hypnotic agents are used for only 3 or 4 days. After the chronic administration of sedative-hypnotic agents, REM rebound may be severe and accompanied by restlessness and vivid nightmares. Depending on the frequency of hypnotic administration, normal sleep patterns may not be restored for weeks. The effects of REM rebound may enhance an individual’s chronic use of and dependence on these agents to avoid the unpleasant consequences of rebound sleep. Because of this, a vicious cycle occurs as the normal physiologic need for sleep is not met and the body attempts to compensate.
Because sedative-hypnotic agents have many adverse effects, especially with long-term use, medications that are recognized for other primary uses are being used by health care providers for the treatment of insomnia. Antidepressants such as amitriptyline, trazodone, and mirtazapine are prescribed in lower dosages for their sedative effects to assist patients with getting to sleep (see Chapter 17). Anticonvulsants that are used in this way include gabapentin and topiramate (see Chapter 19). Antipsychotic agents such as quetiapine and olanzapine are prescribed for patients with psychoses who also have insomnia (see Chapter 18). However, it is important to note that no extensive studies have been completed regarding the use of these antidepressants, antipsychotics, and anticonvulsants for insomnia, so their long-term effects are unknown, and their use for treating chronic insomnia cannot be recommended.
Actions
Sedatives, which are used to produce relaxation and rest, and hypnotics, which are used to produce sleep, are not always different drugs. Their effects may depend on the dosage and the condition of the patient. A small dose of a drug may act as a sedative, whereas a larger dose of the same drug may act as a hypnotic and produce sleep.
The sedative-hypnotic medications may be classified into three groups: barbiturates; benzodiazepines; and nonbarbiturate, nonbenzodiazepine sedative-hypnotic medications.
Uses
The primary uses of sedative-hypnotic medications are as follows: (1) to improve sleep patterns for the temporary treatment of insomnia; and (2) to decrease the level of anxiety and increase relaxation or sleep before diagnostic or operative procedures.
Nursing Implications for Sedative-Hypnotic Therapy
Assessment
Central Nervous System Function.
Since sedative-hypnotic drugs depress overall central nervous system (CNS) function, identify the patient’s level of alertness and orientation as well as his or her ability to perform various motor functions.
Vital Signs.
Obtain the patient’s current blood pressure, pulse, and respiration rates before initiating drug therapy.
Sleep Pattern.
Assess the patient’s usual pattern of sleep, and obtain information about the pattern of sleep disruption (e.g., difficulty falling asleep, inability to remain sleep the entire night, awakening during the early morning hours and unable to return to a restful sleep).
Ask about the amount of sleep (i.e., number of hours) that the patient considers normal and how his or her insomnia is managed at home. Does the patient have a regular time to go to bed and wake up? If the patient is taking medications, determine the drug, dosage, and frequency of administration and whether this may be contributing to sleeplessness. (Medicines that may induce or aggravate insomnia include theophylline, caffeine, pseudoephedrine, ephedrine, nicotine, levodopa, corticosteroids, and selective serotonin reuptake inhibitor antidepressants.)
Patients with persistent insomnia should be carefully monitored for the number of naps taken during the day. Investigate the type of activities that the patient performs immediately before going to bed.
Anxiety Level.
Assess the patient’s exhibited degree of anxiety. Is it really a sedative-hypnotic medication that the patient needs, or does the patient just need someone to listen to him or her? Ask about the stressors that the patient has been experiencing in his or her personal and work environments.
Environmental Control.
Obtain data related to possible disturbances present in the individual’s sleeping environment that may interfere with sleep (e.g., room temperature, lights, noise, traffic, restlessness, a snoring partner).
Nutritional Needs.
Obtain a dietary history to identify sources of caffeinated products that may act as stimulants.
Alcohol Intake.
Although alcohol causes sedation, it disrupts sleep patterns and may cause early-morning awakening.
Exercise.
Obtain data related to the patient’s usual degree of physical activity and at what times during the day he or she is most active.
Respiratory Status.
People with respiratory disorders and those who snore heavily may have low respiratory reserves and should not receive hypnotic agents because of their potential to cause respiratory depression.
Implementation
Vital Signs.
Obtain the patient’s vital signs periodically as the situation indicates.
Preoperative Medication.
Give the patient preoperative medications at the specified time.
Monitoring Effects.
When a medication is administered, carefully assess the patient at regular intervals for the drug’s therapeutic and adverse effects.
As-Needed Medications (PRN).
If giving the patient PRN medications, assess the record for the effectiveness of previously administered therapy. It is sometimes necessary to repeat a medication if an order permits doing so. This is done at the nurse’s discretion on the basis of the evaluation of a particular patient’s needs.
Patient Education
Promote Good Sleep Hygiene
Bedtime.
Encourage the patient to choose a standard time to go to bed to help the body to establish a rhythm and routine.
Nutrition.
Teach the patient appropriate nutrition information concerning the FDA’s recommendations of MyPlate, adequate fluid intake, and vitamin use. Communicate the information at the educational level of the patient.
Avoid Heavy Meals During the Evening.
Alcohol and caffeine consumption should be reduced or discontinued, especially within several hours of bedtime. Introduce the patient to decaffeinated or herbal products that can be substituted for caffeinated foods. Help the patient to avoid products that contain caffeine, such as coffee, tea, energy drinks, soft drinks, and chocolate. Limit the total daily intake of these items, and provide the patient with warm milk and crackers as a bedtime snack. Protein foods and dairy products contain an amino acid that synthesizes serotonin, which is a neurotransmitter that has been found to increase sleep time and decrease the time required to fall asleep.
For insomnia, suggest that the patient drink warm milk about 30 minutes before going to bed.
Personal Comfort.
Position the patient for maximum comfort, provide a back rub, encourage the patient to empty the bladder, and be certain that the bedding is clean and dry. Take time to meet the patient’s individual needs and to calm his or her fears. Foster a trusting relationship.
Environmental Control.
Tell the patient to sleep in the proper environment, such as a quiet, darkened room free from distractions and to avoid using the bedroom or watching television, preparing work for the following day, eating, and paying bills. Provide adequate ventilation, subdued lighting, and the correct room temperature, and control of traffic in and out of the patient’s room.
For safety, instruct the patient to leave a nightlight on and not smoke in bed after taking medication.
Activity and Exercise.
Suggest the inclusion of exercise in the patient’s daily activities so that the patient obtains sufficient exercise and is tired enough to sleep. For some individuals, plan a quiet “unwinding” time before retiring for the night. For children, assist with sleep by providing a warm bath and structure prior to bedtime. Try a bedtime story that is pleasant and soothing (rather than one that may cause anxiety or fear).
Stress Management
Fostering Health Maintenance.
Throughout the course of treatment, discuss medication information and how it will benefit the patient. Stress the importance of nonpharmacologic interventions and the long-term effects that compliance with the treatment regimen can provide.
Provide the patient or the patient’s significant others with important information that is contained in the specific drug monographs for the medicines prescribed. Additional health teaching and nursing interventions for the common adverse effects and serious adverse effects that require contact with the health care provider are described in the following drug monographs (e.g., barbiturates, benzodiazepines, miscellaneous sedative-hypnotic medications).
Written Record.
Enlist the patient’s help with developing and maintaining a written record of monitoring parameters (e.g., extent and frequency of insomnia); see the Patient Self-Assessment Form for Sleeping Medication on the 
Evolve Web site. Complete the Premedication Data column for use as a baseline to track the patient’s response to drug therapy. Ensure that the patient understands how to use the form, and instruct the patient to bring the completed form to follow-up visits. During these follow-up visits, focus on issues that will foster the patient’s adherence with the therapeutic interventions that have been prescribed.
Drug Therapy for Sleep Disturbance
Drug Class: Barbiturates
The first barbiturate went on the market as a sedative-hypnotic product in 1903. It became so successful that chemists identified some 2500 compounds, of which more than 50 went on to be distributed commercially. Barbiturates became such a mainstay of therapy that fewer than a dozen other sedative-hypnotic agents were successfully marketed through 1960. The release of the first benzodiazepine—chlordiazepoxide—in 1961 started the decline in the use of barbiturates. However, several barbiturate compounds are still prescribed (Table 14-1).
Table 14-1
| GENERIC NAME | BRAND NAME | AVAILABILITY | ADULT ORAL DOSAGE | COMMENTS |
amobarbital  | — | Injection: 500-mg vials | < div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue
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