Sleep problems

CHAPTER 28 Sleep problems


Each year more than 10 million Americans seek medical help for sleep problems. Patients report insufficient or nonrestorative sleep, despite adequate opportunity, that results in some form of daytime impairment. Insomnia is prevalent in 30% to 40% of the adult population, with 10% to 15% reporting that it is chronic, severe, or both. More than 40% of parents report sleep problems with their children, and 20% of these are considered significant. The consequences of chronic sleep problems include difficulty with concentration, fatigue, lack of energy, and irritability. Sleep disturbances in the elderly can result in increased falls and accidents. In children, sleep disturbances can produce problems in learning and behavior, alter physical development, and affect family functioning.


Sleep has two separate stages: rapid eye movement (REM) sleep, which is linked with dreaming, and non–rapid eye movement (NREM) sleep, which is a deeper sleep state. NREM is further divided into four sleep stages. In each stage the sleep is progressively deeper. Generally an individual moves through the NREM stages from stage 1 sleep to stage 4. Stages 3 and 4 are the deepest sleep stages. At the end of stage 4, a person goes backward in the stages toward the progressively lighter sleep of stage 1. The pattern is then followed by the first REM sleep stage. Movement from stage 1 to the end of REM is termed a sleep cycle. This cycle usually lasts 90 minutes in adults and approximately 50 minutes in infants. In one night, generally five cycles are completed. As sleep cycles, the REM period increases in length from 10 minutes to occupying most of the 90-minute cycle. Also, the proportion of stage 2 increases, with stages 3 and 4 decreasing in length. The total amount and composition of sleep change throughout life. Sleep quality is often judged by the amount of time spent in stage 4 sleep. People who do not have adequate REM sleep feel they have had too little sleep.


Newborns fall directly into REM sleep. This REM sleep in infancy is thought to provide the brain stimulation for maturation. At age 5, REM sleep decreases to that of the adult, approximately 20% of total sleep. The REM portion of sleep is constant through all age ranges; however, NREM sleep stages 3 and 4 begin to decline in adolescents, and in the elderly, stages 3 and 4 disappear. The elderly may experience more frequent awakenings during the night; some need to compensate for this with rest periods during the day. Some elderly clients view their pattern of diminished sleep with frustration, whereas others accept it as an opportunity to have more time for other activities.


Sleep is regulated by two primary processes: the body’s circadian rhythm, which causes an increase in sleepiness twice during a 24-hour period (usually between midnight and 7 AM and for a brief period in the mid-afternoon), and the physiological need for sleep, which is increased by sleep loss and sleep disruption.



Diagnostic reasoning: focused history





Define the nature of the problem.



Key questions




image What kind of sleep problem are you (or the child) having?


image Are you having difficulty falling asleep?


image Are you having difficulty staying asleep?


image Are you having difficulty staying awake during the day?


image Have you taken medications for the sleep problem? If so, what are they?


image How long has the problem existed?




Nature of the problem


Sleep disorders include sleeplessness (insomnia), episodic disturbance of behavior associated with sleep (parasomnias), and excessive sleepiness (hypersomnia). The most common childhood sleep disorders are night awakening, inability to fall asleep, problems going to bed, circadian rhythm problems, and parasomnias. Often it is the caregiver, not the child, who perceives the sleep disturbances to be a problem.



Difficulty falling asleep


Difficulty in falling asleep is often related to poor sleep hygiene practices, the use of medications or stimulants, or disruption in circadian rhythms. Difficulty falling asleep also can occur as a result of pain or as a symptom of anxiety.



Difficulty staying asleep


Difficulty staying asleep occurs when the sleep cycle is disrupted; this may be related to physiological factors, illness, depression, pain, or use of medications or alcohol.



Daytime sleepiness


Nighttime insomnia and daytime sleepiness are not isolated symptoms. Daytime sleepiness may be related to an increased need for sleep because of nighttime sleep loss, or it may represent narcolepsy.



Medications


All over-the-counter and prescription medications used to promote sleep can have short-term side effects, such as daytime sleepiness and headaches. Long-term use of sleep medications often produces tolerance and a need for increased doses to achieve sleep. Some of the agents, particularly the benzodiazepines, are habituating with long-term use; stopping them may cause withdrawal symptoms. Use of sleep medications by persons with sleep apnea can be dangerous.



Duration of problem


Sleep disorders can be transient (lasting a few days), short term (lasting weeks), or chronic (lasting months to years). An acute problem, lasting a few days to a few weeks, can be caused by stress, acute illness, environmental disturbance, or jet lag. A chronic problem may be due to a specific sleep disorder, a mood disorder, or the use of medications or stimulant substances. Primary insomnia is diagnosed when no underlying cause can be identified.





Is this a specific sleep disorder?



Key questions



image Do you have a creeping, crawling, or uncomfortable feeling in the legs that is relieved by moving the legs?


image Does your bed partner report that your arms or legs jerk during sleep?


image Do you (or the child) snore loudly, gasp, choke, or stop breathing during sleep?


image Do you (or the child) have difficulty staying awake during the day or do you fall asleep during routine tasks (for adults, especially driving)?


image Do you have episodes of muscle weakness?



Limb sensation


Restless legs syndrome includes the sensation of crawling, pulling, and tingling with an irresistible urge to move the legs. Symptoms increase in the evening, especially when the person is lying down and remaining still. Patients often have coexisting periodic limb movements in sleep.



Limb jerking


Periodic leg movements during sleep are common in persons older than 65 years. Bilateral, repeated, rhythmic jerking or twitching movements, primarily in the legs, characterize periodic limb movement disorder. Less frequently, movement occurs in the arms.



Snoring


Obstructive sleep apnea (OSA) is characterized by loud snoring, mouth breathing, and restless sleep patterns. The patient may report insomnia but more commonly notes excessive daytime sleepiness.


Parental smoking can be a risk factor for snoring in children. Passive smoke inhalation can provoke mucosal edema and inflammation, resulting in a narrowing of the pharynx and causing snoring.



Daytime dozing, excessive sleepiness during the day, and muscle weakness


Excessive daytime sleepiness may be caused by narcolepsy. Adults with narcolepsy report falling asleep while driving or while performing routine tasks. Initially, children with narcolepsy have great difficulty getting up in the mornings. When awakened, the child may appear to be confused or may be aggressive or verbally abusive. The child may fall asleep during school, in the vehicle on the way home from school, or while watching television. Cataplexy is common in adults. This disorder is identified as episodes of sudden muscular weakness and atonia generally instigated by an emotional trigger. The patient will have to lean against a wall for support because his or her legs feel rubbery.


The degree of daytime sleepiness can be quantified using the Epworth Sleepiness Scale (Box 28-1).



Box 28-1 The Epworth Sleepiness Scale


One tool that may be used in evaluating daytime sleepiness is the Epworth Sleepiness Scale. The scale is a simple questionnaire that measures general level of daytime sleepiness by gauging the probability of falling asleep in a variety of situations. The patient rates on a scale of 0 to 3 the likelihood that he or she would doze in each of eight different situations as part of his or her “usual way of life in recent times.”


The patient’s responses are added together, and the total score can range from 0 to 24. A normal range of scores is from 2 to 10, with a modal score of 6. Scores increase linearly in obstructive sleep apnea syndrome (OSAS) patients according to the severity of the apnea. Any score higher than 10 is considered significant.


The Epworth Sleepiness Scale has high test-retest reliability in normal subjects (r = 0.82, p <0.001). It is a unitary scale with high internal consistency (Cronbach’s coefficient alpha = 0.88). Strengths of the tool are that it is simple, easy to understand, and a very inexpensive measurement of daytime sleepiness.


On a scale of 0 to 3, indicate the likelihood that you would fall asleep in the following situations, taking into account your usual way of life in recent times. Using the scale below, choose the most appropriate number for each situation:



0 = would never doze


1 = slight likelihood of dozing


2 = moderate likelihood of dozing


3 = high likelihood of dozing



Situation—likelihood of dozing:
































Reading while seated _______________________________________________________________
Watching TV _______________________________________________________________
Sitting, inactive, in a public place such as a theater or meeting _______________________________________________________________
As a passenger in a car for an hour without a1 kg = 2.204 lb break _______________________________________________________________
Lying down to rest in the afternoon when circumstances permit _______________________________________________________________
Sitting and talking to someone _______________________________________________________________
Sitting quietly after a lunch during which you did not drink alcohol _______________________________________________________________
In a car, while stopped for a few minutes in traffic _______________________________________________________________
Total: _______________________________________________________________

Modified from Johns MW: Daytime sleepiness, snoring and obstructive sleep apnea, The Epworth Sleepiness Scale, Chest 103:30, 1993. Permission conveyed through Copyright Clearance Center, Inc.





Could the sleep problem be secondary to a medical condition?



Key questions



image Have you been ill recently?


image Do you have a chronic health condition?


image What medications (prescription and over-the-counter) do you take?


image Do you have depression or anxiety?



Illness: acute or chronic


Acute illness can be a cause of sleep disturbance. In children, otitis media and chronic serious otitis, even without acute infection, can disturb sleep. Some authors believe that middle ear pressure rises when the child is supine at night and have seen sleep improve with treatment of otitis. In children, enlarged adenoids and upper airway obstruction may cause awakening.


Gastroesophageal reflux (GERD) may cause night awakening but produce few symptoms during the day. GERD, chronic obstructive pulmonary disease (COPD), peptic ulcer disease, and congestive heart failure are associated with paroxysmal nocturnal dyspnea (PND), which frequently disturbs sleep and is often interpreted by the patient as insomnia. Prostatic hypertrophy may cause nocturia and thus disturb sleep.



Medications


Many medications can have stimulating effects and cause sleep disruption. Common offenders include antidepressants, decongestants, bronchodilators, β-blockers, thyroid preparations, phenytoin, methyldopa, and corticosteroids. The potential sedating effects of medications should also be considered in patients who report excessive daytime sleepiness. Medications such as antihistamines often cause sleep disturbances.



Pain


Pain may interfere with sleep onset or contribute to early awakenings. Patients with chronic pain may have mood and cognitive disturbances that contribute to insomnia and early morning awakening.



Psychological causes


Psychological conditions causing insomnia include depression, anxiety disorder, panic disorder, mania, and acute psychosis. People with depression tend to have early morning awakening, whereas those with anxiety disorder have trouble falling asleep (see Chapter 3).





Could this be related to sleep hygiene?



Key questions



image What is your bedtime routine?


image What else do you do in your bedroom?


image Do you consume alcohol, nicotine, or caffeine before bedtime?


image Do you exercise before bedtime?


image How do you put your child to sleep?


image Where does your child sleep?

Related posts:

  1. Dizziness
  2. Earache
  3. Urinary problems in females and children
  4. Breast lumps and nipple discharge

Stay updated, free articles. Join our Telegram channel
Tags:
Apr 10, 2017 | Posted by in NURSING | Comments Off on Sleep problems

Full access? Get Clinical Tree
Get Clinical Tree app for offline access