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Course: Mental Health Nursing

Topic: Sleep Disorders

The Nurses International Community

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Module Goals

Learners will be able to:

Define sleep disorders
List the signs and symptoms
Identify the clinical manifestations
Discuss the evidence-based management
Identify the appropriate nursing interventions

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Sleep Disorders

Involve problems with the quality, timing, and amount of sleep, which result in daytime distress and impairment in functioning.

Can interfere with normal physical, mental, social, and emotional functioning.

May affect overall health, safety, and quality of life.

American Psychiatric Association, 2020

Karna & Gupta, 2021

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Types of Sleep Disorders

Broadly categorized into primary and secondary.
Primary sleep disorders:

Result from endogenous disturbances.

Secondary sleep disorders:

Are the result of various medical and psychiatric conditions.
Example: depression, thyroid problems, and stroke.

Karna & Gupta, 2021

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Primary Sleep Disorders

Parasomnias: Unusual behaviors during sleep

Sleep terror disorder
Sleepwalking (occurring during stage 3 sleep), and
Nightmare disorder (occurring during REM sleep).

Dyssomnias:

Abnormalities in the amount, quality, or timing of sleep.
Include:

Primary insomnia and hypersomnia.
Narcolepsy, Breathing-related sleep disorder, circadian rhythm sleep disorder.

Karna & Gupta, 2021

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Critical Thinking Question

Which of the following is a parasomnia?

Nightmare disorder
Insomnia
Hypersomnia
Narcolepsy

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Etiology

Sometimes unknown
May include:

Medical Conditions:

Cardiac: Heart failure, stroke.
Endocrine: Hyperthyroidism, pregnancy, menopause, diabetes mellitus, vitamin D deficiency.
Pulmonary: Obstructive sleep apnea, asthma, chronic obstructive pulmonary disease.
Musculoskeletal: Pain from arthritis, fibromyalgia.

Karna & Gupta, 2021

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Etiology

Psychiatric Conditions:

Depression
Anxiety
Phobias and panic attacks
Antidepressants medication

Other factors:

Environmental problems
Aging
Childhood Trauma (sexual assault)
Medication

Karna & Gupta, 2021

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Symptoms of Sleep Disorder

The symptoms depend on the specific disorder:

Insomnia: Difficulty falling asleep and/or staying asleep.
Hypersomnia: Disabling excessive daytime sleepiness.
Narcolepsy: A chronic neurological disorder to the brain's inability to control sleep and wakefulness

Daytime sleepiness with varying amounts of cataplexy.
Hallucinations while falling asleep or while waking.
Sleep paralysis (inability to move immediately after awakening).

Cleveland Clinic, 2020

Karna & Gupta, 2021

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Symptoms of Sleep Disorder

Obstructive Sleep Apnea:

Caused due to the laxity of pharyngeal musculature leading to the repetitive collapse of the upper airway during sleep.

Excessive daytime sleepiness.
Morning headaches, poor judgment, impotence, and depression.

Bedtime partners report:

Loud snoring, Gasping, Choking.
Snorting or interruptions in breathing while sleeping.

Karna & Gupta, 2021

Contact info: info@nursesinternational.org

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Symptoms of Sleep Disorder

Advanced Sleep Phase Syndrome:

Characterized by an inability to stay awake in the evening (usually after 7 pm).
Early morning insomnia.

Delayed Sleep Phase Syndrome:

Generally go to bed and usually arise two or more hours later than the desired time.

Karna & Gupta, 2021

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Symptoms of Sleep Disorder

Night Terrors:

Most common in children 2 to 12 years of age
Child exhibits features like:

Screaming, intense fear, and flailing while still asleep.
No memory of the event.

Nightmare is a Parasomnia:

Occurs during REM sleep, usually in the middle of the night or early morning.
May scream or call out during a nightmare.
May recall a nightmare.

Karna & Gupta, 2021

Contact info: info@nursesinternational.org

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Symptoms of Sleep Disorder

Restless Leg Syndrome:

A sleep movement disorder in which the individual has an uncomfortable sensation and an urge to move the legs while trying to fall asleep.

The symptoms are relieved by walking or moving the legs.

Karna & Gupta, 2021

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Critical Thinking Question

In which age group, the night terror, is most common?

Age of 2 to 12 yrs
Age of 1 to 3 yrs
Age above 60 yrs
Age of 12 to 20 yrs

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Symptoms of Sleep Disorder

REM Sleep Behavior Disorder:

A parasomnia, characterized by dream-enactment behaviors that emerge during a loss of REM sleep atonia.
The clients show movements such as:

Kicking
Punching
Arm-flailing, or jumping from bed in response to violent dreams.
The client may recall the dream if awakened during the episode.

Karna & Gupta, 2021

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Sign of Sleep Disorders

Poor concentration
Drowsiness
Slowed reaction time
Hypertension (which can be caused by sleep apnea)
Poor growth, enlarged tonsils, and narrowed airway (findings of Obstructive Sleep Apnea)

Karna & Gupta, 2021

Contact info: info@nursesinternational.org

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Management

Non-pharmacological

Cognitive-behavioral therapy (CBT): Depending on the specific symptoms.

Sleep restriction therapy (SRT):

Limits the total time allowed in bed so that the drive to sleep increases.

Stimulus control therapy:

Helps in changing sleep habits.
Clients should not go to bed until they are sleepy.
Use the bed only for sleeping and not for watching television, reading books.

Karna & Gupta, 2021

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Management

Non-Pharmacological (Continued)

Relaxation training:

Implement before sleep

Meditation and breathing exercises are types of relaxation techniques.

Hypnosis:

The hypnotherapist uses varied therapeutic techniques like verbal repetition and mental images

Sleep hygiene

Karna & Gupta, 2021

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Critical Thinking Question

What are the non-pharmacological managements of sleep disorders?

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Management

Pharmacological:

Histamine type 1 receptor blockers
Benzodiazepines (BZD)
Non-benzodiazepine hypnotics
Melatonin receptor agonists
Orexin receptor antagonists

Other Interventions:

Sleep apnea may be alleviated by losing weight.
The use of continuous positive airway pressure (CPAP), and, sometimes, surgical treatment.

Karna & Gupta, 2021

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Client Education

Encouraged Good Sleep Hygiene Practices:

Maintain a regular sleep schedule
Use the bed for sleep.
Avoid watching television, phones, or reading in bed.
Exercise daily, but not right before bedtime.
Avoid caffeine or smoking mainly during the evening.
Maintain a dark, calm, and quiet environment in the bedroom.
Avoid struggling to fall asleep in bed: Get up and read or knit or other relaxing activity and then try again later to sleep.

Karna & Gupta, 2021

Contact info: info@nursesinternational.org

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Nurse’s Role in Sleep Disorders

Assessment

Assess client’s usual sleep habits and recent sleep quality by taking history:

How many hours do you sleep at night?
Do you toss and turn in your sleep?
Do you take naps?
How long does it take you to fall asleep?
Do you wake up in the middle of the night?
Do you work a night shift?
How sleepy do you feel during the day?

Cleveland Clinic, 2020

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Nursing Interventions

Monitor frequency and duration of naps
Create an individualized bedtime ritual:

A light carbohydrate snack, going to the bathroom and settling a routine.

Provide active activities during daytime hours (exposure to natural light and an outdoor environment).
Create an optimal sleep environment:

Comfortable, calm, quiet, and dark bedroom.

Encourage a client to avoid:

Alcohol, tobacco, coffee before bedtime.

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Critical Thinking Question

What are some measures may the nurse suggest to promote good sleep hygiene?

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References:

American Psychiatric Association. (2020). What are Sleep Disorders. https://www.psychiatry.org/patients-families/sleep-disorders/what-are-sleep-disorders

Cleveland Clinic. (2020). Common Sleep Disorders. https://my.clevelandclinic.org/health/articles/11429-common-sleep-disorders

Karna, B., & Gupta, V. (2021 Jun 10). Sleep Disorder. In: StatPearls [Internet]. StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560720/

Sleep Health Foundation. (2019). Common Sleep Disorders. https://www.sleephealthfoundation.org.au/common-sleep-disorders.html

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