sleep and rest

Sleep and Rest

Definition

• Rest: a condition in which body is in a decrease state of activity with a feeling of being refreshed.

• Sleep state of rest accompanied by altered consciousness and relative inactivity.

Physiologic of sleep

• Two systems control sleep:1. Reticular activating system (RAS).2. Bulbar synchronizing region.

Physiologic of sleep• Reticular activating system (RAS): at the core of

the brain stem between medulla oblongata and midbrain and it important to maintain state of consciousness.

• It is affected by many psychotropic drugs and general anesthetics.


• It involved with the circadian rhythm & damage can lead to permanent coma.

• It produce acetylcholine and catecholamine neurotransmitters to maintain wakefulness.

• It brings relevant information to your attention.


• Bulbar synchronizing region: which produce chemicals such as GABA or serotonin to promote sleep.

• Hypothalamus: control center for sleeping and rest and walk.

Circadian rhythms

• It is complete a full cycle every 24 hours.

• Circa: approximately.• Diem: day.• Circadian: one day.

Circadian rhythms

A. Circadian synchronization: when an individual sleep wake pattern follow the inner biologic clock.• The hormones: melatonin and cortisol which

affect sleep circadian rhythm (awake and sleep).• The regulating mechanism of sleep is the persons

biologic clock which is controlled by hypothalamus.

• The rhythm doesn't present at birth and develop over 2 years of life.

Circadian rhythms

B. DE- synchronization: when wake pattern are frequently altered and the person attempt to sleep during high activity rhythm or work when the body is physiologically prepared to rest.

Stages of sleep

• Stage 1: non rapid eye movement (NREM).• Stage 2: rapid eye movement (REM).

• The cycle for the two stages occur in 90-110 minutes cycle.

• During 8 hours sleep, the cycle of the two stages repeats itself 5-6 times.

Non rapid eye movement (NREM)

• It consists of 4 stages:• Stage I and II transition from wakefulness to

sleep and consume about 5% (stage I) and 45% (stage II) of person sleep time (light sleep).

• The person can be aroused with relative ease.• Stage III and IV represents 10-20% of total sleep:

deepest sleep states termed as delta sleep or slow wave sleep, arouse threshold is greatest. Occur in first one third to one half of the night.

Non rapid eye movement (NREM)

• Arousal during this stage (stage 3 or 4): • (30-60 minutes) after sleep onset disoriented,

and disorganized thinking and problems may result such as amnesia, enuresis, nightmare, night terrors.

• Parasympathetic, nervous system dominates and decrease in pulse, RR, BP, metabolic rate, tem.

REM

• More difficult to arouse person during this stage than during NREM sleep and it lasts 15-40 min.

• It consumes about 20-25% of sleep time.• Dreaming occur during this stage.• PB, pulse, RR, metabolic rate and body tem

increase while skeletal muscles tone, deep tendon reflex are depressed.

• High level of brain activity and physiological activities.

REM

• Shortening of REM, result in depressive disorders and nacrolepsy.

Sleep requirement and patterns

• Infant: 14-20 hours.

• Children: 10-14 hours.

• Adult: 7-9 hours.

• Elderly: vary (5-7 hours): need more longer time to sleep than adult, wake early and frequently during night.

Factors affecting sleep

• Developmental consideration.• Psychological stress (illness and life events).• Motivation.• Culture (herbs instead of medication, privacy,

quite).• Lifestyle and habit (shift work, watching TV,

outside activities).


• Physical activity and exercise: increase fatigue especially 2 hours before sleep time, or promote relaxation and sleep.

• Dietary habit: small protein and carbohydrate snakes are effective, large amount of alcohol, caffeine containing beverages, smoking (light sleepers, easily aroused).

• Environmental factors: place of sleep, light, quite and noisy environment.


• Illness: gastric secretion increased during REM (e.g. peptic ulcer), pain associated with coronary artery diseases and myocardial artery diseases and myocardial infarction (REM), liver failure (REM), encephalitis, hypothyroidism (NREM).

• Medications: diuretic, barbiturate, antidepressant, steroids, asthma medication.

Common sleep problems

• Primary sleep disorders: consist of:

• Dyssomnias (problem with initiating or maintain sleep or excessive sleepiness).

• Parasomnias (particular physiologic or behavioral reaction during sleep).

Primary sleep disorders:Dyssomnias

• It consists of primary insomnia, primary hypersomnia, narcolepsy.

Primary Insomnia

Primary Insomnia

• Difficulty to initiate or maintain sleep, or early awakening from sleep far at least 1 month.

• It causes social and functional impairment.

• It does not occur during other mental disorders (narcolepsy, depression, generalized anxiety).

• Not occur as a result of substance or drug use.

Primary Insomnia

• Other information:• Increase with age, women, stress.• Begin in adulthood or middle age and rare in

childhood.• Symptoms may stay for one year or less.• Associated with anxiety.• Specific treatment is usually not required.

Primary Hypersomnia

Primary Hypersomnia

• Excessive sleep for at least 1 month, particularly during day (more than 8-12 hours) e.g during lectures, driving, reading, watch TV, it causes significant distress or impairment.

• It doesn't occur during other sleeping disorders (narcolepsy, parasomnia) or inadequate amount of sleep.

• Doesn’t occur during the course of other mental disorders or substance abuse.

Primary Hypersomnia

• Other information:• It doesn't occur sudden.• Begins between age 15-30 years.• More than 9 hours of sleep per 24 hours

periods suggest primary hypersomnia.• M>F ,daytime nap is long (1 hour or more),

(coping mechanism to stress, no treatment is necessary).

Primary Hypersomnia

• Fall sleep easily but have difficulty in awakening in the morning and don’t feel refresh after awakening.

• Interventions: caffeine drink and chocolate or stimulant drugs (amphetamine).

• Chronic insomnia last 3-4 weeks or more.

Narcolepsy • It is neurological disorder and characterized by uncontrollable

desire to sleep.• Irresistible attacks of refreshing sleep that occur daily over 3

months and the presence of one or both of the following:• Cataplexy (brief sudden bilateral loss of muscle tones triggered by

strong emotion such as laughter and stays for seconds). • Or/and recurrent intrusions of REM sleep into transition between

wakefulness and sleep as manifested by either hallucination (hearing, visual, or sleep paralysis: unable to move or speak when failing asleep or waking up and terminate spontaneously or when someone touches the person)at the beginning or the end of sleep episodes

• It is not due to substance abuse.

Narcolepsy

• Other information:• Appear in adolescence and early adulthood.• Last 10-20 minutes or one hour and dreams are

frequently reported.• Respiratory and eye muscle aren't affected.• Stay full conscious and alert and no confusion

before and after the episode.• Cataplexy is triggered by strong emotional

stimulus (anger, laughter, surprise).

Narcolepsy

• They may isolate themselves or prevent emotion to prevent this disorder.

• At the risk of accidental injury.

• Daytime sleep is the first symptom in addition to sleep hallucination, and paralysis.

Common feature in narcolepsy

• M=F• Cause: genetics (gene 6).• Treatment: • Generally no cure.• Forced naps at regular time of the day.• Central nervous system stimulant:

dextroamphetamine, ritalin, tricyclic antidepressant (imipramine especially for cataplexy).

• Psych education (engage in activity while driving such as music or munching on nuts, schedule naps.

Breathing related sleep disorder: sleep apnea

Breathing related sleep disorder: sleep apnea

• Repeated upper-airway obstruction during sleep.• The absence of breathing between loud snoring

intervals and silence for 20-30 seconds or longer (2min).

• O2 decreases, HR irregular, BP increase.• Occur in middle aged men who are obese and short

thick neck, women and other ages, large neck size.• Causes: obstruction of airways, large tonsils, adenoid

deviated nasal septum, thyroid enlargement and allergic rhinitis, neurological problems.

• At risk of developing hypertension.

Sleep apnea

• Sign and symptoms: irritable during the day, fall asleep during activity, lack of concentration, involve in motor accident.

• Alcohol, tobacco and sleeping pills increase the breathing disruption.

• treatment: surgery to remove soft tissues, remove tonsils, avoid alcohol and sedation.

Parasomnia

• Abnormal behavior or physiological events occurring in association with sleep stages or sleep wake transition.

• It occurs in stage III and IV with poor recall.• Involve activation of autonomic nervous system, motor

system, cognitive process during sleep.• They present with complaints of unusual behavior

during sleep rather than complaints of insomnia or excessive sleep.

• It includes: nightmare disorder, sleep terror disorder, sleep walking disorder.

Nightmare disorder: dream anxiety disorder

• Repeated occurrence of frightening dreams that lead to awakenings from sleep.

• On waking from the frightening dream the person rapidly becomes oriented and alert.

• Onset: 3-6 years and may persist for adulthood, F>M causes severe stress.

• Dreams focus on physical danger and appear during REM episodes (90-110 minutes) and there is details recall of the dream.

Nightmare disorder: dream anxiety disorder

• No specific treatment is usually required.

• Drugs: benzodiazepines and tricyclic drugs to reduce REM.

• No harm to awaken the person during nightmares.

Sleep terror disorder


• Diagnostic criteria: A. recurrent episodes abrupt awakening from sleep usually occurring during the first third of the major sleep episode and beginning with a panicky scream.B. Intense fear and signs of autonomic arousal such as tachycardia, rapid breathing, sweating.C. Relative unresponsive to efforts of others to comfort the person during the episode.


D. No detailed dream is recalled and there is amnesia for the episode.

E. The episode cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to physiological effects of a substance or medical condition.


• Other information:• Difficult to awaken or to recall the episode the

next morning.• Last 1-10 minutes and occurs during stage III

and IV (NREM) and may develop into sleep walking.

• Begin in children between 4-12 years old and resolve spontaneously during adolescence.


• In adult, begins ages 20-30 years and follows chronic course.

• Causes: genetics, minor neurological abnormalities in temporal lope.

• Treatment: specific treatment is not required, investigate family situations.

• Medication: diazepam (valium) may cure it.

Sleep walking disorder (somnambulism)


• Diagnostic criteria:A. Repeated episode of rising from bed during

sleep and walking about usually occurring during the first third of major sleep episode.

B. While sleep walking the person has blank staring face, is relatively unresponsive to the effort of others to communicate with him or her.

C. On walking the person has amnesia for the episode.


D. Within several minutes after awakening from the sleepwalking episode, there is no impairment of mental activity or behavior.E. The sleep walking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.F. The disturbance is not due to physiological effects of a substance or medical condition.


• Sleep walking occurs during the first third of the night, unresponsive to communication or effort to awake and cannot recall in morning (can eat, talk, use bathroom, go around home or drive car during the episode for several min to 30 min).

• First time: common in children, ages 4-8 years, peak: age 12 years and childhood episodes disappear early adolescence (M>F).

• Interventions: remove hazards from bedroom, lock windows, locate bedroom in first floor and medication (benzodiazepine) in difficult cases.


• Causes: genetics, internal stimuli (distend bladder) or external stimuli (noises), psychological stressors, alcohol, sedative use.

• Some may eat during the episode and don’t remember it morning or injure themselves.

• It occurs in first hours, stage (3-4) of sleep.• F>M.• It disappears spontaneously by age 15 years.• In adult: it is a chronic course.• May occur with sleep terror disorder.

Assessment

• Description: how the patient describe the problem:• Stability: does it happen every night.• Intensity: how bad is the problem.• Duration: when did the problem begin? Transient

(from one to several nights) short term (<1 month) or chronic (<1 month).

• Sleep history: problem, cause, sign&symptoms, when it begins and how often occurs.

• How it affects every day living, severity of the problem, coping.

Assessment

• Sleep diary: kept for 24 days to provide more specific data on sleep pattern page.

• Physical assessment: energy level (fatigue, lethargy) facial characteristics (narrowing or glazing of eyes) behavioral characteristics (yawing, rubbing eyes, slow speech) physical data (obesity, enlarge neck, deviated nasal septum).

Assessment

• Snoring: obstruction to airway through the nose and mouth and it may accompanied apnea.

Interventions

• Preparing a restful environment.• Comfortable bed: linen.• Good body alignment to decrease muscles

strain.• Quite and dark room with privacy.• Temp (thermal blanket, cotton sheets, leg

warmer, long underwear).

Interventions

• Promoting bedtime rituals: reading, music, listening to radio, TV, praying, talking to family, personal hygiene, taking snacks.

• Offering appropriate bed time snacks: carbohydrate snacks, avoid alcoholic, spicy food, avoid caffeine for at least 4-5 hours before sleep, or fluid.

• Promoting relaxation: stress and anxiety interfere with sleep so use backrub, warm bath, washing face.

Interventions

• Promoting comfort: one of the greatest deterrents to rest and sleep is pain. Measures: back message, extra blanket, analgesic.

• Using medication to produce sleep: sedative hypnotic induce sleep which loos its effects after 1-2 weeks.

• Sleep medications offer prn.• Teaching about rest and sleep.

Sleep hygiene • Sleep restriction: spend less time in bed to provide more

opportunity to sleep.• Use bed only for sleep.• Only go to bed when sleepy.• Get up if awake after 10 minutes.• Encourage activities such as reading, eating or watching TV

outside of bedroom.• Avoid caffeine product, nicotine, alcohol.• Hot bath (20 minutes).• Relaxation techniques.• Avoid large meals before sleep.• Avoid daytime naps.

Cognitive behavioral therapy

• Cognitive behavioral therapy (CBT): is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, “I will never fall asleep”. It uses actions intended to change behavior.

Light therapy

• The circadian rhythm is more a function of darkness and light rather than actual time of day. Bright light can discourage drowsiness, and darkness can cause sleepiness, day or night.

sleep and rest

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