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1. SLEEP
DISTERBANCES AND
ITS PATTERNS
HARISH KUMAR KUMAWAT
ASST. PROF.
PACIFIC MEDICAL UNIVERSITY,
TIRUPATI CLLEGE OF NURSING, UDAIPUR

2. GENERAL OBJECTIVES =)
• At the end of the seminar, student will be
able to gain the knowledge regarding
sleep disturbances & its patterns & apply
this knowledge into providing care to the
client.
05/02/17 06:53

3. SPECIFIC OBJECTIVE=)
At the end of the seminar student will be able
to,
Define sleep.
Discuss some facts about sleep.
Describe the differences in the sleeping
patterns.
Enlist the factors affecting the sleep.
Explain the physiology of sleeping patterns.
Define sleep regulation.
Discuss about the stages of sleep briefly.
05/02/17 06:53

4. Describe the lack of sleep affect the human body.
Explain the short term and long term consciquences
of sleep.
Explain international classification, sleep disorder
and its management.
Discuss nursing management of sleep
disturbances.
Explain role of nurse.05/02/17 06:53

5. Introduction:
When you have insomnia, you're never
really asleep, and you're never really
awake.
(From the movie Fight Club, based on the
novel by Chuck Palahniuk)
05/02/17 06:53

6. Definition:
SLEEP:- It is a periodic state of rest
accompanied by varying degree of
unconsciousness and relative inactivity.
(Taber’s Cyclopedic Medical Dictionary)
05/02/17 06:53

7. SOME FACTS ABOUT SLEEP YOU
PROBABLY DIDN'T KNOW
• The record for the longest period without sleep
is 18 days, 21 hours, 40 minutes during a
rocking chair marathon. The record holder
reported hallucinations, paranoia, blurred vision,
slurred speech and memory and concentration
lapses.
• It's impossible to tell if someone is really awake
without close medical supervision. People can
take cat naps with their eyes open without even
being aware of it
05/02/17 06:53

8. • Anything less than five minutes to fall
asleep at night means you're sleep
deprived. The ideal is between 10 and 15
minutes, meaning you're still tired enough
to sleep deeply, but not so exhausted you
feel sleepy by day.
• A new baby typically results in 400-750
hours lost sleep for parents in the first year
• Elephants sleep standing up during non-
REM sleep, but lie down for REM sleep
05/02/17 06:53

9. • Ducks at risk of attack by predators are able to
balance the need for sleep and survival, keeping
one half of the brain awake while the other slips
into sleep mode.
• British Ministry of Defence researchers have been able to
reset soldiers' body clocks so they can go without sleep
for up to 36 hrs. Tiny optical fibres embedded in special
spectacles project a ring of bright white light (with a
spectrum identical to a sunrise) around the edge of
soldiers' retinas, fooling them into thinking they have just
woken up. The system was first used on US pilots during
the bombing of Kosovo
05/02/17 06:53

10. • Seventeen hours of sustained wakefulness leads
to a decrease in performance equivalent to a
blood alcohol-level of 0.05%.
• The 1989 Exxon Valdez oil spill off Alaska, the
Challenger space shuttle disaster and the
Chernobyl nuclear accident have all been
attributed to human errors in which sleep-
deprivation played a role.
05/02/17 06:53

11. • After five nights of partial sleep
deprivation, three drinks will have the
same effect on your body as six would
when you've slept enough
• Experts say one of the most alluring sleep
distractions is the 24-hour accessibility of
the internet.
05/02/17 06:53

12. PHYSIOLOGY OF SLEEP:
• Sleep is a cyclical physiological process that alternates
with longer periods of wakefulness. The sleep-wake
cycle influences and regulates physiological function
and behavioral responses.
• Circadian rhythms: People experience cyclical
rhythms as part of their everyday life. The most
familiar rhythm is the 24 hr, day-night cycle known as
the diurnal or circadian rhythm (derived from Latin:
circa, “about,” and dies, “day”).
05/02/17 06:53

13. • Circadian rhythms influence the pattern of major
biological and behavioural functions.
• The fluctuation and predictability of body
temperature, heart rate, blood pressure, hormone
secretion, sensory acuity and mood depend on
the maintenance of the 24-hours circadian cycle.
05/02/17 06:53

14. • Circadian rhythms, including daily sleep-wake
cycles, are affected by light and temperature and
external factors such as social activities and
routines work.
• All persons have biological clocks that
synchronize their sleep cycles.
• Some people can fall asleep at 8 pm, whereas
other go to bed at midnight or early in the
morning.
• Different people also function best at different
times of the day.05/02/17 06:53

15. SLEEP REGULATION:
• Sleep involves a sequence of physiological states
maintained by highly integrated central nervous
system (CNS) activity that is associated with
changes in the peripheral nervous, endocrine,
cardiovascular, respiratory, and muscular systems.
• Each sequence can be identified by specific
physiological responses and patterns of brain
activity.05/02/17 06:53

16. • Instruments such as the EEG, EMG, and
the EOG provide information about
some structural physiological aspects of
sleep.
• Current theory indicates sleep is thought
to be an active inhibitory process.
05/02/17 06:53

17. • Therefore, the control and regulation of sleep
may depend on the interrelationship between two
cerebral mechanism that intermittently activate
and suppress the brain’s higher centers to
control sleep and wakefulness .
• One mechanism causes wakefulness, whereas
the other causes sleep.
05/02/17 06:53

18. SLEEP REGULATION (Contd….)
• The ascending reticular activating system (RAS)
located in the upper brain stem is believed to
contain special cells that maintain alertness and
wakefulness.
• The RAS receives visual, auditory, pain, and
tactile sensory stimuli. Activity from the cerebral
cortex (emotions or thought)also stimulates the
RAS.05/02/17 06:53

19. SLEEP REGULATION (Contd….)
• Wakefulness results from neurons in the RAS
that release catecholamines such as
norepinephrine.
• Sleep may be produced by the release of
serotonin from specialized cells in the raphe
sleep system of the pons and medulla. This
area of the brain is also called the bulbar
synchronizing region (BSR).05/02/17 06:53

20. • As people try to fall asleep, they close
their eyes and assume relaxed position.
Stimuli to the RAS decline.
• If the room is dark and quiet, activation of
the RAS further declines. At some point
the BSR takes over, causing sleep.
05/02/17 06:53

21. Disturbance in the cycle
• Typical routines cause interruptions in sleep or
prevent clients from falling asleep at their usual
time.
• If a person’s sleep-wake cycle is altered
significantly, a poor quality of sleep can result.
Reversals in the sleep-wake cycle such as falling
asleep during the day (or vice versa for people who
work nights) can indicate a serious illness.
05/02/17 06:53

22. • Anxiety,
• restlessness,
• irritability, and
• impaired judgment
• The biological rhythm of sleep frequently
becomes synchronized with other body
functions. Changes in body temperature,
for example, correlate with sleep patterns.
05/02/17 06:53

23. • When the sleep-wake cycle becomes disrupted (e.g
by working rotating shifts), other physiological
functions may change.
• Decreased appetite
• Lose weight.
• Failure to maintain the individual’s usual sleep-wake
cycle can adversely influence the client’s overall
health.05/02/17 06:53

24. STAGES OF SLEEP
• Five stages
• 1, 2, 3, 4 and REM (rapid eye movement).
• These stages progress cyclically from 1 through
REM then begin again with stage 1.
• A complete sleep cycle takes an average of 90
to 110 minutes.
05/02/17 06:53

25. Stages
• Stage 1
– light sleep
– can be awakened easily.
– the eyes move slowly
– muscle activity slows.
– many people experience sudden muscle
contractions preceded by a sensation of
falling.
05/02/17 06:53

26. Stage 2
– eye movement stops
– brain waves become slower with only an
occasional burst of rapid brain waves.
Stage 3: When a person enters stage 3,
extremely slow brain waves called delta
waves are interspersed with smaller, faster
waves.
05/02/17 06:53

27. Stages
stage 4:
• The brain produces delta waves almost
exclusively.
• Stages 3 and 4 are referred to as deep sleep,
• very difficult to wake
• no eye movement or muscle activity.
• This is when some children experience
bedwetting, sleepwalking or night terrors.
05/02/17 06:53

28. REM Period:
• Breathing becomes more rapid, irregular and
shallow, eyes jerk rapidly and limb muscles
are temporarily paralyzed.
• Brain waves during this stage increase to
levels experienced when a person is awake.
• heart rate increases, blood pressure rises,
males develop erections and the body loses
some of the ability to regulate its temperature.
05/02/17 06:53

29. • This is the time when most dreams
occur, and, if awoken during REM
sleep, a person can remember the
dreams. Most people experience three
to five intervals of REM sleep each
night.
05/02/17 06:53

30. NORMAL SLEEP REQUIREMENTS &
PATTERNS
• Sleep duration and quality vary among
persons of all age groups
Sr.
no
Age group Sleep pattern
1 Infant 16 hours/day
2 Toddler 12 hours/day
3 Preschooler 11 hours/day
4 Schooler 9 -10hours/day
5 Adolescence 8-9 hours/day
6 adult 6-8 hours/day
05/02/17 06:53

31. FACTORS AFFECTING SLEEP
1. Physical illness (eg. Nausea, mood
disorders, breathing difficulty, pain)
2. Drugs and substances (eg. Tryptophan)
3. Lifestyle (eg. Daily routines, exercises)
4. Usual sleep patterns
5. excessive daytime sleepiness
05/02/17 06:53

32. 6) Emotional stress
7) Environment( ventilation)
8) Sound
9) Exercise and fatigue
10)Food and caloric intake)
11)Smoking, alcohol drinkers.05/02/17 06:53

33. Sleep Deprivation
• Sleep deprivation has become one of the
most pervasive health problems.
• It is estimated that people on average now
sleep one and a half hours less than people
did a century ago.
• lack of sleep can have dramatic effects on
quality of life.05/02/17 06:53

34. How does a lack of sleep affect
the body?
• A person who loses one night’s sleep will
generally be irritable and clumsy during
the next day and will either become tired
easily or speed up because of adrenalin.
• After missing two night’s sleep, a person
will have problems concentrating and will
begin to make mistakes on normal tasks.
• Three missed nights and a person will start
to hallucinate and lose grasp of reality.
05/02/17 06:53

35. • In 1997 study found that people whose
sleep was restricted to four to five hours
per night for one week needed two full
nights of sleep to recover performance,
alertness and normal mood.
• Sleep deprivation reduces emotional
intelligence and constructive thinking skills.
05/02/17 06:53

36. Other short-term consequences
• Decreased daytime alertness.
• Impaired memory and cognitive ability,
• Occupational injury.
• Impaired immune system.
05/02/17 06:53

37. Long-term consequences
• High blood pressure
• Heart attack
• Heart failure
• Stroke
• Psychiatric
• Mental impairment
• Increased mortality
risk
• Relationship
problems with a bed
partner
• Obesity
05/02/17 06:53

38. SLEEP DEPRIVATION AND
EUPHORIA
• Sleep deprivation gives a lot of people a buzz.
Especially in the first night of staying up, many
people experience euphoria.
• sleep deprivation can even be a short-term way to
address depression. The effects of depression
decline.
05/02/17 06:53

39. • Total sleep deprivation for a whole night
improves symptoms in 40-60% of patients
.
• Sleep restriction is not a viable treatment
for depression on an outpatient basis.
• Supervision is required.
05/02/17 06:53

40. SLEEP DEPRIVATION IN CHILDREN
• Sleep deprivation is particularly a problem for
children.
• In studies of elementary aged children, nearly
40% had some type of sleep problem, 15%
exhibited bedtime resistance and 10% had
daytime sleepiness.
• Nearly half of teens reported at least occasional
difficulty in falling or staying asleep and almost
13% experiencing chronic and severe insomnia.
05/02/17 06:53

41. • This lack of sleep greatly affects mood,
behavior, and academic performance.
• Insufficient sleep has also been associated
with Attention Deficit Hyperactivity
Disorder (ADHD), lower social skills and
learning difficulties.
05/02/17 06:53

42. THE INTERNATIONAL
CLASSIFICAITON OF SLEEP
DISORDERS
1. DYSSOMNIAS
• A. Intrinsic Sleep Disorders
• B. Extrinsic Sleep Disorders
• C. Circadian Rythm Sleep Disorders
2. PARASOMNIAS
• A. Arousal Disorders
• B. Sleep-Wake Transition Disorders
• C. Parasomnias usually asscociated with REM Sleep
• D. Other Parasomnias
3. MEDICAL/PSYCHIATRIC SLEEP DISORDERS
• A. Associated with Mental Disorders
• B. Associated with Neurological Disorders
• C. Associated with Other Medical Disorders
05/02/17 06:53

43. 4) Proposed Sleep disorders
Sr.
no.
Diseases Categiry
1
Short Sleeper 307.49-0
2
Long Sleeper 307.49-2
3
Sub-wakefulness Syndrome 307.47-1
4
Fragmentary Myoclonus 780.59-7
5 Sleep Hyperhidrosis 780.8
6 Menstrual-Associated
Sleep Disorder
780.54-3
7
Pregnancy-Associated Sleep Disorder
780.59-6
05/02/17 06:53

44. Sr.
no.
Disease categiry
8
Terrifying Hypnagogic Hallucinations
307.47-4
9
Sleep-Related Neurogenic Tachypnea
780.53-2
10
Sleep-Related Laryngospasm 780.59-4
11
Sleep Choking Syndrome 307.42-1
05/02/17 06:53

45. Types of sleep disorders
Sleep disorders are generally put into one of
these three categories:
• Disturbed sleep
• Excessive sleep
• Lack of sleep
• Lack of sleep, which is most commonly known
as insomnia, is the most common type of sleep
disorder.
05/02/17 06:53

46. Common Sleep Disorders
Insomnia
• Insomnia tends to increase with age and affects
about 40 percent of women and 30 percent of
men.
• Insomnia includes not only difficulty falling
asleep (this is called sleep-onset insomnia) but
also waking up to early and not being able to fall
back asleep (sleep-maintenance insomnia),
frequent awakenings, and waking up feeling un-
refreshed.
05/02/17 06:53

47. Symptoms of insomnia
• Sleepiness
• Fatigue,
• Decreased alertness
• Poor concentration
• Decreased performance
• Depression during the day and night
• Muscle aches and an overly emotional
state.
05/02/17 06:53

48. Types of insomnia
• Primary Insomnia
• Secondary Insomnia
• Chronic insomnia
• Rebound Insomnia
• Altitude Insomnia
• Insomnia related to substance use
05/02/17 06:53

49. Primary Insomnia
• Primary insomnia is sleeplessness that cannot be attributed to
some other cause. An estimated 10% of the population has
primary insomnia.
• A patient with primary insomnia must experience difficulty in
falling asleep, difficulty in staying asleep, early awakening, or
non-restorative, poor quality sleep.
• The trouble sleeping must be associated with daytime symptoms.
These can include fatigue, trouble concentrating, memory or
mood disturbances, tension, headaches.
05/02/17 06:53

50. Secondary Insomnia
• Secondary insomnia is a result of other causes-illness,
drugs (including caffeine and alcohol), excessive worrying,
pain, etc.
• Depression is a leading cause of secondary insomnia.
• Secondary insomnia causes include stress, arthritis, and
drinking too much coffee. The insomnia is a sequela of
another problem.
• Secondary insomnia is more common than primary
insomnia.05/02/17 06:53

51. Chronic insomnia
• insomnia that goes on for a month or more
– is often considered chronic insomnia.
• Doctors attack insomnia directly (rather
than an unknown “underlying cause”) to
help the patient achieve a better quality of
life.
05/02/17 06:53

52. Rebound Insomnia
• Rebound insomnia is when you can’t sleep
after coming off sleeping pills. Your brain
and body have adjusted to the sleep
medication to some extent and almost
anticipate it.
05/02/17 06:53

53. Altitude Insomnia
• The term “altitude insomnia” is used when
people can’t sleep after climbing a mountain.
• More properly, there is a condition called
Acosta’s syndrome, or hypobaropathy, or altitude
sickness, which can have many symptoms,
including sleeplessness.
• Sensitive individuals experience this when they
go up as little as 2000 ft in elevation.05/02/17 06:53

54. insomnia related to substance
use
• Substance use refers to alcohol, stimulants,
drugs (including sleep aids, both prescription and
over the counter.)
• Substances are often used in tandem,
compounding the effect and making identifying
the cause of the sleeplessness difficult.
05/02/17 06:53

55. Treatment
Medication
– Non-benzodiazepine hypnotics, antidepressants and
hypnotics are prescribed.
behavioral strategies
– Sleep restriction — only sleeping in the bed and only
staying in bed when sleeping (falling asleep within
25 minutes of lying down);
– Stimulus control — reserving the bedroom for sleep ;
– Relaxation techniques;
– Avoidance of caffeine and alcohol;
– Cognitive behavioral therapy with the help of a
psychologist.
05/02/17 06:53

56. Menopause and insomnia
• Sleep onset insomnia (trouble getting to sleep)
and sleep maintenance insomnia (trouble staying
asleep) commonly increase during
perimenopause and menopause.
• The International Classification of Sleep
Disorders includes premenstrual insomnia and
premenstrual hypersomnia under the category of
menstrual-associated sleep disorder.
05/02/17 06:53

57. Sleep Apnea
• The most studied sleep disorder is apnea, a
cessation of breathing during sleep.
• Sleep apnea is a sleep disorder that causes
breathing to repeatedly stop and start.
• This can cause discomfort to both the sufferer
and a significant other, who may be disturbed by
the loud snoring that accompanies sleep apnea.
05/02/17 06:53

58. Types of sleep apnea
1. Central sleep apnea:- Central sleep apnea
involves relaxation of the throat muscles
2. Complex sleep apnea (combination of
obstructive sleep apnea and central sleep
apnea)
3. Obstructive sleep apnea:- Obstructive sleep
apnea involves a lack of brain signals that
control breathing.
Older adults and men are far more likely to
suffer from sleep apnea.
05/02/17 06:53

59. Sleep and Depression
• Many people do not realize that sleep and
depression are linked.
• One of the signs of depression is insomnia, also
known as lack of sleep or inability to sleep.
• Insomnia can also play a role in the
development of depression.
• Medication, sleep techniques and certain types
of therapy can help those who have problems
with sleep and depression.
05/02/17 06:53

60. Sleep Inertia
• It is a transitional state between sleep and
wakefulness.
• Sleep inertia refers to the feeling of grogginess
most people experience after awakening.
• Sleep inertia can last from 1 minute to 4 hours,
but typically lasts 15-30 minutes.
05/02/17 06:53

61. • During this period, you are at a reduced level
of capacity and may have trouble doing even
simple everyday actions.
• Awakening during a stage 3 or 4 sleep
produces more sleep inertia than awakening
in stage 1 or 2.
05/02/17 06:53

62. • Usually people fully “wake up” in a half hour at
most. For many, the morning routine of a shower
or making coffee helps them through the inertial
period.
• Drowsy driving – a lot of drowsy driving
accidents happen early in the morning, not when
the driver has been up too long, but when he or
she has recently awoken and is still suffering
from sleep inertia. Sleep inertia in a driver behind
the wheel can be very dangerous as the
impairment of motor and cognitive functions and
can affect a person's ability to drive safely.
05/02/17 06:53

63. Snoring
05/02/17 06:53

64. • Snoring is a strong marker for sleep apnea
and upper airway resistance.
• Simple snoring (without apnea) is
sometimes considered to be at the mildest
end of the sleep disordered breathing
spectrum and is likely to progress.
05/02/17 06:53

65. • Snoring is not benign according to many experts.
A study found that snoring was positively
associated with the hypertension, cardiovascular
disease, and diabetes.
• The only intervention strategy accepted at
present is weight loss.
05/02/17 06:53

66. Narcolepsy
• These “sleep attacks” can last from several
seconds to more than 30 minutes and can include
cataplexy, hallucinations and temporary paralysis
upon awakening.
• The disorder is usually hereditary though it can
be brought on by brain damage or neurological
disease.
05/02/17 06:53

67. • Symptoms usually appear during adolescence.
• Stimulants, antidepressants and other drugs can
help control the symptoms.
• Behavioral measures to control symptoms
include strategically timed naps, regular timing of
nighttime sleep and avoidance of alcohol and
heavy meals.
05/02/17 06:53

68. Restless Legs Syndrome
• For about 15% of the population, sleep is made difficult
by Restless Legs Syndrome (RLS), an unpleasant
crawling, prickling or tickling sensation in the legs and
feet and the urge to walk or move them to find relief.
• Although not considered serious medically, RLS makes it
difficult to fall asleep and stay asleep.
05/02/17 06:53

69. Sleep Bruxism
• The word bruxism is derived from the
Greek and means gnashing of the teeth.
• In simple terms “sleep bruxism” means
grinding of teeth during sleep.
05/02/17 06:53

70. NURSING PROCESS
• Assessment: Assess client’s usual sleep
habits and recent sleep quality
If sleep quality is reported to be poor, explore the
nature of disturbances by noting the following:
• Usual activities in the hour before retrieving
• Sleep latency
• Number and perceived cause of awakenings
• Regularity of sleep pattern
05/02/17 06:53

71. • Frequency and duration of naps
• Events associated with initial onset of
sleep disturbances
• Situations in which client fights sleepiness
• Daily caffeine intake
• Use of alcohol, sleeping pills, and other
medications05/02/17 06:53

72. • Incidence of morning headaches
• Frequency of snoring, apparent pauses in
breathing, and kicking movements
• Objective data may include visible signs of
fatigue and lack of sleep, such as circles
under the eyes, lack of coordination,
drowsiness and irritability.05/02/17 06:53

73. Nursing Management
Nursing Diagnosis
1.Sleep pattern disturbances related to (specific
medical condition); use of , or withdrawal from,
substances; anxiety or depression; circadian
rhythm disruption; familial patterns; evidenced by
insomnia, hypersomnia, nightmares, sleep
terrors, or sleepwalking.
05/02/17 06:53

74. Outcome criteria
• Client will be able to achieve adequate,
uninterrupted sleep
• Client will report feeling rested and
demonstrate a sensation of wellbeing.
05/02/17 06:53

75. Nursing Interventions
• To promote sleep
– Encourage activities that prepare one for sleep:
soft music, relaxation exercise, warm bath
– Discourage strenuous exercise within 1 hr of
bedtime
– Control intake of caffeine-containing substances
within 4 hr of bedtime.
– Provide a high-carbohydrate snack before bedtime
– Keep the temp of the room between 68°F and
72°F
– Instruct the client not to use alcoholic beverages
– Discourage smoking and daytime napping05/02/17 06:53

76. Nursing diagnosis 2
• Risk for injury related excessive
sleepiness, sleep tremors, or
sleepwalking.
Outcome criteria
• Client will not experience injury
05/02/17 06:53

77. Nursing interventions
• Ensure that siderails are up on the bed.
• Keep the bed in a low position
• Equip the bed with a bell that is activated
when the bed is exited
• Keep a night light on and arrange the
furniture in the bedroom in a manner that
promotes safety.
• Administer drug therapy as ordered.
05/02/17 06:53

78. ROLE OF NURSE
• Preparing a restful environment
• Promoting bedtime rituals
• Offering appropriate bedtime snacks and
beverages
• Promoting relaxation
• Promoting comfort
05/02/17 06:53

79. • Respecting normal sleep patterns
• Scheduling nursing care to avoid
unnecessary disturbances
• Using medication to produce sleep
• Teaching about rest and sleep
05/02/17 06:53

80. Research Input
• Association of physical activity and human
sleep disorders. (Archives of Internal Medicine
(1998, September 28), 158, 1894-1898)
This was the study of 319 men and 403 women who were
taking part in the Tucson epidemiologcal study of
obstructive airways disease. Part of the study
includedcompleting health questionnaires related to
physical exercises and sleep disorders.
Results: A program of regular exercise may be a useful
therapeutic modality for clients with sleep disorders.
05/02/17 06:53

81. SUMMARY
• Introduction
• Facts about sleep
• Definition
• Physiology of sleep
• Sleep regulation
• Stages of sleep
• Sleep deprivations
• Types of sleep disorders
• management
05/02/17 06:53

82. Resources
• Taber’s; Cyclopedic Medical Dictionary; copyright in
1997by F. A. Davis Company; published by JAYPEE
Brothers; 18th
edition; page no.1771.
• Essential of medical physiology; K Sembulingam; Prema
Sembulingam; 4th
edition;published by JAYPEE brothers
medical publishers; page no.400, 775,773,834-838.
• Fundamental of nursing; standard and practice; 2nd
edition; Syc. Delaune; patricia K. Ladner; page no.942-
950.
• A concise text book of Advanced Nursing practice;
Shebeer. P. Basheer; S. Yaseen Khan; published by
EMMESS medical publishers; 1st
edition 2012; page no.
273-284.05/02/17 06:53

83. • Mayo Clinic (2007). Insomnia. Retrieved January 2,
2008, from the Mayo Clinic Web site:
http://www.mayoclinic.com/health/insomnia/DS00187.
• Mayo Clinic (2006). Sleep Apnea. Retrieved January 2,
2008, from the Mayo Clinic Web site:
http://www.mayoclinic.com/health/sleep-apnea/DS00148.
• MedicineNet (2005). Sleep Disorders: Sleep and
Depression. Retrieved January 2, 2008, from the
MedicineNet Web site:
http://www.medicinenet.com/script/main/art.asp?
articlekey=47548.
05/02/17 06:53

84. `
I Can’t
Sleep
Stop thinking
about your
research protocol
submission!!
05/02/17 06:53

85. 05/02/17 06:53