This document discusses sleep, sleep disturbances, and factors that affect sleep. It covers the importance of sleep, circadian rhythms, sleep stages and cycles, functions of sleep, common sleep disorders, and how factors like lifestyle, medications, and medical conditions can impact sleep. Globally, around 150 million adults suffer from sleep disorders with insomnia being the most common. Sleep requirements vary by age, from 15-18 hours per day for newborns to 7-8 hours for adults. Proper sleep is essential for restoration of physiological and cognitive functions.

1. SLEEP
DISTURBANCES
NAVREET KAUR SAINI

2. INTRODUCTION
 Proper rest and sleep are as important as good
nutrition and adequate exercise for a good health.
 Different individuals need different amounts of sleep
and rest. Physical and emotional health depends on
ability to fulfill these basic needs.
 Without proper amounts of rest and sleep, the
ability to concentrate, make judgments, and
participate in daily activities decreases and
irritability increases.

3. SLEEP
 State of rest accompanied by altered state of
consciousness from which a person can be
aroused by sensory or other stimuli.
 It is a complex rhythmic state involving a
progression of repeated cycles, each representing
different phases of body and brain activity.
 Sleep-wake cycle influences behavioural &
physiological responses in an individual.

4. INCIDENCE OF SLEEP DISORDERS
 GLOBAL-150 million adults are suffering from sleep
disorders in the world.
 INSOMNIA
1. 16.6% population of developing nations.
2. 20% population of developed nations
o INDIA
 Very low prevalence rates.
 5% indians aged more than or equal to 50 are suffering
from sleep disorders.
 6.5% of indian women ( 3.7% severe depression ,
2.8% severe anxiety) are suffering
 4.3% of indian men ( 4% severe depression , 3% severe
anxiety ) are suffering.

5. INCIDENCE DEVELOPING NATIONS

6. FUNCTIONS OF SLEEP
 Restores physiological and psychological function
 NREM sleep body conserves energy.
 Biological functions slow in this stage.
 NREM sleep contributes to body tissue restoration

7. FUNCTIONS OF SLEEP
 During NREM stage 4 sleep, body release growth
hormone.
 Further protein synthesis and cell division occur
during the rest and sleep.
 SO NREM sleep especially important for children.
 REM SLEEP is essential for brain tissue or
cognitive restoration.
 Assist with memory storage and learing.

8. PHYSIOLOGY OF SLEEP
 A cycle of normal sleep lasts about 90 – 110 mints
 It is repeated 4-6 times during night.
 Physiologic state of sleep is marked by :
 Reduced consciousness or relative unconsciousness
 Diminished activity of the skeletal or voluntary muscles
and decreased metabolism

9. PHYSIOLOGY OF
SLEEP

10. PHYSIOLOGY OF SLEEP
Impulse from peripheral
sensory receptors and cerebral
cortex stimulates RAS
Stimulation of RAS neurons
releases epinephrine
Wakefulness occurs

11. PHYSIOLOGY OF SLEEP(CONTND…
Decrease in
environmental
stimulus
Decline on
stimulus to
RAS
BSR
stimulated
Serotonin
released from
BSR
Sleep occurs

12. CIRCADIAN RHYTHM
 24 hr, day-night cycle/ diurnal cycle
 The neural basis - the suprachiasmatic nuclei
 This sleep wake cycle is affected by light, temp. and
external factors like social activities, work routine.

13. CONTIUED…..
 Circadian Synchronization
 So the fluctuation and predictability of body
temperature, heart rate, BP, hormone secretion,
sensory acuity, and mood depend on the
maintenance of the 24hr circadian cycle.

14. EFFECT OF DISTURBED
CIRCADIAN CYCLE
 Causes interruption in sleep and prevent from
falling asleep at usual time and can result in poor
quality of sleep.
 Reversals in sleep wake cycle such as falling
asleep during day(or vice versa for people who
work nights) can indicate a serious illness.

15. STAGES OF SLEEP
 Normal sleep involves two phases:
 Non rapid eye movement (NREM)sleep
 Rapid eye movement(REM) sleep
the term coined in 1952 by Fredrick Van Eeden

16. EEG WAVES

17. STAGES OF SLEEP
 PRESLEEP PERIOD..
In this person is aware of a gradully developing
sleepiness.
Normally lasts for 10 to 30 minutes.
 LIGHT SLEEP, NREM STAGE 1 and 2
 DEEP SLEEP, NREM STAGE 3 and 4
 REM
The qualilty of sleep becomes increasingly deep.

18. STAGES OF SLEEP
NREM SLEEP
 lasts about four to six
hours
 restore and rebuild the
body after a long period
of wakefulness
 superficial dreams occur
 less likely to involve
visual images and are
more frequently
forgotten.
 No rapid eye movement
REM SLEEP
 Lasts two hours a night
 Processing of
information, problem
solving, memory
consolidation and
creativity.
 real dreams occur
 wild fluctuations in body
metabolism
 Bursts of rapid eye
movements

19. NREM STAGE 1
 Lightest level of sleep.
 Lasts a few minutes.
 2-5% of sleep time
 Transition from alpha waves to theta waves.
 physiological activity begins to decrease.
 Gradual fall in vital signs and metabolism and
conscious awareness of the external environment
 Person is aroused easily.
 Involuntary muscle jerking may occur

20. NREM STAGE 2
 Period of sound sleep.
 45% to 55% of total sleep in adults
 Sleep spindles and k-complexes
 Body functions continue to slow
 Relaxation progresses
 Conscious awareness of the external environment
disappears
 Arousal remains relatively easy.
 Stage lasts 10 to 20 minutes.

21. NREM STAGE 3
 Involves initial stages of deep sleep / slow wave
sleep.
 Muscles are completely relaxed.
 Sleeper is difficult to arouse and rarely moves.
 Vital signs decline but remain regular.
 Stage lasts 15 to 30 minutes.

22. NREM STAGE 4
 Deepest stage of sleep called “delta sleep”
 Very difficult to arouse sleeper.
 Lasts 15 to 30 minutes.
 Growth hormone reaches peak levels in stage 4
 Usually appears only in the first 1/3 of the sleep
episode
 Sleepwalking, nocturnal enuresis, night terrors may
occur.

23. REM SLEEP
 20%–25% of total sleep time.
 Vivid, full color dreaming may occur
 Stage usually begins 90 minutes after sleep has
begun
 Duration increases with each cycle and averages
20 mints.
 Loss of muscle tone occurs
 Fluctuation in heart rate &BP occurs.
 Very difficult to arouse sleeper.

24.  With each successive cycle, stages 3 and 4 shorten
and the period of REM lengthens.
 The amount of time spent in each stage varies over
the life span.
 NEWBORNS and CHILDREN spend more time in
deep sleep.
 With AGEING sleep becomes fragmented and more
time is spent in lighter stages.
 Shifts to light sleep or wakefulness from deep sleep
tend to occur suddenly and vice versa.

25. SLEEP REQUIREMENTS AND PATTERNS
 Newborn sleeps 15-18 hours in one 24 hour day.
 Approximately 50% is REM Sleep.

26. SLEEP REQUIREMENTS AND PATTERNS
 Toddlers require two naps, one in the morning and
another in the afternoon.
 Toddlers are sleeping a total of 13 or 14 hours per
day
 Percentage of REM Sleep falls
 May be unwilling to go to bed
at night may be due to need for 4
autonomy or fear of separation
from parents.
.

27. SLEEP REQUIREMENTS AND PATTERNS
Children under age of 5 years:
10 to 12 hrs of sleep is required.

28. SLEEP REQUIREMENTS AND PATTERNS
ADOLOSCENT-8 TO 10 HRS

29. SLEEP REQUIREMENTS AND PATTERNS
Adult:7-8 hrs
Pregnant ladies:8-10 hrs
Elderly:5-7 hrs

30. DREAMS
 Dreaming is the perceived experience of sensory
images and sounds during sleep, in a sequence
which the dreamer usually perceives more as an
apparent participant than as an observer.
 Stimulated by the pons.
 Mostly occurs during the REM phase of sleep

31. DREAMS
 Sigmund Freud postulated that dreams are the
symbolic expression of frustrated desires that had
been relegated to the unconscious mind
 John Allan Hobson and Robert
McCarley's Activation Synthesis Theory
Dreams are caused by the random firing of neurons in
the cerebral cortex during the REM period. The forebrain then
creates a story in an attempt to reconcile and make sense of
the nonsensical sensory information presented to it;
hence,there is the odd nature of many dreams.

32. DREAMS
 Analysis of dreams is used as a part of
psychotherapy.
• Content of dreams
Personal experiences from the last day or
week are frequently incorporated into
dreams.
 Emotions
Sex themes
 Recurring dreams
 Color Vs black & white

33. SLEEPING POSITION & YOUR PERSONALITY
The Foetus: tough on the
outside but sensitive at heart.
They may be shy when they first
meet somebody, but soon relax.
This is the most common
sleeping position, adopted by
41% . Men : women = 1:2

34. SLEEPING POSITION & YOUR PERSONALITY
 Log (15%): Lying on your side with both arms down
by your side. Are easy going, social people who like
being part of the in-crowd, and who are trusting of
strangers. However, they may be gullible.

35. SLEEPING POSITION & YOUR PERSONALITY
 The yearner (13%): People who sleep on their side
with both arms out in front are said to have an open
nature, but can be suspicious, cynical. Are slow to
make up their minds, but once they have taken a
decision, they are unlikely ever to change it.
 Soldier (8%): Lying on
back with both arms pinned to
sides. Generally quiet and
reserved. They don't like a fuss,
but set themselves and others
high standards.

36. SLEEPING POSITION & YOUR PERSONALITY
Freefall (7%): Lying on front with hands
around the pillow, and head turned to one
side. Often gregarious and brash people,
but can be nervy and thin-skinned
underneath, and don't like criticism, or
extreme situations.
.

37. SLEEPING POSITION & YOUR PERSONALITY
 Starfish (5%): Lying on back with both arms up
around the pillow. These sleepers make good
friends because they are always ready to listen to
others, and offer help when needed. They generally
don't like to be the centre of attention.

38. SLEEPING POSITION & YOUR
PERSONALITY
Back sleeper with legs
crossed : self
obsessed & find
difficulty in accepting
changes. Solitude is
your priority

39. SLEEPING POSITION & YOUR PERSONALITY
 Back sleeper with arms & leg spread out: Liberty
loving soul! Comfort lover & beauty worshipper
and also a spendthrift. A bit nosy & seem to
enjoy gossiping.

40. FACTORS AFFECTING SLEEP…
 Drugs and substances..eg
 Hypnotics- interfere with reaching deep stages.
 Diuretics- nighttime awakening due to nocturia
 Antidepressants & stimulants- suppress REM
sleep
 Anticonvulsants- decrease REM sleep time.
 Beta adrenergic blockers- cause insomnia,
nightmares, awakening from sleep.
 Alcohol- speeds onset of sleep, awakening during
night, difficulty returning to sleep.
 Caffeine- prevents from falling asleep.

41. CONTINUED…..
 Lifestyle- rotating shifts,heavy work, late night
social activities, changing evening mealtime.
 Unsual sleep patterns- sleep deprivation due to
active social evening or lenghtened work schedule.
 Emotional stress
 Environment
 Exercise and fatigue
 Food and calorie intake
 Illness
 Age

42. FACTORS AFFECTING SLEEP

43. SLEEP DISORDERS

44. CLASSIFICATION OF SLEEP DISORDERS
 Disorders of initiating & maintaining sleep
(DIMS)
Eg : insomnia, sleep wake schedule disorders:
Cataplexy, sleep apnea, JLS, SWSD.
 Disorders of excessive somnolence (DOES)
Eg : narcolepsy
 Parasomnia
Somnambulism, somniloquy, sleep taking, enuresis,
SIDS.

45. SLEEP LABORATORY STUDIES
1. Nocturnal polysomnogram
2. Multiple sleep latency test
3. Actigraphy
4. Unobtrusive videotaping

46. DISORDERS OF INITIATING & MAINTAINING SLEEP
(DIMS)
 Difficulty in falling asleep
 Early morning awakenings
 Waking during night
 May have transient / persistent pattern
 An association with mental illness/ use of or
withdrawal from drugs including alcohol/ and
medical illness

47. INSOMNIA
 Chronic difficulty falling asleep, intermittent
sleep, or early awakening from sleep.
 Most common sleep related complaint
 High risk for:
 Individuals older than 60 years of age, having
chronic pain, menopausal & pregnant women, and
persons with a history of depression
 Occurs more frequently in women and is women’s
most common sleep problem( National Sleep
Foundation)

48. INSOMNIA CONTD…
Causes
 Stress…situational stress leads to transient insomnia.
 Age
 Poor sleep habits
 Pain
 Situations involving some change in normal environment
 Jet lag
 Medications & substance abuse
Clinical manifestations
 Tiredness, lethargy, and irritability during the day.
 Difficulty concentrating
 Depression
 Hypersomnia- condition characterized by excessive sleep,
particularly during the day.

49. INSOMNIA CONTD…
 Transient or intermittent- treatment is unnecessary
 Chronic insomnia- lasts > 3weeks and may
continue lifelong
 Cause- depression, behavioral factors

50. INSOMNIA TREATMENT
 Chronotherapy – Behavioral technique in which
bedtime is systematically delayed each day until
the desired bedtime is reached. Later on a rigid
bedtime & morning rising schedule is
maintained.
 Phototherapy / bright light therapy – in patients
with delayed sleep phase-exposure to bright light
on awakening

51. AEROBIC EXERCISE IMPROVES SELF-
REPORTED SLEEP AND QUALITY OF LIFE IN
OLDER ADULTS WITH INSOMNIA
 Objective
 To assess the efficacy of moderate aerobic physical
activity with sleep hygiene and education regarding
improving sleep , mood and quality of life in older
adults with chronic insomnia.
 Methods
 Seventeen sedentary adults aged ⩾55 years
with insomnia (mean age 61.6 [SD ± 4.3] years; 16
female) participated in a randomized controlled trial
comparing 16 weeks of aerobic physical activity
plus sleep hygiene to non-physical activity
plus sleep hygiene

52. RESEARCH INPUT CONTND…
Results
 The physical activity group improved
in sleep quality on the global PSQI (p <
.0001), sleep latency (p = .049), sleep duration
(p = .04), daytime dysfunction (p = .027),
and sleep efficiency (p = .036) PSQI sub-scores
compared to the control group.
Conclusion
 Aerobic physical activity with sleep hygiene is an
effective treatment approach to improve sleep
quality, mood and quality of life in older adults
with chronic insomnia.

53. SLEEP- WAKE SCHEDULE DISORDERS
1. Cataplexy:
 Is a sudden and transient episode of muscular weakness or
hypotonia caused by reduced levels of neurotransmitter
hypocretin.
 Triggered by emotions like anger, fear, surprise.
 Person falls into deepest stage of REM sleep immediately and
without warning
 Duration of attack: few seconds upto 10 minutes.
 Clinical features
 knee or leg buckling, jaw sagging, & head drooping
 Slurred speech
 impaired vision (double vision, inability to focus)
 hearing and awareness remain normal.

54. 2. SLEEP APNEA
 lack of airflow through the nose and mouth for
periods of 10 seconds or longer during sleep
 lasts from a few seconds to minutes
 May occur 5 to 30 times or more an hour.
 Symptoms
• Excessive daytime sleepiness -primary symptom.
• snoring, snorting, and gasping sounds while
sleeping
• Restless or unrefreshing sleep and headaches in
the morning
 Diagnosed with a polysomnogram or a "sleep
study".

55. PATHOPHYSIOLOGY OF SLEEP APNEA

56. 2. SLEEP APNEA
 Three forms:
 Obstructive (OSA)
 Most common type.
 Occurs when muscles or structures of oral
cavity or throat relax during sleep.
 Common symptoms- loud snoring, restless
sleep, and sleepiness during the daytime
 Types
• Mild
• Chronic

57. PREDISPOSING FACTORS:
 Structural abnormalities
 Deviated nasal septum
 Nasal polyp
 Certain jaw configurations
 Enlarged tonsils.

58. COMPLICATIONS OF OSA
Obstu
ctive
sleep
apnea
High blood
pressure
Insulin
resistance
Cardiac
disorders
Stroke,
seizure
Increased traffic &
work place accidents
Memory problems &
inability to
concentrate

59. 2. SLEEP APNEA CONTD….
Central (csa):
 Central respiratory drive is absent.
 Cheyne-stokes respiration
 No breath is taken.
 Airway stays open, diaphragm and chest muscles stop
working
 Seen in clients with brain stem injury, muscular
dystrophy, and encephalitis.
Complex or mixed sleep apnea
 Starts as brief periods of CSA and becomes OSA

60. SLEEP APNEA CONTD…
Diagnostic studies
 Assessment: oral cavity
 Pulmonary function test
 Multiple sleep latency test(MSLT)
 Nocturnal polysomnography (NPSG)
 Treatment
 Treatment of underlying cause.
 Sleep hygiene , sleeping at low fowlers position,
lateral position

61. 2. SLEEP APNEA - TREATMENT
 Over night sleep study to assess the severity of
apnea.
 Oral appliances to keep the airway open during
sleep.
 Continuous positive airway pressure (CPAP) at
night
 Treat the underlying cardiac or respiratory
complications and emotional symptoms that arise
as a result of this disorder.
 Severe-tonsil, uvula, portion of soft palate removed
surgically

62. 3. JET LAG SYNDROME
 Is a physiological condition which results from
alterations to the body's circadian rhythms due
to rapid long-distance trans meridian (east-west
or west-east) travel on a jet plane.
 Symptoms
 Headaches, fatigue
 Irregular sleep patterns, insomnia
 Disorientation, grogginess
 Irritability
 Mild depression
 Constipation or diarrhea

63. JLS…CONTND………
Before the flight
 Take plenty of rest, exercise and follow a healthy diet.
During the flight
 To avoid dehydration, avoid taking alcoholic
beverages and caffeine
 Drink plenty of water inside the plane
 Exercise legs while sitting and move around the plane when
the seat belt sign is switched off, every hour or two.

64. JLS…CONTND………
 Another option is to break the trip into smaller
segments if it is too long and stay overnight in some
city.
 Adjust sleeping hours on the plane to match the
destination time.
Upon arrival
 Adapt to the local time and eat accordingly. Also,
exposure to sunlight during the day is helpful.

65. 4. SHIFT WORK SLEEP DISORDER (SWSD)
 A circadian rhythm sleep disorder which affects
people who change their work or sleep schedules
frequently or who work long term on other than day
hours.
 Recurrent interruption of sleep patterns may result
in insomnia and/or excessive sleepiness

66. HEALTH RISKS ASSOCIATED WITH NIGHT
SHIFTS: TRANSVERSAL STUDY IN A SAMPLE
OF NURSES AT THE CASSINO HOSPITAL
 This transversal study , by means of a self-
administered questionnaire, evaluated the
incidence of mental and physical problems in
58 nurses at the "Santa Scolastica" Hospital in
Cassino to identify the principal factors responsible
for sleep disturbances and to implement preventive
strategies

67. RESEARCH INPUT CONTND….
 Results showed that in many cases disturbances
were attributable to lack of rest . Shorter and more
irregular sleep was associated with age and
amount of working years, together with poor
organizational capacities : irregular shifts ,
upbringing of children and family burdens
aggravated this situation.
 For nurses, night work can have a negative
influence not only on the quality of care and the
incidence of accidents and errors but also affect
their private life and health.

68. DISORDERS OF EXCESSIVE SLEEP:
NARCOLEPSY
 Disorder of excessive somnolence
 Sudden sleep attack.
 REM may occur within 15 minutes of falling asleep
 If cataleptic attack is severe the client may lose
voluntary muscle control and may fall to the floor.
Reaches REM sleep within 15 minutes.

69. NARCOLEPSY
 Excessive sleepiness during the day is often the
first symptom of narcolepsy.
 Sleep paralysis: feeling of being unable to move or
talk just before waking or falling asleep, is another
symptom.
 Vivid dreams, visual & auditory hallucinations may
occur at the onset of sleep
 Significant problem with narcolepsy is that person
falls asleep uncontrollably at inappropriate times.

70. NARCOLEPSY
 Nervous system disorder
Believed that narcolepsy is caused by reduced
amounts of a protein called hypocretin, which is
made in the brain.
Narcolepsy tends to run in families
No known cure
A CNS stimulant(methylphenidate) that causes
wakefulness is used to control narcolepsy
Others like wakefulness promoting agent-
modafinil.

71. OTHER MANAGEMENT METHODS:
 Brief daytime naps no longer than 20 minutes may
help to remove subjective feelings of sleepiness.
 Regular exercise program
 Eating light meals high in protein
 Practicing deep breathing
 Chewing gum
 Taking vitamins
 Avoiding factors that increase drowsiness like
alcohol, heavy metals, exhausting activities, long
distance driving, long periods of sitting etc.

72. RESTLESS LEG SYNDROME
o Unable to lie still and report experiencing
unpleasant creeping, crawling, or tingling
sensations in the legs.
o Sensation may occur anywhere from ankle to thigh
o Kicking or twitching leg movements during sleep,
and sometimes while awake – primary warning
signs.
o Usually feels better if you get up to walk around or
rub your leg.

73. RESTLESS LEG SYNDROME
Causes
 Not known.
 In middle-aged and older adults.
 Stress
 Hereditary
RLS may occur more often in patients with:
 Peripheral neuropathy
 Chronic kidney disease
 Parkinson's disease
 Pregnancy
 Iron deficiency
No known cure

74. MANAGEMENT: NON
PHARMACOLOGICAL MEASURES.
Rest less leg syndrome
 Aimed at reducing stress and helping the muscles
relax
 Warm baths
 Gentle stretching exercises
 Massage
 Eliminate use of caffeine, tobacco, and alcohol.
 Take a mild analgesic at bedtime
 Use antiembolism stockings at the onset of
symptoms

75. PARASOMNIAS
 Parasomnias are patterns of waking behavior that
appear during sleep
 Examples are- somnambulism, sleeptalking,
bruxism, enuresis, sudden infant death syndrome.
 More commonly seen in children
 Difficult to arouse patient during episode and have
poor recall of events in the morning when fully
awake.

76. NIGHT TERROR
Person quickly awakens from sleep
in a terrified state.
Causes
 The cause is unknown
 May be triggered by fever, lack of sleep, or periods
of emotional tension, stress, or conflict.
 Night terrors may run in families.
 They can occur in adults, especially with emotional
tension and/or the use of alcohol.
 Night terrors are most common in boys ages 5 - 7,
although they also can occur in girls.

77. SYMPTOMS – NIGHT TERROR
 Occurs during deep sleep at the midnight(~2am)
 Children scream ,frightened and confused may thrash around
violently and are unaware of surroundings.
 Unable to talk to, comfort, or fully awaken a child who is
having a night terror.
 sweating, hyperventilation, fast HR, and dilated pupils
 May last 10 - 20 min, then normal sleep returns.
 Most children unable to explain what happened the next
morning.

78. NIGHT TERROR CONTD…
Prognosis
 Most children outgrow night terrors in a short period
of time.
Prevention
 Minimizing stress or using coping mechanisms may
reduce night terrors.
 The number of episodes usually decreases after
age
Possible Complications - insomnia

79. SOMNAMBULISM / SLEEP WALK
 Occurs when a person walks or does another
activity while they are still asleep.
 Most often occurs during deep, non-rem sleep
(stage 3 or stage 4 sleep) early in the night.
 Cause unknown.
 Fatigue, lack of sleep, and anxiety are all
associated with sleepwalking.

80. SOMNAMBULISM
 In adults, sleepwalking may be
 Associated with:
• Mental disorders
• Reactions to drugs and alcohol
• Medical conditions such as partial complex seizures
• In the elderly, sleepwalking may be a symptom of an
organic brain syndrome or REM behavior disorders.
 Can occur at any age, most often in children aged
4 - 8.
 It appears to run in families.

81. SLEEP WALK- SYMPTOMS
 Sleeping while driving
 The episode can be very brief (a few seconds or
minutes) or can last for 30 minutes or longer.
 If not disturbed, sleepwalkers will go back to sleep.
 Eyes open during sleep
 May have blank look on face
 Not remembering the sleep walking episode when they
wake up
 Acting confused or disoriented when they wake up
 Rarely, shows aggressiveness when they are awakened
by someone else

82. SOMNAMBULISM CONTD…
Treatment
 Most people don't need any specific treatment for
sleepwalking.
 Safety measures may be needed to prevent
injury.(moving objects such as electrical cords or
furniture to reduce the chances of tripping and
falling, blocking off stairways with a gate.
 Short-acting tranquilizers – reduces sleepwalking
episodes.

83. SLEEP WALK CONTD…
Complications
 Risk for injury while sleepwalking
Prevention
 Avoid the use of alcohol or central nervous system
depressants if you sleepwalk.
 Avoid getting too tired, stress and try to
prevent insomnia because this can trigger a
sleepwalking episode.

84. NOCTURNAL LEG CRAMPS
 Sudden, involuntary contractions most commonly of
the calf muscles during the night or periods of rest.
 The cramps are painful and may last upto ten
minutes.
 There might also be soreness after the cramp goes
away.
 More in middle-aged or older populations.

85. NOCTURNAL LEG CRAMPS
 Triggering events - prolonged sitting, dehydration,
an overexertion of the muscles,
 Or structural disorders (such as flat feet).
 Have also been linked to certain
conditions like diabetes, PVD,
parkinsons disease.
 Muscle-stretching, exercise, and adequate water
intake may help prevent leg cramps.

86. SLEEP TALKING
 Talk that occurs during sleep can be brief and
involve simple sounds, or it can involve long
speeches by the sleeper.
 Person typically has no recollection of the actions.
 Causes - fever, emotional stress, or other sleep
disorder

87. SLEEP PARALYSIS
 Not able to move their body or limbs either when
falling asleep or waking up.
 Brief episodes of partial or complete skeletal
muscle paralysis
 Cause unknown :can be hereditary
 An episode of sleep paralysis often is terminated by
sound or touch. Within minutes, the person with
sleep paralysis is able to move again.
 It may occur only once in your lifetime or can be a
recurrent phenomenon.

88. SUDDEN INFANT DEATH SYNDROME
 Sudden and unexplained death of infant.
 Referred to as cot death or crib death.
 Exact cause unknown.
 RISK FACTORS:
sleeping in prone position
tobacco smoking in mother.
genetic factors.
 Preventive strategies:
well ventilated room, sleeping in supine position,
giving pacifiers etc.

89. ENURESIS OR BED WETTING
 Involuntary urination while asleep after the age at
which bladder control usually occurs.
 Is acquired by age of three years.
 Enuresis may be primary or secondary.
 Treatment measures include restriction of fluid
after 8pm, bladder training during daytime,
supportive psychotherapy and pharmacotherapy:
imimpramine.
 Protect and promote self esteem of the child.

90. SNORING
 More frequent in men and people who
are overweight.
 worsens with age.
 Occasional snoring is usually not very serious and
is mostly a nuisance for your bed partner.
 What causes snoring?
 Obstructed nasal airways
 Poor muscle tone in the throat and tongue
 Bulky throat tissue
 Long soft palate and/or uvula

91. SNORING(CONTND…..

92. SNORING CONTD…
 Health Risks Associated With Snoring
 Long interruptions of breathing (more than 10
seconds) during sleep caused by partial or total
obstruction or blockage of the airway.
 Frequent waking from sleep
 Light sleeping
 Strain on the heart.
 Poor night's sleep

93. TEETH GRINDING (SLEEP BRUXISM)
Teeth can be damaged and other complications can arise,
such as jaw muscle discomfort.
CAUSES
 Causes unknown
 Stressful situations, an abnormal bite, and crooked or
missing teeth are some of the reasons.
 PREVENTION
 Mouth guard
 Stress reduction and other lifestyle modifications,
including the avoidance of alcohol and caffeine
 Relax your jaw muscles at night by holding a warm
washcloth against your cheek in front of your earlobe

94. TEETH GRINDING – PREVENTIVE MEASURES
CONTD
 Train yourself not to clench or grind your teeth. If
you notice that you clench or grind during the day,
position the tip of your tongue between your teeth.
This practice trains your jaw muscles to relax.
 Do not chew on pencils or pens or anything that is
not food.
 Avoid chewing gum as it allows your jaw muscles to
get more used to clenching and makes you more
likely to grind your teeth.

95. MANAGEMENT

96. PHARMACOLOGICAL MANAGEMENT
Insomnia & night terror
 short term use of sedative hypnotics-Zolpidem
 Antidepressants – benzodiazepines
Narcolepsy
 CNS stimulants like methylphenidate 5 – 100 mg/day,
modafinil ( provigil) 200 – 800 mg/day
 Tricyclic antidepressants & SSRIs
 Sodium oxybate – improves sleep quality in patients
Jet lag
 Melatonin supplements
 Melatonin Receptor Stimulant – Rozerem
 Short-acting benzodiazepines such as Xanax
 Nonbenzodiazepine Hypnotics - Ambien, Sonata,
Lunesta

97. PHARMACOLOGICAL MANAGEMENT OF RESTLESS
LEG SYNDROME
• Low doses of pramipexole or ropinirole (requip) –
dopaminergic agents- controlling symptoms
• If sleep is severely disrupted,
• sinemet (an anti-parkinson's medication)
• Gabapentin and pregabalin
• Tranquilizers - clonazepam.
• Patients with iron deficiency will receive iron
supplements.
• Low doses of narcotics

98. ADVERSE EFFECTS OF HYPNOTICS &
BENZODIAZEPINES
 Somnolence
 Dizziness
 Ataxia
 Amnesia
 Nausea
 Discontinuation effects
– Rebound insomnia, withdrawal syndrome,
recurrence
 Dependence liability
– Dose escalation, self-administration outside
therapeutic context

99. NON PHARMACOLOGICAL MEASURES
 Changing unhealthy behaviors
 Moderate intensity exercise programs during day time
 Regular sleep – wake cycle
 Sleep restriction-avoid naps in daytime
 Sleep hygiene education & modification of lifestyle
patterns
 Treat underlying cause & associated medical problems
 Comfort and reassurance
 Relaxation technique
 Behavioral therapy

100. THERAPEUTIC ENVIRONMENT
 DURING hospital stay…
 A comfortable bed promotes rest and sleep.
 A quiet and darkened room with privacy should be
provided.
 Unfamiliar noises should be kept to minimum.
 Patient’s wishes should be met when possible
( thermal blankets, leg warmers, cotton flannel
sheets, amount of bed covering).
 Bedtime routine should be established.

101. THERAPEUTIC ENVIRONMENT FOR
UNCONSCIOUS CLIENT
 PAIN- Analgesics should be given as prescribed to
promote sleep.
 NOISES- should be kept to minimum as hearing
sense of patient is active.
 BEDDING- top and bottom linen should be properly
placed.
 LIGHT- At night lights should be kept dim to
promote sleep.
 VISITING HOURS- should be kept in morning .
 REDUCING ANXIETY- explaining procedure before
performing.

102. EFFECTS OF DISTURBED SLEEP
 Anxiety, restlessness, irritability and impaired
judgment - common symptoms
 Affects somatic growth & decreased appetite
 loss of weight
 Weakening of immune system
 Increase in perception of pain
 Loss of REM sleep can lead to feelings
of confusion and suspicion.

103. EFFECTS OF DISTURBED SLEEP
 Decreased performance and alertness
 Memory and cognitive impairment
 Stress relationships
 Poor quality of life
 Occupational injury
 Automobile injury
 Depression

104. SLEEP PROBLEMS IN CHILDREN
Signs :
 Snoring
 Breathing pauses during sleep
 Problems with sleeping through the night
 Difficulty staying awake during the day
 Unexplained decrease in daytime performance
 Unusual events during sleep like night terrors,
nightmares, bed wetting

105. SLEEP DISORDERS IN THE ELDERLY
 Problems with falling or staying asleep, excessive
sleep, early morning awakening, taking more
daytime naps or abnormal behaviors associated
with sleep.
 The change is in the quality of sleep not in the
quantity of sleep.
 Older people cannot get into the stage four sleep,
which is a deep sleep.

106. SLEEP DISORDERS IN THE
ELDERLY
Causes And Risk Factors
 A need to urinate frequently at night
 Chronic pain caused by diseases such as arthritis
 Chronic diseases such as congestive heart failure
 Depression
 Neurological conditions
 Alzheimer's disease
 Organic brain syndrome
 Sedentary lifestyle
 Stimulants such as caffeine
 Prescription drugs , recreational drugs, or alcohol

107. SLEEP DISORDERS IN THE ELDERLY
Symptoms
 Difficulty falling asleep
 Difficulty in telling the difference between night and
day
 Early morning awakening
 Waking up frequently during the night
Signs And Tests
 Patient's history of sleep disturbances &
contributing factors.
 Physical examination to rule out medical causes.

108. SLEEP DISORDERS IN THE ELDERLY
 Treatment
 The relief of chronic pain and control of underlying
medical conditions such as frequent urination
 Effective treatment of depression
 Sleep hygiene
 Avoid use of sleeping pills to promote sleep on a
long-term basis since it can lead to dependence
and worsening sleep problems over time

109. SLEEP DISORDERS IN THE ELDERLY
 Eg: ambien and lunesta are relatively safe when
used properly.
 It is best to not take sleeping pills on consecutive
days or for more than 2 - 4 days a week.
 Alcohol can make the side effects of all sleeping
pills worse and should be avoided.
 Prognosis
 Most people see improvement in sleep with
treatment or interventions. However, others may
continue to have persistent sleep disruptions.

110. SUPPORTS & RESOURCES
 American Academy of Sleep Medicine
 American Sleep Association
 National Sleep Foundation
 Narcolepsy Network
 National Center for Sleep Disorders
Research
 Restless Legs Syndrome Foundation

111. SLEEP CLINIC AIIMS
 The FIRST sleep clinic and sleep laboratory and
developed the 'state-of art' Clinical Neurophysiology
Laboratory under the Neurology services since
2001
 An average of 200 patients with different types of
sleep disorders are managed annually.

112. NURSING ASSESSMENT
o Sleep history-
Nature of the problem
Its cause
Related signs and symptoms
When it first began and how
often it occurs
How it affects everyday living
Severity of problem
How patient is coping with the
problem

113. CONT…
 Sleep diary
A graph of the total number of hours of
sleep per day
A daily record of patient’s sleep patterns,
behaviors, foods, worry, anxiety etc.
 Physical assessment: key findings are-
Diminished energy level
Facial characteristics
Behavioral characteristics
Snoring
Nocturnal myoclonus

114. NURSING DIAGNOSIS
 Sleep pattern disturbances related to ;use of or
withdrawal from, substances; anxiety or depression;
circadian rhythm disruption; familial patterns;
evidenced by insomnia, hypersomnia, nightmares,
sleep terrors, or sleep walking.
 Risk for injury related to excessive sleepiness,
sleep tremors, or sleep walking.

115. NURSING INTERVENTIONS
 Promoting sleep/sleep hygeine
 The promotion of regular sleep is known as
sleep hygiene.
 Maintain a regular bedtime and arising
time.
 Develop a ‘going to bed' routine. This pre-
bedtime routine should include relaxation
and soothing activities.
 Wear comfortable, loose-fitting clothing
 Get adequate exposure to bright light during
the day. Go outside and enjoy the day.

116. SLEEP HYGIENE CONTD…
 Eat a balanced diet with regular mealtimes.
 Eat a light meal for dinner
 Eat a light carbohydrate snack at bedtime if hungry
 Sleep in a quiet, dark, and relaxing environment,
which is neither too hot nor too cold
 Lose weight if you are overweight.

117. SLEEP HYGIENE
DON'T:
 Don't nap during the day or evening.
 Don't eat heavy meals or drink large amounts of
liquid before bedtime.
 Don't dwell on intense thought or feeling before
bedtime.
 Don't lie awake in bed for long periods of time. If
not asleep within 20 or 30 minutes, leave your
bedroom and do something relaxing until you fall
asleep again.

118. SLEEP HYGIENE - DON’T
 Don't allow your sleep to be disturbed by your
phone, pets, family, etc.
 Don't use alcohol, caffeine, or nicotine.
 Make your bed comfortable and use it only for
sleeping and not for other activities, such as
reading, watching TV, or listening to music.

119. NURSING INTERVENTIONS (CONT..)
PREVENTING INJURY
 Ensure that side rails 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

120. RESEARCH INPUT
 Effect of sleep-inducing music on sleep in persons with
percutaneous transluminal coronary angiography in the
cardiac care unit.
 Keimyung University, DongSan Hospital, Daegu, South Korea.
 AIM AND OBJECTIVE:
 The study compared the effect of earplug-delivered sleep-
inducing music on sleep in persons with percutaneous
transluminal coronary angiography in the cardiac care unit.
 DESIGN:
 An experimental research design was used.

121. CONT……….D
 METHODS:
 Data collection was conducted in the cardiac care
unit of K University Hospital in D city, from 3
September-4 October 2010. Fifty-eight subjects
participated and were randomly assigned to the
experimental group (earplug-delivered sleep-
inducing music for 52 min beginning at 10:00 pm,
while wearing an eyeshield, n = 29) and the control
group (no music, but earplugs and eyeshield worn,
n = 29). The quantity and quality of sleep were
measured using questionnaires at 7 am the next
morning for each group.

122. CONT………….D
 RESULTS:
 Participants in the experimental group reported that
the sleeping quantity and quality were significantly
higher than control group (t = 3·181, p = 0·002, t =
5·269, p < 0·001, respectively).
 CONCLUSION:
 Sleep-inducing music significantly improved sleep
in patients with percutaneous transluminal coronary
angiography at a cardiac care unit. Offering
earplugs and playing sleep-inducing music may be
a meaningful and easily enacted nursing
intervention to improve sleep for intensive care unit
patients.

123. SUMMARY
 Sleep
 Physiology of sleep
 Circadian rhythm
 Stages of sleep
 Sleep cycle
 Factors affecting sleep
 Dreams
 Sleep requirements and patterns
 Classification of sleep disorders
 Sleep laboratory studies
 Sleep problems in pediatric population, elderly
 Nursing process

124. CONCLUSION
 Sleep is a complex phenomenon.
 Disruption of sleep patterns can disrupt
physical & mental health.
 A good night’s sleep is a bridge between
despair and hope.

125. REFERENCES
 Taylor C, Lillis C, LeMone P; Fundamentals of
Nursing- The Art and Science of Nursing Care; fourth
edition, Lippincott; page no:1013-1031
 Potter P, Perry A; Fundamentals of Nursing; 6th
edition; Mosby; page no-1198-1225
Kryger,Roth,Dement,”principles & practices of sleep
medicine”,2nd edtn, Saunders,pg no:411 – 598
 Ellen Barker,”Neurosceince Nursing – A Spectrum of
Care”, mosby 3rd edn,:pg 200 - 215
 Mary C Townsend,”Psychiatric Mental Health
Nursing”,5th edn,Jaypee;pg 583 - 591