Introduction The sleep – wakefulness cycle is genetically determined rather than learned and is established sometime after birth.Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity and [inhibition of nearly all voluntary muscle during REM sleep] reduced interactions with surroundings. Sleep can be regarded as a physiological reversible reduction of conscious awareness. Nearly one third of human life is spent in sleep. Disorders of sleep can affect activities of daily living (ADL) of an individual. Definition It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day. The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases: 1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep. 2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person fifi rst passes through these stages of NREM-sleep. Stages of sleep The EEG recording during the waking state shows alpha waves of 8-12 cycles/sec. frequency. The onset of sleep is characterised by a disappearance of the alpha-activity. Stage 1, NREM-sleep is the first and the ligh test stage of sleep characterised by an absence of alphawaves, and low voltage, predominantly theta activity. Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two typical EEG changes: i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0 seconds, with a charac teristic waxing and waning amplitude. ii. K-complexes: High voltage spikes present intermittently. Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec. Stage 4, NREM-sleep shows predominant δ-activity in EEG. NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1 NREM-sleep. One of the most characteristic features of the REM-sleep is presence of REM or rapid (conjugate) eye move ments. The other features include generalised mus cular atony, penile erection, autonomic hyperactivity (increase in pulse rate, respiratory rate and blood pressure), and movements of small muscle groups, occurring intermittently. Although it is a light stage of sleep, arousal is diffificult. These stages occur regularly throughout the whole duration of sleep. The first REM period occurs typically after 90 minutes of the onset of sleep, although it can start as early as 7 minutes after going off to sleep, e.g. in narcolepsy, in major depression, and after sleep deprivation.

1. A 45-years old gentleman visited the OPD
clinic with c/o heavy snoring in the night,
difficulty in sleeping, disturbed sleep
timings, sleeping late and waking late in
the morning, sleep talking, sudden jerky
movements while asleep and
occasional sleepless nights.
O/E, BMI was 30.24 and had a shorter
neck. He looked tired and sleepy.
On subjective assessment, he mentioned
his tea intake was 10cups
across the day and the last cup was
around 8pm in the night. He
did not have any relevant medical history

2. What history needs to be taken?
What are the points should be
assessed during examination?
What is the possible diagnosis?
What is your action as a Nurse?

3. Nearly one third of
human life is spent
in sleep!

4. Sleep
Disorders

5. Sleep:
It is an easily reversible state of relative
unresponsiveness and serenity which occurs more
or less regularly and repetitively each day.

6. Purpose of
sleep
Energy
conservation :
Decreased
metabolism to
allocate limited
energy resources
Restorative
function :
Tissue repair
and protien
synthesis
Immune
function
regulation :
Sleep boosts
immunity
Memory
consolida
tion
Synaptic
hemostasis

7. The EEG recordings show typical features of sleep which is broadly
divided into two broadly different phases:
1.D-sleep (desynchronised or dreaming sleep), also called as REM-
sleep (rapid eye movement sleep),active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-
REM sleep), quiet sleep, or orthodox sleep.
S-sleep or NREM-sleep is further divided into four stages, ranging
from stages 1 to 4. As the person falls asleep, the person first passes
through these stages of NREM-sleep.

10. Brain waves
Stages Type of brainwave Frequency of brainwave Time Spent Type of sleep
0 Alpha Rhythm 8 to 12 cycles per second 2-5% Awake
1 Beta rhythm 18 to 25 cycles per second 5 to 10 minutes (5%) Non – REM
2 Theta Rhythm 4 to 7 cycles per second Almost half of sleep
cycle (50%) 30-60 min
Non – REM
3 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 20 to 40 min Non – REM
4 Delta rhythm (Slow wave sleep) 1.5 to 3 cycles per second 15 to 30 min Non – REM
5 Beta rhythm 18 to 25 cycles per second 20% REM

12. Circadian Rhythms (Biological Clock)

13. Circadian Rhythms (Biological Clock)

14. Circadian Rhythms (Biological Clock)

15. Neuro-chemical influences on circadian
rhythm [sleep – wake cycle]:
Serotonin • Induction of sleep
Serotonin &
Norepinephrine
• Non-REM Sleep
Acetylcholine • REM
GABA • Regulation of sleep & arousal
Histamine • Prolongs REM Sleep

16. Sleep Need and Age

17. Age group Sleeping Time REM Sleep
Percentage
Miscellaneous
Neonates 16 hours of sleep a day, sleeping
almost constantly during 1st
week, sleep cycle is generally 40
to 50 min
50% as it
stimulates
higher brain
function
Awakening occurs after 1 or 2 sleep cycles.
Infants [after 3
months]
Several naps during day, sleeps 8
to 10 hours at night with total 15
hours sleep.
30% Awakening commonly occurs early in the morning but can
awake at night also.
Toddlers By age 2, children usually sleep
through night and take daily
naps. After 3 years, usually give
up daytime naps. Total sleep
almost 12 hours a day.
20% Common to awaken at night. Toddler may unwilling to go to
bed at night due to a need for autonomy or a fear of
separation from their parents.
Pre – schoolers 12 hours 20% The pre-schoolers usually have difficulty relaxing or quieting
down after long, active days and has problem with bedtime
fears, waking during the night or nightmares. Partial
awakening followed by normal return to sleep is common. In
waking period, the child exhibit crying, walking around,
unintelligible speech, sleep walking or bed wetting.

18. Age group Sleeping Time REM Sleep
Percentage
Miscellaneous
School age
children
6 years -
11 years
11 to 12 hours
9 to 10 hours
20% They go to bed doing some quiet activities.
They resist sleeping because of an
unawareness of fatigue or a need to be
independent.
Adolescents 7 hours 30 mins 20% Shortened sleep time due to busy schedule
leads to EDS.
Young
adults
6 hours to 8 hours and
30 min of sleep
20% Insomnia and use of drugs to sleep is
common.
Middle
adults
Sleeping time declines.
Stage 4 sleep falls.
20% Insomnia is common because of stress or
changes, anxiety, depression, menopause can
cause sleep disturbances.
Older adults Decrease in stage 3 and
stage 4 / no stage 4
20-10% Awakens more often at night and it takes
more time to fall asleep, tendency for nap
increases.

19. Sleep Patterns
Long Sleepers >9 Hours
Short sleepers <6 Hours

20. ICD-10 Classification
F51 Non-organic sleep disorders
F51.0 Non-organic insomnia
F51.1 Non-organic hypersomnia
F51.2 Non-organic disorder of the sleep-wake cycle
F51.3 Sleep walking
F51.4 Sleep terrors
F51.5 Nightmares
F51.8 Other non-organic sleep disorders
F51.9 Non-organic sleep disorders, unspecified

21. Dyssomnias
Dyssomnias are sleep disorders
that are characterized by
disturbances in the amount, quality
or timing of sleep. These are the
commonest disorders of sleep.

22. Dyssomnias
Insomnia
Hypersomnia
Disorders of
sleep-wake
schedule
Parasomnias
Stage IV
disorders
Other disorders

23. Prevalence of Insomnia
• More than 33% of adults experience
insomnia intermittently
• 10-22% suffer chronic sleep difficulties
• Prescriptions for sleep aids increased by
nearly 300% during same period

24. Insomnia
Insomnia is also known as the Disorder of Initiation and/or Maintenance of Sleep ( DIMS). This
includes frequent awakening during the night and early morning awakening.
Insomnia means one or more of the following:
1. Difficulty in initiating sleep (going-off to sleep).
2. Difficulty in maintaining sleep (remaining asleep).
This can include both:
a. Frequent awakenings during the night, and
b. Early morning awakening.
3. Non-restorative sleep where despite an adequate duration of sleep, there is a feeling of not having
rested fully (poor quality sleep).

25. Causes
Medical illnesses
• Any painful or uncomfortable illness
• Heart disease
• Respiratory diseases
• Brain stem or hypothalamic lesions
• Delirium
• Rheumatic and other musculoskeletal diseases
• Periodic movements in sleep
• Oldage
• Rheumatic and musculo-skeletal disease
• PMS ( Periodic movements in sleep)

26. Alcohol and drug use
• Delirium tremens
• Amphetamines or other stimulants
• Chronic alcoholism
• Drug or alcohol withdrawal syndrome
Current medication
• e.g. fluoxetine, steroids, theophylline, propranolol

27. Psychiatric disorders
• Mania (due to decreased need for sleep,(may not complain of
decrease in sleep, as there is often a decreased need for sleep)
• Major depression (early morning awakening or late
insomnia,difficulty in maintenance of sleep is more prominent,
although diffifi culty in initiating sleep is also present)
• Dysthymia or neurotic depression (difficulty in initiating sleep or early
insomnia)
• Schizophrenia and other psychoses (due to psychotic symptoms)
• Anxiety disorder (difficulty in initiating sleep due to worrying
thoughts)

28. Social causes
• Financial loss
• Separation or divorce
• Death of spouse or a close relative
• Retirement
• Stressful life situations (may cause temporary insomnia).

29. Behavioral causes
• Naps during the day
• Irregular sleeping hours
• Lack of physical exercise
• Excessive intake of beverages in the evening, e.g. coffee
• Disturbing environment (heat, cold, noise)
Idiopathic insomnia
One cause of insomnia, PMS ( periodic movements in sleep) needs further
mention. PMS actually consists of two different syndromes, which often occur
together:
1. Periodic Limb Movement Disorder (PLMD), and
2. ‘ Restless Legs’ Syndrome (RLS or Ekbom syndrome).

30. Treatment of Insomnia
A person suffering from insomnia should be differentiated
from a short-sleeper, who needs less than 6 hours of sleep
per night and has no symptoms or dysfunction. A short-
sleeper does not need any treatment.
1. A thorough medical and psychiatric assessment.
2. Treatment of the underlying physical and/or sychiatric
disorder, if present.
3.Withdrawal of current medications, if any.

31. Sleep Hygiene
1. Regular, daily physical exercises (preferably not in the evening).
2. Minimise daytime napping. 3.
Avoid fluid intake and heavy meals just before bedtime.
4. Avoid caffeine intake (e.g. tea, coffee, cola drinks) before sleeping hours.
5. Avoid regular use of alcohol (especially avoid use of alcohol as a hypnotic for promoting
sleep).
6. Avoid reading or watching television while in bed.
7. Sleep in a dark, quiet, and comfortable environment.
8. Regular times for going to sleep and waking-up
9. Try relaxation techniques
10. Backrubs, warm milk and relaxation exercises.

32. Sleep hygiene to maintain sleep – wake
cycle:
Sleep – wake
pattern
Environment Medications
Diet
Physiological
/ Illness
Factors

33. Medications for treatment of insomnia

34. Sleep Diary
It is a record of a patient’s sleepand wake patterns is meant to capture sleep wake information over
several weeks.
Patients can be instructed to record the information by themselves
or it can be recorded by a caregiver. It aims to measure the pattern
and quality of sleep, and factors that may affect patient’s sleep.
General Instruction for the Patient
• Fill the diary every day for minimum two weeks
• Generally, fill the diary after one hour of getting up from the bed in the morning
• Be as specific as you can
• If you forget to fill the diary on a particular day, leave it blank for that day
• Make brief notes of anything unusual which has affected your sleep in the diary

35. Sleep Diary
• Each row corresponds to
24 hours (from noon
today to noon tomorrow)
• Each column corresponds
to 1 hour
• Shade in the time you are
actually sleeping
• Arrow down ( ↓ ) when
you get in bed
• Arrow up ( ↑ ) when you
get out of bed

36. Non-drug treatment for insomnia
• Progressive relaxation.
• Autosuggestion.
• Meditation, yoga.
• Stimulus control therapy: do not use the bed for
reading or chatting - go to bed for sleep only.

37. Hypersomnia
Hypersomnia is also known as Dis order of excessive
somnolence ( DOES). Hypersomnia means one or more of the
following:
1. Excessive day time sleepiness.
2. ‘ Sleep attacks’ during day time (falling asleep
unintentionally).
3. ‘ Sleep drunkenness’ (person needs much more time to
awaken; and during this period is confused or disoriented).

38. Causes of hypersomnia
1. Medical illnesses
i. Narcolepsy (in about 25% of all patients with hypersomnia)
ii. Sleep apnoea (in about 50% of all patients with hypersomnia)
iii. Kleine-Levin syndrome
iv. Menstrual-associated somnolence
v. Sleep deprivation
vi. Following or with insomnia
vii. Encephalitis
viii. Hypothyroidism
ix. Head Injury
x. Cerebral tumours in the region of mid-brain
xi. Hypothalamic lesions
xii. Trypanosomiasis
xiii. PMS ( Periodic movements in sleep); in about 10% of all patients with hypersomnia.
2. Alcohol and drug use
i. Stimulant withdrawal
ii. Alcohol intoxication
iii. Use of CNS depressant medications.
3. Psychiatric disorders
i. Dysthymia
ii. Atypical depression
iii. Seasonal mood disorder.
4. Idiopathic hypersomnia

39. Treatment
1. A thorough physical and psychiatric assessment.
2. Treatment of the underlying cause is the most important method.
3. Associated or underlying insomnia should be looked for and
treated.
4. Withdrawal of current medication causing hypersomnia,
especially depressant medication.
5. Benzodiazepines at night may paradoxi cally decrease
hypersomnia by correcting night time insomnia.

40. Disorders of Sleep-wake Schedule(F51.2)
The person with this disorder is not able to sleep when
he wishes to, although at other time he is able to sleep
adequately.
Causes
• Work shifts
• Jet Lag
• Unusual sleep phases
• Unspecified

41. Treatment
No specific treatment is usually needed. Benzodiazepines may
be needed for short-term correc tion of insomnia. Changes in
‘work-shifts’ may be needed for persons with unusual sleep
phases. Exposure to
sunlight during outdoor activity (instead of staying indoors)
and adopting the local (new) hours for sleeping (and working)
can help in combating jet lag.

42. Classification of Stage IV Sleep Disorders
• Sleep walking (somnambulism)
• Night terrors
• Sleep-related enuresis
• Bruxism (tooth-grinding)
• Sleep talking (somniloquy)
• REM sleep behaviour disorders
• Sleep related head banging

43. Treatment
Since benzodiazepines suppress stage 4 of
NREM- sleep, a single dose at bedtime usually
provides relief from stage 4 parasomnias.

44. Other Sleep Disorders
 Nocturnal angina
 Nocturnal asthma
 Nocturnal seizures
Sleep related cluster headaches and chronic paraxysmal
hemicranias
Sleep related abnormal swallowing syndrome
Sleep related gastroesophageal reflex
 Sleep paralysis
Nightmares ( dream anxiety disorder)
Paraxysmal nocturnal hemoglobinuria
Substance induced sleep disorders

45. Examination in sleep apnea
• Obesity
• Body mass index (height/weight)
• Neck circumference
• Enlarged tonsils
• Elongated soft palate
• Larger tongue
• High-arched hard palate
• Enlarged uvula
• Facial abnormalities (retrognathia or micrognathia)
• Large degree of overjet
• Medical conditions: High blood pressure, metabolic disease,
cardiovascular disease, stroke.
Obesity is a major concern in obstructive sleep apnea (OSA). It
is estimated that 45% obese individuals may have OSA. What simply
happens in obesity is the fat deposition in the tissues surrounding
the upper airways leading to smaller lumen and increased chances
of collapsibility during sleep leading to sleep apnea.

46. Treatment
There is no specific treatment. Treatment of the
underlying condition is the most impor tant step. The
treatment of nightmares is by suppression of REMsleep,
e.g. by bedtime dose of a benzo diazepine. However, on
stopping the drug, arebound increase in symptoms may
occur.

47. METHODS OF SLEEP STUDY
1.Observation of a sleeping person for exter nally visible changes.
2.EEG.
3.Polysomnography (This is usually the preferred method in the sleep research centers).
It consists of:
i.Continuous EEG recording, parti cularly from occipital and parietal leads.
ii.EOG (electro-oculography) to record the eye movements.
iii.EMG (electromyography) for muscle potential and activities.
iv.ECG for changes in cardiac status.
v.In certain cases, respiratory tracings of various kinds are used, such as oxymetry, expired CO2 , O2 saturation.
vi.MSLT (Multiple sleep latency test): It involves repeated measures of the sleep latency (i.e. time to onset of sleep).
vii.Penile tumescence, body temperature, GSR (galvanic skin response), and body movements
are also sometimes studied.
The recordings are made throughout the night sleep

48. Detailed Sleep History Questionnaire
Sleep Timings
• How many hours do you generally sleep? (do not include the hours you spend awake on bed)
• How many hours does it take for you to feel well rested?
• Do you take daytime naps and for how long (weekdays and weekends)?
Normal Sleeping Habits
• What time do you go to bed on a normal day?
• What time do you get out of bed on a normal day?
• What is the time required for you to fall asleep once you go to bed?
• Do you get up in middle of the night? If yes, how many times and what is it that wakes you up?
• How quickly are you able to get back to sleep? (Address these questions separately for weekdays as
well as weekends)

49. Sleep Quality
• Do you feel refreshed in the morning?
• How long does it take for you to feel refreshed after awakening?
• During the day, are you chronically fatigued, sleepy or tired?Snoring
• Do you think, you snore in the night?
• Are your snores heard outside the bedroom?
• Do you think your snoring is worse while lying on back or on either side?
• Can you suggest, how many nights per weeks do you snore?
• Does it awaken the bed partner?
• Is this worse on the night you have stuffed nose or consume alcohol.
Apneic Event
• Has your bed partner noticed that you transiently stop breathing while asleep?
• Have you ever witnessed that while you sleep there is a silent period with no snoring followed by a loud snort or a body jerk
which awakens you?
• Have you experienced episodes of choking or waking up in the night shortness of breath?
This history is often elicited by the bed partners.

50. Abnormal Behavior During Sleep
• Do you have an urge to move your limbs in early part of night?
• Has anyone noticed any abnormal movements/behavior in
the night?
Daytime Functioning
• Do you wake up with a headache or heaviness in head?
• Have you felt that you are mostly tired/fatigued during the day?
• Have you ever dozed of in meeting or while driving?
• What time do you get home from your work place?
• What time do you have your dinner?

51. Personal Habits
• Any history of alcohol consumption?
– How many drinks? per day/per week/per month
– What time of day is your last drink?
• Any history of tobacco consumption?
– If yes, how many per day and for how many years?
– If yes, what time of day is your last use?
• History of consumption of tea/coffee
– How many time and what time of the day/night
– Any consumption of hyper caffeinated drinks.

52. Medical History
A detailed medical history needs to be taken and specific details
need to asked regarding
• Heart diseases/skipped heart beats/ heart failure/ high blood
pressure
• Thyroid problems/
• Diabetes
• Stroke/epilepsy/headaches
• Asthma/emphysema/sinusitis/nasal congestion/deviated nasal
septum/enlarged tonsils allergies
• Depression/anxiety/bipolar disorder

53. Drug History
• All medications need to be noted with special emphasis on
• Any sedatives/antidepressants/anxiolytics.
Any Established Comorbidities State/Condition
• Cardiovascular disease
• Cerebrovascular disease
• Metabolic syndrome
• Gastroesophageal reflux
• Obesity.
Occupational History
• Does your job involve a lot of stress?
• Is your work timing out of 9 AM–5 PM? (if not everyday/ but
mostly)
• Does your job demand regular flight travel to the western
countries?
Social History
• General quality of life should be evaluated
• General attitude of the patient and his family/colleagues.

55. Nursing diagnosis:
• Disturbed sleep pattern related to, use or, withdrawal from
substances: anxiety or depression: circadian rhythm disturbance:
familial pattern: or specific medical condition.
• Risk for injury related to excessive sleepiness, sleep terrors or sleep
walking.
• Ineffective breathing pattern related to obstructive sleep apnea,
obesity and decreased ventilation

56. Planned interventions
• Monitor the client's sleep pattern and identify the risks ( sleep walking, breathing related sleep disorders etc) to prevent the harm and injury to the
client
• Activate the client to keep a sleep diary, so that he/she will be identify the patterns that promote sleep pattern disturbances
• Develop a sleep hygiene plan and educate the client about sleep hygiene practices to promote rest and sleep in the sleep deprived client. Teach the
client about useful strategies for symptoms management to promote a sense of control over the problem Help the patient to structure and maintain a
quiet, comfortable environment that is conducive to sleep to promote sleep and rest during designated period through out the day/night
• Help the client to identify specific structures that effects his or her ability to obtain restorative sleep to help the client avoid or reduce stressors and
obtain restorative sleep .
• Promote the development of adaptive coping skills, such as relaxation tequeniques, through, client and family educaton to assess the client in
managing, the psycho social stressors that negatively affect his/her ability to obtain restorative sleep
• Identify the persons social support system to foster use of this resource, in the clients adaptation to perceived psychosocial stressors
• Promote the compliance with prescribed medication plans in the treatment of a co-occurring psychiatric illness or in the short term treatment of
primary sleep disorder. The use of medication is an effective intervention in the treatment of primary or secondary sleep pattern disturbances.

57. • Teach the client the importance of limiting the intake of substance that causes a
substance induced sleep disorder. Use of prescription medications such as opioids,
sedatives, hypnotics, and anxiolytics also affect sleep quality, and the client should
only use them when directed by the client's health care provider. Some substances
negatively affect a client's ability to attain restorative sleep.
• Educate the client regarding the effect that circadian rhythm disturbances have on
restorative sleep patterns, and explore ways to establish regular sleep patterns when
sleep routines and are disrupted. Knowledge will inform and empower the client to
accept help and initiate learned strategies to restore regular sleep patterns.
• Refer the client to a sleep disorder specialist as needed to determine if advanced
practice interventions are necessary. Further testing, such as polysomnography, is
sometimes necessary to arrive at a differential diagnosis for the client.

58. Expected outcome
• The client will -
• Identify the primary causes of the sleep pattern alteration
• Demonstrate significant reduction of sleep pattern through self
report Participate actively in the discharge planning .

59. BIBLIOGRAPHY:
1.Townsend C. Mary. Psychiatric Mental Health Nursing. Eighth
Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd:
2018
2.Basavanthappa BT. Psychiatric Mental Health Nursing. 1st
Edition. New Delhi: Jaypee Brothers Medical Publisher (P) Ltd:
2007
3.Sreevani, R. A Guide to Mental Health and psychiatric Nursing ;
Jaypee Brothers, Medical Publishers Pvt. Ltd, 2010
4.Kapoor, Dr. Bimla , Textbook of Psychiatric Nursing, Volume I,
Kumar Publishing house, 2013
5.Ahuja N. A short textbook of psychiatry. New Delhi, India:
Jaypee Brothers Medical; 2011.

60. Thank you for
listening