Unit 6 Sleep Disorder
Unit 6 Sleep Disorder
Unit 6 Sleep Disorder
Sleep
• Sleep is a process required for proper brain function. Sleep is not a single process;
there are several distinct types of sleep. These different types of sleep differ both
qualitatively and quantitatively. Each type of sleep has unique characteristics,
functional importance, and regulatory mechanisms. Selectively depriving one
particular type of sleep produces compensatory rebound.
• Sleep is not a passive process; during sleep, there is a high degree of brain activation
and metabolism.
Contd…
• Nearly 1/3 of human life is spent in sleep, an easily reversible state of relative
unresponsiveness and serenity which occurs more or less regularly and repetitively
each day.
Phases of sleep
1. D-sleep (desynchronized or dreaming sleep), also called as REM- sleep (rapid eye
movement sleep), active sleep, or paradoxical sleep.
Relaxed Wakefulness
This is not a real stage of sleep. It is a state of relaxed wakefulness for comparison. The
alpha waves are at steady series with frequency of 8 to 12 per second.
Stage 1, NREM-sleep is the first and the lightest stage of sleep characterized by an
absence of alpha waves, and low voltage, predominantly theta activity.
During this period, sleep has just begun. The EEG is dominated by irregular, jagged.
Overall brain activity is less than in relaxed wakefulness but higher than other sleep
stages.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterized
by two typical EEG changes. The most prominent characteristics of stage 2 are
sleep spindles and K-complexes.
• Psychiatric disorders can cause sleep problems. For example, difficulties getting to sleep
or staying asleep are common in anxiety and depressive disorders, while nightmares can
be a prominent feature of post-traumatic stress disorder.
• Conversely, sleep disorders may cause, mimic or aggravate psychiatric disorders. For
instance, sleep deprivation in a 6-year-old may result in over-activity, poor concentration,
impulsiveness and irritability, that is, features that are normally part of ADHD and
disruptive behavioural disorders.
• It may be hard to distinguish between sleep disorders and psychiatric disorders, for
example, nocturnal panic attacks can be mistaken for nightmares or night terrors, or
vice versa.
• Psychotropic medication (or its withdrawal) may induce sleep problems, for
example, difficulty getting to sleep when taking methylphenidate, or nightmares
following the abrupt withdrawal of antidepressants.
• A single risk factor may predispose a child to both sleep problems and psychiatric
difficulties. For example, children growing up in chaotic household without routines
or consistently enforced rules are more likely to develop both disruptive behavioural
problems and difficulties getting a regular night’s sleep.
• Notes:
• REM = Rapid Eye Movement: the phase of sleep when most dreaming occurs and
muscle tone is at its lowest. Makes up about 25% of sleep and is commonest
towards the end of the night.
• Non-REM: the deepest non-REM sleep (stages 3 and 4, shown in black) mostly
occurs in the first two cycles. Brief awakenings are normal at all ages, and can
occur from either REM or light non-REM.
• After early infancy, falling asleep is a transition to non-REM sleep. Sleep cycles
last about 50–60 minutes in childhood, increasing to 90–100 minutes in adolescents
and adults.
• Total sleep declines from an average of 12 hours per day in 4-year-olds to an
average of 8 hours per day by late adolescence
Epidemiology of sleep problems
• Very severe sleep disorders are rare, for example, narcolepsy affects fewer than 1
in a thousand children and adolescents, while some degree of obstructive sleep
apnoea affects 2% of children and adolescents.
• Less severe sleep problems are much commoner, for example, about a quarter of
preschool children have significant problems getting to sleep or staying asleep,
while up to 15% of adolescents have an erratic or delayed sleep–wake cycle.
• Sleep problems are particularly common among children and adolescents with
intellectual disability and are also linked to physical disabilities (for example,
cerebral palsy), sensory impairments (for example, blindness), psychiatric
disorders (for example, generalised anxiety), and physical disorders that worsen at
night (for example, asthma) or that cause night-time discomfort (for example,
itching due to eczema.
Specific Sleep Disorders
• When bedtime resistance and disruptive nighttime awakenings are included, the
prevalence of sleep-disrupted behavior approaches 25% to 50% in preschool
children (Owens & Mindell, 2011).
Parasomnias
• Parasomnias are disruptive physical behaviors that occur during sleep and are
typically classified by the sleep stage (NREM or REM) in which they arise. We
focus here on NREM parasomnias; these include somnambulism, night terrors,
sleep-talking, bruxism, and rhythmic movement disorders (enuresis).
• NREM parasomnias usually occur in the first few hours of the sleep cycle. These
behaviors arise when the cortex incompletely arouses from deep NREM sleep,
often due to comorbid conditions that provoke repeated arousal or promote sleep
inertia (defined as extreme difficulty waking accompanied by confusion or sleep-
drunkenness)
Sleepwalking
Sleepwalking or somnambulism is the combination of ambulation with the
persistence of impaired consciousness after arousal from sleep. Although a large
percentage of children have at least one episode of somnambulism, far fewer
present with recurrent and disruptive episodes.
Children typically have amnesia of the event and the behaviors are often
inappropriate (such as urinating in a wastebasket, moving furniture around
haphazardly or climbing out of a window).
Sleepwalkers are sometimes able to navigate familiar surroundings but are prone to
bumping into objects or to fall down.
Sleep terrors
• Sleep terrors or night terrors are episodes of intense fear initiated by a sudden cry or
loud scream and accompanied by increased autonomic nervous system activity. They
most commonly occur in preadolescent children.
• Parents usually describe the child as being inconsolable during the episode. Several
studies have demonstrated a relationship between anxiety levels and parasomnias in
children, showing that increased anxiety correlates with increased prevalence of
night terrors and awakenings (Kovachy et al, 2013).
Sleep-talking
• Sleep-talking or somniloquy is considered the most common parasomnia, with a
reported prevalence greater than 50% in children between the ages of 3 and 13
(Laberge et al, 2000).
• They are recommended in cases that fail to respond to surgical treatment or in whom
adenotonsillectomy is not indicated.
• Other adjunctive strategies include treating nasal allergies, reducing weight, and
avoiding environmental irritants
• Restless legs syndrome and periodic limb movement disorder
• Although the restless legs syndrome has been traditionally considered a disorder of
middle and old age, several studies (summarized in Picchietti & Picchietti, 2008)
have shown that it can occur in childhood .
• Differential diagnoses of restless legs syndrome include (Picchietti & Picchietti
2010):
Positional discomfort
Sore leg muscles
Ligament sprain/tendon strain
Bruises
Orthopaedic disorders
Dermatitis
• Management
• The management of restless legs syndrome/periodic limb movement disorder is
non-pharmacological for mild to moderate cases (i.e., cases with mild to moderate
impact on sleep, cognition, and behavior).
• This includes establishing healthy sleep habits, physical exercise and avoiding
putative exacerbating factors such as insufficient sleep for age, irregular sleep
schedule, low body iron stores, pain, caffeine, nicotine, alcohol, and certain drugs
(e.g., SSRIs, antihistamines, and neuroleptics) (Picchietti & Picchietti 2010).
Narcolepsy
DSM 5
• These symptoms are the result of a sudden burst of REM sleep in patients who are
awake. Diagnosis of narcolepsy requires sleep laboratory assessment, including
nocturnal polysomnography and multiple sleep latency tests (Guilleminault &
Pelayo, 2000).
• Kleine-Levin syndrome Another uncommon and rare disorder characterized by
recurrent episodes of hypersomnia and to various degrees behavioral or cognitive
disturbances, compulsive eating behaviour, and hypersexuality. Kleine-Levin
syndrome is a rare condition that affects mainly male adolescents; it starts during
the second decade in about 80% of cases, with a male/female ratio of 2:1. Kleine-
Levin syndrome is characterised by periods of extreme somnolence
Management
• Sleep history
Detailed history of the sleep complaint and a typical sleep–wake cycle
Factors that improve or worsen sleep
Effect on mood and functioning
Past and present treatment
History from bed partner
Sleep diary Systematic 2-week or longer record
Possible investigations
Video recording Actigraphy (wrist-worn)
Polysomnography
Cerebrospinal fluid orexin (hypocretin) levels
Treatments
The tools for sleep assessments are: Sleep history including -Description of client’s sleep
problem; nature, sign/symptoms, onset, duration, predisposing factors, severity, effects on
client. -Usual sleep pattern prior to sleep problem -Recent changes in sleep pattern -Physical
illness -Bedtime routine and sleeping environment -Use of any medication
Pattern of dietary intake or any substance -symptoms experienced during waking hours -
recent life event - Current emotional and mental status
Sleep diary including -times when patient tries to fall asleep -approximate time that patient
fall asleep -time of awakening during night -record of food, physical activity, worries, mental
activity
Diagnosis
• Get regular exercise at least 40 min each day that causes sweating
• Don’t use bright light even you have to remain awake for long during nighttime
• Don’t smoke to get sleep , Give up smoking entirely or don’t smoke after 7 p.m.
• Avoid caffeine entirely or limit no more than 3 cups per day and not after 10 a.m.
• Too much time in bed is not good .Remember that quality of sleep is important.
• Keep the clock face turned away. Don’t see what time of night you are awake.
• Don’t eat heavily or drink 3 hrs before bedtime. A light bedtime snacks is o.k.
• Incase of problem of regurgitation, elevate the head of bed and prevent spicy as
well as oily meal before bedtime
• Keep your room well ventilated, dark and quiet during nighttime.
• Make sure that mattress isn’t too firm or too soft. Ensure that the pillow is of appropriate
height and firmness.
• An occasional sleeping pill is alright but use only after consultation with doctor.
• Use bedroom only for sleep. Avoid activities that lead to prolonged arousal.
Collaborative Care
• Emphasize the importance of interdisciplinary collaboration in managing sleep
disorders.
• Discuss the involvement of healthcare professionals like physicians,
psychologists, respiratory therapists, and dietitians.
Education and Sleep Hygiene