INTRODUCTION

A sleep disorder, or somnipathy, is a medical disorder of the sleep patterns of a person or

animal. Some sleep disorders are serious enough to interfere with normal physical, mental,

social and emotional functioning. Primary sleep disorders are common in both children and

adults. However, there is a significant lack of awareness in children with sleep disorders, due

to most cases being unidentified.[3] Several common factors involved in the onset of a sleep

disorder include increased medication use, age-related changes in circadian rhythms,

environmental and lifestyle changes [4] and pre diagnosed physiological problems and stress

Types of Sleep Disorders

1. Insomnia.
dyssomnias

2. Hypersomnia.

3. Parasomnia.

4. Sleep Related Breathing Disorders (Sleep Apnea).

5. Circadian Rhythm Sleep Disorder

INSOMNIA

Insomnia and excessive daytime sleepiness are primary complaints regardless of the stage of

the disease. Insomnia includes difficulty falling asleep, difficulty staying asleep, and early

morning awakening. It is not defined by the number of hours of sleep, but rather, by an

individual‘s ability to sleep long enough to feel healthy and alert during the day.

TYPES

Transient insomnia - < 4 weeks triggered by excitement or stress, occurs when away from

home

Short-term - 4 weeks to 6 months on going stress at home or work, medical problems,

psychiatric illness

Chronic - Poor sleep every night or most nights for > 6 months, psychological factors

(prevalence 9%

ASSESSMENT

 Determine the pattern of sleep problem (frequency, associated events, how long it

takes to go to sleep, and how long the patient can stay asleep)

 Include a full history of alcohol and caffeine intake and other factors that might affect

sleep

 Review current medications that patient is taking to eliminate these as possible causes

 Take a history to rule out physical cause and/or psychosocial cause

POSSIBLE CAUSES OF INSOMNIA

 Headache Bad or vivid dreams  Abdominal pains

 Problems of breathing  Fever/night sweats

 Chest pain/heartburn  Leg cramps

 Need to pass urine or move bowels

 Fear/anxiety Depression

ASSOCIATED PROBLEM

At least one (or more) of the following

 Malaise (feeling of general discomfort or uneasiness)

 Attention, concentration impairment

 Social/ vocational dysfunction/ poor work

 Mood disturbance or irritability

 Daytime sleepiness

 Proneness for errors or accidents at work or while driving

 Tension, headaches or gastrointestinal symptoms in response to sleep loss

 Concerns or worries about sleep

DIAGNOSIS

Sleep log: A sleep log is a simple diary that keeps track of details about sleep. In a sleep log,

record details like bedtime, wake up time, how sleepy feel at various times during the day,

and more. A sleep log can also help doctor figure out what might be causing insomnia.
Sleep inventory: A sleep inventory is an extensive questionnaire that gathers information

about your personal health, medical history, and sleep patterns.

Polysomnography

Polysomnography recordsr brain waves, the oxygen level in blood, heart rate and breathing,

as well as eye and leg movements during the study.

TREATMENT

Pharmacological management

Type of medication

Example

 CNS stimulants D-amphetamine, Methyphenindrate

 Antihypertensive - beta-blockers

 Respiratory medicines - Albuterol, Theophylline

 Decongestants- Phenylephrine, Pseudoephedrine

 Hormones - Thyroxin, Corticosteroids

 Other substances - Alcohol, Nicotine, Caffeine

 Benzodiazepines - Lorazepam (1-6mg), Clonezepam (0.5-5mg), Temazepam (10-

20mg)

Non-Pharmacologic Management

Treat underlying causes whenever possible

 Go to bed when sleepy

 Get up the same time every morning

  Get up when sleep onset does not occur in 20 min

 No daytime napping

 Reduce or stop Caffeine, Alcohol, Nicotine

 Exercise < 4hrs before bed

 Meditation, Yoga

 Hypnosis to decrease anxiety & tension at bedtime

 Progressive muscle relaxation

HYPERSOMNIA

Hypersomnia is a term used to define a condition and class of sleeping disorders

characterized by hyper somnolence: excessive daytime sleepiness (EDS) and extensive night-

time sleeping periods. It is common for people with a hypersomnia disorder to sleep 10 or

more hours per 24 hour period and wake up exhausted despite extensive time asleep.

TYPES

 Idiopathic hypersomnia

 Kleine-Levin syndrome

 Narcolepsy (both type 1 and type 2),

 Hypersomnia due to a medical disorder

 Hypersomnia due to a medication or substance

 Insufficient sleep syndrome

 Hypersomnia associated with a psychiatric disorder

ANOTHER CLASSIFICATION- PRIMARY AND SECONDARY

PRIMARY HYPERSOMNIA INCLUDE:

Both type 1 and type 2 narcolepsy

Narcolepsy with Cataplexy

In addition to the other narcolepsy symptoms, people who have narcolepsy with cataplexy

experience sudden muscle weakness and lose control of the muscles in their face, arms, legs,

or torso. This causes the person to slur words, have a sagging jaw, collapse, or slump over

and be unable to move. During cataplexy, the person is awake. An episode can last for

seconds or up to one or two minutes and is often triggered by a strong emotion, such as

excitement or laughter.

Narcolepsy without Cataplexy

A person with narcolepsy without cataplexy has all the symptoms of narcolepsy extreme

sleepiness, sleep attacks, dream-like hallucinations and paralysis while falling asleep or

waking up, and disrupted night time sleep), but without episodes of sudden muscle weakness

triggered by strong emotions. This type of narcolepsy can be less severe than narcolepsy with

cataplexy.

Kleine-Levin syndrome

Kleine Levin syndrome is a rare disorder characterized by recurrent episodes of excessive

sleep (hypersomnia) along with cognitive and behavioural changes. Affected individuals may

sleep for up to 20 hours per day during an episode

Idiopathic hypersomnia

Cause is unknown

SECONDARY HYPERSOMNIA INCLUDE

Hypersomnia due to a medical disorder

Neuromuscular disorders such as muscular dystrophy, ALS, or myasthenia gravis;

neurodegenerative conditions such as Alzheimer’s or Parkinson’s disease; or obstructive

sleep apnoea
Hypersomnia due to a medication or substance

Sleepiness as a result of prescription or over the counter medications or drugs

Hypersomnia associated with a psychiatric disorder

The relationship is not cause and effect, but rather one is related to the other

Insufficient sleep syndrome

Sleeping less than the recommended 7-9 hours with variability within that shortened range of

sleep

DIAGNOSIS

The overnight polysomnogram includes a multitude of electrodes monitoring brain waves,

heart rate, oxymetry, breathing patterns and muscle activity in the legs. If the overnight

polysomnogram is negative, meaning there was no diagnosable sleep related breathing

disorder or existence of primary snoring, an MSLT commonly follows.

TREATMENT

There are three classes of medications typically used for treatment.

The three classes include

 Stimulants

Stimulants may include medications like Adderall or Ritalin.

 Non-stimulants

Non-stimulant medications include modafinil (Provigil) and armodafinil. They are

considered non-stimulant because though they do act as a stimulant and assist in

 maintaining wakefulness, they do not have same chemical structures as that of

traditional stimulants

 Sodium oxybate

. Sodium oxybate works to foster deep sleep while also improving sleepiness

experienced during the daytime.

Other prescribed medications can include antidepressants or monoamine oxidase

inhibitors (MAOIs). MAOIs work by impeding the breaking down of serotonin, a

neurotransmitter pivotal for wakefulness 

PARASOMNIAS

Parasomnias are a category of sleep disorders that involve abnormal and unnatural

movements, behaviours, emotions, perceptions, and dreams that occur while falling asleep,

sleeping, between sleep stages, or arousal from sleep. Most parasomnias are dissociated

sleep states which are partial arousals during the transitions between wakefulness and NREM

sleep, or wakefulness and REM sleep.

TYPES:

 Restless Leg Syndrome

 Night Terror Sleepwalking (Somnambulism)

 Sleep Enuresis

 REM Sleep behaviour

Restless Leg Syndrome

Characterized by intense dysesthesias (unpleasant abnormal sensation), repetitive jerking ,

worse at bedtime and often awakens patient

ETIOLOGY

 Unknown

 Often familial, progresses with age

 May be caused by uremia, Iron deficiency anaemia or alcohol abuse.

TREATMENT

 Carbidopa -Levodopa 25mg/100mg qhs (70% respond)

 Clonazepam 0.5-2 mg qhs

Night terror

Emerge from Stage 3-4 sleep. Autonomic arousal is interpreted as fear .Arousal is abrupt.

Occurs primarily in children

FEATURES

 Cry

 Automatic and behavioural manifestation of intense fear(marked tachycardia,

mydriasis sweating).

 The child is agitated and confused.

 Lasts for few minutes, sleep resumes.

 Amnesia
TREATMENT:

Reassurance, diazepam and imipramine

Sleepwalking (somnambulism)

Emerge out of Stage 3 and 4 sleep .May overlap with night terror

FEATURES

Involves complex behaviour while sitting up in bed, walking, dressing, eating and even

driving a car which is last for few minutes and mostly seen in children.

TREATMENT

Reassurance, safety restraints and if frequent consider diazepam

Sleep Enuresis

Involuntary micturition during sleep following attainment of control while awake. Usually

idiopathic may be caused by urogenital disease, or other medical problem

TREATMENT:

Bladder training and Imipramine

REM Sleep behaviour

A rare neurological disorder in which a person does not become paralyzed during REM

sleep. and thus acts out dreams. The condition usually idiopathic and neurological cause in

1/3rd.

TREATMENT

Sleep study and clonazepam

SLEEP RELATED BREATHING DISORDERS (SLEEP APNEA)

RISK FACTORS INCLUDE:

 Older age

 Male sex

 CVD risk factors such as obesity

 Anatomical abnormalities like neck obesity, narrow airway, and fixed upper airway

lesions (e.g., polyps, enlarged tonsils)

 Alcohol

SYMPTOMS INCLUDE

 Loud snoring, choking, gasping during sleep

 Associated with daytime sleepiness

Sleep apnea’s are divided into two:

Central sleep apnea: (CSA) causes fragmented sleep and consequent daytime somnolence.

Obstructive sleep apnea: (OSA) is characterized by partial or complete closure of the upper

airway, posterior from the nasal septum to the epiglottis, during inspiration

DIAGNOSIS

Polysomnography is a detailed overnight sleep study with recordings of ECG (arrhythmias),

EEG (brain waves – level of sleep ), Ventilatory variables- movement of chest wall and

airflow at the mouth and nose, Arterial O2 saturation (finger/ear-oximetry) and Heart rate

MANAGEMET

Mild OSA – avoid alcohol and sedatives

Mild to moderate OSA –weight reduction, avoid supine position and use oral prosthesis to

keep airway patent

Severe OSA: Surgery (uvulopalatopharyngoplasty) and tracheotomy

Medical management-Continuous Positive Airway Pressure (CPAP)

MEDICATION

The most important pharmacologic intervention is the avoidance of all CNS depressants (e.g.,

alcohol, hypnotics) and drugs that promote weight gain.

Tricyclic antidepressants (TCAs) (i.e., imipramine, protriptyline), and clonidine have

effects on sleep architecture or upper airway patency but do not clinically improve severity of

OSA

CIRCADIAN RHYTHM DISORDER

The sleep-wake cycle is under the circadian control of oscillators and can be disrupted by

misalignment between an individual’s biologic clock and external demands on the sleep

cycle. Circadian rhythm sleep disorders usually present with either insomnia or hypersomnia,

depending on the individual’s performance requirements. Two commonly occurring circadian

rhythm sleep disorders are jet lag and shift work sleep problems.

Jet Lag

Jet lag occurs when a person travels across time zones, and the external environmental time is

mismatched with the internal circadian clock.

SYMPTOMS

 Malaise
  Insomnia / hypersomnia

 Fatigue

 Poor performance

 Gastrointestinal disturbance

TREATMENT

Short-acting benzodiazepine receptor agonists or 0.5 to 5 mg melatonin taken at appropriate

target bedtimes

Shift Work

Night shift work causes a misalignment in the sleep-wake cycle and circadian rhythm that is

associated with a decrease in alertness, performance, and quality of daytime sleep.

TREATMENT

Short-acting benzodiazepine receptor agonists or 0.5 to 5 mg melatonin taken at appropriate

target bedtimes

Delayed sleep phase disorders

DSPD is commonly found in teenagers and young adults (average age of onset, 20 years),

with the pattern developing in adolescence.4,5 Sleep onset is delayed by 3–6 hours compared

with conventional times (10–11 pm).6 Once sleep is attained, it is normal in length and

quality but is delayed, resulting in social and often psychological difficulties

TREATMENT

Manipulating sleep timing

MEASURES TO IMPROVE SLEEP

Sleep hygiene

 Sleep in cool, quiet, comfortable place.

 Keep regular sleep-wake schedule.

 When having trouble sleeping at night, avoid daytime naps.

 Exercise < 4hrs before bed.

 Avoid caffeine, food close to bedtime.

 Make bed a restful heaven for sleep.

 Don’t worry about not getting enough sleep .

 Change sleeping place, if unable to sleep.

Sleep control

 Limiting the time in bed at night to 5hours and gradually increase the time

Cognitive therapy

Structured programme that help you to identify and replace thought and behaviours that cause

or worsen sleep problem with habits that promote sound sleep.

Stimulus control

 Going to bed only when sleepy

 Getting out of bed when unable to sleep

 Using the bed only for sleep

Progressive muscle relaxation

  Progressive muscle relaxation is based upon the simple practice of tensing, or

tightening, one muscle group at a time followed by a relaxation phase with release of

the tension.

 While inhaling, contract one muscle group (for example your upper thighs) for 5

seconds to 10 seconds, then exhale and suddenly release the tension in that muscle

group.

 Give yourself 10 seconds to 20 seconds to relax, and then move on to the next muscle

group (for example your buttocks).

 While releasing the tension, try to focus on the changes you feel when the muscle

group is relaxed. Imagery may be helpful in conjunction with the release of tension,

such as imagining that stressful feelings are flowing out of your body as you relax

each muscle group.

 Gradually work your way up the body contracting and relaxing muscle groups.

CONCLUSION

Even though sleep disorders are common most of the time these are not identified. Extensive

education regarding optimum sleep and the consequence of inadequate sleep is an essential

thing to develop a future healthy citizen.

BIBILIOGRAPHY

1. Joanne V. Hickey “The clinical practice of neurological and neurosurgical nursing”5th

edition, Lippincott publications P-108-109

2. I Clement, Textbook on Neurological and Neurological Nursing, Jaypee Brothers

Medical Publishers Pvt Ltd, New Delhi, India.