- Email: [email protected]
Sleep disorders
SLEEP Marshelle
D BORDERS
Thobaben,
RN, C, MS, PHN,
FNP
Many clients have trouble battling afternoon fatigue, falling asleep, staying asleep, or having a restful nights sleep. Approximately 33% of the adult U.S. population-about 65 million people-suffer from sleep disorders. One of two people have experienced insomnia. At least 10 million people have sleep apnea, hundreds of thousands have experienced narcolepsy, and approximately 12 million suffer from restless legs syndrome or periodic limb movements during sleep. However, most people with sleep disorders remain undiagnosed and untreated.’ You probably have been asked by clients, “How much sleep does a person need?” No one really knows how much sleep we need. In a recent National Sleep Foundation Gallup survey, “Sleepiness in America,” U.S. adults were asked a series of questions from the Epworth Sleepiness Scale, used to help diagnose sleep disorders. The results indicated that many adults do not know what is normal concerning sleep, what is not, and what deserves a physician’s attention. The study reported that 39% said excessive daytime sleepiness (EDS) interfered with their day-to-day activities at least some of the time. Although most respondents (82%) believed that feeling tired or sleepy during the day could have a negative effect on their overall productivity, more than one third (36%) believed feeling very sleepy in the mid-afternoon was normal.2 Sleeping
14 HOME
patterns vary widely,
CARE PROVIDER
from clients who are natural
“short sleepers”-those who may need only 3 or 4 hours of sleep at night and function worse if they have moreto clients who are “long sleepers” and need more than 9 hours of sleep. Sleeping patterns may change as we age, but sleep disorders are not an inevitable part of aging. Clients need enough sleep to feel alert and function during the day. If your clients are having difficulty sleeping, they may have symptoms of a sleep disturbance. They need to be carefully evaluated to rule out concurrent mental disorders, general medical conditions, and substance use (including medications) that may be responsible for the sleep disturbance.3-4 Do you routinely assess your clients for sleep disorders, including EDS, a type of sleepiness that interferes with a client’s concentration and performance? EDS is a characteristic symptom of primary sleep disorders (PSDs). The
FEBRUARY 1998, VOL. 3 NO. 1
BEYOND
PHYSICAL
CARE
Disorder
Descrbtion
of the comtAaint
Primary
insomnia
Difficulty
Primary
hypersomnia
Excessive sleepiness as evidenced by either almost every day for at least 1 month
Narcolepsy
initiating
or maintaining
or nonrestorative
sleep
prolonged
pattern
sleep
that lasts for at least 1 month
or daytime
sleep
episodes
that occur
Irresistible attack of refreshing sleep that occurs daily for at least 3 months; cataplexy (episodes of sudden, bilateral, reversible loss of muscle tone that lasts for seconds to minutes, usually precipitated by intense emotion); or recurrent intrusion of elements of rapid eye movement sleep into the transition between sleep and wakefulness, manifesting itself by either sleep paralysis at the beginning or end of sleep episodes or dreamlike hallucinations
Breathing-related
sleep
disorder
Sleep disruption that leads to excessive sleepiness or insomnia as a result of a sleep-related condition, such as obstructive sleep apnea syndrome (repeated episodes of upper-airway tion), central sleep apnea syndrome (episodic cessation of ventilation during sleep without obstruction), or central alveolar hypoventilation syndrome (impairment in ventilatoty control in abnormally low arterial oxygen levels further worsened by sleep)
Circadian
sleep
disorder
Persistent or recurrent pattern of sleep disturbance result of a mismatch between the client’s sleep/wake
rhythm
Dyssomnia
NOTE: These physiological
not othetwise
specified
Examples include: Restless legs syndrome-uncomfortable Periodic limb movements-repeated, extremities, that begin near sleep
disorders do not occur effects of a substance
American Psychiatric p. 557,562,567,573.
Association.
exclusively or medical
Diagnostic
during other condition.
and statistical
sleep
manual
following questions are a sleepiness test that may indicate your clients have symptoms of EDS. If they answer yes to any of the following questions, they may not be getting enough quality sleep as a result of either a shortened sleep period or a sleep disorder. Ask them if they: l
sleep,
Need an alarm to wake up in the morning (if so, do they usually press the snooze button)
l
Feel they need a nap during the day
l
Fall asleep while watching TV
l
Feel sleepy while reading a book5
EDS can reduce clients’ energy levels and concentration, affect their mood, cause impaired social and familial relationships, and create difficulties in other areas of functioning. These symptoms are characteristic of PSDs. According to the American Psychiatric Associationb Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PSDs include primary insomnia, primary hypersomnia, narcolepsy, breathingrelated sleep disorder, circadian rhythm sleep disorder, and dyssomnia not otherwise specified. Refer to Table 1 for definitions of various PSDs. This primary class excludes sleep disorders as a result of other mental disorders (often depression or anxiety disorder), general medical conditions (arthritis, cancer, Parkinson’s disease,
FEBRUARY 1998, VOL. 3 NO. 1
breathing obstrucairway that results
leading to excessive sleepiness or insomnia schedule and circadian sleep/wake pattern
sensations that lead to an intense brief, low-amplitude brief limb jerks,
as a
urge to move the legs particularly in the lower
onset
disorders
or other
of mental
disorders.
mental
disorders
and are not results
4th ed. Washington,
of the direct
DC: The Association;
1994.
dementia, chronic obstructive pulmonary disease, congestive heart disease), or substance-induced sleep disorder (current or recently discontinued use of a substance, including medications). If your clients have sleep problems that continue longer than a week, are bothersome, or interfere with their ability to function, they should be evaluated for the cause and offered appropriate treatment. Sometimes it can be difficult to tell if clients are suffering from a sleep disorder, sleep deficit, or depression. For example, clients with primary insomnia may appear fatigued or have an increase in stressrelated psychophysiolgical problems (tension headaches) but have no other abnormalities on physical examination. Many older clients may think poor sleep is not worth complaining about because it is inevitable. Clients may be using anxiolytics to combat tension or anxiety and caffeine or other stimulants to combat excessivefatigue. They may need a sleep disorder work-up, including a polysomnography that monitors multiple electrophysiological limits during sleep. Encourage your clients to practice good sleep habits by telling them to: l
Avoid caffeine and nicotine in the late afternoon and evening because they can delay sleep
HOME
CARE PROVIDER
t5
BEYOND
l
l
l
l
PHYSICAL
CARE
Avoid alcohol in the evening because it may interrupt sleep later in the night Avoid exercising at least 3 hours before bedtime because the body needs time to “unwind Establish a regular, relaxing bedtime hour to send a signal to the brain that it is time to sleep Use the bed only for sleep or sex so it is associated only with those activities
l
Have a light snack before bed
l
Take a hot bath 90 minutes before bed
l
Make sure the bed and bedroom are comfortable
If your clients are unable to sleep after 30 minutes in bed, they should get up and do something relaxing until they feel sleepy.6 A good habit for you is to include an assessment of your clients’ sleep patterns in your routine assessments.Diagnosis and treatment for a sleep disorder could greatly aid your clients’ general well-being. REFERENCES 1 National
Sleep
Foundation.
Sleep.
Available
from:
htip://www.ssleepioundation.org/pub/ications/nsfgen. Posted:
Dec.
2. Wunder
16,
H. NSF
Alert
releases
1997;2(3).
him.
1997. sleepiness
Available
from:
in America.
Sleep Medicine
hrtp://www.
s/eepfoundation.org/publications/sma2.3.
htm. Posted:
Dec.
16,
1997. 3. National
Sleep
Foundation.
Sleep
and
aging.
Available
from:
hffp://www.ssleepfoundaiion.org/pub/ications/sleepage. Posted
Dec.
4. American of mental 1994:
16,
Psychiatric
Association.
disorders.
4th ed. Washington
Diagnostic
and DC:
statistical
manual
The Association;
of Ethics
providers arises in this area. Because caregivers empathize with the patient and the loss that would be involved, removing a person from his or her home is not to be taken lightly. The seriousness of this matter brings us to the second difficulty of deciding when to intervene. Home care practitioners recognize that being able to live alone is not a single capacity but might be considered more of a continuum. These providers often care for patients in whom the capacity to care for themselves is not an allor-nothing situation. When to intervene along this continuum is often the heart of this difficult issue; pat answers are not available. If no incidents endangering the physical safety of the client have occurred, clinicians often take a wait-and-see position in which vigilance is increased in the hope they are present in a crisis. On a final note, I want to reemphasize that in addition to the tension between the different meanings of autonomy, a tension also exists between autonomy and other concerns. For example, tension can be created by the patient’s autonomy and the responsibility a practitioner has as both a professional and an agent of the home care institution. Home care clinicians and agencies regularly deal with elderly people in a variety of situations concerning patients’ abilities to care for themselves. Although viewing autonomy in terms of these four meanings may explain why such decision-making is difficult for staff members, whether this delineation is useful in clinical practice remains to be seen.
5.5 l-79.
5. National
Sleep
Foundation.
The nature
htip://www.ssleepfoundation. Posted: 6. How
hrm.
1997.
A Question
Dec.
to sleep
16, well.
of sleep.
Available
org/publications/nosZ.
from:
3. hrm.
1997. Available
REFERENCES 1. Miller
B. Autonomy
Hastings from:
leland.srandford.edu/-demenf/howto.hrm/.
hftp://www
Cent
2. de Sousa Posted:
Dec.
18,
Press:
Rep
and
the refusal
of lifesaving
treatment.
198 1;2 1:22-8.
R. The rationality
of emotion.
Cambridge
(MA]:
MIT
1987.
1997.
16
HOME
CARE PROVIDER
FEBRUARY 1998, VOL.
3 NO.
1
D BORDERS
Thobaben,
RN, C, MS, PHN,
FNP
Many clients have trouble battling afternoon fatigue, falling asleep, staying asleep, or having a restful nights sleep. Approximately 33% of the adult U.S. population-about 65 million people-suffer from sleep disorders. One of two people have experienced insomnia. At least 10 million people have sleep apnea, hundreds of thousands have experienced narcolepsy, and approximately 12 million suffer from restless legs syndrome or periodic limb movements during sleep. However, most people with sleep disorders remain undiagnosed and untreated.’ You probably have been asked by clients, “How much sleep does a person need?” No one really knows how much sleep we need. In a recent National Sleep Foundation Gallup survey, “Sleepiness in America,” U.S. adults were asked a series of questions from the Epworth Sleepiness Scale, used to help diagnose sleep disorders. The results indicated that many adults do not know what is normal concerning sleep, what is not, and what deserves a physician’s attention. The study reported that 39% said excessive daytime sleepiness (EDS) interfered with their day-to-day activities at least some of the time. Although most respondents (82%) believed that feeling tired or sleepy during the day could have a negative effect on their overall productivity, more than one third (36%) believed feeling very sleepy in the mid-afternoon was normal.2 Sleeping
14 HOME
patterns vary widely,
CARE PROVIDER
from clients who are natural
“short sleepers”-those who may need only 3 or 4 hours of sleep at night and function worse if they have moreto clients who are “long sleepers” and need more than 9 hours of sleep. Sleeping patterns may change as we age, but sleep disorders are not an inevitable part of aging. Clients need enough sleep to feel alert and function during the day. If your clients are having difficulty sleeping, they may have symptoms of a sleep disturbance. They need to be carefully evaluated to rule out concurrent mental disorders, general medical conditions, and substance use (including medications) that may be responsible for the sleep disturbance.3-4 Do you routinely assess your clients for sleep disorders, including EDS, a type of sleepiness that interferes with a client’s concentration and performance? EDS is a characteristic symptom of primary sleep disorders (PSDs). The
FEBRUARY 1998, VOL. 3 NO. 1
BEYOND
PHYSICAL
CARE
Disorder
Descrbtion
of the comtAaint
Primary
insomnia
Difficulty
Primary
hypersomnia
Excessive sleepiness as evidenced by either almost every day for at least 1 month
Narcolepsy
initiating
or maintaining
or nonrestorative
sleep
prolonged
pattern
sleep
that lasts for at least 1 month
or daytime
sleep
episodes
that occur
Irresistible attack of refreshing sleep that occurs daily for at least 3 months; cataplexy (episodes of sudden, bilateral, reversible loss of muscle tone that lasts for seconds to minutes, usually precipitated by intense emotion); or recurrent intrusion of elements of rapid eye movement sleep into the transition between sleep and wakefulness, manifesting itself by either sleep paralysis at the beginning or end of sleep episodes or dreamlike hallucinations
Breathing-related
sleep
disorder
Sleep disruption that leads to excessive sleepiness or insomnia as a result of a sleep-related condition, such as obstructive sleep apnea syndrome (repeated episodes of upper-airway tion), central sleep apnea syndrome (episodic cessation of ventilation during sleep without obstruction), or central alveolar hypoventilation syndrome (impairment in ventilatoty control in abnormally low arterial oxygen levels further worsened by sleep)
Circadian
sleep
disorder
Persistent or recurrent pattern of sleep disturbance result of a mismatch between the client’s sleep/wake
rhythm
Dyssomnia
NOTE: These physiological
not othetwise
specified
Examples include: Restless legs syndrome-uncomfortable Periodic limb movements-repeated, extremities, that begin near sleep
disorders do not occur effects of a substance
American Psychiatric p. 557,562,567,573.
Association.
exclusively or medical
Diagnostic
during other condition.
and statistical
sleep
manual
following questions are a sleepiness test that may indicate your clients have symptoms of EDS. If they answer yes to any of the following questions, they may not be getting enough quality sleep as a result of either a shortened sleep period or a sleep disorder. Ask them if they: l
sleep,
Need an alarm to wake up in the morning (if so, do they usually press the snooze button)
l
Feel they need a nap during the day
l
Fall asleep while watching TV
l
Feel sleepy while reading a book5
EDS can reduce clients’ energy levels and concentration, affect their mood, cause impaired social and familial relationships, and create difficulties in other areas of functioning. These symptoms are characteristic of PSDs. According to the American Psychiatric Associationb Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, PSDs include primary insomnia, primary hypersomnia, narcolepsy, breathingrelated sleep disorder, circadian rhythm sleep disorder, and dyssomnia not otherwise specified. Refer to Table 1 for definitions of various PSDs. This primary class excludes sleep disorders as a result of other mental disorders (often depression or anxiety disorder), general medical conditions (arthritis, cancer, Parkinson’s disease,
FEBRUARY 1998, VOL. 3 NO. 1
breathing obstrucairway that results
leading to excessive sleepiness or insomnia schedule and circadian sleep/wake pattern
sensations that lead to an intense brief, low-amplitude brief limb jerks,
as a
urge to move the legs particularly in the lower
onset
disorders
or other
of mental
disorders.
mental
disorders
and are not results
4th ed. Washington,
of the direct
DC: The Association;
1994.
dementia, chronic obstructive pulmonary disease, congestive heart disease), or substance-induced sleep disorder (current or recently discontinued use of a substance, including medications). If your clients have sleep problems that continue longer than a week, are bothersome, or interfere with their ability to function, they should be evaluated for the cause and offered appropriate treatment. Sometimes it can be difficult to tell if clients are suffering from a sleep disorder, sleep deficit, or depression. For example, clients with primary insomnia may appear fatigued or have an increase in stressrelated psychophysiolgical problems (tension headaches) but have no other abnormalities on physical examination. Many older clients may think poor sleep is not worth complaining about because it is inevitable. Clients may be using anxiolytics to combat tension or anxiety and caffeine or other stimulants to combat excessivefatigue. They may need a sleep disorder work-up, including a polysomnography that monitors multiple electrophysiological limits during sleep. Encourage your clients to practice good sleep habits by telling them to: l
Avoid caffeine and nicotine in the late afternoon and evening because they can delay sleep
HOME
CARE PROVIDER
t5
BEYOND
l
l
l
l
PHYSICAL
CARE
Avoid alcohol in the evening because it may interrupt sleep later in the night Avoid exercising at least 3 hours before bedtime because the body needs time to “unwind Establish a regular, relaxing bedtime hour to send a signal to the brain that it is time to sleep Use the bed only for sleep or sex so it is associated only with those activities
l
Have a light snack before bed
l
Take a hot bath 90 minutes before bed
l
Make sure the bed and bedroom are comfortable
If your clients are unable to sleep after 30 minutes in bed, they should get up and do something relaxing until they feel sleepy.6 A good habit for you is to include an assessment of your clients’ sleep patterns in your routine assessments.Diagnosis and treatment for a sleep disorder could greatly aid your clients’ general well-being. REFERENCES 1 National
Sleep
Foundation.
Sleep.
Available
from:
htip://www.ssleepioundation.org/pub/ications/nsfgen. Posted:
Dec.
2. Wunder
16,
H. NSF
Alert
releases
1997;2(3).
him.
1997. sleepiness
Available
from:
in America.
Sleep Medicine
hrtp://www.
s/eepfoundation.org/publications/sma2.3.
htm. Posted:
Dec.
16,
1997. 3. National
Sleep
Foundation.
Sleep
and
aging.
Available
from:
hffp://www.ssleepfoundaiion.org/pub/ications/sleepage. Posted
Dec.
4. American of mental 1994:
16,
Psychiatric
Association.
disorders.
4th ed. Washington
Diagnostic
and DC:
statistical
manual
The Association;
of Ethics
providers arises in this area. Because caregivers empathize with the patient and the loss that would be involved, removing a person from his or her home is not to be taken lightly. The seriousness of this matter brings us to the second difficulty of deciding when to intervene. Home care practitioners recognize that being able to live alone is not a single capacity but might be considered more of a continuum. These providers often care for patients in whom the capacity to care for themselves is not an allor-nothing situation. When to intervene along this continuum is often the heart of this difficult issue; pat answers are not available. If no incidents endangering the physical safety of the client have occurred, clinicians often take a wait-and-see position in which vigilance is increased in the hope they are present in a crisis. On a final note, I want to reemphasize that in addition to the tension between the different meanings of autonomy, a tension also exists between autonomy and other concerns. For example, tension can be created by the patient’s autonomy and the responsibility a practitioner has as both a professional and an agent of the home care institution. Home care clinicians and agencies regularly deal with elderly people in a variety of situations concerning patients’ abilities to care for themselves. Although viewing autonomy in terms of these four meanings may explain why such decision-making is difficult for staff members, whether this delineation is useful in clinical practice remains to be seen.
5.5 l-79.
5. National
Sleep
Foundation.
The nature
htip://www.ssleepfoundation. Posted: 6. How
hrm.
1997.
A Question
Dec.
to sleep
16, well.
of sleep.
Available
org/publications/nosZ.
from:
3. hrm.
1997. Available
REFERENCES 1. Miller
B. Autonomy
Hastings from:
leland.srandford.edu/-demenf/howto.hrm/.
hftp://www
Cent
2. de Sousa Posted:
Dec.
18,
Press:
Rep
and
the refusal
of lifesaving
treatment.
198 1;2 1:22-8.
R. The rationality
of emotion.
Cambridge
(MA]:
MIT
1987.
1997.
16
HOME
CARE PROVIDER
FEBRUARY 1998, VOL.
3 NO.
1