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Author:    David Tilton (RN, BSN)

Objectives

On completion of this activity participants should be able to:

  1. Recognize the importance of good sleep.
  2. Identify the names of the two major sleep cycle components, REM and NREM.
  3. Explain to others the concept of sleep debt.
  4. Discuss at least three sleep hygiene interventions.
  5. Identify at least two of the most common sleep disorders.

Introduction

We live in a society deprived of sleep. Early estimates gathered from active research sponsored by the National Institute of Health (NIH), place 70 million Americans as suffering from sleep disturbance, with over half of these possessing a chronic sleep disorder. The impact of poor sleep is seen in the 100,000 accidents each year identified by the National Highway Traffic and Safety Administration as being related to drowsy driving. In health care costs alone, sleep problems result in an additional $16 billion spent annually within the U.S., as well as an estimated $50 billion of lost productivity (NIH, 2006).

Disturbances of sleep may well be the most frequently encountered problem facing health care professionals. Of the more than 70 sleep disorders currently recognized, Insomnia, Obstructive Sleep Apnea, Restless Legs Syndrome, Narcolepsy, and the Parasomnias pose great challenges to both patients and staff alike.

Sleep is Life

Sleep is a natural part of every person's life. Everyone spends about one third of their life asleep. For such a big time investment, it is highly ironic that so very little is known about sleep. One myth that most health care professionals recognize as incorrect, though most have attempted to implement it, is that sleep is optional.

Rumor: I can function fine without sleep whenever I choose. Sleep is just something to fill time that is otherwise not being used.

Truth: Sleep is required activity. It is not an optional event.

Impact: Studies where rats have been deprived of sleep result in death within roughly the same time span as death would result from starvation (Clark Steven, 2005)

 

While some of the mechanisms remain unclear, it is obvious that sleep is essential to life. During sleep, the metabolic activity of some cells shift. Contrary to once popular theories, cells do not appear to shut down in order to rest during sleep. Some tissues actually appear to speed up their levels of function, partially in efforts to renew spent resources and clear the byproducts of an active lifestyle. While further studies are being made to better understand the physiologic response to sleep, what is clear is that the body maintains peak function only by routine, sufficient sleep.

Rumor: During sleep, the body in general, and the brain specifically, shut down for rest.

Truth: Brain activity increases dramatically during sleep, while tissues in the body remain metabolically active, and may even peak.

Example: The endocrine system increases secretion of certain hormones during sleep, such as prolactin and growth hormone.

 

Sleep Categories and Stages

Sleep is an active time in our body, brain, and psyche. Research reveals that sleep is a dynamic event resulting in stimulation of many organs, especially the brain. There are several studies that are used in sleep study. Electroencephalograms (EEGs) record neural activity in the brain. Electrooculograms (EOGs) measure eye muscle motion. Electromyograms (EMGs) record large muscle actions.

Studies reveal is that sleep is divided into two categories or distinctly separate periods. In one sleep category is rapid eye movements (REM) that can be readily observed. The second category lacks brisk ocular gyrations and is therefore distinguished by the term nonrapid eye movements (NREM). Each of these distinct categories of sleep is associated with different types and levels of central nervous system activity.

REM sleep is commonly recognized as the time of diminished muscle tone or atonia, during which the most vivid dreams occur. NREM sleep is composed of less vivid dreaming, deeper breathing, a slowing of the heart rate, a drop in blood pressure, and a pronounced decrease in core body temperatures. NREM sleep is further divided into four progressive stages, sleep stages 1 through 4. Each increasing sleep stage requires more effort in order to rouse the sleeper. Stage 4, delta sleep, is the state of sleep from which a person is least able to be aroused.

Rumor: Just one less hour of sleep per night will have no effect on daytime functioning.

Truth: Sleep time that is less than an individual needs results in a sleep debt. This debt can accumulate across days with growing effects on mood, performance, and problem solving.

Impact: Rats experiencing sleep debt live only about five months compared to the normal 2-3 years (Clark-Steven, 2005).

 

Research indicates that each type of sleep serves a different purpose, though it is not yet clear exactly what benefits are derived from each type and stage of sleep. What is known is that visible changes in EEGs often accompany sleep disorders. Changes in the frequency and duration of both REM and NREM sleep are commonly observed in people having troubled sleep. Further study into these changes and the areas of the brain associated with them hold great promise for developing future treatments.

Cycle of Sleep

Sleep is a repeating cycle of activity. During a typical nights sleep, everyone experiences first a yo-yo ride through the stages of deepening NREM sleep, followed by a gradual progression into the realm of REM sleep. For most people the sleep cycle, lasts about 90 minutes, and when once completed, the cycle immediately returns to the NREM sleep stage 1. The sleep cycle repeats four to six times during each night. During the night, the total time spent in NREM slowly lessens and the duration of REM increases gradually. The REM cycle increases from about 10 minutes duration in the first of the nightly cycles up to about 30 minutes in the REM state interval nearest the time of wakening.

These repeating cycles that are present during each nights sleep are simply one of the reoccurring patterns affecting the quality and duration of our sleep. The circadian rhythm, the body’s internal clock, also plays a pivotal role. The circadian rhythm is powered by the region of the brain known as the suprachiasmatic nucleus (SCN) that regulates our body's expectation of periods of activity and rest. This clock within our brain is set consistently on a cycle slightly longer than 24 hours. Like man made clocks, the SCN can be reset to compensate for discrepancies such as the changing day/night durations accompanying seasons. Control of the reset mechanism can occur by either of two primary mechanisms: 1) from cues outside the body such as daylight and darkness, known as exogenous rhythms, or from 2) internal cues such as changes in core temperature, known as endogenous rhythms.

Rumor: Should I want to, I can make my body quickly adapt to a changed sleep schedule.

Truth: The biological clock in your brain will not respond to reasoning. Resetting the SCN takes time, and at best will adjust no faster than a rate of change from one to two hours in twenty-four hour period.

Example: Light can be used as he least painful means of resetting an internal clock.

 

Sleep Time Requirements

Everyone needs sleep, yet we all vary in our own personal needs. The term normal can be a treacherous thing. For most of people, the peak statistical indices on a Bell Curve dispersion graph are 8-hours of sleep within a 24-hour cycle for the body to function optimally. Some individuals may do fine with 7-hours or less per night. At least half of the population actually requires more than 8-hours and some people need more hours spent in sleep.

Rumor: It is wrong to need more than 8 hours of sleep, I must be lazy.

Truth: Sleep needs vary between individuals as well as during different developmental stages, and can also vary with differing physiologic stressors or medical conditions.

Example: Teenagers commonly need 8.5-10 hours of sleep per night, with the optimal sleep duration being around 9.25 hours (Clark-Steven, 2005)

 

For persons of all ages, though it tends to be more often noticed among teenagers and pre-teens, the effects of sleep deprivation may exhibit symptoms that are virtually identical to those of ADHD, such as memory problems, mood changes, focus problems, restlessness, and poor performance (Clark-Steven, 2005).

Findings from the 2005 Sleep in America Poll by The National Sleep Foundation revealed that on average, adults in America sleep only 6.9 hours each night. This finding brings substance to the statement that American’s live in a sleep deprived society (National Sleep Foundation, 2005).

Sleep Hygiene

Sleep hygiene is a systematic approach for developing lifestyle and dietary habits that promote sound sleep. The goal of developing a pattern of behaviors which have positive effects on sleep before, during, and after time spent in bed. Good sleep hygiene is the most important regimen of therapy in the exhausting fight against all forms of disruption to sleep. The practice of good sleep hygiene is also an uphill battle because it is a reversal in a long societal trend of forcing ever increasing quantities of activities into daily schedules at the expense of not only sleep duration, but also of the time needed to prepare mind and body for the process of sleep.

Sleep hygiene as an aid to troubled sleep patterns may feel uncomfortable or strange to some people, who have the anticipation that their tiredness can be remedied by the use of a pill. The use of prescription sleep aids; however, is not the answer for most people. Pharmacologic therapies are commonly limited to a span of two weeks or less, while the focus of sleep hygiene is lifestyle changes favorable to experiencing full, quality sleep.

There are benefits to pharmacologic therapy for sleep disorders. The use of sedatives, hypnotics, anti-anxiety medications or other chemical aids is beneficial for persons suffering from specific medical conditions or short-term episodes of broken sleep. Short term assistance should always be in conjunction with treatments that hold long term benefit.

The misconceptions about what does and does not influence the body, mind, and psyche in the goal of obtaining quality sleep are varying. Sleep hygiene education is essential. Education is the place to begin the process toward good sleep hygiene.

Components of Good Sleep Hygiene

Environment – Light, heat, noise and comfort are all essential elements in our search for sleep. Light excites centers in our brain causing them to secrete chemicals that promote alertness and wakefulness. The use of room darkening shades can help, and placing lights on dimmers to mute out brightness before bed or during middle of the night bathroom trips aids to minimize the rousing effect of bright lights. Temperature also plays a big environmental cue to the body's internal clock, so seek an ambient temperature cooler than that of the rest of the house for better sleep. Odors can provide comfort and relaxation effects, so consider the use of a sachet of lavender or other relaxing fragrances for use inside of pillow cases. Noise that is unfamiliar or unusual stimulates us, as our brain seeks to interpret the sounds, automatically scanning for the unusual or potentially threatening. Consider the use of a fan or other low background noise as a means of masking disruptive sounds. Do advise caution with environmental noises such as those marketed on CD’s for relaxation. Unusual bird sounds or even the trickling of water may provide unwanted distractions from sleep. Keep sleeping areas dark, cool, quiet, and especially comfortable. Few things are more disruptive to sleep hygiene than the automatic shifting of our bodies trying to find the best position in an uncomfortable bed. Benefit may be gained from demonstrations of proper sleep positions, such as laying on the side with a pillow between the knees and another snuggled up to the chest in a supportive hug.

Consistent Wakening Times – To create the mind/body habit that allows recognition of when the time to sleep has arrived, as well as when it should end, it is important to have consistent bed and awakening times, even on your days off. Remember to advise caution however for clients who are carrying a large sleep debt, as attempting consistent waking times may create frustration or resentment due to lingering fatigue. It is important to help clients create realistic schedules, and to be generous when working out times for waking. Your client can always shorten scheduled times set aside for sleep later, after some of their sleep debt is repaid.

Exercise – Exercise and when not to exercise can be a confusing proposition. Regular exercise actually helps everyone to sleep better. However, exercise within the six hours prior to bedtime has an excitatory effect on our metabolism and can disrupt sleep throughout the night. No exercise or very limited activity during the day can also contribute to sleep disruption, so do exercise; however, try to schedule exercise times as consistently as possible, and during daylight hours only.

Manage Stress – When we think of things causing stress, we need to stop it. Stress, worry, and anger are all sleep killers. Dozens of programs are available for stress management, so pick a few to have on hand for clients and get them involved with actively managing their stress. Combat stress with a multi-faceted regimen, so have the client choose two, or at most three stress reduction activities that they feel will work for them and focus on these first. More activities can be added in or switched with others as each person finds the correct balance that fits with their style. Some basic stress reduction activities include encouraging routine times of talking with friends, exercising regularly, playing computer games, learning to meditate, using progressive muscle relaxation, the list is endless, yet it must actually be done in order to show benefits.

Designate Worry Time – One way to fight the stress associated with troubled sleep is to harness it. Stress is actually a good thing, in limited amounts, during short periods of time. It helps us focus better, work harder, problem solve more clearly. Worry is our self-check that we have done everything we reasonably could for a particular event or situation. Set aside a designated time each day to do introspection on your life, events, plans, or expectations. Write down what you are concerned about and especially actions you want to take so you will not forget to do them. Use worry to find areas you can effect, use stress to fix them, and then get on with life. I recommend, and everyone has to figure out what works for them, about 30 minutes of worry time in the afternoon each day. During daylight hours only though, as you want to have stimulating thoughts, events or concerns out of your system as your body readies itself for sleep. As an additional aid to the middle of the night worrier, suggest that they place a writing pad and pencil next to the bed. Should they wake up with a concern, have them jot it down so they will be certain that they will not forget to deal with it, after they awaken.

No Napping – Seems counterintuitive, yes? Seriously though, we are creating lifelong life-style habits by implementing good sleep hygiene. That means we want each individual to avoid teaching their body bad patterns. Unless they are confident that a daily nap regimen will be available throughout the rest of their years, persuade them not to start now. If your client is already a nap-aholic, take the time to discover if this is in fact contributing to a lack of sleep discipline. Naps may be part of the sleep problem, not the solution. Should naps appear to not be contributing to sleep difficulty and therefore a non-issue, or should removing naps be non-negotiable, encourage reasonable limits such as no naps longer than one hour, and never later than 3 p.m. in the afternoon.

Alcohol – Alcohol of any amount is a trap when taken near bedtime. The depressant effects tend to induce a feeling of sleepiness at first, yet will continue to affect the central nervous system throughout the night, disrupting the normal cycle of sleep. A nightcap before bed often results in awakenings, nightmares, and even early morning headaches. Alcoholic beverages should be avoided for at least four to six hours before bedtime. One easy method of remembering is the rule no alcohol after dark.

Stimulants - Coffee, tea, colas, cocoa, chocolate, and nicotine all have stimulation effects that negatively affect internal signals that prepare our bodies for sleep. Encourage developing a habit of avoiding these items for at least the three to four hours prior to bedtime. This allows the winding down process our body undergoes in preparation for sleep to proceed uninterrupted by outside chemical stimulants.

Diet - Consuming a full meal shortly before bedtime can interfere with your ability to fall asleep and stay asleep. A light snack prior to bedtime, however, may actually promote sleep. Good bedtime snacks include milk and other dairy products, turkey and items rich in the amino acid tryptophan. If your client is a midnight snacker, have them develop the habit of preparing a light, ready to eat snack before bed for consumption later in order to minimize the time and trouble associated with that late night voyage to the kitchen.

Establish Signals – Our minds are continually taking in environmental clues, whether we want them to or not. Encourage clients to use this to send preparation for sleep signals to their bodies and minds. Such things as turning down the lights, turning off the TV, turning on soft music, especially something relaxing such as a familiar CD, putting on bed clothes, turning down the sheets, brushing teeth, washing the face, all of these can be used as sensory and action cues to our body that yes, it is now time to sleep. Remember to stress that the key to success with such cues is consistency of use.

Make a No-Clock Zone – Many individuals with troubled sleep become fixated on time issues. Needless to say, the added pressure of watching the seconds drift past only adds stress to the problem. If your client must have a clock such as an alarm clock, in the bedroom, encourage them to turn the face of it away from the bed.

Time Awake in Bed – The longer in bed awake, the harder it is to achieve sleep. Both sleep hygiene and cognitive behavioral therapies focus on the relationship between our mind and body anticipating that when in bed it should sleep, rather than doing awake activities (i.e. reading, eating, watching TV, surfing the net, etc). As a general rule encourage bedroom activities be limited to intimacy, and sleep.

Sleep Only when Tired – Closely connected to the frustration of laying in bed awake and unable to sleep is the importance reminder to purposely avoid awake activities in bed, including laying awake unable to sleep. Encourage your client to work on forming a habit in their mind and body that bed is only for sleep. Suggest that on those occasions when they are unable to get to sleep in a reasonable time, say twenty minutes, or awaken during sleep and find that they are wide awake – they get up out of bed and find something mindless to do until sleepy again, i.e. read a boring book, listen to soft music, but no TV. Television, studies show, has an enchanting ability to captivate the attention, and stimulate thoughts, feelings and emotions. This is no surprise really, considering that advertisers desire you to pay attention to their products.

Practice

Once sleep talk reveals areas that need adjustment, it is time to begin putting the parts of sleep hygiene into practice. Often the place to start is with the mapping out of your client's daily routine and the formation of a sleep hygiene schedule.

It is important not to induce panic at the thought of another daily schedule. We all have regular habits and routines we follow, so if the term schedule creates discomfort, the creation of a sleep wish list of what, when and how long preferred daily activities should occur, may circumvent schedule anxiety and give an opportunity to get things down on paper for the purpose of comparing current activities to those desired in the promotion of sleep.

The funnel method is one way of sorting out scheduling needs, and promoting sleep hygiene practice. The following is a description of the funnel method.

Life in the Past – Start with a typical day focusing on what the client is currently doing. Make a general listing of wakening time, the time they go to bed, typical meals, activities, and events. Special emphasis should be placed on areas of emotional stress such as work related activities, physical stress such as exercise, and the typical use of items that introduce stimulation such as chemical stimulants (i.e. coffee, nicotine, etc) or recreational stimulation (i.e. exciting TV, stimulating music, etc).

Wishes for the Future – Next list how out what the client would like to see in a well rested day, adding in the sleep hygiene components that would best accomplish the individual needs that have been presented. Include in this the number of hours of sleep desired, noting the time going for bed and arising that is needed to achieve this. Also include a reasonable period of preparation for bed that includes the activities which best suits the client. These activities will grow to form a consistent physical cue to the body that it is time for bed (i.e. putting on sleep clothes, washing face, brushing teeth, etc). Depending on individual preferences the preparation time needed may consist of as little as half an hour before actual head to pillow time. Now add in the time and durations for daily de-escalation, pre-sleep relaxation, or other components based on individual need. Do not forget to include on this sleep wish list a period of exercise during the daylight hours, also reminders such as when to begin avoiding the use of such things as caffeine or alcohol during the course of the day.

Funneling out an Individual Care Plan – Now, both lists in hand, it is time to funnel the items on them past each other and make some choices aimed toward achieving better sleep. Often the decisions made to reschedule activities not compatible with the desired sleep practices are more painful in anticipation then they are in practice, so reassurance is key. Once good sleep becomes a regular feature in the life of a client they often express no desire to return to the previous life habits that may have seemed so essential to them during the planning process.

Tools such as a sleep hygiene schedule formed into an individual care plan help during the transition into good sleep practice. Other tools include scheduled follow ups to encourage sleep hygiene changes, and the use of a mechanism to tie the educational aspects of sleep hygiene to the practice of good sleep hygiene. This last, is the sleep journal or sleep log.

Logging Sleep

Just a schedule in the hand and a talk about good practices is rarely enough to offset a major sleep disorder or a lifetime of poor sleep habits. Sometimes it takes a log.

Logging or journaling the activities and feelings that revolve around sleep does not need to be a time consuming event. It is however an important one as it creates a period of introspection within the person about their sleep, how successful sleep was the proceeding night and recognition of the factors before, during and after sleep that played direct roles in the success or failure of the sleep effort.

Journaling also allows an opportunity for the client to clarify how they feel about their sleep schedule and the activities they may feel they are now denied due to efforts to implement good sleep practices. A journal also helps identify whether some aspects of sleep hygiene work better for them than others.

Creation of a sleep log does not require a paragraph for each hour spent seeking sleep. Instead, a few words on the practical aspects (e.g. when they went to bed, when they got up, how many times they awoke during the night, how much of the night was spent in actual rest) can be combined with general observations made by the person.

Example:

August 4th - I went to bed at 9:10 instead of my goal of 8:30. I arrived home late after a few drinks to celebrate getting that raise I wanted, then spent an hour on the phone with my sister talking about the raise. I was so pumped it took a while to get to sleep. Woke up at the 5:30 a.m. alarm after sleeping straight though the rest of the night. I feel tired, but not exhausted like I used to every morning. I will get some exercise in during lunch at work, and get back on my schedule this evening.

 

Disorders of Sleep

Sleep hygiene practices contain benefits for all of us, and consistently provide aid to those suffering from disorders of sleep. One report shows that approximately one third of all Americans report significant sleep difficulties in any given year. Around half of the adults who acknowledge sleep problems, 17 percent, report the problem as being serious. In studies, one third of all adults are observed to have some form of insufficient sleep syndrome. With numbers like these, it is no wonder that sleep disturbance is one of the most frequent complaints leading to help being sought from health care providers (Bonds & Lucia, 2006).

Insomnia

One of the most commonly experienced of the sleep disorders is referred to as Primary Insomnia. Twenty percent of adults surveyed, report experiencing chronic insomnia, and as health care professionals we are aware that this phenomenon tends to be vastly under-reported.

Rumor: Insomnia is just having trouble getting to sleep.

Truth: In reality insomnia is a disorder that can affect the beginning, end, and even the middle of our normal sleep cycle.

Examples: Difficulty falling asleep (i.e. takes more than 30 minutes to initiate sleep), Difficulty maintaining sleep (repeated wake ups or breaks in sleep), Early morning awakenings (waking much earlier than planned and not being able to return to the sleep state).

 

In general the term insomnia is used to indicate difficulty initiating or maintaining the state of sleep. It can be a transient (acute) problem, or one of long standing (chronic). When we refer to primary insomnia, what is meant is that the disturbance in sleep is not a direct result of another condition or behavior, or even the result of a distinct originating physiologic process such as the use of psychostimulants (e.g. caffeine, nicotine, etc.) or the active presence of a medical process such as nausea or pain. Keep in mind also that in true insomnia, ample opportunity for sleep must be present.

Among the 2005 Sleep in America findings is that just over half of those surveyed (51% in men, 57% in women) report at least one of the major symptoms associated with insomnia on one or more nights each week (2005 Sleep in America Poll, 2005).

Daytime symptoms associated with insomnia can include:

  • Fatigue or malaise
  • Attention, concentration, or memory impairment
  • Social or vocational dysfunction or poor school performance
  • Mood disturbance or irritability
  • Daytime sleepiness
  • Motivation, energy, or initiative reduction
  • Proneness for errors or accidents at work or while driving
  • Tension, headaches, or GI symptoms in response to sleep loss

Available research suggests that primary insomnia may in some sufferers result from the presence of a heightened state of metabolic arousal which can be reflected in changes of cortisol levels, EMG readings, EEG activity levels, heart rate changes, and other physiologic indicators. (Roth, 2006).

Certain factors are associated with a higher incidence of insomnia, though it can be found among any age range or demographic dispersion: (Roth, 2006)

  • Older more than younger
  • Women more than men
  • At the monthly onset of menses as well as during menopause
  • Those suffering with medical problems
  • Adult mental illness
  • Shift workers, especially on night or rotating shifts

Treatment for the sleep disorder insomnia can take many forms:

  • Sleep Hygiene
  • Pharmaceutical aids to sleep
  • Natural health aids
  • Traditional interventions (e.g. relaxation strategies)
  • Cognitive Behavioral Therapy (CBT)
  • Light Therapies

Sleep hygiene components frequently found to benefit clients suffering from primary insomnia include; sleep scheduling, stress management, limiting stimulants prior to time of sleep, eliminating awake activities in the place of sleep, creation of habits that promote relaxation prior to time of sleep, and use of a sleep log or journal.

Obstructive Sleep Apnea

Strangling slowly during sleep is not a good thing. This however is what Obstructive Sleep Apnea is all about.

OSA, the medical shorthand for Obstructive Sleep Apnea, is a potentially fatal condition that involves mechanical obstruction of the airway during sleep. At a guess, around 12 million Americans currently suffer from OSA. Please realize that this number is a conservative one, for like Insomnia, vast numbers of cases go unreported. The tissues which close in to narrow or obstruct the airway during times of muscular relaxation, such as sleep, may be either soft tissue or tissue associated with the bony anatomy of the region. The diminishment of airway dimensions however is consistently worse in the presence of excessive fatty tissues (Bonds & Lucia, 2006).

During the deep relaxation associated with the sleep state, muscle tensions that otherwise contain or constrain tissues relax, allowing an anatomical decrease in the open regions of the upper airway most frequently, though other areas can also be involved. When the upper airway is the area of risk, reports of chronic loud snoring are common.

Snoring is a key component of OSA, for as musculature progressively relaxes allowing increasing encroachment on air flow, the force of inhalation/exhalation past these obstructing tissues creates the distinctive industrial tool sound most of us have been serenaded with at one time or another. The distinctive sounds are simply a prelude however, to what occurs next.

As tissues continue to squeeze out free airway flow, episodes occur where ineffective breath efforts are made. These ineffective breaths are repetitive efforts to push or pull air past the obstruction that look like the person is taking several quick, very shallow breaths. Typically the chest muscle effort being made produces little or no air exchange. The body responds to resulting drops in blood oxygen saturation by rousing or partially breaking the sleep cycle in order to restore muscle tension through the area involved. This tightening of muscles shifts obstructing tissue allowing at least a partial restoration of the airway, and results in the shuddering breaths commonly reported by observers after an episode of rapid shallow breathing.

Repeating episodes of ineffective breathing may occur 20 or more times in the space of an hour. Each episode brings with it periods of diminished oxygen saturation, increased blood carbon dioxide levels, as well as significant breaks in the cycle of sleep.

The resultant frequent arousals are a direct cause of ineffective sleep and lead to a state of chronic sleep deprivation with excessive daytime sleepiness that is a diagnostic red flag for this condition. Commonly associated with OSA are;

  • Morning headaches
  • High blood pressure
  • Heart attacks
  • Heart-rhythm disorders
  • Stroke

OSA can occur in any age group, and when in children is frequently associated with enlarged adenoids or tonsils. Because structural anatomy is an integral component of OSA the condition is more common in those who have a relative already diagnosed, as similarities in body tissue distribution commonly accompany members of families.

Treatment for OSA in adults may include:

  • Sleep Hygiene
  • Behavioral therapies (i.e. weight loss, sleep positioning, etc)
  • Mechanical Aids (dental appliances that reposition tongue or lower jaw, or continuous positive airway pressure to force air past obstructing tissues)
  • Surgery (to remove or decrease obstructing tissues, and/or to increase airway size)

Sleep hygiene components frequently found beneficial in the presence of obstructive sleep apnea include; exercise, elimination of stimulants and alcohol prior to time of sleep, practice in beneficial sleep positioning, formation of habits that promote sleep, the use of a sleep log or journal.

Restless Leg Syndrome

Broken sleep frequently involves unwanted movement, the most commonly diagnosed of which is Restless Leg Syndrome, or RLS. Restless leg is a neurologic movement disorder occurring more frequently in women than men that creates unpleasant sensations and an irresistible urge to shift, or move, during rest or sleep. Despite its name, these sensations may not be limited to lower extremities, but may involve or include hands, arms or torso. Individuals suffering from RLS frequently describe feeling itching, tingling, creeping, crawling, or pulling sensations. Sufferers report that movement or rubbing of the affected areas frequently provides temporary respite from these unpleasant sensations (Lee-Chiong, 2006).

RLS is not an exclusive sleep phenomenon, and may occur during any relatively inactive period such as when sitting for an extended time during a movie, concert, or meeting. Symptoms are frequently worse however during the evening or night, with reports of inability to enter the sleep state being common.

Spontaneous movements of the legs or arms during sleep are characteristic of RLS, and are occasionally categorized by the term Periodic Limb Movement Disorder.

Treatments for Restless Leg Syndrome frequently include one or more of the following:

  • Sleep Hygiene
  • Distraction techniques (i.e. leg massage, topical creams, progressive muscle relaxation)
  • Pharmacological sleep aids
  • Chiropractic adjustment

Sleep hygiene components frequently found to benefit clients suffering from restless leg syndrome include; sleep scheduling, stress management, limiting stimulants prior to time of sleep, eliminating awake activities in the place of sleep, creation of habits that promote relaxation prior to time of sleep, lower lighting with soft music prior to sleep.

Narcolepsy

Sleep attacks are another term for the condition we know as Narcolepsy. Estimates place as many as 250,000 Americans with significant Narcolepsy, with fewer than half of these being diagnosed. The major characteristic of narcolepsy is an excessive, overwhelming daytime sleepiness that occurs even after adequate nighttime sleep. Sufferers of this sleep disorder can become drowsy and even fall asleep without warning and during extremely inconvenient, even dangerous times or places such as while driving, flying an airliner, or at a job interview.

Individuals with narcolepsy are often identified during young adulthood or adolescence, and both women and men can be affected. Somewhat ironically, nighttime sleep is also often disrupted by narcoleptic episodes, which can disturb the even flow of normal sleep cycles and interfere with the quality of sleep. One aspect of normal sleep frequently affected is that of sequence, with REM sleep frequently occurring at sleep onset in those suffering from narcolepsy, rather than after the stages of NREM sleep as is typically seen.

Not every person who suffers from narcolepsy will display identical symptoms. Of note however are three sets, or primary patterns, of symptom manifestation often discussed with narcolepsy. They are;

  1. Cataplexy (a period of sudden muscle weakness often triggered by strong emotions such as anger, surprise, laughter, or exhilaration)
  2. Sleep paralysis (the temporary inability to talk or move especially when falling asleep or waking up)
  3. Hypnagogic hallucinations (vivid dreamlike experiences that occur while dozing or falling asleep)

Treatment strategies for individuals diagnosed with narcolepsy may diverge widely, and take on characteristics specific to each individual. Most however will contain components of the following therapeutic options:

  • Sleep Hygiene
  • Lifestyle structuring (life choices where episodic drowsiness will not result in personal injury or risk to others, assistance animal accompaniment, etc)
  • Pharmacological stimulants and/or sleep aids

Sleep hygiene components frequently found to benefit clients suffering from narcolepsy include; exercise, sleep scheduling, stress management, limiting stimulants and alcohol prior to time of sleep, eliminating awake activities in the place of sleep, creation of habits that promote relaxation prior to time of sleep, use of a sleep log or journal.

Parasomnias

In many ways the Parasomnias are the quintessential disorders of sleep. They include sleep walking, sleep terrors, talking during sleep, and many, many more. This loosely related collection is what comes immediately to mind whenever the subject of troubled sleep is brought up, and what connects them together is the common theme of abnormal behavior and/or movement which occurs either during sleep itself, or at the time of transitioning from sleep into wakefulness. Of special note is that the parasomnias are typically distinct from insomnia and surprisingly are often unaccompanied by the feeling of excessive sleepiness (Buysse, 2006).

Children and adults both suffer from the parasomnias. For children the more common troubles include sleepwalking, enuresis (bed wetting), sleep talking, nightmares and sleep terrors. Often children have no lasting memory of events related to a parasomnia, and usually require no treatment of them unless the severity level becomes unusually high. For all the Grandmothers out there, yes you were right when you advised they will grow out of it, as indeed the typical pattern of childhood parasomnias is that they fade with age, especially as the child nears adolescence.

Adult parasomnias can be more tenacious, and have a more serious impact than simply being the transient annoyance found in childhood. In adults sleep talking, walking, and night terrors seem to be those more commonly experienced. Some parasomnias however pose indirect or even direct risks to the safety of the sleeper and those around them. Some recognized adult parasomnias are;

  • Rhythmic Sleep Movement Disorders – in no way associated with restless leg syndrome (i.e. head banging, flailing of the limbs, rocking, etc)
  • Sleep Paralysis (inability to move, talk, or purposely control breathing during the waking transition from a state of sleep)
  • Confusional Arousal (not recognizing the environment or persons seen on waking from the sleep state)
  • Sleep Starts (sudden, perhaps violent movements during sleep resulting in an abrupt transition to awake state)
  • Sleep Eating (eating while asleep and even attempting to cook or prepare food while in a sleep walking state)
  • Sleep Terrors (the sudden awakening from sleep in a state of extreme fear, panic or terror)
  • Sleep Behavioral Disorders (screaming, kicking, punching, running, during sleep)

While pharmaceutical sleep aids or cognitive behavioral therapies are sometimes employed, the primary method of treatment for parasomnias centers on education in and the practice of Sleep Hygiene. To one degree or another most if not all of the sleep hygiene components find productive use in the battle to retake control of our lives from the affliction of parasomnias.

Conclusion

Sleep is an essential part of life. Our society promotes poor sleep practices, resulting in increased loss of health, injuries, and death. One third of Americans complain of significant sleep disturbances, making this the most prevalent medical problem seen within the health care system. Tools exist to combat disorders of sleep however, and at the forefront of these is the practice of good sleep hygiene. By education and encouragement of the life practices that promote relaxation and preparation for sleep in the mind, body and psyche we can help clients achieve sleep quicker, sleep longer, and have a better quality of rest during sleep.

References

Bonds, C. and Lucia, M. April 3, 2006. Sleep Disorders. eMedicine. Retrieved from http://www.emedicine.com/med/topic609.htm on April 10, 2007.

Buysse, Daniel. June 16, 2006. Classification of Sleep Disorders. UpTo Date 15.2. Retrieved from www.uptodate.com on April 13, 2007.

Clark-Steven, M. July 15, 2005. Sleep. Harvard Life Sciences Outreach Program. Retrieved from http://outreach.mcb.harvard.edu/teachers/Summer05/MargieClark/Sleep.ppt on April 10, 2007.

Lee-Chiong, Teofilo. December 2006. Common Sleep Disorders. National Jewish Medical and Research Center. Retrieved from http://www.nationaljewish.org/disease-info/diseases/sleep/about/disorders.aspx on April 13, 2007.

Roth, Thomas. March 17, 2006. Expert Column: The Sleep-Wake Cycle and Its Clinical Implications in Understanding and Managing Insomnia. Medscape Current Perspectives in Insomnia, Volume 8. Retrieved from http://www.medscape.com/viewprogram/5181 on April 10, 2007.

The National Institutes of Health. December 12, 2006. Research on Sleep and Sleep Disorders: Program Announcement PA-07-140. Retrieved from http://grants.nih.gov/grants/guide/pa-files/PA-07-140.html on April 9, 2007.

The National Sleep Foundation. March 29, 2005. 2005 Sleep in America Poll. Retrieved from http://www.sleepfoundation.org on April 10, 2007.