SLEEP DISORDERS

INTRODUCTION

Sleep can be regarded as a physiological reversible reduction of conscious awareness. Sleep is a naturally recurring state characterized by reduced or absent consciousness, relatively suspended sensory activity, and inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, and is more easily reversible than being in hibernation or a coma. Sleep is also a heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal and muscular systems, it is observed in all mammals, all birds, and many reptiles, amphibians, and fish. The purposes and mechanisms of sleep are only partially clear and are the subject of intense research. Sleep is often thought to help conserve energy, but actually decreases metabolism only about 5-10%. Sleep disorders and other sleep problems cause more than just sleepiness. A lack of quality sleep has a negative impact on energy, emotional balance, productivity, and health. The sleep disorders-cause, signs and symptoms, diagnostic criteria, treatment are described below.

NORMAL SLEEP REQUIREMENTS & PATTERNS

Sleep duration and quality vary among persons of all age groups

·         Infants 16 Hours /Day

·         Toddlers 12 Hours /Day

·         Preschoolers 11 Hours /Day

·         Schoolers S -10 hours /day

·         Adolescents 8-9 hours/day

·         Adults 6-8 hours/day

As people age, their circadian clock advances, causing advanced sleep phase syndrome. The syndrome is common in older adults and often is the reason behind the complaint of waking early in the morning and unable to get back to sleep. They get sleepy early in the evening.

CLASSIFICATION

The sleep disorders are labelled as non- organic sleep disorders in ICD-10. They are divided in 2 subtypes:

I. Dyssomnia

I.       Insomnia

2.   Hypersomnia

3.   Disorders of sleep wake schedule

II. Parasomnia

1. Stage 4 disorders

2. Other sleep disorders

DYSSOMINIA

Primarily psychogenic conditions in which the predominant disturbance in the amount, quality or timing of sleep due to emotional causes, i.e., insomnia, hypersomnia, and disorder of sleep wake schedule. These are the commonest sleep disorders.

 1. INSOMNIA:

Insomnia, the inability to get to sleep or sleep well at night, is an all-too common sleeping Problem in fact; it is the most common sleep complaint. Insomnia can be caused by a wide variety of things including stress, jet lag, a health condition, the medications, or even the amount of coffee taken. Insomnia can also be caused by other sleep disorders or mental health conditions such as anxiety and depression. Insomnia is defined as repeated difficulty with the initiation, duration, maintenance, or quality of sleep that occurs despite adequate time and opportunity for sleep that results in some form of daytime impairment.

ICD 10 DIAGNOSTIC GUIDELINES

The following are essential clinical features for a definite diagnosis:

1.    The complaint is either of difficulty falling asleep or maintaining sleep, or of poor quality of sleep

2.    The sleep disturbances has occurred atleast three times per week for atleast 1 month

3.    There is preoccupation with the sleeplessness and excessive concern over its consequences at night and during the day

4.    The unsatisfactory quantity and or quality of sleep either causes marked distress or interfere with ordinary activities in daily living.

CAUSES OF INSOMNIA

Symptoms of insomnia can be caused by or can be co-morbid with:

v  Use of psychoactive drugs (such as stimulants), including certain medications, herbs, caffeine, nicotine, cocaine, amphetamines, methylphenidate, and modafinil Use of fluoroquinolone antibiotic drugs.

v  Restless Legs Syndrome, which can cause sleep onset insomnia due to the discomforting sensations felt and the need to move the legs or other body parts to relieve these sensations.

v  Periodic limb movement disorder (PLMD), which occurs during sleep and can cause arousals that the sleeper is unaware of.

v  Pain -An injury or condition that causes pain can preclude an individual from finding a comfortable position in which to fall asleep, and can in addition cause awakening.

v  Hormone shifts such as those that precede menstruation and those during menopause.

v  Life events such as fear, stress, anxiety, emotional or mental tension, work problems, financial stress, birth of a child and bereavement.

v  Mental disorders such as bipolar disorder, clinical depression, generalized anxiety disorder, post traumatic stress disorder, schizophrenia, obsessive compulsive disorder, Dementia or Excessive Alcohol intake.

v  Disturbances of the circadian rhythm, such as shift work and jet lag, can cause an inability to sleep at some times of the day and excessive sleepiness at other times of the day. Chronic circadian rhythm disorders are characterized by similar symptoms.

v  Certain neurological disorders, brain lesions, or a history of traumatic brain injury

v  Medical conditions such as hyperthyroidism and rheumatoid arthritis

v  Abuse of over-the counter or prescription sleep aids can produce rebound insomnia

v  Poor sleep hygiene, e.g., noise

v  A rare genetic condition can cause permanent and eventually fatal form of insomnia called fatal familial insomnia.

v  Physical exercise. Exercise-induced insomnia is common in athletes, causing prolonged sleep onset latency.

COMMON SIGNS AND SYMPTOMS OF INSOMNIA INCLUDE:

ü  Difficulty falling asleep at night or getting back to sleep after waking during the night.

ü   Waking up frequently during the night, sleep is light, fragmented, or unrefreshing.

ü  Need to take something (sleeping pills, nightcap, supplements) in order to get to sleep.

ü  Sleepiness and low energy during the day.

 INSOMNIA- NON-MEDICAL TREATMENT AND BEHAVIORAL THERAPY

Non-pharmacologic or non-medical therapies are sleep hygiene, relaxation therapy, stimulus control, and sleep restriction. These also are referred to as cognitive behavioral therapies.

SLEEP HYGIENE

Sleep hygiene is one of the components of behavioral therapy for insomnia. Several simple steps can be taken to improve a patient's sleep quality and quantity. These steps include:

Ø  Sleep as much as needed to feel rested; do not oversleep.

Ø  Exercise regularly at least 20 minutes daily, ideally 4-5 hours before bedtime.

Ø  Avoid forcing to sleep.

Ø  Keep a regular sleep and awakening schedule.

Ø  Do not drink caffeinated beverages later than the afternoon (tea, coffee, soft drinks etc.)

Ø  Avoid "night caps," (alcoholic drinks prior to going to bed). Do not smoke, especially in the evening.

Ø  Do not go to bed hungry.

Ø  Adjust the environment in the room (lights, temperature, noise, etc.)

Ø  Do not go to bed with worries; try to resolve them before going to bed.

 RELAXATION THERAPY

Relaxation therapy involves measures such as meditation and muscle relaxation or dimming the lights and playing soothing music prior to going to bed.

STIMULUS CONTROL

Stimulus control therapy also consists of a few simple steps that may help patients with chronic insomnia.

·         Go to bed when you feel sleepy.

·         Do not watch TV, read, eat, or worry in bed. Bed should be used only for sleep and sexual activity.

·         If do not fall asleep 30 minutes after going to bed, get up and go to another room and resume relaxation techniques.

·         Set alarm clock to get up at a certain time each morning, even on weekends.

·         Do not oversleep.

·         Avoid taking long naps in the daytime.

SLEEP RESTRICTION

Restricting your time in bed only to sleep may improve your quality of sleep. This therapy is called sleep restriction. It is achieved by averaging the time in bed that the patient spends only sleeping. Rigid bedtime and rise time are set, and the patient is forced to get up at the rising time even if they feel sleepy. This may help the patient sleep better the next night because of the sleep deprivation from the previous night. Sleep restriction has been helpful in some cases. Other simple measures that can be helpful to treat insomnia include: Avoid large meals and excessive fluids before bedtime Control your environment.

•        Light, noise, and undesirable room temperature can disrupt sleep. Shift workers and night workers especially must address these factors. Dimming the lights in the bedroom, relaxation, limiting the noise, and avoiding stressful tasks before going to bed may be beneficial.

•        Avoid doing work in the bedroom that should be done somewhere else. For example, do not work or operate your business out of your bedroom and avoid watching TV, reading books, and eating in your bed.

MEDICATIONS

Many insomniacs rely on sleeping tablets and other sedatives to get rest, with research showing that medications are prescribed to over 95% of insomniac cases. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence, which manifests in withdrawal symptoms if the drug is not carefully tapered down. The benzodiazepine and nonbenzodiazepine hypnotic medications also have a number of side-effects such as day time fatigue, motor vehicle crashes, cognitive impairments and falls and fractures.

Benzodiazipine

These may be used, either alone, or may be used with treatment of underlying physical or psychiatric disorders. The use should only be for short term periods, not more than 4-6 wks at one time.

General Prescribing Guideline

Insomnia Level & Benzodiazepine Utilization

Mild to moderate

Alprazolam., Diazepam., Flurazepam, Lorazepam., Oxazepam.Quazepam

Moderate to Severe

Cinolazepam, Estazolam, Loprazolam, Lormetazepam, Midazolam,Nitrazepam

Severe to debilitating

Brotizolam, Flunitrazepam, Flutoprazepam, Nimetazepam, Temazepam,Triazolam

Non-benzodiazepines

Nonbenzodiazepine sedative-hypnotic drugs, such as Zolpidem, zaleplon, zopiclone, and eszopiclone, are a newer classification of hypnotic medications indicated for mild to moderate insomnia. They work on the benzodiazepine site on the GABAA receptor complex similarly to the benzodiazepine class of drugs

Opioids

Opioid medications such as hydrocodone, oxycodone, and morphine are used for insomnia that is associated with pain due to their analgesic properties and hypnotic effects

Other medications

Some antidepressants such as amitriptyline, doxepin, mirtazapine, and trazodone can often have a very strong sedative effect, and are prescribed off label to treat insomnia. The hormone melatonin, sold as a "dietary supplement" in some countries, is effective in several types of insomnia. Melatonin has demonstrated effectiveness equivalent to the prescription sleeping tablet zopiclone in inducing sleep and regulating the sleep/waking cycle. Low doses of certain atypical antipsychotics such as quetiapine, olanzapine, and risperidone are also prescribed for their sedative effect, but the danger of neurological, metabolic, and cognitive side-effects makes these drugs a poor choice to treat insomnia. 2.HYPERSOMNIA

Hypersomnia is characterized by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep. It is also known as DOES (disorder of excess insomnolence) .It means one or more of the following as per ICD10:

1. Excessive day time sleepiness or sleep attacks, not accounted for by an inadequate amount of sleep and or prolonged transition to the fully aroused stage upon wakening

2. Sleep disturbances occurring daily for more than 1 month or for recurrent periods of shorter duration, causing either marked distress or interference with ordinary activities in daily living

3. Absence     of auxiliary symptoms of narcolepsy or of clinical evidence for sleep apnoea

4. Absence of any neurological or medical condition of which daytime somnolence may be symptomatic.

HYPERSOMNIA CAUSES

Hypersomnia may be caused by another sleep disorder (such as narcolepsy or sleep apnea), dysfunction of the autonomic nervous system, or drug or alcohol abuse. In some cases it results from a physical problem, such as a tumor, head trauma, or injury to the central nervous system. Certain medications, or medicine withdrawal, may also cause hypersomnia. Medical conditions including multiple sclerosis, depression, encephalitis, epilepsy, or obesity may contribute to the disorder. Some people appear to have a genetic predisposition to hypersomnia; in others, there is no known cause.

HYPERSOMNIA SYMPTOMS

Different from feeling tired due to lack of or interrupted sleep at night, persons with hypersomnia are compelled to nap repeatedly during the day, often at inappropriate times such as at work, during a meal, or in conversation. These daytime naps usually provide no relief from symptoms. Patients often have difficulty waking from a long sleep, and may feel disoriented. Other symptoms may include:

      anxiety, increased irritation, decreased energy, restlessness,slow thinking, slow speech,loss of appetite, hallucinations, and memory difficulty. Some patients lose the ability to function in family, social,occupational, or other settings.

HYPERSOMNIA TREATMENT

Treatment is symptomatic in nature.

Changes in behavior (for example avoiding night work and social activities that delay bed time) and diet may offer some relief. Patients should avoid alcohol and caffeine.

MEDICATIONS

Stimulants such as the following may be prescribed:

amphetamine, methylphenidate (Concerta, Metadate CD, Metadate ER, Methylin, Methylin ER, Ritalin, Ritalin LA, Ritalin-SR), and modafinil (Provigil).

Other drugs used to treat hypersomnia include:

clonidine (Catapres), levodopa (Larodopa), bromocriptine (Parlodel), antidepressants, and monoamine oxidase inhibitors.

3. SLEEP-WAKE SCHEDULE DISORDER

These are characterized by a disturbance in the timing of sleep. The person with this disorder is not able to sleep when he wishes to, although at other times he is able to sleep adequately. This is due to a mismatch between the person’s circadian rhythm and the normal sleep wake schedule demanded by the environment. A form of dyssomnia caused by a conflict between a person's circadian rhythm and the socioeconomic demands of society, such as work and travel schedules.

DIAGNOSTIC GUIDELINES

The following clinical features are essential for a definite diagnosis:

1.      the individual's sleep wake pattern is out of synchrony with the sleep wake schedule that is normal for a particular society and shared by most people in the same cultural environment;

2.      insomnia during the major sleep period and hypersomnia during waking period are experienced nearly every day for at least 1 month or recurrently for shorter periods of time

3.      The unsatisfactory quality, quantity and timing of sleep cause marked distress or interfere with ordinary activities in daily living.

CAUSES OF SLEEP WAKE SCHEDULE DISORDER

The common causes are listed below:

1. Jet lag or rapid change of time zone: This typically occurs during international flights crossing many time zones. At the new place, personi js internal time of sleep and the sleep time of surroundings are different leading to insomnia during new sleep time and somnolence in the new daytime, thus causing functional impairment.

2. Work shift from day to night or vice versa.

3. Unusual      sleep phases: Some persons are unable to sleep early. They typically sleep late at night and get up late in the morning. They are called owls. Others are similarly unable to remain awake at night. They typically sleep early at night and get up early in the morning. They are called larks.

TREATMENT OF SLEEP WAKE SCHEDULE DISORDER

No specific treatment is usually needed for short term correction of insomnia. Changes in work shift may be needed for persons with unusual sleep phases. Exposure to sunlight during outdoor activity, and adopting the local hours for sleeping can help in combating jetlag.

II.PARASOMNIA

Parasomnias are a category of sleep disorders that involve abnormal and unnatural movements, behaviors, emotions, perceptions, and dreams that occur while falling asleep, sleeping, between sleep stages, or during arousal from sleep. It includes stage 4 sleep disorders and other sleep disorders

1. STAGE 4 SLEEP DISORDERS /NREM PARASOMNIAS

NREM parasomnias are arousal disorders that occur during stage 3 (or 4 by the R&K standardization) of NREM sleep also known as slow wave sleep (SWS). They are caused by a physiological activation in which the patient’s brain exits from SWS and is caught in between a sleeping and waking state. In particular, these disorders involve activation of the autonomic nervous system, motor system, or cognitive processes during sleep or sleepwake transitions. Some NREM parasomnias (sleep-walking, night-terrors, and night mares) are common during childhood but decrease in frequency with increasing age. They can be triggered in certain individuals by alcohol, sleep deprivation, physical activity, emotional stress, depression, medications, or a fevered illness.

2. OTHER SLEEP DISORDERS

The other sleep disorders include confusion arousal, teeth grinding, somniloquy, and enuresis.

I. SLEEP TERROR OR NIGHT TERROR OR PAVOR NOCTURNUS

A night terror, also known as a sleep terror or pavor nocturnus, is a parasomnia disorder that predominantly affects children, causing feelings of terror or dread. In Children

Children from age two to six are most prone to night terrors, and they affect about fifteen percent of all children, although people of any age may experience them. Episodes may happen for a couple of weeks then suddeniy disappear. The symptoms also tend to be different, like the child being unable to recall the experience, and while nearly arisen, hallucinating. Children who have night terrors are usually described as 'bolting upright' with their eyes wide open, with a look of fear and panic, and will often scream. They will usually sweat, breathe fast and have a rapid heart rate (autonomic signs). Although it seems like children are awake during a night terror, they will appear confused, will not be consolable and will not recognize others. Strong evidence has shown that a predisposition to night terrors and other parasomniac disorders can be passed genetically. Though there are a multitude of triggers, emotional stress during the previous day and a high fever are thought to precipitate most episodes. Ensuring the right amount of sleep is an important factor. In Adults

Though the symptoms of night terrors in adolescents and adults are similar, the etiology, prognosis and treatment are qualitatively different. These night terrors can occur each night if the sufferer does not eat a proper diet, get the appropriate amount or quality of sleep (eg. Sleep apnea), is enduring stressful events in their life or if they remain untreated. Adult night terrors are much less common, and often respond to treatments to rectify causes of poor quality or quantity of sleep. There is no scientific evidence of a link between night terrors and mental illness. There is some evidence of a link between adult night terrors and hypoglycemia. In addition to night terrors, some adult night terror sufferers have many of the characteristics of depressed individuals including inhibition of aggression, self-directed anger, passivity, anxiety, impaired memory, and the ability to ignore pain.

TREATMENT OF NIGHT TERRORS

Since night terrors are most commonly triggered by being overtired, sometimes no treatment is necessary except for a bedtime schedule that ensures proper sleep. If the night terrors are more frequent, however, it has been suggested that the sufferer should be awakened from sleep just before the time when the terrors occur most to interrupt the sleep cycle. Unfortunately, no adequate treatment exists for night terrors. Management primarily consists of educating the family about the disorder and reassuring them that the episodes are not harmful. In severe cases in which daily activities (for example, school performance or peer or family relations) are affected, tricyclic antidepressants (such as imipramine) may be used as a temporary treatment, imipramine) are rarely indicated for night terrors because they do not provide long-term help for the child, they may be used as a temporary treatment. Tricyclic antidepressants are usually only prescribed for severe symptoms in which the child's waking behavior (for example, school performance or peer or family relations) is affected.

PREVENTION OF NIGHT TERRORS

If the child has several night terrors, parents can try to interrupt his/her sleep in order to prevent the night terror.

•        Parents should note how many minutes the night terror occurs from child's bedtime.

•        Then, awaken child 15 minutes before the expected night terror, and keep him/her awake and out of bed for 5 minutes. Parents may want to take child to the bathroom to see if he/she will urinate.

•        Parents can continue this routine for a week.

GUIDANCE TO PARENTS

Parents should be advised to examine the adequacy of the child's sleep. Parents should be educated about the importance of establishing a consistent bedtime routine and maintaining a consistent wake- up time. Additionally, parents should be instructed to make the child's room a safe environment and to provide barriers that prevent the child from impulsively leaving the room and going into environments that could lead to injury. Potential sources of sleep disturbance should also be eliminated.

II. NIGHT MARES

Nightmares (dream anxiety disorder) occur during REM sleep. They are characterised by fearful dreams occurring most commonly in the last one third of night sleep. The person wakes up very frightened and remembers the dream vividly. This is in contrast to night terror which occur early in the night, are a stage 4 NREM disorder, and are characterized by complete amnesia. In both conditions, the observer finds the person frightened during the episode. Nightmare disorder', or 'dream anxiety disorder', is a [sleep] disorder characterized by frequent [nightmares]. The nightmares, which often portray the individual in a situation that jeopardizes their life or personal safety, usually occur during the second half of the sleeping process, called the [REM stage]. Though such nightmares occur within many people, those with nightmare disorder experience them with a greater frequency.

DIAGNOSTIC GUIDELINES

The following clinical features are essential for a definite diagnosis:

1. Awakening from nocturnal sleep or naps with detailed or vivid recall of intensely  frightening dreams usually involving threat to survival, security or self esteem; the awakening may occur at any time during the sleep period, but typically during the second half;

2. Upon awakening from the frightening dreams, the individual rapidly becomes oriented and alert

3. The experience itself and the resulting disturbance of sleep, cause marked distress to the individual CAUSES OF NIGHT MARES

Nightmares can be caused by extreme stress or anxiety if no other mental disorder is discovered. The death of a loved one or a stressful life event can be enough to cause a nightmare but mental conditions like post-traumatic stress disorder and other psychiatric disorders have been known to cause nightmares as well.

If the individual is on medication, the nightmares may be attributed to some side effects of the drug. Amphetamines, antidepressants, and stimulants like cocaine can cause nightmares. Blood pressure medication, levodopa and medications for Parkinson's disease have also been known to cause nightmares as well as SSRIs like Prozac and Effexor.

SYMPTOMS OF NIGHTMARES

During the nightmare, the sleeper may moan and move slightly. The victim is often awakened by these threatening and frightening dreams and can often vividly remember their experience. Upon awakening, the sleeper is unusually alert and oriented within their surroundings, but may have an increased heart rate and symptoms of anxiety, like sweating. They may have trouble falling back to sleep for fear they will experience another nightmare. A person experiencing nightmare disorder would have trouble going through everyday tasks; the lack of sleep and anxiety caused by the fearful dreams would hinder the individual from completing everyday jobs efficiently and correctly.

TREATMENT OF NIGHTMARES

The treatment of nightmares is by suppression of REM sleep. Eg. bedtime dose of a benzodiazepine. However on stopping the drug, a rebound increase in symptoms may occur. There are many ways to treat dream anxiety without seeking the help of a therapist. Alleviating stress within the home and personal life is a good way to eliminate any anxiety the individual may have upon going to bed. A regular fitness routine and perhaps relaxation therapy would help to make the individual fall asleep faster and more peacefully. Yoga and meditation can also help to eliminate stress and create a more peaceful sleeping atmosphere. Psychotherapy can also help an individual learn how to cope and deal with the various stressors in their life.

Diagnosis and medication can only be given to patients that report the recurring nightmares to a psychiatrist or other physician. Therapy usually helps to deal with the frightening themes of the nightmares and alleviate the recurrence of the dreams. The persistent nightmares will usually improve as the patient gets older. Treatments are generally very successful

III. SOMNABUUSM

Sleepwalking is characterized by complex behavior (walking) accomplished while asleep. Occasionally nonsensical talking may occur while sleepwalking. The person's eyes are commonly open but have a characteristic glassy "look right through you" character. This activity most commonly occurs during middle childhood and young adolescence. Approximately 15% of children between 4-12 years of age will experience sleepwalking. Generally sleepwalking behaviors are resolved by late adolescence; however, approximately 10% of all sleepwalkers begin their behavior as teens. A genetic tendency has been noted.

DIAGNOSTIC GUIDELINES

The following clinical features are essential for a definite diagnosis

1.   The predominant symptom is one or more episodes of rising from bed, usually during the first third of nocturnal sleep and walking about

2.   During an episode the individual has a blank, staring face is relatively unresponsive to the efforts of others to influence the event or to communicate with him or her and can be awakened only with considerable difficulty.

3.      Upon wakening the individual has no recollection of the episode

4.            Within several minutes of awakening from the episode, there is no impairment of mental activity or behavior although there may initially be a short period of some confusion and disorientation e. there is no evidence of an organic mental disorder such as dementia or a physical disorder such as epilepsy.

SLEEPWALKING- CAUSES

1. Genetic factors

Sleepwalking occurs more frequently in identical twins, and is 10 times more likely to occur if a first- degree relative has a history of sleepwalking.

2. Environmental factors

Sleep deprivation, chaotic sleep schedules, fever, stress, magnesium deficiency, and alcohol intoxication can trigger sleepwalking.

Drugs, for example, sedative/hypnotics (drugs that promote sleep), neuroleptics (drugs used to treat psychosis), minor tranquilizers (drugs that produce a calming effect), stimulants (drugs that increase activity), and antihistamines (drugs used to treat symptoms of allergy) can cause sleepwalking.

3. Physiologic factors

·         The length and depth of slow wave sleep, which is greater in young children, may be a factor in the increased frequency of sleepwalking in children.

·         Conditions, such as pregnancy and menstruation, are known to increase the frequency of sleepwalking.

Associated medical conditions

·         Arrhythmias (abnormal heart rhythms)

·         Fever

·         Gastroesophageal reflux (food or liquid regurgitating from the stomach into the food tube or esophagus)

·         Nighttime asthma

·         Nighttime seizures (convulsions)

·         Obstructive sleep apnea (a condition in which breathing stops temporarily while sleeping)

SLEEPWALKING SYMPTOMS

Ø Episodes range from quiet walking about the room to agitated running or attempts to "escape." Patients may appear clumsy and dazed in their behaviors.

Ø Typically, the eyes are open with a glassy, staring appearance as the person quietly roams the house. They do not, however, walk with their arms extended in front of them as is inaccurately depicted in movies.

Ø On questioning, responses are slow with simple thoughts, contain non-sense phraseology, or are absent. If the person is returned to bed without awakening, the person usually does not remember the event.

Ø Older children, who may awaken more easily at the end of an episode, often are embarrassed by the behavior (especially if it was inappropriate). In lieu of walking, some children perform repeated behaviors (for example, straightening their pajamas). Bedwetting may also occur.

Ø Sleepwalking is not associated with previous sleep problems, sleeping alone in a room or with others, achluophobia (fear of the dark), or anger outbursts.

Ø Some studies suggest that children who sleepwalk may have been more restless sleepers when aged 4-5 years and more restless with more frequent awakenings during the first year of life.

TREATMENT

If sleepwalking is caused by underlying medical conditions, for example, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements (restless legs syndrome), or seizures, the underlying medical condition should be treated.

Medications for the treatment of sleepwalking disorder may be necessary in the following situations:

•      The possibility of injury is real.

•       Continued behaviors are causing significant family disruption or excessive daytime sleepiness.

•       Other measures have proven to be inadequate.

Benzodiazepines, such as estazolam (ProSom), or tricyclic antidepressants, such as trazodone (Desyrel), have been shown to be useful. Clonazepam (Klonopin) in low dose* before bedtime and continued for 3-6 weeks is also usually effective.

Medication can often be discontinued after 3-5 weeks without recurrence of symptoms. Occasionally, the frequency of episodes increases briefly after discontinuing the medication.

OTHER SLEEP DISORDERS

1. SLEEP RELATED ENURESIS OR BEDWETTING

Sleep related enuresis, commonly referred to as bedwetting, involves urinating during sleep and occurs most often during deep (stage 3) sleep. Bedwetting occurs more frequently in children, and in some cases carries over into adulthood. Bedwetting is frequently the result of a failure of the brain to engage in appropriate "alarming" of bathroom needs during sleep before urination occurs. Bedwetting has been reported to have a genetic predisposition. As part of the evaluation of this disorder, a medical workup is required to rule out medical problems (such as anatomical/urinary problems) that may be causing the episodes of bedwetting. Bedwetting can be exacerbated by other sleep disorders (such as OSA), sleep deprivation, substance use/medications, or stress. It is treated in some cases using medication, but more often is treated using “alarming" devices to arouse the patient from sleep before bedwetting occurs.

There are two types of bedwetting:

 Primary enuresis: bedwetting since infancy

Secondary enuresis: wetting developed after being continually dry for a minimum of six months

Primary bedwetting

Primary bedwetting is viewed as a delay in maturation of the nervous system. At 5 years of age, approximately 20% of children wet the bed at least once a month, with about 5% of males and 1% of females wetting nightly. By 6 years of age, only about 10% of children are bedwetters & the large majority being boys. The percentage of all children who are bedwetters continues to diminish by 50% each year after 5 years of age. Family history plays a big role in predicting primary bedwetting. If one parent was a bedwetter, the offspring have a 45% chance of a developing primary enuresis as well.

Some common recommended management and treatment options include the following:

1. Encourage voiding prior to bedtime, and restrict fluid intake before bed.

2. Cover the mattress with plastic.

3.  Bedwetting alarms: There are generally reserved for older school-age children. There are commercial alarms that are available at most pharmacies. When the device senses urine, it alarms and wakes up the child so he/she can use the toilet. The cure rate is variable.

4.  Bladder-stretching exercises are aimed at increasing the bladder volume and increasing the periods between daytime urinations.

5.      Medications, such as DDAVP (desmopressin acetate or antidiuretic hormone) and Tofrinil (imipramine), have been shown to be very effective and are used to temporarily treat the nighttime urination, but they do not "cure" the enuresis. Many pediatricians will prescribe one of these medications, especially if the child is engaged in behavioral conditioning as well. Medications are very helpful when a child is not sleeping at home (camp or sleepovers), since the trauma of bedwetting in those settings is predictable. In addition, a recent study presented at the 2009 Pediatric Academic Society's annual meeting suggested that ibuprofen (Motrin, Advil, etc.) may also decrease the incidence of bedwetting by possibly stabilizing the bladder muscle that contracts during urination (detrusor muscle). Only approximately 2%-3% of all children with bedwetting have a medical cause for the condition.

Secondary bedwetting

Urinary tract infections, metabolic disorders (such as diabetes), external pressure on the bladder (such as from a rectal stool mass), and spinal cord disorders are among the causes of secondary bedwetting. Therapy of secondary bedwetting is directed at the primary problem causing the symptom of wetting the bed. As expected, cure rates vary depending on the cause of the loss of control.

2. BRUXISM

Bruxism ("gnashing of teeth") is characterized by the grinding of the teeth and typically includes the clenching of the jaw. It is an oral parafunctional activity that occurs in most humans at some time in their lives. In most people, bruxism is mild enough not to be a health problem. While bruxism may be a diurnal or nocturnal activity, it is bruxism during sleep that causes the majority of health issues and can even occur during short naps. Bruxism is one of the most common sleep disorders. A suffer of bruxism is pejoratively known an an "orrener".

CAUSES OF BRUXISM

Bruxism is a habit rather than a reflex chewing activity. Reflex activities happen reliably in response to a stimulus, without involvement of subconscious brain activity. Chewing and clenching are complex neuromuscular activities that can be controlled either by subconscious processes or by conscious processes within the brain. During sleep, (and for some during waking hours while conscious attention is distracted) subconscious processes can run unchecked, allowing bruxism to occur. Some bruxism activity is rhythmic with bite force pulses of tenths of a second (like chewing), and some has a longer bite force pulses of 1 to 30 seconds (clenching). Researchers classify bruxism as "a habitual behavior, and a sleep disorder

SYMPTOMS OF BRUXISM

Patients may present with a variety of symptoms, including:

Anxiety, stress, and tension

Depression

Earache

Eating disorders

Headaches /Migraines

Loose teeth

Tinnitus

Gum recession

Neck pain

Insomnia

Sore or painful jaw

MANAGEMENT OF BRUXISM Dental guards and splints

A dental guard or splint can reduce tooth abrasion. Dental guards are typically made of plastic and fit over some or all of upper and/or lower teeth. The guard protects the teeth from abrasion and can reduce muscle strain by allowing the upper and lower jaw to move easily with respect to each other

Biofeedback

Various biofeedback devices are currently available, and effectiveness varies significantly depending on whether the biofeedback is used only during waking hours, or during sleep as well. The first wearable nighttime bruxism biofeedback device (a biofeedback headband) was introduced in 2001. A biofeedback headband is a battery-powered device that sounds a tone when it senses EMG muscle activity in the temporalis muscles. The tone starts off at a low volume and gets louder until the clenching incident stops, or until a maximum volume level is reached. The intent is to allow people to stop clenching without awakening.

Botox

Botulinum toxin (Botox) can lessen bruxism's effects, though serious side-effects (including death) are possible. In extremely dilute form Botox is injected to weaken (partially paralyze) muscles and has been used extensively in cosmetic procedures to 'relax' the muscles of the face

Dietary supplements

There is anecdotal evidence that suggests taking certain combinations of dietary supplements may alleviate bruxism; pantothenic acid ,magnesium, and calcium[citation needed] are mentioned on dietary supplement websites. Calcium is known to be a treatment for gastric problems, and gastric problems such as acid reflux are known to increase bruxism.

Repairing damage

Damaged teeth can be repaired by replacing the worn natural crown of the tooth with prosthetic crowns. Materials used to make crowns vary; some are less prone to breaking than others and can last longer. Porcelain fused to metal crowns may be used in the anterior (front) of the mouth; in the posterior, full gold crowns are preferred. All-porcelain crowns are now becoming more and more common and work well for both anterior and posterior restorations. To protect the new crowns and dental implants, an occlusal guard should be fabricated to wear during sleep.

3.SOMNILOQUY OR SLEEP-TALKING

Somniloquy or sleep-talking that refers to talking aloud in one's sleep. It can be quite loud, ranging from simple sounds to long speeches, and can occur many times during sleep. Listeners may or may not be able to understand what the person is saying. Sleep-talking usually occurs during transitory arousals from NREM sleep, which is when the body does not move smoothly from one stage in NREM sleep to another, and they become partially aroused from sleep. Further it can also occur during REM sleep at which time it represents a motor breakthrough of dream speech, words spoken in a dream are spoken out loud. Sleep-talking can occur by itself or as a feature of another sleep disorder such as: Rapid eye movement behavior disorder (RBD) - loud, emotional or profane sleep talking, Night terror - intense fear, screaming, shouting, Sleep-related eating disorder (SRED)

PREVALENCE AND DIAGNOSIS

Sleep-talking is very common and is reported in 50% of young children, with most of them outgrowing it by puberty; although it may persist into adulthood (about 4% of adults are reported to talk in their sleep). It appears to run in families. Sleep-talking can be associated with fever. Sleep-talking by itself is harmless; however, it can wake up others and cause them Consternation- especially when misinterpreted as conscious speech by an observer. If the sleep-talking is dramatic, emotional, or profane it may be a sign of another sleep disorder. Sleep-talking can be monitored by a partner or by using an audio recording device; devices which remain idle until detecting a sound wave are ideal for this purpose. Polysomnography (sleep recording) shows episodes of sleep talking that can occur in any stage of sleep.

MANAGEMENT OF SOMNILOQUY

ü  Avoid heavy meals before bedtime.

ü  Practice proper sleep hygiene.

ü  Use of medicines: use of antidepressants or sleeping pills to encourage sleep.

ü  Avoid use of drugs such as alcohols before going to bed

ü  Avoid intake of large quantity of food and meal before getting into bed.

ü  Cognitive behavioral therapy

ü  Reduce tensions and stress

ü  Follow proper sleeping

CONFUSIONAL AROUSALS

With a prevalence of 4%, confusional arousals are not observed  very often in adults; however, the y are common in children. Confusional arousals are occasional thrashing or inconsolable crying among children. They are characterized by movements in the bed and Somnambulism.sleep walkers arise from the slow wave sleep stage in a state of low consciousness and perform activities that are performed during a state of full consciousness. These activities  can be as begin as sitting up in bed, walking to the bath room, and cleaning or as hazardous as cooking, driving, extremely violent gusters, grabbing at hallucinated objects, or even homicide.

Causes of confusional arousal

Several experts theorize that the development of sleep walking in childhood is due to a delay in maturation. There are also high voltage delta waves in somnambulists up to 17 years of age. This presence might suggest an immaturity in the central nervous system, also a possible cause of sleep walking. Sleep walking is clustered in families, and percentage of childhood sleepwalking increases up to 45 % if one parent was affected and 60% if both parents were affected. However, there is no recorded preference to male or female individuals.

Treatment of confusional arousal

There are some drugs can be prescribed for sleep walkers such as a low dose benzodiazepine, tricyclic antidepressants, and clonazepam. However, for most sleep walkers, many experts advice putting away dangerous items and locking doors and windows before sleep to reduce risk of harmful  activity. Good sleep hygiene and avoiding sleep deprivation is also recommended.

Other important sleep disorders

1. Narcolepsy

Narcolepsy is one of the disorders characterized by excessive day time sleepiness. The client also experiences disturbed nocturnal sleep and repeated episodes of almost irresistible day time drowsiness followed by brief period of sleep, especially when engaged in monotonous activities. Many narcoleptic clients also experience cataplexy, a sudden loss of muscle tone at times of unexpected emotion (E.g. Fright). Malfunctioning of the mechanism controlling REM sleep leads to sleep paralysis for one or several minutes and hypnagogic hallucinations, i.e. hallucinatory experiences that occur at sleep onset or awakening.

On polysomnography, the most characteristic finding is sleep onset REM periods. Narcolepsy is genetically related condition with autosomal dominance in some cases. The effect of disease on life style are significant- many clients reporting episodes of having fallen asleep at work, while driving or both.

Medical management consists of low doses of stimulants to improve alertness and tricyclic antidepressants to control cataplexy. It is important that they maintain a regular schedule with adequate nocturnal sleep. Recommend regular naps at times when clients are prone to increased sleepiness. Safety is the major issue in these clients.

2. 0BSTRUCTIVE SLEEP APNEA SYNDROME: In Obstructive Sleep apnea syndrome, respiratory efforts of the diaphragm and intercostals muscles are apparent but ineffective against a collapsed or obstructed upper airway. Snoring indicates partial obstruction. As hypoxia ensues; the person eventually awakens to breathe. The frequent awakenings impair the normal sleep cycle. Repeated micro arousals lead to daytime sleepiness.

Women are less likely than men to develop Obstructive Sleep apnea syndrome, particularly before menopause. It is common among males who are obese with short, thick necks, and who are heavy snorers. A much smaller percentage progresses to the classic pickwickian syndrome, characterized by obesity, severe sleep apnea, daytime hypercapnea, and cor pulmonale.

The application of continuous positive airway pressure (CPAP) by means of a face mask covering the nose is the treatment of choice for clients with moderate to severe Obstructive Sleep apnea syndrome. The CPAP device provides room air under increased pressure, essentially providing a pressure splint to keep the upper airway open. It should be turned on whenever the client is ready to go to sleep and should be maintained throughout the sleep period. Clients may experience nasal congestion, air leak, pressure marks on the face, or pressure intolerance. People who use CPAP regularly should bring their units to the hospital with them. These clients need to be monitored when recovering from anesthesia, and when receiving narcotics because they are at risk for developing ineffective breathing patterns.

3. Periodic limb movement disorder

It may also contribute to daytime sleepiness and frequent nocturnal wakening. Originally described as nocturnal myoclonus, it is characterized by periodic episodes of repetitive, stereotypic leg movements that occur during sleep, causing partial arousals. It is common in the elderly population. Clonazepam, a benzodiazepine, or baclofen, a skeletal muscle relaxant, may be ordered to diminish the magnitude of the movement and frequency of arousals. For some clients the use of transcutaneous electrical nerve stimulation (TENS) before sleep has been helpful.

5. Restless leg syndrome:

Restless leg syndrome involves anything "crawling", itching or tingling sensations of the leg while at rest and causes an almost irresistible urge to move. The syndrome is often most severe before sleep onset. Clients always have periodic limb movements during sleep. Treatment is similar to that of Periodic limb movement disorder.

NURSING IMPLICATIONS

Offer meals at regular times, corresponding to client's previous pattern, provide active meaningful activities during daytime hours, including exposure to natural light, and an outdoor environment when possible, monitor frequency and duration of naps, create an individualized bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom and settling a routine. People with sleep apnea or hypopnea are encouraged to stop smoking, avoid alcohol or drugs of abuse, and lose weight in order to improve the stability of the upper airway. Some alternative approaches may be effective in treating insomnia caused by anxiety or emotional stress. Meditation practice, breathing exercises, and yoga can break the vicious cycle of sleeplessness, worry about inability to sleep, and further sleeplessness for some people. Yoga can help some people to relax muscular tension in a direct fashion. The breathing exercises and meditation can keep them from obsessing about sleep.

NURSING PROCESS

A. Assessment: Assess client's usual sleep habits and recent sleep quality as part of the initial nursing history. If sleep quality is reported to be poor, explore the nature of disturbances by noting the following:

·         Usual activities in the hour before retrieving

·         Sleep latency

·         Number and perceived cause of awakenings

·         Regularity of sleep pattern

·         Consistency of rising time

·         Frequency and duration of naps

·         Events associated with initial onset of sleep disturbances

·         Ease of falling asleep in places other than the usual bedroom

·         Situations in which client fights sleepiness

·         Daily caffeine intake

·         Use of alcohol, sleeping pills, and other medications

·         Objective data may include visible signs of fatigue and lack of sleep, such as circles under the eyes, lack of coordination, drowsiness and irritability.

a. Nursing diagnosis:

Disturbed sleep pattern (insomnia) related to poor sleep hygiene as evidenced by low energy during the day.

NURSING INTERVENTIONS	RATIONALE
1. Assess the sleep pattern of the client	Provides base line data
2.Encourage to exercise daily before bed time	Promotes sleep
3. Instruct to avoid caffeinated beverages later	The change in sleep pattern observed suggests an
than the afternoon and also to avoid night caps		increased capability for arousal and decreased ability to develop or sustain deeper stages of non- rapid eye movement sleep after caffeine.
4. Adjust the environment in the room like low noise, dim light etc..		As bright light and loud noise may interefere with sleep
5.Don't read books, watch TV in bed . Use bed only for sleeping		Sleep restriction helps to improve quality of sleep
6. Set alarm clock to get up at a certain time each morning		Oversleeping may also interferes with sleep.

Disturbed sleep pattern related to enuresis as evidenced by frequent arousal of the child from bed

NURSING INTERVENTIONS	RATIONALE
l.Assess for anatomical or urinary problems, if any.	Organic problems should be ruled out to treat accordingly
2.lnsist the parents to make the child void before bedtime	Decrease the possibility of bed wetting
З.ЕхрІаіп about the availability of bedwetting alarms	Devices senses urine, so that the child can use the toilet.
4.Taught bladder stretching exercises	Increase bladder volume ;periods between daytime urination
5. Administer medications as per physician's order. l.T.lbuprofen	Stabilize the bladder muscle that contracts during urination

OUTCOME CRITERIA: The sleep pattern of the client has improved.

Disturbed sleep pattern related to lack of cues for day- night schedule; evidenced by erratic sleep schedule, frequent naps and nocturnal wandering

C. Client Outcome criteria: client increases nocturnal sleep time by 20% over next 2 weeks.

D. Nursing intervention

Rationale

*offer meals at regular times, corresponding to client's previous pattern *provide active meaningful activities during Idaytime hours, including exposure to natural light, and an outdoor environment when possible *monitor frequency and duration of naps *create an individualized bedtime ritual that includes a quieting activity, a light carbohydrate snack, going to the bathroom and settling a routine *Do not waken even if incontinent. Change and assist the client to the bathroom when he or she spontaneously awakens *if turning or other care is necessary, try to [provide for periods up to 2 hours of jundisturbed sleep time whenever possible

*mealtimes are important social cues, that reinforce circadian rhythms, which tend to weaken with advancing age *ight exposure is communicated through the retina to the suprachiasmatic nucleus, helping to set the circadian clock *Napping is not contraindicated but is best at the time of day opposite to the midpoint of the j nocturnal sleep period. Short naps are {preferable to avoid deep sleep  *reduced stimulation and rituals associated with sleep enhance sleep onset *Older adults who can turn themselves Generally do better to have their sleep undisturbed and tend to waken spontaneously j if wet when their sleep cycle lightens *Sleep cycles average 90 mts. A sleep latency (of 20- 30 mts mean it would take about 2 hours (to experience a full sleep cycle.

CONCLUSION

The adequacy of sleep is important factor in caring for clients with acute and chronic illness. Some sleep disturbances are temporary and related to the stress of hospitalization. It is possible that temporary stress problems will be corrected only after the client's return home. Clients with sleep disturbances may need follow -up care with repeated assessments to determine whether the problem was corrected. Clients with long term sleep disorders may need ongoing support to maintain the effectiveness of treatment. The nurse can play a pivotal role in environmental modification and client teaching to minimize the impact of sleep.

REFERENCES

1. Kaplon         & Saddock. Comprehensive textbook of psychiatry: 7th edition . Philadelphia. Lippincott Williams & Wilkins ;1999.p.2377-2389.

2. Mary           CTownsend. Psychiatric mental health nursing. Concepts of care in evidence based practice: 5th edition . Philadelphia : F.A.Davis Company; 2007 . p.581-589.

3. Niraj Ahuja.A short t extbook of psychiatry: 5th edition.New Delhi Jaypee brothers.2005.p.90-93 4.Sreevani .R. Aguide to mental health and psychiatric nursing. 2nd edition.New DelhiJaypee brothers. 2008. p. 176-179.

5. www.healthieryou.com

6. www.sleepdisorders.about.com