Sleep Disorders
Karen M. Kress, Jill C. Cash, Cheryl A. Glass, and Alyson Wolz
Definition
A.In normal sleepers, transient insomnia occurs in those who have traveled to another time zone (i.e., jet lag
), are under situational stress, or are sleeping in unfamiliar surroundings. Treatment is not required in these situations because time takes care of the problem. With short-term insomnia, the normal sleeper experiences difficulty sleeping that does not resolve within a few days. This can be the result of stress, such as financial difficulty and divorce. These patients may require short-term symptomatic relief of insomnia.
B.Long-term insomnia is persistent and disabling. Studies suggest that almost all have an associated psychiatric disorder, especially depression; an associated drug use/abuse/withdrawal problem; or an associated medical disorder.
Incidence
A.Difficulties with sleep are among the most common complaints of medical patients and affect a large percentage of the population. From 10% to 20% of all adults express sleep-related complaints they consider to be serious. Sleep disorders also can affect proper mental functioning (53% of chronic insomniacs complain of memory difficulties). Sleep disorders are also implicated in decreased work efficiency, impaired industrial productivity, and increased risk of traffic accidents. They also seem to enhance the propensity for cardiovascular disease and increase the risk of death. Insomniacs are also at increased risk for the development of depression and anxiety disorders. Patients with obstructive sleep apnea (OSA) syndrome have significant performance impairments on complex motor tasks.
The risk of depression increases with time if insomnia is left untreated.
Pathogenesis
A.Other than situational stress, jet lag, and sleeping in unfamiliar surroundings, difficulty with sleep can be related to psychiatric illness or medical problems. It is most frequently due to chronic depression and/or anxiety. Antisocial and obsessive-compulsive features are also common among these patients. Patients may self-medicate, which produces more insomnia.
Predisposing Factors
A.Alcohol use: Initially assists with sleep but produces fragmented sleep.
B.Hypnotic medications can produce tolerance, which causes sleep disruption and rebound insomnia with withdrawal from the medication.
C.Substances such as caffeine, nicotine cigarettes, amphetamines, steroids, methylphenidate, hallucinogens, aminophylline, ephedrine, decongestants, bronchodilators, weight loss/diet pills, thyroid preparations, monoamine oxidase (MAO) inhibitors, and anticancer agents.
D.Persons with fibromyalgia syndrome.
E.Women experiencing menopausal symptoms.
F.Upper respiratory symptoms.
G.OSA disorders such as nasal obstruction, large uvula, low-lying soft palate, craniofacial abnormalities, excessive pharyngeal tissue, pharyngeal masses (tumors, cysts), macroglossia, tonsillar hypertrophy, and vocal cord paralysis.
H.Obesity.
I.Hypothyroidism.
J.Acromegaly.
K.Chronic pain.
L.Urinary frequency and nocturia due to prostatism, diabetes, diuretics, and infection.
Common Complaints
A.Statements regarding impaired sleep pattern:
1.Inability to fall asleep.
2.Restless throughout the night.
3.Early morning awakening with inability to fall back to sleep.
4.Difficulty concentrating during the daytime hours.
5.Feels fatigued after 8 hours of sleep, no energy.
6.Partner complains of the patient’s snoring.
Other Signs and Symptoms
A.Excessive daytime sleepiness.
B.Feels tense, irritable, and agitated.
C.Heightened anxiety and aggressiveness (occasionally).
D.Reports of prolonged pauses in respiration during sleep.
E.Weight gain.
F.Frontal headaches on awakening.
G.Difficulty with short-term recall.
Subjective Data
A.Review the onset, course, and duration of problems and symptoms.
B.Take a thorough history of the sleep problem, including the 24-hour sleep–wake cycle: Sleep–wake habit history, sleep hygiene history, meal and exercise times, ambient noise, and light and temperature.
C.Identify the pattern: Trouble falling asleep, trouble staying asleep (frequent awakenings), and early morning awakenings.
D.Inquire about life stresses, drug and alcohol use, and marital and family problems.
Statements suggesting self-medication with alcohol to facilitate sleep could indicate a coexistent alcohol abuse/dependence diagnosis. In patients who have developed tolerance to alcohol or sleep medications, abrupt cessation of these agents may produce increased insomnia and anxiety.
E.Determine whether the insomnia is simply normal sleep. Some insomniacs
get ample sleep (pseudoinsomnia), and the problems are psychological.
F.Review the patient’s smoking and caffeine intake history.
G.Review all medications, including prescribed and overthe-counter (OTC) medications, recreational drug use, and weight loss medications.
H.Review the patient’s medical history: Thyroid problems, hypertension, steroid use, diabetes, and cancer.
I.Conduct an interview with the patient’s bed partner to provide information about snoring, breathing pauses, and unusual body positions or movements. Is the partner concerned/frightened about the apneic pauses?
J.Review cardiopulmonary dysfunction: Orthopnea, paroxysmal nocturnal dyspnea, or nocturnal angina.
K.If female, establish last menses; rule out pregnancy or menopause. Are there regular menses, vaginal dryness, and/or hot flashes?
L.If male, review for signs of prostatism (>age 50, hesitancy, dribbling, nocturia, frequency, incomplete emptying, and so on. See section in Chapter 15, Benign Prostatic Hypertrophy
).
Physical Examination
A.Check pulse, respirations, blood pressure, and weight.
B.Inspect:
1.Observe general overall appearance; note grooming and behaviors during interview.
2.Evaluate eyes: Pupil dilation/constriction (may indicate recent medication/nonprescription
drug use).
3.Inspect nasal mucosa for erythema, edema, discharge, and nasal patency; look for septal deviation and polyps. Transilluminate sinus (if indicated).
4.Inspect the mouth for erythema, the teeth for uneven surfaces (grinding), and the retropharynx for abnormality.
C.Auscultate:
1.Heart.
2.Lungs.
3.Abdomen.
D.Palpate:
1.Conduct a neurologic examination.
2.Palpate the neck and thyroid; evaluate for goiter.
3.Check the joints for swelling and arthritis, and range of motion (ROM;rule out musculoskeletal cause).
4.Perform rectal examination if indicated for men with prostate symptoms.
5.Perform speculum/bimanual examination if indicated to evaluate menopausal atrophy and bladder complaints.
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Electrolytes.
C.Thyroid-stimulating hormone (TSH) or full thyroid profile, follicle-stimulating hormone (FSH), luteinizing hormone (LH).
D.Prostate-specific antigen (PSA) for men.
E.Serum creatinine and blood urea nitrogen (BUN).
F.Urinalysis: Check hematuria.
G.Urine culture (if indicated).
H.Glucose tolerance test.
I.Urine drug screen.
J.Sinus x-rays.
K.Urodynamics tests if bladder issues suspected.
L.Postvoid residual (catheterization or ultrasound).
M.Nocturnal polysomnography or actigraphy.
N.Administer psychiatric evaluation (if indicated).
Differential Diagnoses
A.Insomnia/sleep disorder:
1.Inadequate sleep hygiene: Habitual behaviors that harm sleep, such as delaying morning awakening time or napping.
2.Insufficient sleep syndrome: Curtailing time in bed in response to social and occupational demands, over long periods of time (shift work, circadian rhythm sleep–wake disorder).
3.Adjustment sleep disorder: Acute emotional stressors (job loss or hospitalization) resulting in difficulty falling asleep because of tension and anxiety.
4.Psychophysiologic insomnia: Anticipatory anxiety over the prospect of another night of sleeplessness and the next day of fatigue.
5.Narcolepsy: Persistent daytime sleepiness with brief naps accompanied by vivid dreams:
a.Cataplexy or abrupt paralysis or paresis of skeletal muscles following anger, surprise, laughter, or physical exercise.
b.Hypnagogic hallucinations (vivid and often frightening dreams that occur shortly after falling asleep or on awakening).
c.Sleep paralysis, a transient global paralysis of voluntary muscles that occurs shortly after falling asleep and lasts a few seconds or minutes.
d.Disturbed and restless sleep.
B.Alcoholism and drug abuse/dependence.
C.Major depressive disorder.
D.Acute psychosis, mania, and hypomania.
E.Medical problems such as chronic pain, anxiety, depression, hyperthyroidism, epilepsy, general paresis, diabetes, benign prostatic hypertrophy, urinary problems related to age/diuretic use, cardiopulmonary dysfunction, and menopause.
Plan
A.General interventions:
1.Identify cause of insomnia.
2.Treat physical/laboratory findings if underlying conditions exist. Treat conditions according to diagnosis made, that is, hormone replacement therapy, thyroid medications, diabetes, and so forth, as indicated. See related chapters for plans of care.
B.Patient teaching:
1.Have the patient record a 2-week log for sleep–wake habits. A sleep diary is available from the National Sleep Foundation at sleepfoundation.org/sleep-diary/sleepdiaryv6.pdf.
2.Advise the patient to avoid alcohol, caffeine, and stimulating agents during the evening hours.
3.Avoid exercising prior to going to bed.
4.
(see Section III: Patient Teaching Guide Nicotine Dependence
).
5.Encourage regular sleep habit/hygiene. Recommend going to bed the same time every night and waking up the same time every day.
6.Recommend keeping the bedroom cool, quiet, and dark while sleeping.
7.Encourage relaxation exercises prior to going to bed.
8.If stress/anxiety contributes to sleeping disorder, recommend counseling with psychologist or counselor to identify and deal with issues.
9.See Section III: Patient Teaching Guide Sleep Disorders/Insomnia.
C.Pharmaceutical therapy:
1.Eliminate prescription medications (when possible) and OTC products as part of your management plan before writing another prescription.
2.Only after making the assumption that the insomnia cannot be adequately treated by addressing the underlying medical problem responsible for causing the insomnia should medications for sleep be prescribed.
Do not prescribe medications for insomnia to patients with alcohol/drug or depressive disorders.
3.Use short-term pharmaceutical therapy.
4.Drug of choice: Sedative anxiolytic hypnotics: Try initially for 1 week to establish a sleep pattern:
If insomnia continues for more than 1 month, refer the patient to a physician or specialist.
a.Temazepam (Restoril) 7.5 to 30 mg at bedtime (1–2 weeks).
b.Zolpidem (Ambien) 5 to 10 mg at bedtime (4 weeks maximum).
c.Eszopiclone (Lunesta) 2 to 3 mg at bedtime. Start with 1 mg in the elderly.
d.Ramelteon (Rozerem) 8 mg by mouth 30 minutes before bedtime. Do not take with meals.
Anxiolytic agents such as diazepam (Valium) and alprazolam (Xanax) tend to increase the duration and frequency of sleep apneas and are contraindicated for patients with possible/undiagnosed apnea spells.