TO SLEEP, PERCHANCE TO DREAM SLEEP IN CHILDREN WITH LIFE-LIMITING CONDITIONS

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Joseph Daniel
5 years ago
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1 SLEEP I WEAKEN ALL PEOPLE FOR HOURS EACH DAY. I SHOW YOU STRANGE VISIONS WHILE YOU ARE AWAY. I TAKE YOU BY NIGHT, BY DAY TAKE YOU BACK, NONE SUFFER TO HAVE ME, BUT DO FROM MY LACK.

2 TO SLEEP, PERCHANCE TO DREAM SLEEP IN CHILDREN WITH LIFE-LIMITING CONDITIONS

3 MAHATMA GHANDHI EACH NIGHT, WHEN I GO TO SLEEP, I DIE. AND THE NEXT MORNING, WHEN I WAKE UP, I AM REBORN. I WEAKEN ALL PEOPLE FOR HOURS EACH DAY. I SHOW YOU STRANGE VISIONS WHILE YOU ARE AWAY. I TAKE YOU BY NIGHT, BY DAY TAKE YOU BACK, NONE SUFFER TO HAVE ME, BUT DO FROM MY LACK.

4 FUNCTION OF SLEEP EXACT FUNCTION UNKNOWN MANY THEORIES 1. RESTORATION 2. EVOLUTIONARY & ADAPTIVE 3. ENERGY CONSERVATION 4. LEARNING 5. UNLEARNING 6. OTHERS IMPAIRED FUNCTION WITHOUT CONFLICTING EVIDENCE (ALL) 1. SOMATIC & CNS FUNCTION 2. ENVIRONMENT MODIFIES 3. ONLY 8 TO 10% IN BMR! 4. DIFFERENT ROLES FOR NREM & REM SLEEP 5. SYSTEM TO SCRUB AWAY NEURAL WASTE DURING SLEEP

5 VIGNETTE 1 5 YR OLD BOY WITH SMA 2 ADMITTED WITH RESPIRATORY INSUFFICIENCY 2 O TO PNEUMONIA 4 DAY PICU ADMISSION; JUST AVOIDED VENTILATION 12 DAY WARD ADMISSION; IV ANTIBIOTICS, CHEST PHYSIO DISCHARGE AT ~ 90% PRE-MORBID RESPIRATORY FUNCTION HOME VISIT 5 DAYS AFTER DISCHARGE RESPIRATORY REVIEW GOOD EVERYONE TIRED & FATIGUED FROM LACK OF SLEEP WHY?

6 VIGNETTE 2 15 ½ YR OLD GIRL EARLY RELAPSE OF AML AFTER BMT ELECTS NO FURTHER THERAPY AS STRUGGLED WITH CHEMOTHERAPY & BMT WAS HORRENDOUS HOME VISIT IDENTIFIES PAIN & FATIGUE SLEEPING POORLY MEDICATION PARACETAMOL 1GM QID & CODEINE 30MG (OCCASIONAL)

SLEEP-WAKE CYCLE TWO-PROCESS MODEL CIRCADIAN RHYTHM (PROCESS C) CIRCADIAN DRIVE FOR AROUSAL REGULATION OF INTERNAL PROCESSES & LEVELS OF ALERTNESS SLEEP-WAKE HOMEOSTASIS (PROCESS S)

7 SLEEP-WAKE CYCLE TWO-PROCESS MODEL CIRCADIAN RHYTHM (PROCESS C) CIRCADIAN DRIVE FOR AROUSAL REGULATION OF INTERNAL PROCESSES & LEVELS OF ALERTNESS SLEEP-WAKE HOMEOSTASIS (PROCESS S) ACCUMULATION OF SLEEP-INDUCING SUBSTANCES IN BRAIN GENERATES HOMEOSTATIC SLEEP DRIVE BOTH PROCESSES INFLUENCED BY GENETICS OVERALL INFLUENCE FROM EXTERNAL FACTORS

8 CIRCADIAN RHYTHM ANY BIOLOGICAL PROCESS DISPLAYING ENDOGENOUS & ENTRAINED OSCILLATION OF ~24 HRS ENTRAINED MEANS ADJUSTS TO LOCAL ENVIRONMENT FROM EXTERNAL CUES CUES INCLUDE LIGHT, TEMPERATURE & REDOX CYCLES CIRCADIAN CLOCK PRESENT IN PLANTS, ANIMALS, FUNGI & CYANOBACTERIA CLASSIC MEASURES: MELATONIN SECRETION CORE BODY TEMPERATURE MINIMUM PLASMA CORTISOL

PROCESS C THE CLOCK CLOCK CENTRED IN HYPOTHALAMUS AT SCN (SURACHIASMATIC NUCLEUS) MAIN MECHANISM TO CONTROL TIMING OF SLEEP COORDINATED WITH DAY-NIGHT/LIGHT-DARK CYCLE ~ 24HRS INDEPENDENT OF PREVIOUS

9 PROCESS C THE CLOCK CLOCK CENTRED IN HYPOTHALAMUS AT SCN (SURACHIASMATIC NUCLEUS) MAIN MECHANISM TO CONTROL TIMING OF SLEEP COORDINATED WITH DAY-NIGHT/LIGHT-DARK CYCLE ~ 24HRS INDEPENDENT OF PREVIOUS SLEEP OR WAKEFULNESS REGULATES SLEEP PATTERNS, FEEDING PATTERNS, CORE BODY TEMPERATURE, BRAIN WAVE ACTIVITY, CELL REGENERATION, HORMONE PRODUCTION & OTHER BIOLOGICAL ACTIVITIES ALONE NOT SUFFICIENT TO CAUSE & REGULATE SLEEP

PROCESS S THE SWITCH HOMEOSTATIC DRIVE FOR SLEEP AT VLPO (VENTROLATERAL PREOPTIC NUCLEUS) INTERNAL BIOCHEMICAL SYSTEM TO COUNTERBALANCE CIRCADIAN ELEMENT GENERATES PRESSURE TO SLEEP & REGULATES SLEEP

10 PROCESS S THE SWITCH HOMEOSTATIC DRIVE FOR SLEEP AT VLPO (VENTROLATERAL PREOPTIC NUCLEUS) INTERNAL BIOCHEMICAL SYSTEM TO COUNTERBALANCE CIRCADIAN ELEMENT GENERATES PRESSURE TO SLEEP & REGULATES SLEEP INTENSITY INTUITIVE REMINDER FOR NEED TO SLEEP LONGER BEEN AWAKE STRONGER DESIRE & NEED FOR SLEEP MORE LIKELY TO FALL ASLEEP LONGER BEEN ASLEEP MORE PRESSURE FOR SLEEP TO DISSOLVE MORE LIKELY TO WAKE INFLUENCED BY LAST SLEEP & WAKEFULNESS (QUALITY & DURATION)

THE CLOCK (SCN) RECEIVES INFORMATION FROM RETINA ON LENGTH OF DAY & NIGHT (ILLUMINATION) INTERPRETS & PASSES ON TO PINEAL GLAND PINEAL SECRETES MELATONIN IN RESPONSE TO

11 THE CLOCK (SCN) RECEIVES INFORMATION FROM RETINA ON LENGTH OF DAY & NIGHT (ILLUMINATION) INTERPRETS & PASSES ON TO PINEAL GLAND PINEAL SECRETES MELATONIN IN RESPONSE TO LIGHT THE SWITCH (VLPO) SWITCH BETWEEN WAKEFULNESS & SLEEP PROMOTES SLEEP BY INHIBITING ACTIVITY IN AROUSAL AREAS WHEN AWAKE AROUSAL AREAS INHIBIT VLPO & STIMULATE CEREBRAL CORTEX

12 SLEEP GATE & AWAKENING MELATONIN PRODUCTION OPENS SLEEP GATE IN EVENING PRODUCTION CAUSES DROWSINESS & HELPS LOWER BODY TEMPERATURE BY EARLY MORNING BACK TO NORMAL, NEGLIGIBLE LEVELS NEAR END OF NIGHT CORTISOL PRODUCTION TO BE READY FOR STRESS OF DAY PEAKS AS SPIKE MIN AFTER WAKING = CORTISOL AWAKENING RESPONSE

13 MELATONIN CONVERTED FROM SEROTONIN IN PINEAL GLAND REGULATES CYCLE BY INHIBITING CIRCADIAN ALERTING SYSTEM IN SCN NEGATIVE FEEDBACK ON SCN REGULATES OWN PRODUCTION PRODUCTION INHIBITED BY LIGHT; STIMULATED BY DARK INTERNAL REPRESENTATION OF EXTERNAL LIGHT CONDITIONS PEAKS AT NIGHT & EBBS DURING DAY PRESENCE PROVIDES INFORMATION ABOUT NIGHT LENGTH

14 OTHER NEUROTRANSMITTERS MANY DIFFERENT NEUROTRANSMITTERS DRIVE WAKEFULNESS & SLEEP NONE INDIVIDUALLY NECESSARY BUT ALL APPEAR TO CONTRIBUTE

16 SLEEP ARCHITECTURE NON-RAPID EYE MOVEMENT SLEEP (NREM) STATE OF DEEP, USUALLY DREAMLESS, SLEEP OCCURS REGULARLY DURING A NORMAL PERIOD OF SLEEP 4 STAGES EACH ASSOCIATED WITH DISTINCT BRAIN ACTIVITY & PHYSIOLOGY RAPID EYE MOVEMENT SLEEP (REM) INTERVENING PERIODS DREAM SLEEP

17 NREM STAGE 1 TRANSITIONAL ROLE DURATION 1 TO 7 MIN (1 ST CYCLE) CONSTITUTES 2-5% TOTAL SLEEP SLEEP EASILY INTERRUPTED BY NOISE EEG TRANSITIONS FROM WAKEFULNESS (RHYTHMIC Α & Β-WAVES) TO LOW-VOLTAGE, MIXED-FREQUENCY Θ-WAVES Α-WAVES ASSOCIATED WITH WAKEFUL RELAXATION

18 NREM STAGE 2 DURATION 10 TO 25 MIN (1 ST CYCLE) LENGTHENS WITH SUCCESSIVE CYCLES CONSTITUTES 45-55% TOTAL SLEEP REQUIRES MORE INTENSE STIMULI TO AWAKEN EEG SHOWS RELATIVELY LOW-VOLTAGE, MIXED- FREQUENCY ACTIVITY CHARACTERISED BY SLEEP SPINDLES & K-COMPLEXES SPINDLES MAY BE MEMORY CONSOLIDATION INDIVIDUALS WHO LEARN NEW TASK HAVE HIGHER DENSITY THAN CONTROL

19 NREM STAGE 3 & 4 SLOW-WAVE SLEEP MOSTLY DURING FIRST 1/3 RD OF NIGHT AROUSAL THRESHOLD IS HIGHEST EEG HIGH-VOLTAGE, SLOW-WAVE ACTIVITY STAGE 3 STAGE 4 DURATION FEW MINS CYCLE) CONSTITUTES 3-8% SLEEP 20 TO 40 MIN (1 ST 10-15% SLEEP

20 SLEEP ARCHITECTURE RAPID EYE MOVEMENT SLEEP (REM) SLEEP ASSOCIATED WITH DREAMING DESYNCHRONIZED BRAIN WAVE ACTIVITY, MUSCLE ATONIA & BURSTS OF RAPID EYE MOVEMENTS DURATION 1 TO 5 MIN (1 ST CYCLE) BECOMES LONGER AS SLEEP PROGRESSES CONSTITUTES 20-25% OF SLEEP EEG TRANSITIONS TO STAGE 1 & AWAKE ACTIVITY

22 I SLEPT LIKE A BABY!

23 NEWBORN (FIRST FEW WEEKS) DISTINCTIVE ARCHITECTURE TIMING EVENLY DISTRIBUTED ACROSS DAY & NIGHT NO REGULAR RHYTHM OR CONCENTRATION OF SLEEP/WAKE 3 TYPES OF SLEEP QUIET SLEEP ( NREM) ACTIVE SLEEP ( REM) INDETERMINATE SLEEP ONSET OCCURS THROUGH REM (NOT NREM) IMMATURE CIRCADIAN RHYTHMS DEVELOP IN FIRST 3 MONTHS 1 MO 24-HR CORE BODY TEMPERATURE CYCLE 2 MO PROGRESSION OF NOCTURNAL SLEEPING 3 MO CYCLING OF MELATONIN & CORTISOL HORMONES SLEEP CYCLES ALSO CHANGE BECAUSE OF GREATER RESPONSIVENESS TO SOCIAL CUES SUCH AS BREAST- FEEDING & BEDTIME ROUTINES EACH SLEEP EPISODE CONSISTS OF ONLY 1 OR 2 CYCLES

24 MEANS YOU WAKE UP CRYING EVERY 3 OR 4 HRS NEEDING TO POOP, PEE (THEN CHANGE) & EAT! I SLEPT LIKE A BABY!

25 INFANTS & CHILDREN 3 MONTHS SLEEP ONSET NOW BEGINS WITH NREM REM & SHIFTS TO LATER PART OF CYCLE TOTAL SLEEP CYCLE TYPICALLY 50 MIN 6 MONTHS USUAL MUSCLE PARALYSIS OF REM REPLACES NEWBORN ACTIVE SLEEP YOUNG CHILDREN DEVELOP SLEEP PHASE PREFERENCE BY TIME ENTER SCHOOL NIGHT OWL VS. MORNING LARK HOW, WITH WHOM & WHERE SLEEP PREFERENCE DAYTIME NAPPING INTRODUCTION OF SCHOOL ROUTINE

26 OLDER CHILDREN & ADOLESCENTS OLDER CHILDREN MORE LIKELY TO EXPERIENCE CHALLENGES IN INITIATING & MAINTAINING SLEEP HAVE NIGHTMARES; USUALLY DISRUPTS SLEEP HAVE LONGER REM SLEEP LATENCIES THAN ADOLESCENTS % TIME IN SWS (STAGES 3 & 4) ADOLESCENTS COMPLEX, BIDIRECTIONAL RELATIONSHIP B/W PUBERTAL DEVELOPMENT & SLEEP MEASURE BY PUBERTAL STAGE RATHER THAN AGE HORMONAL CHANGES PLAY A ROLE FEW OBTAIN REQUIRED 9 TO 10 HRS EACH NIGHT

27 ARCHITECTURE WITH AGE DAILY RHYTHM BEGINS ~ 4 MO INFANTS & CHILDREN > % REM CHANGES WITH INCREASING AGE TOTAL TIME TIME IN STAGE 2 SWS & SLEEP LATENCY REM SLEEP FROM ~ 50% TO 20-25% DURATION REMAINS CONSTANT IF BEDTIME FIXED

28 SLEEP DURATION AVERAGE SLEEP TIME VARIES CONSIDERABLE WITH AGE RECOMMENDATIONS FOR HEALTHY CHILDREN NEWBORN 16 TO 18 HRS PER DAY IN CYCLES OF 3 TO 4 HRS (DAY & NIGHT) 6 MONTHS CAN SLEEP FOR > 6 HRS AT NIGHT WITHOUT A FEED 18 MONTHS PATTERNS MATURE TO OVERNIGHT SLEEP & ONE DAYTIME NAP SCHOOL AGE CONSOLIDATES INTO A SINGLE NIGHT SLEEP OF 11 TO 12 HRS PREPUBESCENT TO 16 YRS DURATION SLOWLY FROM 10 TO 8 HRS INDIVIDUAL CHILDREN & ADOLESCENTS MAY BENEFIT FROM LONGER ENQUIRE ABOUT DAY TIME FUNCTIONING AS PART OF ASSESSMENT GALLAND. SYSTEMATIC REVIEW. SLEEP MED REV 2012;16

29 SLEEP PROBLEMS IN HEALTHY CHILDREN AFFECT 30 TO 40% OF INFANTS & CHILDREN BEFORE SCHOOL AGE EFFECTS ON CHILD HEALTH POOR GROWTH ADVERSE BEHAVIOURAL & LEARNING OUTCOMES ADVERSE PHYSICAL HEALTH OUTCOMES EFFECTS FOR THE CHILD & FAMILY WORSENED MENTAL HEALTH QUALITY OF LIFE

30 SLEEP DISORDERS DYSSOMNIAS PRIMARY DISORDER OF SLEEP INITIATION OR MAINTENANCE OR EXCESSIVE SLEEPINESS WHICH DISTURBS SLEEP AMOUNT, QUALITY, OR TIMING PARASOMNIAS UNDESIRABLE MOTOR, AUTONOMIC OR EXPERIENTIAL PHENOMENA OCCURRING EXCLUSIVELY OR PREDOMINANTLY DURING SLEEP WATERS. MJA 2013;199 SUPPL

31 DYSSOMNIAS INTRINSIC IDIOPATHIC HYPERSOMNIA NARCOLEPSY PERIODIC LIMB MOVEMENT DISORDER RESTLESS LEGS SYNDROME SLEEP APNOEA EXTRINSIC ALCOHOL-DEPENDENT SLEEP DISORDER FOOD ALLERGY INSOMNIA BEHAVIOURAL SLEEP DISORDERS INCL. INADEQUATE SLEEP ROUTINE COMMON IN CHILDHOOD SLEEP STATE MISPERCEPTION

32 SLEEP & RESPIRATORY DISORDERS SNORING & OSA COMMON AFFECTS 3 TO 15% OF HEALTHY CHILDREN PEAK PREVALENCE IN PRESCHOOL YEARS LYMPHOID TISSUE LARGEST IN UPPER AIRWAY RELATIVE TO SIZE OF FACIAL SKELETON CERTAIN MEDICAL DISORDERS RISK FOR OSA CONGENITAL ABNORMALITIES AFFECTING CRANIOFACIAL OR THORACIC GROWTH NEUROMUSCULAR DISEASES INCIDENCE OSA IN FIRST DECADE CONGENITAL CARDIOTHORACIC ABNORMALITIES OR RESTRICTIVE LUNG DISORDERS NEURODEVELOPMENTAL CONDITIONS SUCH AS CEREBRAL PALSY PREDISPOSE TO NOCTURNAL RESPIRATORY FAILURE

33 Delayed sleep phase Advanced sleep phase Non-24 hr sleep-wake disorder Irregular sleep-wake disorder Shift work disorders Jet lag disorders CIRCADIAN RHYTHM DISORDERS CHRONIC ALTERATIONS, DISRUPTIONS, OR MISALIGNMENT OF CIRCADIAN CLOCK IN RELATION TO ENVIRONMENTAL CUES & LIGHT-DARK CYCLE

34 PARASOMNIAS NREM-RELATED NIGHT TERRORS, HYPNOGOGIC IMAGERY (LUCID DREAM), SLEEP WALKING REM-RELATED DREAMS, NIGHTMARES, SLEEP PARALYSIS SLEEP STATE INDEPENDENT BRUXISM, SLEEP TALKING, RHYTHMIC MOVEMENT DISORDER

35 VIGNETTE 1 5 YR OLD BOY WITH SMA 2 2 WEEK INTENSIVE HOSPITAL STAY FAMILY STRUGGLING AT HOME WHAT NEXT? POOR SLEEP

36 ASSESSMENT THOROUGH HISTORY & EXAMINATION BEARS SCREENING TOOL B = BEDTIME (SETTLING) PROBLEMS E = EXCESSIVE DAYTIME SLEEPINESS A = NIGHT AWAKENINGS R = REGULARITY AND DURATION OF SLEEP S = SNORING PARENTS DEFINE PRESENCE OF SLEEP PROBLEMS EVALUATION OF PARENTAL EXPECTATIONS (MAY NOT BE VALID)

37 VIGNETTE 1 Behaviour USUAL SLEEP PATTERN AFTER DINNER HAS BATH & READIES FOR BED STORY FOR 15 TO 20 MIN BED NO LATER THAN 6:30PM ASLEEP WITHIN 15 MIN SLEEPS THROUGH; WAKING 7AM EVERYDAY WAKES REFRESHED FATIGUED BY 1PM & HAS NAP FOR ~2 HR SINCE HOSPITALISATION DISRUPTIVE BEHAVIOUR AT DINNER; BATTLE TO GET HIM READY FOR BED NO STORY & PUT TO BED AT USUAL TIME NOT SETTLING UNTIL 8PM WAKING FREQUENTLY DURING NIGHT; FIRST WAKING AT 10PM OFTEN ENDS UP IN PARENTAL BED AFTER WHICH SLEEPS THROUGH UNREFRESHED & FATIGUED ON BEING WOKEN 9AM SLEEPING X2 DURING DAY; X1 OF 3 TO 4 HRS

38 EFFECT OF BEING IN HOSPITAL ADMISSION OF PREVIOUSLY HEALTHY CHILDREN CAN RESULT IN 25 TO 50% LOSS OF SLEEP TIME ENVIRONMENT DEPENDENT; WARD VS. ICU CAN PERSIST OF UP TO 7 WEEKS CHILDREN WITH LLC 52% WITH POOR SLEEP HERBERT A. SLEEP BIOLOG RHYTHMS 2006;6 (SUPPL 1) PHYSICAL FACTORS UNDERLYING CONDITION PAIN & OTHER SYMPTOMS PROCEDURES ENVIRONMENTAL FACTORS NURSING INTERRUPTIONS TOILETING NEEDS NOISE & LIGHT WARD, OTHER PATIENTS, ALARMS PSYCHOSOCIAL FACTORS LOSS OF ROUTINE LACK OF CONTROL, ANXIETY, FEAR SEPARATION FROM FAMILY

39 Canadian Paediatric Society

41 VIGNETTE 2 15 YR OLD GIRL WITH RELAPSED AML AFTER BMT HOME VISIT IDENTIFIES BONE PAIN FATIGUE SLEEP DISRUPTION SLEEP DISRUPTION NO ROUTINE PRIOR TO BED ISOLATING SELF TO ROOM EXCESSIVE SCREEN TIME; MAINLY IN BED SLEEP INITIATION ERRATIC; AVERAGE 2 AM WAKING HOURLY FOR 30 MIN UNTIL 6AM; 50% TIME PAIN FROM 6 AM TO 10 AM SLEEPS NO MORE THAN 3 HRS DURING DAY WITHOUT SLEEPING

42 PAIN & SLEEP BED TIME IMPACT DELAY IN SLEEP ONSET ANXIETY, RUMINATION INTENSE FATIGUE & MORE INTENSE PAIN WAKE TIME IMPACT UNREFRESHING SLEEP SENSATION, FATIGUE, HEADACHE SLEEPINESS ANXIETY & ANGER AT NOT COMPLETING DAY MISSED SCHOOL, POOR CONCENTRATION, TIME WITH FRIENDS SLEEP TIME SYMPTOMS LOWER SLEEP EFFICIENCY (<90%) LONGER TIME IN S1; LESS IN SWS NUMEROUS SLEEP STAGE SHIFTS (SWS TO S2 OR S1) FRAGMENTATION OF SLEEP CONTINUITY MICROAROUSALS, AWAKENINGS, RESPIRATORY EVENTS (APNOEA) PARASOMINAS NIGHTMARES, PERIODIC LEG MOVEMENTS PHYSIOLOGIC CHANGES SWEATING, HEART PALPITATIONS & ABSENT IN HR VARIABILITY (CARDIAC SYMPATHETIC OVER ACTIVITY) Α-WAVE INTRUSIONS IN SWS WAKE TIME IN SLEEP WITH PAIN LAVIGNE 2005

43 VIGNETTE 2 15 YR OLD GIRL WITH RELAPSED AML AFTER BMT HOME VISIT IDENTIFIES BONE PAIN WELL MANAGED FATIGUE CONTINUES SLEEP DISRUPTION CONTINUES SLEEP DISRUPTION NO BED ROUTINE CONTINUES STILL STAYING IN ROOM ON MOBILE, LAPTOP; MAINLY IN BED SLEEP INITIATION IMPROVED; NOW 12AM WAKING X3 EACH NIGHT FOR 60 MIN RISING AT 10 AM X2 NAPS OF 1 TO 2 HRS DURING DAY

44 Canadian Paediatric Society

45 SLEEP IN CPC 3 RD GROUP OF SLEEP DISORDERS ARE THOSE ASSOCIATED WITH MEDICAL CONDITIONS DIRECTLY FROM PHYSICAL EFFECTS OF CONDITION OR ITS MANAGEMENT INDIRECTLY FROM EMOTIONAL IMPACT I.E. ANXIETY, DEPRESSION HIGH PREVALENCE (50 TO 80%) IN NEUROLOGICAL & OTHER COMPLEX ILLNESSES LARGE IMPACT ON CAREGIVERS MARKEDLY IMPAIRED HEALTH-RELATED QOL IN MOST DOMAINS OF SF-36 IMPAIRED SLEEP QUALITY IN > 50% FATIGUE, SOMATIC COMPLAINTS, DEPRESSION & OTHER PSYCHIATRIC DISORDERS TIETZE A. DEV MED CHILD NEUROL 2014;56

46 MEASURES SNAKE SCHLAFFRAGEBOGEN FÜR KINDER MIT NEUROLOGISCHEN UND ANDEREN KOMPLEXEN ERKRANKUNGEN SLEEP QUESTIONNAIRE FOR CHILDREN WITH SEVERE PSYCHOMOTOR IMPAIRMENTS 16 QUESTIONS TO LOOK AT 6 COMPONENTS OF SLEEP 1. SLEEP CONDITIONS 2. SLEEP ONSET LATENCY 3. LENGTH OF SLEEP 4. SLEEP EFFICIENCY RATIO TOTAL SLEEP TIME TO TIME SPENT IN BED 5. SLEEP QUALITY 6. SYMPTOMS AND CONSEQUENCES OF SLEEP DISORDERS DISTURBANCES GOING TO SLEEP DISTURBANCES REMAINING ASLEEP AROUSAL DISORDERS DAYTIME SLEEPINESS DAYTIME BEHAVIOUR DISORDERS

47 MEASURES HOST HOLISTIC ASSESSMENT OF SLEEP AND DAILY TROUBLES IN PARENTS OF CHILDREN WITH SEVERE PSYCHOMOTOR IMPAIRMENTS 12 QUESTIONS TO LOOK AT 5 COMPONENTS OF PARENTAL SLEEP BEHAVIOUR 1. SLEEP CONDITIONS 2. SLEEP ONSET LATENCY 3. LENGTH OF SLEEP 4. SLEEP EFFICIENCY RATIO TOTAL SLEEP TIME TO TIME SPENT IN BED 5. EFFECTS OF CHILDREN S SLEEP DISORDERS ON PARENTS SLEEP DISTURBANCES IMPAIRMENTS OF PHYSICAL/ MENTAL FUNCTIONING IMPAIRMENTS OF SOCIAL FUNCTIONING IMPAIRMENTS OF WORKING ABILITY

48 RULES OF THUMB HISTORY SHOULD ALWAYS INCL. ASKING ABOUT SLEEP (CHILD & CARERS) MOSTLY NEEDS FOCUSSED QUESTIONS SLEEP DURATION TIME FOR SLEEP ONSET TO MORNING WAKENING SLEEP EFFICIENCY % TIME ASLEEP IN BED SLEEP ONSET LATENCY TIME TO SLEEP; < 30 MIN SLEEP MAINTENANCE NUMBER & DURATION OF NIGHT AWAKENINGS SLEEP DIARIES (SNAKE & HOST) CAN PROVIDE MORE DETAIL POLYSOMNOGRAPHY (SLEEP STUDY) USED FOR SPECIFIC ANALYSIS SLEEP-DISORDERED BREATHING UPPER AIRWAY OBSTRUCTION CENTRAL SLEEP APNOEA PRE-SURGICAL RISK ASSESSMENT STARTING NON-INVASIVE VENTILATION MONITORING CHILDREN ALREADY ON RESPIRATORY SUPPORT MEASURES

49 MANAGEMENT INTERDISCIPLINARY APPROACH RATIONALISE MEDICATIONS IF POSSIBLE, SEDATIVE AGENTS AT NIGHT IDENTIFY & MANAGE PHYSICAL & PSYCHOLOGICAL SYMPTOMS REINFORCE SIMPLE SLEEP HYGIENE STRATEGIES CONSIDER MEDICATIONS MELATONIN SLEEP INITIATION & REGULATION HYPNOSEDATIVES BARBITUATES BENZODIAZEPINES CHLORAL HYDRATE OTHER AGENTS ANTI-DEPRESSANTS ANTI-CONVULSANTS ANTI-PSYCHOTICS ANTI-HISTAMINES ALPHA-2 AGONISTS

50 MEDICATIONS ANTI-HISTAMINE AGENTS CAUSE DROWSINESS & NON-REM SLEEP ANTI-CHOLINERGIC AGENTS CAUSE DROWSINESS & REM SLEEP HISTAMINE MASTER WAKEFULNESS-PROMOTING NT HIGH ACTIVITY DURING WAKEFULNESS ACTIVITY DURING NREM SLEEP AT LOWEST LEVELS DURING REM SLEEP ACETYLCHOLINE NT ACTIVITY IN RAS STIMULATES FOREBRAIN & CEREBRAL CORTEX ENCOURAGING ALERTNESS & WAKEFULNESS ACTIVE DURING REM SLEEP

Index. sleep.theclinics.com. Note: Page numbers of article titles are in boldface type.

Index. sleep.theclinics.com. Note: Page numbers of article titles are in boldface type. Note: Page numbers of article titles are in boldface type. A Actigraphy, 475, 485, 496 Adolescents, sleep disorders in, 576 578 Adults, sleep disorders in, 578 580 Advanced sleep phase disorder, 482 Age,