Sleep Apnea & Insomnia: Common Sleep Disruptions Donna Scemons PhD MSN MA RN FNP-C CNS CWOCN donnahs@earthlink.net
Sleep Apnea & Insomnia: Common Sleep Disruptions - Objectives Discuss what sleep is, how much sleep is needed in different populations Discuss sleep apnea symptoms, diagnosis, and management Discuss insomnia - symptoms, diagnosis, and management
What is Sleep? What sleep is = actually unknown. What we know: Little movement Stereotypic posture: usually lying down Reduced response to stimulation: low intensity sounds, touches Reversibility: readily awake from sleep
What are Sleep Stages? (in general) Stage 1: alpha activity decreases, REMs absent Stage 2: mixed frequency activity, rare eye movements Stage 3 & 4: delta sleep; delta waves appear on EEG; stage 4 they dominate REM: (rapid eye movement), come in bursts Begins 70-90 minutes after falling asleep NREM: (non-rem): sleep begins with 80 minutes of NREM, followed by 10 minutes of REM. This cycle is repeated 3-6 times during sleep Complete cycle 90-110 minutes
Sleep Stages
How much sleep is needed? Dependent on variety of factors. Infants: 16/24 hours Teenagers: 9/24 hours Most adults: 7-8/24 hours Some require only 5/24; others 10/24 hours First trimester: more than usual in 24 hours Deprivation: increases need for more sleep in 24/hours Too little sleep creates a sleep debt
Sleep Debt Humans do not adapt well to sleep deprivation although may become used to it Judgment impaired Reaction time slows Eye-hand coordination slows Magnifies alcohol effects on the body Driver fatigue = 100,000 MVAs & 1500 deaths/year (National Highway Traffic Safety Administration)
Sleep Debt If you feel drowsy during even boring activities you have not had enough sleep Falling asleep within 5 minutes of lying down = probable severe sleep deprivation Microsleeps = very brief episodes of sleep in an otherwise awake person = probable severe sleep deprivation Caffeine & stimulants cannot overcome the effects of severe sleep deprivation
Sleep & Circadian Rhythms Regular changes in mental & physical characteristics during a day Regulated by suprachiasmatic nucleus & functions as a biological clock Pineal gland responds to light-induced signals & switches off melatonin (normal=signals body to feel drowsy) Signals regulate sleep/wake cycle, body temperature, hormone secretion, urine production, & blood pressure changes.
Sleep & Circadian Rhythms
Sleep & Disease Stroke & asthma attacks occur more frequently during night and early morning Changes in hormones, heart rate Sleep deprivation triggers some types of epileptic seizures Depression & schizophrenia: early morning wakefulness with inability to return to sleep Some forms of depression are treated with sleep deprivation
Sleep & Disease Infections often create sleepiness (neurons controlling sleep interact with immune system) Sleep disorders common in Alzheimer s, stroke, cancer, head injury If sleeping problems develop, often add to other impairments = confusion, frustration, depression, hallucinations, increased pain perception, decreased quality of life
U.S. Sleep Statistics 70 million affected by some sleep disorder 40 million with chronic sleep disorders 20-30 million with intermittent sleep disorders Majority are undiagnosed & untreated Cost $100 billion annually in lost productivity, medical expenses, sick leave, property & environmental damage 7 in 10 Americans state they experience frequent sleep problems 69% of children experience 1 or more sleep problems at least some nights of each week 67% older adults report frequent sleeping problems Up to 15% of people sleep walk http://www.njsleepdisorderscenter.com/sleep_facts.htm
U.S. Sleep Statistics Approximately 15% of people have restless leg syndrome Vehicular crashes are the third leading cause of death & injury in the United States; up to 20% of them are sleep related Seizures occur more commonly during sleep than during waking hours Many tranquilizers actually decrease deeper stages of sleep that are required for the restoration & fresh feeling in the morning Jet Lag is worse when traveling toward the East http:www.sleepfoundation.org http://www.njsleepdisorderscenter.com/sleep_facts.htm
U.S. Sleep Statistics 63% adult Americans do not get 7-8 hours of sleep 33% report less than 7 hours each week night Sleep loss of four hours is equivalent to being drunk with a blood alcohol level of 0.1% One-third of young adults are pathologically sleepy during the day 18 million have Sleep Apnea $3.4 billion in medical costs/year http:www.sleepfoundation.org http://www.njsleepdisorderscenter.com/sleep_facts.htm
Sleep Apnea: Overview One or more pauses in breathing or shallow breathing during sleep (National Heart Lung and Blood Institute US Department of Health & Human Services) Pauses last few seconds to minutes 5-30 times/hour Normal breathing starts (may start with snort or choking sound) A common disorder
Sleep Apnea: Overview Chronic disrupts sleep May move from deep sleep to light sleep with breathing pauses or shallow breathing Poor sleep quality results in daytime tiredness 1 of leading causes of excessive daytime sleepiness Often undiagnosed Most don t know they have it it is the family member or bed partner who first notices it
Sleep Apnea: Overview Obstructive sleep apnea (OSA) = most common The Focus of this presentation Airway collapse or blockage results in shallow breathing or breathing pauses Attempts to breathe cause loud snoring sounds
Sleep Apnea: Overview Central sleep apnea less common type of sleep apnea Occurs alone or with obstructive sleep apnea Brain does not signal correctly to respiratory muscles
Obstructive Sleep Apnea: Statistics 28% of the patients with ADD ( Attention Deficit Disorder) have symptoms of Obstructive Sleep Apnea (OSA). 30% of people with hypertension have OSA. 29% of the people with sleep disorders are depressed. 38% of obese women have symptoms of sleep disorder. 88% of people with night-time GERD ( gastric reflux) have symptoms of sleep disorder. http://www.bcmedsvcs.com/sleep%20disorder%20statistics%20and%20facts.htm http://www.njsleepdisorderscenter.com/sleep_facts.htm
Obstructive Sleep Apnea: Statistics 18 million people in the U.S. have Obstructive Sleep Apnea. 95% people with Sleep Disorders remain undiagnosed & untreated. 70% of these patients indicate that their sleep problem negatively affects their perception their current health status & quality of life. Untreated sleep apnea causes 500,000 motor vehicle crashes annually One in 20 men have sleep apnea http://www.bcmedsvcs.com/sleep%20disorder%20statistics%20and%20facts.htm http://www.njsleepdisorderscenter.com/sleep_facts.htm
Sleep Apnea: Risk Factors May affect anyone at any age but most common: Males Overweight Over 40 yrs. Neck size = 17 inches males; 16 inches females Large tonsils Family history
Sleep Apnea: Common Symptoms Awakening with very sore or dry throat Awakening with sensation of choking or gasping for breath Sleepiness during waking hours (unrelated to activity)
Sleep Apnea: Common Symptoms Morning headaches Forgetfulness Mood changes Decreased interest in sexual activity Recurrent awakenings Recurrent insomnia
Sleep Apnea: Tests & Diagnosis Sleep study/polysomnogram (PSG) Specific physical activities during sleep Done at night most often in a sleep center/lab Private room with central monitoring area & technicians (nearby) Electrodes on face & scalp Belts around abdomen & chest Oximeter probe on finger
Sleep Apnea: Other Tests/equipment EEG (electroencephalogram: measures & records brain activity) EMG (electromyogram: records muscle activity e.g.. facial twitching, teeth grinding) EOG (electro-oculogram: records eye movements; determines sleep stages especially rapid eye movement or REM sleep) EKG (electrocardiogram: records heart rate & rhythm) Nasal airflow sensor (records airflow) Snore microphone (records snore activity)
Sleep Apnea: Treatments Behavioral modifications: Lose weight: reduces number of apneic times, a part of most sleep apnea programs Avoid alcohol: reduce amount & do have before sleep; reduces REM sleep & deeper levels of sleep Avoid sleeping medications: reduce amount taken before sleep Viagra: taken shortly before sleep may worsen sleep apnea
Sleep Apnea: Treatments Behavioral modifications: Change sleep positions to promote regular breathing Stop smoking: smoking increases swelling in upper airway = worsens snoring & apnea Avoid sleeping on back (differing opinions) (sew pocket in sleepwear at back & place padding there) Use a comfortable, special pillow Obtain adequate amount of sleep: apnea increases with increasing lack of sleep
Sleep Apnea: Treatments Continuous Positive Airway Pressure (CPAP) Mask worn over nose/mouth during sleep Hooked to machine delivering continuous air flow to nostrils = positive pressure assists airways to remain open and breathing is not impaired
Sleep Apnea: Treatments Dental devices Appliances made by dental lab Assist in keeping airway open during sleep May require dentist with specialty in sleep disorders
Sleep Apnea: Treatments Surgery (most common procedural types): Somnoplasty: reduces soft tissue in upper airway = minimally invasive Nasal surgery: correction of nasal obstructions e.g.. deviated septum Uvulopalatopharyngoplasty: (UPPP) removes soft tissue at back of throat and palate = increases airway width Mandibular maxillar advancement surgery: correction of facial abnormalities or throat obstructions = invasive
Sleep Apnea: Treatments Pillar Palatal Implant: May reduce snoring & improve sleep Implant reduces the vibration of soft palate (polyester mesh inserted with specific needle into soft palate at the junction of the hard palate local anesthesia outpatient procedure)
What is Insomnia? Trouble falling & staying asleep. Wake too soon but fall asleep without difficulty Difficulty falling asleep but do not wake too soon Both falling & waking difficulty Awakening without feeling refreshed
Insomnia Overview A common health problem Causes excessive awake time sleepiness & lack of energy Creates difficulty with concentration, learning, & remembering Reduces job, school, activity performance May be mild to severe: how often it occurs & how long it lasts
Insomnia Overview Chronic: lasts at least 3 times per week for more than 1 month Acute: lasts for less time; aka short-term Secondary often resolves or improves without treatment Eliminate the cause Improved sleep & lifestyle habits Persistent requires medical intervention
Who is at Risk for Insomnia? Anyone under stress (unrelieved) Depressed or having other emotional distress Working night shift Having major shifts in working hours/shifts Traveling long distances with time changes = jet lag
Signs & Symptoms of Insomnia Waking up feeling tired or not well rested & refreshed Tiredness &/or sleepiness during waking hours Difficulty concentrating or focusing on tasks Feeling anxious, depressed, or irritable
Types of Insomnia Secondary = most common 8-10 people with insomnia Certain illnesses e.g.. heart & lung diseases, diabetes, Pain, especially chronic pain e.g. arthritis, headache disorders, fibromyalgia, neuropathies Anxiety Depression Stress e.g.. occupational, life or lifestyle Eating too much before sleep
Types of Insomnia Secondary = most common Medications that delay or disrupt sleep as a side effect Caffeine or other stimulants Antidepressants, corticosteroids, decongestants, weight loss Alcohol or other sedatives Tobacco & products with nicotine Restless legs syndrome Poor sleep environment Change in sleep routine Antihistamines may increase urinary problems causing more frequent nighttime urination
Types of Insomnia Secondary = most common Overactive thyroid GI disorders, heartburn, GERD Specific asthma medications e.g.. theophylline Some allergy or cold medications Beta blockers e.g.. atenolol Staying up too late Getting up too early
Types of Insomnia Primary Not due to another medical or emotional condition Typically occurs for at least 1 month Unclear whether some may be born with greater probability of having this type or not Causes Major or long lasting stress or emotional changes Travel or other factors e.g.. work schedules that disrupt sleep routine Habits developed to deal with it e.g.. taking naps, going to bed early, worrying about sleep
Insomnia Changes of Aging Change in sleep patterns More time in stage 1 & 2 cause more wakefulness May feel tired earlier, go to bed earlier which results in awakening earlier May be less physically active May have more free time Drink more caffeine, alcohol Take a daily nap
Insomnia Changes of Aging Change in health Chronic pain Anxiety Depression Stress Nonmalignant prostate enlargement Increases nighttime urination & wakefulness Hot flashes in women Increased sleep apnea & restless legs syndrome with aging
Insomnia Treatment Lifestyle changes Avoid caffeine, tobacco, other stimulants too close to bedtime (caffeine effects may last up to 8 hours) Avoid OTCs or prescription medications at bedtime that disrupt sleep Avoid alcohol before sleep Follow a bedtime routine: Relax or wind down before bedtime Stay with a routine
Diagnosing Medical History: Any new or ongoing health problems? Any painful injuries or health conditions? e.g.. arthritis Taking any medications? Includes OTCs
Diagnosing Sleep History: Frequency of sleeping difficulty, length of time When go to sleep during work days & off days? Length of time to fall asleep? Frequency of awaking during sleep time? Length of time to fall back to sleep? Snoring? y/n loudly/frequently? Wake up gasping or out of breath?
Diagnosing Sleep History: Frequency of dosing off during routine tasks? Trouble staying awake during routine tasks? Sleep diary: Frequency of worrying about: falling asleep? staying asleep? getting enough sleep?
Diagnosing Sleep diary: What eat or drink before going to bed? What medications taken before going to bed? What routine is followed before going to bed? What noise level, lighting, room temperature are like where sleeping occurs? What distractions are in the place of sleeping? e.g.. TV, computer, other people, pets. Physical Exam Polysomnogram (possible)
Insomnia Treatment Lifestyle changes Avoid exercise, eating heavy meals, drinking large quantities shortly before bedtime Go to sleep at the same time each night Wake up around the same time each day even on days off Make sleeping location sleep-friendly Minimize sleep distractions e.g.. TV, noise, lights, computers, pets, etc.
Insomnia Treatment Lifestyle changes Avoid night shifts or alternating schedules if possible Avoid trying to sleep Hide bedroom clocks Vigorous exercise 20-30 minutes daily, 5-6 hours before bedtime Cognitive-Behavioral Therapy Relaxation training or biofeedback at bedtime to reduce anxiety Replace worry with more positive thoughts Therapy when necessary Limit time spent in bed while awake Find healthful ways to relax
Insomnia Treatment Medications when necessary & prescribed by professional 1-2 weeks to help establish a regular sleeping schedule Insomnia medications may result in awakening with grogginess or feeling unrefreshed Most medications are NOT for long-term use L-tryptophan or valerian or melatonin OTC & not all are regulated Use with caution more research is needed
New Tricks
THE CREATOR GAVE YOU TWO ENDS-- ONE FOR SITTING, ONE FOR THINKING. YOUR SUCCESS DEPENDS ON WHICH YOU USE. HEADS YOU WIN TAILS YOU LOSE! Copyright 2006 D Scemons
Thank You
Resources & References University of Wisconsin School of Medicine http://www.medicine.wisc.edu/mainweb/dompagestext.php?section=s leepmed&page=sleepdisorders Sleep Foundation http://www.sleepfoundation.org/site/c.huixkjm0ixf/b.2419253/k.7989/s leep_facts_and_stats.htm About Insomnia http://insomnia.about.com/od/whatisinsomnia/ New Jersey Sleep Disorder Center http://www.njsleepdisorderscenter.com/sleep_facts.htm