Psychiatric / Mental Health Nursing

1. Psychiatric / Mental Health Nursing Theories of Sleep Disorders

2. Theories of Sleep Disorders • Conflicting evidence that sleep is restorative • Function of sleep poorly understood • Beliefs important to mental health nursing

4. Theories of Sleep Disorders - continued • Insomnia likely due to combination of factors: • predisposing • precipitating • perpetuating

5. Theories of Sleep Disorders - continued • Studies show those with chronic insomnia have physiological differences. • Studies suggest that gene variations are involved in human circadian activity. • There is predisposition to sleep disorders based on genetic susceptibility and familial pattern.

6. Theories of Sleep Disorders - continued • Any emotional or cognitive arousal can precipitate or perpetuate insomnia. • Environmental conditions, including associating the sleeping room with lying awake, cause distress and are a powerful perpetuating factor to sleep problems.

7. Sleep Patterns in Major Depressive Disorder • Insomnia of maintenance or early wakening type most common • Insomnia is the most commonly reported residual symptom after remission • Sleep pattern disturbance may respond to antidepressant treatment sooner than other symptoms

8. Sleep Patterns in Manic Episodes of Bipolar Disorder • Sleep time significantly reduced • Clients don’t complain of insomnia and can go without sleep • Reduced slow-wave sleep • Reduced REM latency

9. Sleep Patterns in Schizophrenia • Exacerbation of illness causes significant sleep disruption • Extreme sleep difficulty can accompany severe anxiety • Heightened concern of delusions and hallucinations • Circadian cycle disrupted

10. Sleep Patterns in Schizophrenia - continued • Reduction in REM sleep • Do not experience REM rebound • Deficits in slow-wave sleep found in clients with acute and chronic schizophrenia

11. Sleep Patterns in Substance Abuse • Severe sleep disorder during intoxication or withdrawal periods • Persists even after prolonged abstinence of some substances

12. Sleep Patterns in Substance Abuse - continued • Substance-induced mood disorder characterized by sustained use of stimulants to stay awake or alcohol to induce sleep • Examples of substances

13. Key Assessments • “Good sleeper” can be identified three ways: - self-defined - behaviorally defined - sleep-study defined

14. Key Assessments - continued • Self-defined - say they get enough sleep to feel refreshed, have energy, fall asleep quickly

15. Key Assessments - continued • Behaviorally defined - observe alertness during sedentary, repetitive activity; note ability to fall asleep and final wakening at habitual rising time; utilize photographic serializing of movement during sleep

16. Key Assessments - continued • Comprehensive sleep studies are conducted in sleep labs: - polysomnogram - multiple sleep latency test

17. Guidelines for Good Sleep Hygiene • Maintain regular sleep–wake schedule • Rise at the same time each day • Go to bed when sleepy and relaxed • Maintain rituals in preparation for sleep • Control for temperature, lighting, noise • Avoid stimulants before bed • Focus on enjoying sleep that is achieved

18. Guidelines for Insomnia • Treatment for sleep disorders is complex • Follow guidelines for good sleep hygiene • Utilize good sleep hygiene before taking sedative hypnotic medications • Instill a sense of hope that insomnia will improve, client can manage it effectively

19. Guidelines for Insomnia - continued • Facilitate setting realistic goals. • Teach normal developmental changes in sleep patterns. • See treatment provider for continued insomnia. • Differentiate between myths and evidence-based practice.

20. Guidelines for Insomnia - continued • See physician for comprehensive PE to rule out physical factors. • Interview bed partner. • Determine if problem is positional or disappears under certain circumstances. • Treat underlying mental health issues.

21. Pharmacology

22. Sleep and Wakefulness • Goal: Improve quantity and quality of sleep • May prevent worsening of mood, anxiety and pain if sleep improves • Many choices: evaluate lifestyle • Do not underestimate the POWER of sleep

23. Sleep Agents: NT • Nearly all hypnotics work on at least one of these neurotransmitters: • GABA • Histamine

24. Rx Sleep agents • Barbiturates • Benzodiazepines • Non-benzos • Melatonin Receptors Agonists

25. Sleep agents • Barbituturates – first used in 1860s named after St Barbara • Nembutal (pentobarbital) • Seconal (secobarbital)

26. Sleep agents • Benzodiazepines • Short Acting • Halcion (triazolam) • Intermediate • Restoril (temazepam) • Prosom (estazolam) • Long Acting • Dalmane (flurazepam)

27. Sleep Agents • Non-Benzos • Ambien • Ambien CR • Sonata (zaleplon) • Lunesta (eszopiclone)

28. Sleep Agents • Melatonin Receptor Agonist • Rozerem (remalteon) • Valdoxan (agomelatine) also works on 5-HT2c so is antidepressant

29. Sleep Agents • Over the Counter OTC • Benadryl (diphenhydramine) • Atarax/Vistaril (hydroxyzine Kava Kava Caution: may cause liver toxicity Valerian

30. Side Effects • Hangover • Amnesia • Headache

31. When Starting on Sleepers • Sleep hygiene first – remember caffeine • Cool, quiet, dark room without dogs and kids • Don’t mix with Alcohol • Go straight to bed and lay down

32. Wake Agents: NT • Nearly all wake promoting agents work on at least one of these neurotransmitters: • Norepinephrine • Dopamine

33. Wake Agents • Provigil = Nuvigil • FDA Indication • Excessive sleepiness due to narcolepsy • Obstructive sleep apnea • Shift work sleep disorder Treat fatigue and sleepiness due to other conditions – depression and MS

34. Wake Agents • Stimulants • Provigil (modafinil) • Nuvigil (armodafinil)

35. When Starting on Wakers • Sleep hygiene first – not a replacement for sleep