Date post: | 14-Dec-2015 |
Category: |
Documents |
Upload: | lamar-foot |
View: | 224 times |
Download: | 2 times |
Insomnia and sleep hygiene: Making friends with the monsters under your bed and the voices in
your headJamie Neal, APRN
10/24/14
Objectives Explain the importance of sleep Describe the symptoms of insomnia Identify treatment of insomnia Describe the symptoms of restless leg
syndrome (RLS) Identify treatments for RLS Describe good sleep hygiene techniques
Why is sleep important? Insufficient sleep can
lead to: Mood disturbances
◦ Irritability, emotional lability, depression, anger
Fatigue and daytime lethargy
Cognitive impairment◦ Memory, attention,
concentration, decision making, problem solving
Daytime behavior problems◦ Over activity, impulsivity,
noncompliance Risk taking behaviors Academic problems
◦ Chronic tardiness, falling asleep in class
Use of stimulant meds◦ Other alertness
enhancers like caffeine, nicotine
Sleep Requirements for kids
By Age What they are really getting
Infant 14-15 hrs Toddler 12-14 hrs Preschool 11-13 hr School age 10-11hrs Adolescents 9.5 hrs
Infant 12.7 hrs Toddler 11.7 hrs Preschool 10.3 hrs
School age 9.5 hrs Adolescents 7 hrs
Difficulty with sleep initiation, duration, consolidation or quality that occurs despite adequate time and opportunity for sleep and results in daytime impairment
Acute (adjustment) insomnia-short lived due to life circumstances (identifiable stressor) ◦ i.e.: can’t fall asleep because of a test the next day,
it’s the first day of school Chronic insomnia-at least 3 nights a week for 3
months. ◦ Can be associated with a comorbidity, but not always.
What is insomnia?
Types of Insomnia Behaviorally induced Insufficient sleep Psycho physiologic Paradoxical Medical problems Psychiatric conditions
Relies on inappropriate sleep association Usually presents with frequent night time
awakenings The process of falling asleep is associated
with a specific habit, object, or setting Child becomes unable to fall asleep within a
reasonable time in the absence of these conditions
Examples: extended rocking, parent has to sleep with child or vice versa
Behavioral insomnia- sleep onset-association type
Stalling or refusing to go to bed When parent enforces limits, child falls asleep
quickly Problem arises when parent has trouble setting
and maintaining limits and managing the stalling behavior (inconsistent)
Child’s stalling techniques are based on what they have learned will work
Examples: refusing to put on pajamas, get in bed, saying they are scared, need kisses, etc
Daytime anxiety may trigger night time fears
Behavioral insomnia- limit setting type
◦ Bedtime or middle of the night fears◦ Begin in the preschool years, disappear age 5-6◦ May be provoked by anxiety, stress, traumatic
events◦ Treatments:
Try monster spray Have a pet sleep in the room Security objects Night lights Have the child involved in the solution
Night time fears
◦ Frightening dreams that cause waking, are upsetting and require comfort
◦ Start around age 2◦ Treatment: think happy, pleasant thoughts at
bedtime
Nightmares
Heightened mental arousal and learned sleep-preventing associations
May be associated with emotional reactions Hyper vigilant about sleep Can complain of “racing main” The more the person tries to sleep, the more
irritated they become and the less able one is to fall asleep
People who sleep better when they are not in their own bedroom
May be associated with people who are overanxious about their overall health
Psycho physiologic insomnia
Complaints of severe insomnia that occurs in the face of a normal sleep study or without evidence of an objective sleep disturbance
The severity of the night time complaint is not matched by evidence of pathologic daytime sleepiness ◦ still complain of being tired◦ may not be falling asleep at school, work
No other psychiatric illnesses No suspicion of malingering Overestimate of how long it takes to fall asleep
and underestimate total sleep time
Paradoxical insomnia
Persistent failure to obtain the amount of sleep required to maintain normal levels of alertness and wakefulness
Voluntary but unintentional chronic sleep deprivation
Sleep history of the current sleep patterns reveals disparity between the amount of sleep they are getting and the amount of sleep they need!
Insufficient sleep syndrome
Restless leg syndrome Central apnea Pain-low back pain, chronic pain GI issues such as reflux Arthritis Endocrine issues such as hyperthyroidism Neurological conditions such as Parkinson’s
Medical causes of insomnia
Bipolar disorder Depression
◦ Insomnia can be a symptom of depression, especially middle of the night waking
◦ Increased risk of severe insomnia in the face of major depressive disorder
Anxiety◦ Tension◦ Ruminating about past events◦ Worrying about future events◦ Feeling overwhelmed◦ Feeling over stimulated
Psychiatric causes of insomnia
Restless Legs Syndrome (RLS)
A sensory disorder characterized by an uncomfortable sensation in extremities accompanied by an urge to move the extremities while awake
Sensations relieved by movement (walking, rubbing, stretching, shaking, rocking)
Legs and arms can be affectedEpisodes occur or are exacerbated by
episodes of rest (sometimes with exercise)Worse in the evening
Sensory RLS Symptoms in Children Ants, spiders, bugs crawling on legs “Lightening in my legs” Squeezing, tingling, itching, aching, or
hurting “My legs feel wiggly” “My legs want to run” “My legs won’t stay still” “Lava running down my legs”
Mechanism of Iron in RLS/PLMD
Low brain iron stores leads to disrupted dopamine synthesis in the CNS= reduction of dopamine availability within critical regions of the brain= development of RLS/PLMD
Risk Factors for RLS
Genetic link, especially first degree relative Sleep deprivation Medical Conditions: iron deficiency anemia,
end stage renal disease, hypothyroidism, DM
Pregnancy Medications: antihistamines,
antidepressants, antipsychotics, antiemetic Caffeine and alcohol may increase RLS
symptoms
Treatment: Iron Supplementation
First line treatment in children with ferritin levels less than 50 ng/mL
Goal is to increase peripheral iron levels and to increase iron stores
Ferritin acts as a marker for the stored iron levels in the body
Goal for iron treatment is a ferritin between 50-70 ng/mL
Dose for oral iron : 3-6 mg/kg/day for 3 or 6 months Iron is continued for 3 month intervals and iron and
ferritin levels are assessed along with clinical improvement (improved RLS sensations, less difficultly with sleep onset, maintenance)
Iron Supplementation Sounds easy, right?
Oral iron is poorly absorbed Compliance with medications for many months
is difficult Liquid iron tastes bad! (We have them take it
with orange or apple juice) Calcium, magnesium, zinc all bind with iron and
decrease absorption Anti reflux medications decrease iron absorption Side effects: most common is constipation Iron toxicity a risk of acute iron overdose
Iron is not the same as lead!
Other RLS treatment Dopamine agonists
◦ Act like dopamine◦ Pramipexole (Mirapex)◦ Ropinirole (Requip)◦ First line treatment for adults (not FDA approved
for kids) Anticonvulsants
◦ Gabapentin (off –label) Alpha 2 agonists
◦ Clonidine (short term use only)
Dim lights 1 hours before bed Room darkening shades and curtains Colors and decorations that are relaxing Room temp between 60 and 67 degrees Comfortable mattresses, pillows and sheets Reduced noise with white noise or fan Keep the TV off while asleep Relaxing scents like lavender
National sleep foundation
Sleep-Friendly environment
Sleep hygiene reality… Watching television is the most popular activity
(76%) for adolescents in the hour before bedtime◦ surfing the internet/instant-messaging (44%)◦ talking on the phone (40%)
Nearly all adolescents (97%) have at least one electronic item in their bedroom.◦ 6th graders=2 items, 12th graders=4
Adolescents with four or more items are 2x likely to fall asleep in school and while doing homework.
• National Sleep Foundation 2006, 2011 Sleep in America Poll.
27% of parents of teens who leave electronic device ON rate their teen’s sleep as excellent
53% of parents of teens who leave devices OFF rate their teen’s sleep as excellent
17% of parents said that their child read or sent electronic communications after initially going to bed
On school nights, teens who leave their TV or iPod on get 1 hour less sleep than those who don’t
On school nights, teens who leave their phone on get 2 hours less sleep than those who don’t
National Sleep Foundation
Electronics and sleep
Kids using electronics as a sleep aid to relax at night have later weekday bedtimes fewer hours of sleep per week and report more daytime sleepiness
Teens with a TV in their bedroom have later bedtimes, more trouble falling asleep and shorter total sleep times
Texting and emailing after bedtime, even once per week, increases self-reported daytime sleepiness among teens
National Sleep Foundation
More bad news about electronics and sleep
Treatment of insomnias
Improve the sleep hygiene!◦ Regular bedtime routine and bedtime◦ 1 hr of sunlight exposure early in the day◦ Regular physical activity◦ Dim lights in the evening◦ No stimulating activities (TV, video/computer
games) for at least 1 hr prior to bedtime◦ No caffeine or chocolate, ◦ Bath time earlier?◦ Relaxing activity when first getting in bed?
Naps Naps may help to improve:
◦ Alertness◦ Performance◦ Memory recall
◦ Short nap(under 45 minutes) Only if no sleep onset/ maintenance problems
Ficca et.al., Sleep Medicine Reviews, 2010Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006
Light and Sleep
Exposure to light before sleep can inhibit production of melatonin◦Decrease/avoid light at night◦Increase exposure during the day
Horrocks and Pounder, Working the Night Shift: Preparation, Survival and Recovery, 2006
Bonnefond et al., Industrial Health, 2004
Melatonin Sleep Time Tea Natural supplements Marley’s Mellow Mood Lazy Cakes
Sleep aids
Secreted by pineal gland Tryptophan → 5HTP → serotonin → melatonin Natural melatonin levels rise at night about
1-2 hours prior to bedtime Give melatonin 1-2 hours prior to bedtime Adult doses range from 0.3mg to 10mg NSF warns against using in patients with
immune system disorders, cancers, taking corticosteroids or immune suppressants
Melatonin
Not regulated by FDA Considered dietary supplement Works best in children with
◦ Circadian rhythm disorders ◦ Mid-line brain defects such as agenesis of the
corpus callosum ◦ Blindness ◦ ADHD◦ Autism
Melatonin and kids
Marley’s Mellow Mood
Lazy cake relaxation brownies
Healthy sleep tips Stick to the same
bedtime and wake time, even on the weekends
Have a relaxing bedtime ritual
Avoid naps, especially in the afternoons
Exercise daily Adjust your sleep
environment
Sleep on a comfy bed Use bright light to help
manage your circadian rhythm
Avoid alcohol, cigarettes and heavy meals in the evening
Give yourself some wind down time
Go to another room and do something relaxing until you are tired
Scaring your child to sleep i.e.: the bogeyman
Talking negatively about ghosts Letting kids watch scary movies, TV shows Discussing vampires, werewolves and
zombies Letting kids play scary video games
Things that won’t help
Goya 1797 Que Viene el Coco (Here comes the bogeyman)
The boogeyman – German/English An imaginary creature used to scare
children into behaving well Aka “If you don’t go to bed right now, the
boogeyman is going to get you” There is a similar creature in many
cultures and countries Usually male He has a sack to carry naughty children
away
Resources for Parents Guide to Your Child’s Sleep.
◦ George J. Cohen, M.D., F.A.A.P. Take Charge of Your Child’s Sleep.
◦ Judy Owens, M.D., and Jodi Mindell, Ph.D. Sleeping Through the Night.
◦ Jodi Mindell, Ph.D.
References American Academy of Pediatrics Section on Pediatric
Pulmonology. 2011. Pediatric Pulmonology. American Academy of Pediatrics.
American Academy of Sleep Medicine. 2005. The international classification of sleep disorders. 2nd edition. American Academy of sleep medicine.
Mindell, J.A & Owens, J.A. 2003. A clinical guide to pediatric sleep: diagnosis and management. 2nd edition. Wolters Kluwer.
Sheldon, S.H., Ferber, R., Kryger, M.H. 2005. Principles and practice of pediatric sleep medicine. Elsevier Inc.
Panitch, H.B. 2005. Pediatric Pulmonology The Requisites in Pediatrics. Elsevier Inc.
Eggermont S., & Van den Bulck J. 2006. Nodding off or switching off? The use of popular media as a sleep aid in secondary-school children. Journal of Paediatrics Child Health. Vol 42 (7-8) pp 428-433b
Shochat, T., Flint-Bretler O., &Tzischinsky O. 2010. Sleep patterns, electronic media exposure and daytime sleep-related behaviours among Israeli adolescents. Acta Paediatrics Vol 99 (9) pp 1220-1223
Pelayo, R., & Dubik, M. 2008. Pediatric Sleep Pharmacology. Semin Pediatr Neuro. 15: 79-90.
Picchietti, D., Allen, R.P., Walters, A.S., Davidson, J.E.Myers, A., et al. 2007. Pediatrics. Restless legs syndrome: Prevalence and impact in children and adolescents the pediatric REST study. 120; 253-266
References