NRS 451 Sleep - Wake Disorders Case 3

NRS 451 Reading Case 3 Dunphy, L.M., Winland-Brown, J. E., Porter, B.O. & Thomas, D.J. (2019). Primary Care-The art and science of Advanced Practice Nursing-An interprofessional approach. (5th ed.) Philadelphia: F.A. Davis Company. • Chapter 70: Sleep Wake Disorders: Insomnia (p.) (WO3.3) • Description and classification of sleep–wake disorders have been expanded in DSM-5 to reflect the important diagnostic overlay of medical conditions that affect normal sleep patterns. Of particular importance to primary care are insomnia disorder, obstructive sleep apnea hypopnea (OSAH) (see Chapter 29), substance/medication induced disorder (see Chapter 65), and restless legs syndrome (RLS). Insomnia disorder is presented in detail because it is an underpinning of each of these disorders. The criteria and important contributing factors for insomnia disorder and RLS are discussed. • Box 70.5 Education and Referral for Patients With Eating Disorders • Source: Vitousek KB, Orimoto L. Cognitive-behavioral models of anorexia nervosa, bulimia nervosa, and obesity. In: Kendall P, Dobson KS, eds. Psychopathology and cognition. San Diego, CA: Academic Press; 1993:191. • INSOMNIA DISORDER • Insomnia disorder, or difficulty sleeping, is an extremely common problem, yet it is one that is etiologically complex. It is defined as difficulty in falling or staying asleep, waking up too early in the morning, or any combination of these. • EPIDEMIOLOGY AND CAUSES • It is estimated that 10% to 15% of the primary-care population report daytime impairment because of insomnia, and that 6% to 10% meet criteria for the disorder. Women appear to be slightly more affected than men, and up to 50% of sufferers have a comorbid mental disorder. Difficulty maintaining sleep is the most common complaint. • Acute insomnia may be precipitated by physical or emotional discomfort. Examples include pain, acute illness, and environmental disturbances such as noise, light, and temperature. Sleeping at a time that is inconsistent with daily biological (circadian) rhythms because of plane travel across time zones (jet lag) or shift work may also precipitate acute insomnia. Pain may contribute to wakefulness; indeed, often the question “Does the pain awaken you at night?” is an important piece of information in determining the severity of pain. • PATHOPHYSIOLOGY • Normal sleep is a periodic state of rest accompanied by varying degrees of unconsciousness and relative inactivity. It is normally an easily reversible, regular, recurrent state. The functions of sleep are restorative and hemostatic, critical for normal thermoregulation and energy conservation. Sleep disturbance is often an early symptom of impending mental illness. • Two physiological states compose sleep: non–rapid eye movement (NREM) and rapid eye movement (REM) sleep. In NREM sleep, most physiological functions are markedly lower than in wakefulness, although there may be episodic, involuntary body movements during NREM sleep. In contrast, REM sleep is characterized by physiological activity levels similar to those in wakefulness and a high level of brain activity and is sometimes called paradoxical sleep. NREM sleep is composed of stages 1 through 4, with stages 3 and 4 being deep sleep. Typically, NREM sleep is punctuated with an REM cycle every 90 to 100 minutes during the night. The first REM period tends to be the shortest, lasting less than 10 minutes; later REM periods may last 15 to 40 minutes each. Most REM periods occur in the last third of the night; most stage 4 sleep occurs in the first third of the night. • These sleep patterns change over the course of a person’s life. In young adulthood, REM comprises about 25% of sleep, and NREM approximately 75%. These figures remain fairly constant in normal sleep, although there is a reduction in both slow-wave sleep and REM sleep in older persons. NREM sleep increases after exercise and starvation and is thus thought to be associated with satisfying metabolic needs. • Daily variations in a variety of physiological functions affecting the endocrine, thermoregulatory, cardiac, pulmonary, renal, gastrointestinal, and neurobehavioral systems, as well as sleep–wake cycles, are governed by the 24-hour circadian rhythm in humans. The timing and internal architecture of sleep are coupled directly to the output of the endogenous circadian pacemaker. Misalignment of the output of the endogenous circadian pacemaker with the desired sleep–wake cycle can, therefore, induce insomnia, decrease alertness, and impair performance of shift workers, and accounts for the phenomenon of jet lag. Sleep deprivation for prolonged periods can lead to hallucinations, ego disorganization, and delusions, and REM-deprived patients may exhibit irritability and lethargy. • CLINICAL PRESENTATION • Insomnia may not be the chief reason for an office visit. It may be detected, however, by incorporating sleep-related questions into the general review of systems. Direct inquiry is important because patients with chronic insomnia often have never discussed their problem or have lived with it for so long that they think nothing can be done about it. The primary consequences of acute insomnia are sleepiness, negative mood, and impairment of performance, with severity related to the amount of sleep lost on one or more nights. Patients with chronic insomnia frequently complain of fatigue, mood changes (e.g., depression, irritability), difficulty concentrating, and impaired daytime functioning. • The assessment should include questions about sleep, as well as questions about daytime functioning, where the full effects of altered sleep are manifested. The amount of sleep required for each individual to subjectively feel refreshed varies markedly. Although the ability to maintain sleep alters with age, the individual’s need for sleep does not change significantly. The patient’s medical history and comorbidities are other important parameters that should be documented. Many medical problems, such as gastroesophageal reflux disease, worsen at night because they may be aggravated by recumbency. • Focus on History: Insomnia Disorder • Questions to ask: • • How has the person been sleeping recently? • • How long has the person had difficulty sleeping? • • Does the person have any underlying psychiatric or medical conditions? • • Is the person’s sleep environment conducive to sleep? For example, are there any problems that would make sleeping difficult, such as noise, temperature, light, or space? • • Does the person work shift work or odd hours? • • What does the person do in the evenings and to prepare to go to sleep? • • What time does the person usually go to sleep? Get up? Are these hours the same on the weekday as well as the weekend? • • Does the person travel frequently? • • Does the person use caffeine, alcohol, drugs, or tobacco? If so, how much, and what are the specifics concerning the patient’s use? • • Does the person have difficulty staying awake or report dozing off during normal daily activities? • • Does the person report any daytime consequences of not sleeping? • • Does the person take daytime naps? • • Does the person (or his or her partner) report: • • Loud snoring, gasping, or stop breathing at night? (suggests sleep apnea) • • Legs or arms jerking during sleep? (suggests periodic limb movement) • • Creeping, crawling, or uncomfortable feelings in the legs that are relieved by moving them? (suggests restless legs syndrome) • It may also be helpful for the patient to keep a sleep diary over 2 to 4 weeks. A sleep diary is a useful tool to track exactly when and under what conditions the patient sleeps, as well as diet, exercise, and drug habits that may help reveal the underlying problem. In addition, a record of all exercise and physical activity may prove helpful. The sleep diary also helps to further define the nature of the sleep problem, as patients should document what time they got into bed, what they did until they fell asleep, what time they recall falling asleep, any night-time awakenings (including ability to fall back asleep), and what time they awoke in the morning. Consider screening for insomnia as part of regular patient care (Schutte-Rodin et al., 2008). • DIAGNOSTIC REASONING • Symptoms • The diagnosis of insomnia disorder is made clinically using DSM-5 criteria; please refer to the DSM-5 for complete diagnostic criteria. Symptoms should occur frequently and for a significant duration of time. Common symptoms include: • • Poor quality of sleep (difficulty falling asleep, difficulty staying asleep, and/or early morning awakening) • • Trouble sleeping is not an effect of a medication or drug. • Collateral information from family or bed partners can be helpful to corroborate the diagnosis. Excessive daytime sleepiness can be assessed using the Epworth Sleepiness Scale. Polysomnography (sleep study) cannot distinguish those with insomnia from those without, and thus is only indicated if sleep apnea, periodic limb movements, or a REM sleep behavior disorder is suspected, or if usual treatment fail. • Differential Diagnosis • It is necessary to rule out all potential underlying causes of insomnia. Boxes 70.6 and 70.7 list medical and psychiatric causes of and contributors to insomnia. A thorough medication history must be taken, including all over-the-counter drugs, such as decongestants and cough syrups that contain decongestants, which act as stimulants. In addition, a complete history of all herbal remedies used, especially teas that may contain caffeine or ginseng and a variety of other central nervous system stimulants, should be obtained. When patients buy products in health food stores, they often do not think of them as “drugs.” The patient also should be screened for any illicit drug and alcohol use. • MANAGEMENT • Nonpharmacological Management • Insomnia can be a chronic, lifelong illness, and given the chronic nature of this problem, long-term treatment is often advisable. Evidence supports the efficacy of CBT for the first-line treatment of chronic insomnia (Schutte-Rodin et al., 2008). CBT can occur in an individual or group setting over 6 to 8 weeks. The clinician should review sleep hygiene strategies with the patient and identify any barriers to implementation (see Box 70.8). Any coexisting medical, psychiatric, or pain conditions should be adequately treated. • Box 70.6 Medical Causes of and Contributors to Insomnia • Source: Gutierrez C, Brady P. Obstructive sleep apnea: A diagnostic and treatment guide. J Fam Pract. 2013;62(10):565–572. • Box 70.7 Psychiatric Causes of and Contributors to Insomnia • Source: Roth T. Comorbid insomnia: Current directions and future challenges. Am J Manag Care. 2009;15:S6–S13. • Reassurance and supportive counseling are essential; insomnia is not a complaint that should be taken lightly. Issues of caregiving for young children or older adults living in the home may be a part of the clinical picture. Again, diversionary lifestyle changes and situational support may be more effective than pharmacological measures for these patients. Sleep parameters can be reviewed and reemphasized several times during return visits before resorting to pharmacological measures (see Table 70.1). • Pharmacological Management • Evidence suggests that for some patients with persistent insomnia, adding a short course of a medication to CBT produces an additive benefit. Advantages of the sedative- hypnotics are that they hasten sleep onset, decrease the number of nighttime awakenings, increase total amount of sleep time (varies with medication duration of action), and make sleep more refreshing. Some of the disadvantages are that they may alter sleep architecture over time by decreasing slow-wave sleep and REM sleep and that they may cause residual sedation, psychomotor and cognitive impairment, psychological dependence in vulnerable individuals, and rebound insomnia. • Medications indicated for insomnia include five older benzodiazepines (estazolam, flurazepam, quazepam, temazepam, and triazolam) and three newer benzodiazepine- receptor agonist medications (eszopiclone, zaleplon, and zolpidem). The elimination half- lives and duration of action of the sedative-hypnotics (see Drugs Commonly Prescribed 70.1) vary tremendously. The advantages and disadvantages of a given duration of action must be assessed in light of each patient’s individual needs. A limiting factor is that all agents in this class have some potential for abuse and are classified as Schedule IV by the Drug Enforcement Administration. In older adults, benzodiazepines should be avoided due to the risk of falls and rebound insomnia. Clinical trials have provided some evidence that sleep can improve to some degree without the use of any medication because patients receiving placebo often reported as much improvement during the study as those taking medication. In sleep studies, a placebo is not an “inactive” treatment in that all study participants must adhere to nonpharmacological regimens (such as going to bed and getting up at regular hours, not napping, avoiding caffeine and alcohol) that are recognized as effective remedies for insomnia. • Box 70.8 Sleep Hygiene Strategies • Source: Sateia MJ, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017;13(2):307–349. • TABLE 70.1 Advanced Practice Nursing Interventions for Insomnia Behavioral Treatment Relaxation therapy (progressive muscle relaxation therapy), autogenic training, electromy Sleep Restriction Therapy Poor sleepers often increase their time in bed. Sleep restriction therapy curtails this time. For example, if a person reports sleeping only 5 hours per night, he or she should be couns increase time in bed in 15- to 30-minute intervals. It works best to alter bedtime and keep per night. Stimulus Control Therapy Functions on premise that insomnia is a conditioned response to temporal (bedtime) and e the bed and bedroom with rapid sleep onset. Stimulus control therapy counsels: (1) Go to bed only when sleepy. (2) Use the bed only for sleep. (3) Get out of bed and go into another room when awake; go back into the bedroom only (4) Maintain a regular rise time, regardless of sleep deprivation during the night. (5) Avoid daytime napping. Cognitive Therapy Identify dysfunctional ideas about sleep and replace them with more functional approache insomnia and less sleep does not have to destroy one’s life. This approach helps minimize Exercise Regular physical activity will assist with sleep. Advise the patient not to exercise too close Massage Weekly massage may assist with relaxation. Reassurance and Support Active listening and patience; encourage expression of feelings, especially if stress is a co • Drugs Commonly Prescribed 70.1: Sedatives and Hypnotics • Abbreviations: CNS, central nervous system; CYP, cytochrome P-450; REM, rapid eye movement. • Other agents often used to treat insomnia include antihistamines (diphenhydramine), antidepressants (trazodone, mirtazapine, doxepin), antipsychotics (quetiapine, olanzapine), melatonin, and the melatonin receptor agonist ramelteon. Of these, only doxepin and ramelteon are FDA approved for insomnia, with limited evidence for the others, despite their widespread use. Depression is the most common comorbid psychiatric diagnosis with chronic insomnia; however, antidepressants should be used most often in the setting of comorbid depression (Schutte-Rodin et al., 2008). Concurrent treatment of both insomnia and an underlying psychiatric comorbidity may result in greater improvements for the patient. • FOLLOW-UP AND REFERRAL • Transient insomnia may turn into chronic insomnia. For this reason, treatment is essential. Insomnia should resolve with patience, counseling, and treatment, and patients should be followed until the situation is resolved (Schutte-Rodin et al., 2008). A concern is daytime sleepiness (sleep apnea, for example, is highly correlated with car accidents). The patient may need to be referred for supportive counseling, especially if insomnia is related to a traumatic event. • RESTLESS LEGS SYNDROME • RLS is a neurological, sensorimotor condition that is typified by uncomfortable sensations in the lower extremities, such as burning, tingling, crawling, or itching, and an uncontrollable desire to move the legs, with associated sleep disturbance. Relief of symptoms is usually obtained once the individual moves his or her legs. • EPIDEMIOLOGY AND CAUSES • Prevalence rates of RLS vary from 2% to 7%, with women up to twice as likely as men to report symptoms. The prevalence of RLS increases with age, with onset typically occurring in the second or third decade of life. Those with familial RLS typically have an earlier age of onset and more progressive disease course. There is significant comorbidity with periodic limb movements of sleep, with up to 90% of individuals with RLS demonstrating periodic limb movements on polysomnogram. • PATHOPHYSIOLOGY • Dysfunction of dopaminergic systems is implicated in the pathophysiology of RLS, as evidenced by improvement of symptoms when dopaminergic drugs are administered. In addition, low iron levels can contribute to symptoms, so all patients should have iron studies completed, and appropriate supplementation should be implemented when necessary. • CLINICAL PRESENTATION • Symptoms occur when the patient is at rest and often worsen at night when attempting to initiate sleep. Patients often present complaining of an uncontrollable urge to move their legs that impairs their ability to initiate and maintain sleep. This leads to excessive daytime sleepiness and impaired functioning the next day. Bed partners may also notice the excessive movement during sleep. Many patients will report a family history of RLS. • DIAGNOSTIC REASONING • The diagnosis is based primarily on patient self-report, although a complete neurological examination and appropriate laboratory testing can help to rule out other possible diagnoses. In addition, patients should be referred for polysomnography. • Symptoms • Diagnosis is based on DSM-5 criteria for RLS; please refer to the DSM-5 for complete diagnostic criteria. Symptoms should occur frequently and for a significant duration of time. They include: • • An urge to move the legs • • An uncomfortable sensation in the legs • • The urge or discomfort begins or worsens when at rest, at night, or attempting to sleep • • The urge or discomfort is relieved by movement • Differential Diagnosis • RLS needs to be differentiated from leg cramps or positional discomfort. Important medical differential diagnoses are arthritis, peripheral neuropathy, peripheral vascular disease/ischemia, numbness, and radiculopathy, which may be associated with pain or discomfort in the extremities, but less often with the urge to move the extremities. Psychiatric comorbidity includes depressive disorders, anxiety disorders, panic disorder, and PTSD. • MANAGEMENT • The management of RLS includes reinforcing the sleep hygiene strategies listed in Box 70.8. Other interventions that can help include baths, whirlpool, massage, and exercise. The FDA has approved Relaxis, a vibrating pad that provides counter-stimulation to the legs. The American Academy of Sleep Medicine indicates that there is good evidence for use of the FDA-approved dopaminergic agents pramipexole (0.125–0.5 mg 2 to 3 hours before bedtime) and ropinirole (0.25–4.0 mg 1 to 3 hours before bedtime) in the treatment of RLS when there is moderate to severe impairment in sleep or daytime functioning. • FOLLOW-UP AND REFERRAL • All patients should be encouraged to maintain good sleep hygiene and keep a sleep diary. The primary-care provider should follow-up the response to the sleep hygiene strategies. Patients with suspected RLS should be referred for polysomnography. A trial of a dopaminergic agent is often warranted because a good response to these medications further supports the diagnosis of RLS. Patients who have complex sleep difficulties or are nonresponsive to first-line agents should be referred to a sleep specialist. 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