Presentation on theme: "Jamie Neal, APRN 10/24/14. Explain the importance of sleep Describe the symptoms of insomnia Identify treatment of insomnia Describe the symptoms."— Presentation transcript:
Jamie Neal, APRN 10/24/14
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
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
By Age What they are really getting Infant hrs Toddler12-14 hrs Preschool11-13 hr School age10-11hrs Adolescents9.5 hrs Infant 12.7 hrs Toddler11.7 hrs Preschool10.3 hrs School age9.5 hrs Adolescents7 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.
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
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
◦ 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
◦ Frightening dreams that cause waking, are upsetting and require comfort ◦ Start around age 2 ◦ Treatment: think happy, pleasant thoughts at bedtime
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
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
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!
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
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
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 affected Episodes occur or are exacerbated by episodes of rest (sometimes with exercise) Worse in the evening
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”
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
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
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 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)
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!
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
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. ◦ 6 th graders=2 items, 12 th 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
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 ing after bedtime, even once per week, increases self-reported daytime sleepiness among teens National Sleep Foundation
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 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, 2010 Horrocks 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
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
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
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
Goya 1797 Que Viene el Coco (Here comes the bogeyman)
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
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.
American Academy of Pediatrics Section on Pediatric Pulmonology Pediatric Pulmonology. American Academy of Pediatrics. American Academy of Sleep Medicine The international classification of sleep disorders. 2 nd edition. American Academy of sleep medicine. Mindell, J.A & Owens, J.A A clinical guide to pediatric sleep: diagnosis and management. 2 nd edition. Wolters Kluwer. Sheldon, S.H., Ferber, R., Kryger, M.H Principles and practice of pediatric sleep medicine. Elsevier Inc. Panitch, H.B Pediatric Pulmonology The Requisites in Pediatrics. Elsevier Inc.
Eggermont S., & Van den Bulck J 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 b Shochat, T., Flint-Bretler O., &Tzischinsky O Sleep patterns, electronic media exposure and daytime sleep-related behaviours among Israeli adolescents. Acta Paediatrics Vol 99 (9) pp Pelayo, R., & Dubik, M Pediatric Sleep Pharmacology. Semin Pediatr Neuro. 15: Picchietti, D., Allen, R.P., Walters, A.S., Davidson, J.E.Myers, A., et al Pediatrics. Restless legs syndrome: Prevalence and impact in children and adolescents the pediatric REST study. 120;