Introduction

A good nights sleep and a hearty laugh are the best cures for many illnesses. Moreover if we want to be in good mood the whole day we need to sleep well and long enough. All sleep experts have the same opinion on this, unfortunately in this busy present day, fast paced world most of us feel that we cannot spend so much time for sleeping. Motivational orators encourage us to spend less time sleeping and more time working. But to be energetic and refreshed throughout the day one must have enough good quality sleep.

Definition
Sleep: Sleep can be defined as a normal state of altered consciousness during which the body rests, it is characterized by decrease responsiveness to the environment, but a person can be aroused from sleep by external stimuli. Sleep pattern disturbance: Sleep pattern disturbance is a nursing diagnosis that is defined as a disruption of sleep time that causes discomfort or interferes with a desired life style.

Physiology of sleep and arousal

A daily rhythmic activity cycle, based on 24-hour intervals, that is exhibited by many is called a circadian rhythm. The timing of sleep wake cycle and other circadian rhythms such as body temperatures is controlled in part by the suprachiasmatic nucleus in the anterior hypothalamus located above the opltic chiasm. This area receives input from the retina which provides information about darkness and light. The suprachiasmatic nucleus controls the production of the hormone melatonin, which is believed to be a potent sleep inducer. Arousal from sleep, wakefulness and the ability to respond to stimuli rely on an intact Reticular Activating System (RAS). The RAS is located in the brain stem and contains projections to the thalamus and cortex. The diffused network of neurons in the RAS is in a strategic position to monitor ascending and descending stimuli through feedback loops. The neurotransmitters of the RAS serve as chemical messengers regulating the sleep-wake cycle and the stages of sleep. The onset of sleep and of each subsequent sleep stages is an active process involving delicate shifts in the balance of several of these neurotransmitters. The transmission from the awaken state to a Non-Rapid Eye Movement (NREM) sleep is marked by decrease in concentrations of serotonin, norepinephrine and acetylecholine and further decreases in serotonin and norepinephrine. As REM sleep continues the concentrations of serotonin and norepinephrine increases eventually stopping REM sleep. The release of acetylcholine seems to re-establish REM sleep. The continuous interaction of these two systems produces the normal alterations between NREM and REM sleep. Other neuro transmitters such as Gamma

Amminobutyric acid (GABA) and dopamine contribute to the reciprocal process involved in shift in sleep stage. All these neurotransmitters are also actively involved in the waking process. For example, neurons that produce serotonin and norepinephrine play a role in the modulation of sensory input, mood, energy and information processing including attention, learning and memory. Imbalance in these neurotransmitters induces sleep pattern disturbance.

Stages of sleep
There are several different stages of sleep that people go through each night in which REM sleep and non REM sleep occurs. By EEG (Electroencephalograph) we can see the brain wave activities as person passes through delirious stages of sleep and to determine what type of sleep the person has entered. A person who is wide awake and mentally active will show a brain wave pattern on the EEG called beta waves. Beta waves are very small and very fast. As the person relaxes and gets drowsy slightly larger and slower alpha waves appear. The alpha waves are eventually replaced by even slower and larger theta waves. Stage 1: NREM - As theta wave activity increases an alpha wave activity fades away, people are said to be entering stage 1 sleep. - This stage lightest level of sleep - This stage lasts for few minutes - Respiration begins to slow and muscles relaxes - Person is easily aroused by sensory stimuli such as noise - If awakened at this stage, person always claims that they were not asleep at all. Stage 2: NREM Theta wave still predominates in this stage but if people are awakened during this stage they will be aware of having been asleep. It is a period of sound sleep The body temperature continues to drop, heart rate slows and breathing becomes more shallow and irregular. Relaxation progresses Arousal is still easy This stage lasts for 10 to 20 mins

Stage 3: NREM The slowest and largest waves makes their appearance, these waves are called delta waves. In this stage, delta waves make up only 20% to 50% of the brain wave pattern. 2

This is the initial stage of deep sleep. Sleeper is difficult to arouse and rarely moves. Muscles are completely relaxed. Vital signs decline but remains regular. This stage lasts for 15 to 30 mins.

Stage 4: NREM Once delta waves account for more than 50% of total brain activity, the person is said to have entered stage 4 sleep, the deepest stage of sleep. During this stage growth hormones are released from the pituitary gland and reach their peak. It is the deepest stage of sleep. It is very difficult to arouse sleepers Sleep lasts for approximately 15 to 30 mins. Sleep walking and enuresis may occur.

REM Sleep After spending some time in stage 4 the sleeping person will go backup through stage3, stage 2 and then into a stage in which the eyes move rapidly under the eyelids. The body is almost as aroused as in awaken state and brainwaves resemble beta waves. 90% of dreams actually takes place in REM sleep People have dreams in other NREM but REM dreams tends to be more vivid, more detailed, longer and more bizarre than dreams in NREM sleep.

Factors affecting sleep

Factors that promote sleep in one person may hinder sleep in another. A single factor may not be the only course for a sleep problem. Physiological, psychological and environmental factors can alter the quality and quantity of sleep. Physical illness Any illness that causes pain, physical discomfort such as difficulty in swallowing, anxiety or depression can result in sleep problems. Person with such alterations may have trouble falling or staying asleep. Illness also forces clients to sleep in positions to reach they are unaccustomed. Assuming an awkward position while in traction, for example can interfere with sleep. Respiratory disease often interferes with sleep. Clients with chronic lungs disease such as emphysema are short of breath and frequently cannot sleep without two or three pillows to raise their head. A person with a common cold has nasal congestion, sinus drainage and a sore throat which impair breathing and the ability to relax. Coronary heart disease is characterized by episodes of sudden chest pain and irregular heart rates. Clients with these disease are often afraid to go to sleep because of the fear of hear attacks at night. Heart attacks occur more often during REM sleep. Death from heart disorder frequently occurs at night between 5am to 6 am when REM sleep lasts longer. 3

Nocturia Urination during night disrupts sleep and the sleep cycle. This condition is most common in older people with reduced bladder tone or persons with cardiac disease, diabetes, urethritis or prosthetic diseases. After a person awakens to urinate, returning to sleep may be difficult. Older adults often experience restless leg syndrome which occurs during the presleep stage. People experience recurrent, rhythmical movement of the feet and legs. An itching sensation is felt deep in the muscle. Relief comes only from moving the leg which prevents relaxation and subsequent sleep. Drugs & Substances Various types of drugs affect the pattern and quality of sleep such as diuretics cause nocturia, beta blockers cause insomnia, hypnotics interfering with reaching deeper sleep stages etc. Medications prescribed for sleep often causes more problems than benefit. Young and middle adults may rely on sleeping medications to deal with lifestyle stresses. Older adults often take a variety of drugs to control or treat chronic illness and the combine effects of several drugs can seriously disrupt sleep. Lifestyle A persons daily routine may influence sleep patterns. An individual working a rotating shift (e.g. two weeks of daytime work followed by a week of nighttime work) has difficulty adjusting to the altered sleep schedule. The bodys internal clock might be set at 11 pm but the work schedule forces sleep at 9 am instead. The individual often can sleep only three or four hours because the bodys clock perceives that it is time to be awake and active. Only after several weeks of working a night shift does a persons biological clock adjusts. Other alterations in routine that can disrupt sleep pattern include performing unaccustomed heavy work, engaging in late night social activities and changing evening meal time. Sleep Pattern The pattern and adequacy of sleep experienced each day affect a persons functioning. The most significant cause of daytime sleepiness is inadequate or abnormal sleep at night. Everyone has an increased sleep tendency from 2am to 7 am and to a lesser degree from 2 pm to 5 pm. For example, single vehicle accidents related to the driver falling asleep at the wheel occurs most often between midnight and 4 am. Sleep deprivation may result in difficulty in performing tasks and remaining active. Chronic lack of sleep is much more serious than temporary sleep deprivation and can cause serious alterations in the ability to perform daily functions. Emotional Stress Worry over personal problems of situations can disrupt sleep. Emotional stress causes a person to be tense and often leads to frustration when sleep doesnt come. Stress may also cause poor sleep habits. Older clients frequently experience losses that lead to emotional stress. Retirement, physical impairment, death of a loved one and loss of economic security are examples of situations that predispose older adults to anxiety and depressions. With

emotional stress older adults experience delay in falling asleep, earlier experience of REM sleep , frequent awakening, increase total bedtime and early awakening. Environment The environment has a significant influence on the ability to fall and remain asleep. Good ventilation is essential for restful sleep. The size, firmness and position of the bed can affect the quality of sleep. Sounds also influence sleep. The level of noise needed to awaken people depends on the state of sleep. Low noises are more likely to arouse a person from stage one sleep whereas louder noises awaken people in stage 3 or 4 sleep. Some persons require silence to fall asleep whereas some prefer noise such as soft music. Light level may affect the ability to fall asleep. Some clients may prefer a dark room whereas others such as children keep a soft light on at all times. Clients also may have trouble sleeping depending on the temperature of the room. A room that is too warm or too cold causes a client to become restless. Sleeping at temperature higher than 24 C causes poor quality sleep. Exercise and fatigue A person who is moderately fatigued usually achieves restful sleep specially if the fatigue is the result of enjoyable work or exercise. Exercising two hours before bedtime allows the body to cool down and maintain a state of fatigue that promotes relaxation. However excess fatigue resulting from exhausting or stressful work can make falling asleep difficult. Caloric Intake Weight loss or gain influence sleep pattern. When a person gains weight sleep periods becomes longer with fewer interruptions. Weight loss can cause short and fragmented sleep. Certain sleep disorders may be the result of semi-starvation diets popular in a weight conscious society. Need for sleep Sleep is believed to have a restorative and protective function. During sleep sympathetic activities decreases while parasympathetic sleep may increase. Hormonal shifts facilitate anabolic process. Rapid Eye Movement sleep may be especially important for maintaining mental activity such as learning, reasoning and emotional adjustments. Sleep also appears to serve as energy conserving measure for most of the body except for the brain.

Normal sleep pattern

Sleep duration and quality vary widely among persons of all age groups Age and condition Newborn 112 months 13 years 35 years 512 years Adolescents Adults Average amount of sleep per day Up to 18hours 1418 hours 1215 hours 1113 hours 911 hours 910 hours 78 (+) hours

Neonates A neonates averages 16 hours of sleep a day with a range of up to 18 hours. For the first week, the neonate sleeps almost constantly to recover from birth. Approximately 50% of the sleep is REM sleep. This is essential for development because the neonate is not awake long enough for significant external stimulation. Infants Sleep patterns vary among infants. Active infants typically sleep less than quite infants. Infants usually develop a night time pattern of sleep during three to four months of age. The infants may take several naps during daytime but usually sleeps an average of 8 to 10 hrs. during the night. Awakening commonly occurs early in the morning although it is not unusual for an infant to be awakened during the night. A large infant sleeps longer than a smaller one because of greater stomach capacity. An infant between one month and one year of age sleeps an average of 14 hrs a day. REM sleep is predominant. Toddler By the age of two children usually sleep through the night and takes daily naps. Total sleep averages 12 - 15hrs a day. Naps may be eliminated at three years. It is common for toddlers to awaken during the night. The percentage of REM sleep begins to fall because toddlers have access to variety of meaningful external stimuli. Preschoolers An average preschooler sleeps about 11- 13hrs a night and rarely takes naps. The preschoolers usually have difficulty relaxing after long active days. A preschooler also has problem with bed time fears and nightmares. Parents are most successful in getting a preschooler to bed by establishing a consistent bedtime ritual. A child should not be allowed to become manipulated with by sleeping with parents or by staying up past a reasonable hour. When nightmares occur parents should comfort the childs own bed. School age children The amount of sleep needed during the school years is highly individualized because of varying states of activity and level of health. The school age child usually does not require a nap. A 6 year old requires an average of 11 to 12 hrs of sleep a night whereas a 11 years old child sleeps about 9 to 10 hrs.

Adolescents An adolescent's day is usually active and mentally and physically exhausting. Often the desire to spend time with peers prevents adolescents from realizing their need for sleep. Once bedtime approaches, however, the adolescent offers little resistance to sleep. An adolescent requires an average of 9 - 10hrs of sleep a night. Because of staying up late an adolescent frequently sleeps late in the morning. Young Adults Healthy young adults require rest and sleep to participate in the busy activities that fill their days. However it is common for busy lifestyles to interrupt. Most young adults average 7 - 8 hrs of sleep a night. But this can vary. It is unusual for young adults to take regular naps. Approximately 20% of sleep time is spent in REM sleep which remains consistent throughout life. Middle Adults During adulthood the total time spent sleeping at night begins to decline. Also the amount of stage 4 sleep begins to fall continuing throughout older age. Sleep disturbance are common. Insomnia is particularly common because of the changes and stresses of middle age. Sleep disturbance can be caused by anxiety, depression or certain physical ailments. Women experiencing menopausal symptoms may have insomnia. Members of this age group may rely on sleeping medication. Older Adults The total amount of sleep does not change as age increases. However quality of sleep deteriorates. REM sleep shortens. There an older adult has almost no stage 4 sleep. An older adult awakens more often during the night and total wake time increases. It may also take more time for an older adult to fall asleep. The changes in an older persons sleep pattern are due to changes in CNS that affect the regulation of sleep. Sensory impairment, common with aging, may reduce sensitivity to time cues that maintain circadian rhythm. An older adults chronic illness may also impair the quality of sleep.

Sleep Disorders
1. Dyssomnias Dyssomnias include sleep disorders characterized by difficult initiating or maintaining sleep (insomnia) or by excessive sleepiness. The disorders may arise predominantly from within the body (intrinsic), from external sources (extrinsic) or from disruption of circadian rhythm. A. Intrinsic sleep disorders i. Insomnia: Insomnia is defined as difficulty with initiating or maintaining sleep. It is a symptom of clients who have chronic difficulty in falling asleep. The insomniac complains of insufficient quantity of sleep. Insomnia may signal and underlying physical or physiological disorders. This disorder is primary insomnia. To differentiate it from insomnia that is secondary to another sleep disorder, it specifies the symptoms must be of or at least 1 months duration and must cause 7

significant impairment in social, occupational or other important areas of functioning and must be due to the direct effects of a substance, a general medical condition or a mental disorder. Primary insomnia may be manifested by a combination of difficulty falling asleep and intermittent wakefulness during sleep. This disorder often becomes a vicious cycle when the individual becomes more and more distressed by the inability to achieve sleep and the additional stress in turn contributes to insomnia. ii. Narcolepsy: Narcolepsy is one of the disorders characterized by excessive daytime sleepiness. The client also experience disturbed nocturnal sleep and repeated episodes of almost irresistible daytime drowsiness followed by brief periods of sleep especially when engaged in monotonous activities. iii. Sleep Apnea Syndrome: Sleep apnea is characterized by association of breathing for 10 sec or longer occurring at least 5 times per hour. It can be classified as obstructive central nervous system apnea and mixed. Obstructive Sleep Apnea Syndrome: In this case respiratory efforts of the diaphragm and intercostals muscles are apparent but ineffective against a collapsed or obstructed upper airway. Snoring indicates partial obstruction. Escalating snoring followed by a silent pause that ends with a gasp of snort probably indicates complete airway obstruction. As hypoxia ensures the person eventually awakens to breathe. The frequent awakening impair the normal sleep cycle. Central Sleep Apnea Syndrome: Central Sleep Apnea is characterized by apneic periods during which no apparent respiratory effort occurs. Central apnea involves detects in the brains respiratory control centre. The impulse to brains respiratory control centre. The impulse to breathe temporarily fails and nasal airflow and chest wall movement ceases. The oxygen saturation of the blood falls slightly. The condition is seen in clients with brain stem injury, muscle dystrophy. Periodic limb movement disorder: Periodic limb movement disorder may also contribute to daytime sleepiness and frequent nocturnal awakenings. It is characterized by periodic episodes of repetitive, stereotypic leg or arm movements that occur during sleep causing partial arousal. It is more common in elderly population. Restless leg syndrome: Restless legs syndrome involves annoying, crawling, itching or tingling sensation of the leg while at rest and causes an almost irresistible urge to move. This syndrome is often most severe before 8

sleep onsets. B. Extrinsic Sleep Disorders The Extrinsic Sleep Disorders encompass a range of factors from environmentally to chemically induced disorders such as: i. Inadequate sleep hygiene ii. Environmental sleep disorder C. Circadian Rhythm Sleep Disorders In the general population, the circadian rhythm sleep disorders such as time zone change syndrome and shifts, work sleep disorder are not uncommon. Older and clinically ill clients who live alone may be vulnerable to irregular sleep-wake pattern. In this disorder, prolonged ignoring or absence of external cues to time such as regular mealtimes, work periods and daylight leads to erratic periods of sleeping and wakefulness. Internal circadian cues may also be damped as a result of aging or diffused brain disease. 2. Parasomnias The parasomnias are disorders that occur during sleep but do not produce insomnia or excessive sleepiness. The underlying pathologic mechanism may involve partial arousal or abnormalities in sleep-wake transition. A. Arousal Disorder Partial arousal typically occur during slow-wave-sleep. Sleep Walking, also known as Somnambulism, may include semi purposeful behavior such as dressing. The behavior may be lacking in co ordination and appropriateness however, such as voiding in the closet. Sleep terrors are sudden arousals from slow-wave sleep accompanied by screaming, tachycardia, tachypnea, diaphoresis and other manifestation of intense fear. If awakened, the person is often disoriented & has little recall of the nature of the dream image. Sleep terrors typically occur in young children but may develop in adults. B. Sleep Wake Transition Disorder Sleep wake transition disorders are common in the general population rarely causing enough disruption to be legitimately called disorder. Sleep starts refers to the sudden jerking movement of the legs that often occurs just as a person is falling asleep. Nocturnal leg cramps are also common. The frequency and intensity may be greater with high caffeine intake, stress or intense physical activity before going to bed. Sleepwalking may also occur more frequently during times of stress.
C. Parasomnia associated with REM sleep

Like other parasomnias, those associated with REM sleep may be distressing but are seldom serious. Nightmares are frightening dreams that arises in REM sleep and are often vividly recalled on awakening whereas night terrors occur in slow wave sleep and there is little recall. 9

Sleep paralysis is an episode of one to several minutes during which they are unable to move. This effect may be the extension of a normal state of low muscle tone during REM sleep.
D. Other Parasomnias

Other Parasomnias are not specifically associated with a particular sleep stage.
i. Sleep bruxism refers to grinding of teeth during sleep. ii. Sleep eneurisis or bed wetting may occur in adults in

association with other disorder such as obstructive sleep apnea syndrome.

iii. Primary snoring is distinguished from Obstructive Sleep Apnea

Syndrome (OSAS) by its rhythmic nature without episodes of Apnea of hypoventilation.

3. Sleep Disorder associated with medical and psychological disorders

Some clients have a pre-existing sleep disorder of the dyssomnia or parasomnia type, others develop a sleep disorder secondary to disease or its manifestation.
A. Neurotransmitter Imbalance

Neurotransmitter imbalance predispose to sleep pattern disturbance. This imbalance may be disease related or drug induced. More than 70% of people being treated for Parkinsons Disease which result from a deficiency of neurotransmitter dopamine, report sleep pattern disturbances. Insomnia is most frequent initial concern followed by sleep fragmentation disturbances in the sleep-wake schedule and visual hallucination. Depression is accompanied by sleep disturbance in at least 90% who suffers from it. Some relationship appears to exist between the pathogenesis of depression and REM sleep mechanism in the depressed people who are deprived of REM sleep often showing improved moods. The action of tri-cyclic antidepressants in suppressing REM sleep has been proposed as the primary mechanism underlying their effectiveness in treating depression.
B. Brain Injury

Brain injury of all degrees of severity affect sleep patterns. The appearance of differentiated sleep stages on EEG in comatose clients with severe brain injuries is a favourable prognostic indicator. Sleep stages indicate that connections between the brain stem, diencephalon

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and telencephalon are intact and allow shifts to occur between NREM & REM sleep.
C. Hormonal Imbalance

Hormonal imbalance also contribute to sleep pattern disturbance. Clients with hyperthyroidism tend to have fragmented short sleep periods with an excess of slow wave sleep. Hypothyroidism is characterized by excessive sleepiness and polysomnographic recordings show a reduction in the proportion of slow wave sleep.
D. Respiratory disorders

Nocturnal asthma attacks contribute to frequent awakenings up to 70% of people with asthma. Chronic airway limitations, such as asthma and emphysema contribute to difficulty initiating sleep, frequent arousal with shortness of breath or cough and chronic fatigue.
E. Cardiovascular Disorders

Up to 25% people with hypertension have been found to have OSAS. In clients with severe heart failures, periodic breathing of cheyne stokes type occur. This pattern may result in significant hypoxemia, frequent arousal, increased stage 1 sleep & reduced total sleep time.
F. Gastrointestinal disorder

Gastric acid secretion normally decreases during sleep but people with duodonal ulcers have higher than average level of secretion. Recurrent awakenings with epigastric pain are common especially in the first four hours after sleep onset and antacids or histamine antagonist may need to be administered. Gastroesophageal reflux can be more serious when it occurs during sleep because the longer exposure of the esophagus to gastric acid can lead to esophagitis.
G. Other disorders

Numerous other disorders seem to have an effect on or an association of sleep. Any condition may result in pain, discomfort or impaired mobility has the potential to disrupt sleep. Hospital Acquired Sleep Disturbance Clients in the hospital may report difficulty getting to sleep, awakening frequently with difficulty getting back to sleep or early morning awakening. The etiologic mechanism and intervention range with the types of difficulty A. Sleep onset difficulty Sleep onset difficulty is a common problem in hospitals because of the strange environment, noise and the anxieties associated with illness and hospitalization.
B. Sleep maintenance disturbance

Sleep maintenance disturbance may be associated with sustained use or 11

withdrawal from a variety of medication and related to substance. Alcohol hastens sleep onset but leads to awakening later in the night. In acute intoxication, REM sleep is suppressed. Abrupt withdrawal, as occurs with hospitalization, may trigger massive REM rebound. Sustained use of or withdrawal from antidepressants, monoamine oxidase inhibitors, prepranolol and phenytoin can also contribute to insomnia.
C. Early morning awakening

Early morning awakening occurs frequently among older clients. Sensitivity to environmental disturbances increases towards morning in people of all ages but even more so in older adults.
D. Sleep deprivation

Sleep deprivation is of particular concern for clients in critical care units. The noise level, 24 hour lighting & frequency of caregiver interruptions create sensory overload and sleep deprivations. Clients who have had surgery are also at a risk of sleep pattern disturbance because of disruption of the circadian rhythms. The cause is unclear but the disruptions may be related to the length and type of anesthesia, postoperative analgesia or mechanism associated with the procedure itself. Dignostic Assesment The primary diagnostic test for sleep disorders is polysomnography. Clients may be referred to a sleep disorder centre for overnight EEG, Electro Oculography (EOG) and submental EMG with surface electrodes. Clients may also have continuous recording of - arterial oxygen saturation by year or finger oximeter, air flow as detected by monitoring expired carbon dioxide, respiratory movement by means of transducers placed around the chest and abdomen En Electrocardiogram (ECG) and Heart rate determination with standard limb leads

A multiple sleep latency test (MSLT) may also be performed to assess impairment of daytime alertness. The MSLT is performed the day after a standard overnight polysomnogram. The time required for client to fall asleep when in a relaxed state is evaluated at 2 hrs interval with each nap limited to 20 mins. The type of sleep is also assessed making the test particularly useful in diagnosing narcolepsy.

General management for sleep disorders

1. Dyssomnias

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A. Intrinsic Sleep Disorders

i. Insomnia

Management of insomnia is complex. Clients often feel that they have already tried the usual intervention to promote sleep. Sleep habits can become increasingly erratic if the client tries to sleep during the day to compensate for sleeplessness at night. Relaxation exercise can be helpful but initially they should be practiced at times other than bedtime. In this way, by the time the exercises are introduced at bedtime, they are effective. Cognitive behavioral therapy has become an established approach for treating people with insomnia.
ii. Narcolepsy

Medical management of narcolepsy usually consists of low doses of stimulants such as modafinil (provigil) or methylphenidate (Ritalin). Emphasize on good sleep hygiene. They should maintain regular naps at times when clients are prone to increase sleepiness. Safety is a major issue for these clients. iii. Sleep Apnea Syndrome
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Obstructive Sleep Apnea Syndrome: The application of Continuous Positive Airways Pressure (CPAP) by means of a face mask covering the nose is the treatment of choice. The CPAP device provides room air under increased pressure, essentially providing a pressure splint to keep the upper airway open. It should be turned on whenever the client is ready to go to sleep and should be maintained throughout the sleep period. Additional humidification may be necessary especially in dry climate. Central Sleep Apnea Syndrome: For this also, Continuous Positive Airway Pressure (CPAP) is the usual treatment. As with OSAS sedative & hypnotic drugs should be avoided. In severe cases with CNS involvement, the use of diaphragmatic pacemaker or mechanical ventilation may be required. Periodic Limb movement disorder: Clonazepam, a benzodiaszepine or baclofen, a skeletal muscle relaxant, may be ordered to diminish the magnitude of the movement and the frequency of arousals. The antiparkinsonian drug carbidopa-levodopa (sinement) and 13

the tri-cyclic antidepressant imipramine seem to act more directly and almost eliminate the movements.
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Restless leg syndrome: Treatment is similar to that for periodic limb movement.

B. Extrinsic sleep disorder: Extrinsic sleep disorders can be managed

by i. Maintaining a consistent and a regular bedtime routine ii. Avoiding stimulants such as caffeine iii. Adequate sleep 2. Parasomnia:
A. Arousal Disorders

If it is a severe case that leads to injury or involves violence, excessive eating, or disturbs the bedpartner or family, treatment by a sleep specialist may be necessary. Treatment might involve medical intervention with perscription drugs or behavior modification through hypnosis or relaxation/mental imagery B. Sleepwalker: i. Plenty of rest; being overtired can trigger a sleepwalking episode. 14

ii. A calming bedtime ritual. Some people meditate or do relaxation

exercises; stress can be another trigger for sleepwalking. iii. Remove anything from the bedroom that could be hazardous or harmful. iv. The sleepwalker's bedroom should be on the ground floor of the house. The possibility of the patient opening windows or doors should be eliminated. v. An assessment of the sleepwalker should include a careful review of the current medication so that modifications can be made if necessary. vi. Hypnosis has been found to be helpful for both children and adults. vii. An accurate psychiatric evaluation could help to decide the need for psychiatric intervention. viii. Benzodiazepines have been proven to be useful in the treatment of this disorder. A small dose of diazepam or lorazepam eliminates the episodes or considerably reduces them. 3. For sleep disorder associated with medicine and psychological disorder: A. Neurotransmitter imbalance: a thorough assessment of the sleep patternerns. Minimizing caregiver-initiated awakenings and ensuring a regular bed-time may help to reduce nocturnal and daytime agitation.
B. Brain injury: For clients in the confused, agitated stage of recovery

that results from more severe brain injury. Use of enviournmental cues (eg, light & darkness). Regularity of daily schedule, and appropriate daytime exercise and activity can help to restore the sleep-wake cycle.
C. Respiratory disorder: If there is respiratory disorders, encourage

clients to use several pillows or to have the head of the bed elevated. Clients with advanced respiratory disease are more vulnerable to hypmotics & CNS depressed.
D. Hormonal Imbalances: Clients with diabetes mellitus particularly type

1, may experience hypoglycemic attacks during the night. If there manifestations are present, blood glucose levels is to be checked at regular intervals during night. Insulin dosage or timing may need to be changed.
E. Gastrointestinal Disorder: Gastroesphagial relux can be more

serious when it occurs during sleep because the longer exposure of the oesophagus to gastric acid can lead to oesophagitis. These clients are suggested to avoid eating within 3 hours of bedtime, consider use of the antacids or histamine antagonists and raise the head of on block to decrease the likelihood of reflux & subsequent aspiratia. 15

F. Cardiovascular disorder: Upto 25% of people with hypertention have

been found to have OSAS. Thus it is important that raf. A clients who have hypertension or who have hypertension or who snore while having repeated apmeic periods during sleep. Client who is recovering such as from M.I, there will be greater cardiac demands during REM sleep may put some additional strain or recovering heart, which makes continued nursing survelliance during this period particularly important. 4. Hospital Acquired Sleep Disturbances:
A. Sleep onset difficulty: Enviournmental controls , such as reduction of

noise and interruptions, and conservative relaxation measures , such as back rub, should be given before restoring to a hypnotic agent. The rapid acting hypnotics, as zolpidem are most effective with this type of insomnia.
B. Sleep maintainence disturbances: To reduce nocturnal stimuli by

darkening the clients room, reduce as much noise as possible etc. Adjusting the temperature by providing bed covering according to the clients preference and by modifying room temperature such as by closing certain or adjusting ventilations.
C. Early morning awakening: It can be treated by finding out the

underlying cause for, such as delirium, depression etc. Treating underlying cause will treat it.

Conclusion
To be energetic and refreshed throughout the day one have enough hood quality sleep. The number of hours one sleeps varies from person to person for example infants sleeps in daytime as well as in night, while elderly people sleep less even during night. Decrease

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sleep on a long term basis in the young and middle aged will affect their career, health and at extreme result in death. Sleep is not a matter of lavishness; its a requirement.

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