Sleep disruption

The most common CRDs include jet lag, shift-work sleep disruption, delayed sleep-phase disorder, and advanced sleep-phase disorder. Jet lag occurs when a person travels across time zones, and the external environmental time is mismatched with the internal circadian clock. Delayed and advanced sleep-phase disorders occur when bed and wake times are delayed or advanced (by 3 or more hours) compared with socially prescribed bed and wake times. 

Evaluate how sleepiness changes throughout the day to best determine how to use sustained- and immediate-release stimulants to maintain wakefulness. If the patient complains of sleep disruption from stimulant therapy, move the dosing time a few hours earlier until sleep disruption is avoided. 

Keifer, J. C., Baghdoyan, H. A. Lydic, R. (1992). Sleep disruption and increased apneas after pontine microinjection of morphine. Anesthesiology 77, 973-82. 

A final limitation of stimulant treatment alone has to do with its applicability to home behavior problems. Many pharmacotherapists limit the use of stimulants to school hours during the 9 months of the academic year, to avoid growth and appetite suppression, sleep disruption, and other undesirable side effects. This leaves parents to their own devices to manage impulsive, oppositional, and disruptive behavior in the afternoons and evenings, weekends, and summers. When no other treatment is provided, parents frequently resort to coercive, hostile, and overly punitive interactions with their children, which may exacerbate rather than improve the child s behavioral problems. This is a par-... 

New-onset sleep problems may be a side effect of psychoactive or other medication, and the first intervention should be consideration of adjusting the dosage or time of day the medication is given. For example, sleep disruption from stimulants can generally be relieved by adjustments based on careful history of the time-action effects. 

Table 12-7 lists considerations regarding sleep disruption in the elderly, and Table12-8 lists considerations regarding BZD hypnotics in this population.

Bonnet MH. Effect of sleep disruption on sleep, performance, and mood. Sleep 1985 8 11-19. 

Nicotine is a potent nerve poison, and is included in many insecticide preparations. In lower concentrations, nicotine is a stimulant, i.e. it increases activity, alertness and memory, and this is one of the main factors that contribute to the dependence-forming properties of tobacco smoking. Nicotine increases heart-rate and blood pressure, and reduces appetite. In higher doses, nicotine acts as a depressant. In large doses, it can cause nausea and vomiting. The main symptoms of the withdrawal of nicotine intake include irritability, headaches, anxiety, cognitive disturbances and sleep disruption. 

Hoping to avoid such side effects as the sleep disruption and the occasional cardiac complications of the tricyclic antidepressants, and following the principle that clean drugs are theoretically preferable to dirty ones, the pharmaceutical industry has developed the selective serotonin reuptake blockers, a third generation of chemical agents to relieve depression. 

When these issues are taken into consideration, there is still a high frequency of primary insomnia, as well as secondary insomnia the primary cause of which cannot be satisfactorily treated. Many patients also have both a psychiatric disorder and a primary insomnia. Still others have a psychiatric disorder requiring a sleep-disrupting antidepressant. Here we will discuss the use of sedative-hypnotics for these patients. 

Bourne RS, Mills GH. Sleep disruption in critically ill patients pharmacological considerations. Anaesthesia. 2004 59 374-384. 

Sleep disorders are common, and are generally underdiagnosed. The two major complaints related to sleep are insomnia ( I can t sleep ) and excessive daytime sleepiness (EDS, I can t stay awake ). EDS is a relatively nonspecific symptom. It can be the end result of any factor that causes sleep disruption, and it can be caused by primary or intrinsic sleep disorders. Insomnia of any cause can result in sleep deprivation and subsequent EDS. The most common cause of EDS in the general population is self-imposed sleep deprivation, or insufficient sleep syndrome. By contrast, the most common causes of EDS seen in a sleep center are primary (intrinsic) disorders of EDS. The American Academy of Sleep Medicine (AASM, formerly the American Sleep Disorders Association) classification of sleep disorders includes over 80 diagnoses that are associated with EDS, but the majority of patients evaluated at sleep centers have sleep apnea, narcolepsy, idiopathic hypersomnia, or periodic limb movements of sleep. 

Periodic limb movement disorder (PLMD), originally described by Symonds as nocturnal myoclonus (11), was questioned as being an epileptic equivalent. Lugaresi et al. (12) demonstrated that it was not epileptic in nature and found a close association between it and restless legs syndrome. Guilleminault et al. (13) showed that it may be associated with insomnia, nocturnal sleep disruption, and daytime fatigue. Further studies have shown that periodic limb movements can vary greatly in severity. 

Montplaisir J, Billiard M, Takahashi S, Bell I, Guilleminault C, Dement WC. Twenty-four hour recordings in REM narcoleptics with special reference to nocturnal sleep disruption. Biol Psychiatr 1978 13 73-89... 

Of the aforementioned comorbid symptoms, hypoglycemia does not appear to significantly increase the number of awakenings or account for the increased sleep disruption (160,161). In a study of children with insulin-dependent diabetes mellitus, Matyka et al. (160) found that sleep was disrupted among children with diabetes, with an increased number of awakenings in the diabetic children, compared to controls. However, hypoglycemia did not appear to affect sleep in these children. In another study that assessed adult diabetes patients, path analyses revealed that nocturia and pain, such as the discomfort associated with neuropathy, accounted for much of the sleep disruption (151). 

Although only a limited number of disorders are discussed in this chapter relative to the large number of disorders that produce or are related to sleep disturbance, it is evident that sleep deprivation secondary to medical disorders is prevalent. Other disorders that are associated with significant sleep disruption and sleep disturbance include cancer, chronic pain, dementia, depression, cystic fibrosis, reflux, cardiovascular disorders, asthma/respiratory disorders, and gastrointestinal disorders. 

When thinking of sleep disturbance associated with medical disorders, it may be valuable to utilize a conceptual framework for the treatment of sleep disruption that is general in nature, and not specific to a particular disorder. Optimal treatment of secondary sleep disturbances may result in increased daytime functioning, increased quality of life, and improvement of disorder-associated symptoms. It is important for clinicians to be educated in the appropriate assessment and treatment of sleep disturbance that is associated with other medical disorders. This entails knowledge of the appropriate questions to be directed to patients, their partners, and/or caregivers, the interactions of the disorder with potential treatments, and the range of treatment options available. 

Lamond N, Tiggemann M, Dawson D. Factors predicting sleep disruption in Type II diabetes. Sleep 2000 23 415—416. 

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