Insomnia: Insomnia is defined as a lack of sleep that occurs when there is adequate and normal opportunity to sleep (differentiating insomnia from sleep deprivation that occurs with circadian rhythm disturbances such as time zone changes or shift work). The type of sleep disturbance and the duration of the problem classify insomnia. The type of sleep disturbance may be because of a problem with sleep onset (getting to sleep), difficulty in maintaining continuous sleep (remaining asleep for the time necessary for renewal and refreshment), or waking up too early (National Institutes of Health [NIH], 2005). The duration of the insomnia determines whether it is considered acute or chronic. Acute insomnia can occur in anyone and lasts for a relatively short time (less than 30 days), and can reoccur for short periods of time when "triggered" by transient events (primarily stress). Chronic insomnia lasts longer than 30 days and has a more extended impact on an individual's daytime function. Women are more prone to insomnia than men (especially during menstruation or menopause when the menstrual cycle causes changes in hormones), and complaints of insomnia increase with age (NIH; Forth, 2006). Chronic insomnia can occur as a primary condition. However, it often exists with other conditions and can exacerbate those conditions. Psychiatric disorders, such as depression or generalized anxiety, and physical problems that cause pain, immobility, or changes in cardiovascular, gastrointestinal, or respiratory impairment can coexist with insomnia. However, there is little support for assuming that insomnia will improve if the other disorders are relieved or go into remission (NIH, 2005). Although there is a paucity of research that clearly identifies measurable consequences of different types of insomnia or specific consequences within different aggregates of people, it is known that insomnia is associated with adverse daytime functioning and decreased quality of life. Several studies have indicated a relationship between chronic insomnia and impaired work performance, work days missed, and impaired cognitive function. Daytime sleepiness may also make people with insomnia more prone to have driving accidents, although there have been few studies to support a direct correlation (NIH, 2005).
Diagnosing Insomnia: The first step in diagnosing insomnia is obtaining a detailed sleep history. Determining the nature and the duration of insomnia includes questions such as "How long does it take you to fall asleep?" "How long are you able to maintain sleep?" "How do you feel the next day?" These questions are all necessary in developing an individualized treatment plan. It is also important to ascertain how long insomnia has been a problem; it may be a self-perpetuating problem when a patient worries about getting enough sleep so much that the concern about sleep actually causes additional sleep-disturbing stress. Identifying and evaluating other health problems also can be used to identify patients at risk of developing insomnia; for example, those who have conditions that are known to coexist with insomnia. Patients with comorbid conditions may have a tendency to not recognize symptoms of insomnia but rather to blame the coexisting problem for frequent wakenings or unrestful sleep. For instance, someone with severe arthritis may think that sleep disturbances are a normal part of arthritis and not complain of the sleep problems. A careful evaluation of any prescribed medications, over-the-counter products, or herbal remedies is necessary. Waking with sore limbs and an overall less restful sleep can signify restless leg syndrome (RLS) or periodic limb movement during sleep (PLMS). Frequent wakenings accompanied by gasps for air may indicate sleep-disordered breathing or sleep apnea. Such more serious sleep disorders require assessment and treatment by a sleep specialist. Objective assessment of sleep by a family member or bed partner often provides valuable information because individuals with chronic insomnia can underestimate or overestimate the amount of sleep they get and the time it takes them to fall asleep. Assessing functional ability associated with insomnia before and after treatment is essential in measuring the success of each therapeutic intervention.
A sleep log may be of value when assessing insomnia. This 2-week diary of an individual's assessment of his or her sleep habits should identify bedtime, routine for sleep preparations, lime it takes to fall asleep, wake time, any wakening during the sleep period and its reason for it (hunger, toileting, restlessness, etc.), any medications used, and subjective assessment of sleep quality as well as any daytime naps.
Eight Tips for Improved Sleep Health
The following suggestions may help you achieve more restful sleep. They are guidelines that may be adapted to your life-style and environment when you have difficulty falling asleep or awaken frequently from sleep.
1. Develop and maintain a regular bed time and wake schedule: Setting a regular pattern for sleep and waking strengthens a regular circadian rhythm. Sleep only as long as necessary to feel refreshed; sleeping too long may upset the sleep onset at night.
2. Establish a regular, relaxing bedtime routine: A relaxing routine followed regularly before bedtime distinguishes sleep time from the non-sleep activities. Relaxation promotes restful sleep- If you find that stress or anxiety prevents you from falling asleep relaxation therapy may help. Avoid bright lights before bedtime; bright light signals the circadian clock that it is time to wake up.
3. Avoid heavy, spicy foods close to bedtime: Heavy meals may make you less comfortable when settling for bed, spicy food have a tendency to cause heartburn which can make it difficult to fail asleep and can cause discomfort during the sleep period.
4. Restrict excessive fluids close to bedtime: Warm milk or decaffeinated teas may be soothing for some people as part of a bedtime routine. However, excess fluids may result in wakening to go to the bathroom during the night.
5. Avoid alcohol, caffeine, and nicotine close to bedtime: Alcohol disrupts sleep and causes nighttime wakenings. Caffeine and nicotine are stimulants and may make falling asleep more difficult.
6. Create an environment that is conducive for sleeping: A room that is neither to warm or to cold, dark, quiet, comfortable and free of interruptions helps establish conditions that are conducive to sleep and separates the sleeping room from other rooms where non-sleep and stimulating activities take place. Move the clock from sight if looking at the clock makes you anxious about how long you have been awake or how soon you must get up.
7. Have comfortable bedding: A comfortable mattress and pillows support the body in alignment during sleep and reduce cramping and back discomfort that disrupts restful sleep.
8. Use the bedroom only for sleep and sex (not work): Removing work materials such as desks, computers, briefcases, telephones, etc. from the sleep environment establishes a distinct separation from the area for sleep and the areas for work. If you wake and cannot sleep do something outside of the sleeping room.
Suggestions for inclusion in Sleep History Information Forms
1. Describe your sleep problem in as much detail as you can. Is this a new problem? How long has this been a problem? is this every day or is there a pattern you can identify?
2. Circle the days of the week that you work — Mon. Tues. Wed. Thurs. Fri. Sat. Sun What hours do you work? On the days you work: What time do you go to bed? How long does it take you to get to sleep? Do you have trouble falling asleep? Do you wake during the sleep period? How often? How long are you awake? Is there a reason that you wake during the steep period? If so, what disturbs your sleep? (eg. pain, hunger, thirst, urination, worry, dreams) How long do you sleep? (not how long you spend in bed awake) What time do you get out of bed? Do you feel rested when you get out of bed or are you still sleepy? How long does it take you to fully waken after you get up? Do you chronically feel sleepy, fatigued or tired when you are "supposed" to be awake? Do you ever feel sleepy while driving? How many naps do you take other than regular sleep hours?
3. On the Days you do not work: What time do you go to bed? How long does it take you to get to sleep? Do you have trouble failing asleep? Do you wake during the sleep period? How often? How long are you awake? Is there a reason that you wake during the sleep period? If so, what disturbs your sleep? (eg. pain, hunger, thirst, urination, worry, dreams)
How long do you sleep? (not how long you spend in bed awake) What time do you get out of bed? Do you feel rested when you get out of bed or are you still sleepy? How long does it take you to fully waken after you get up?
4. Do you chronically feel sleepy, fatigued or tired when you are "supposed" to be awake? Do you ever feel sleepy when driving? How many naps do you take other than regular sleep hours?
5. Grade your tendency to fall asleep during the following (0 = never, 1 = slight, 2= moderate, 3 = high)
Reading Watching TV Theater, meeting, or movie As passenger in a car Sitting quietly alone Sitting visiting with someone else
6. Do you have a regular routine to prepare for sleep? If so, please describe in detail? (eg. warm milk, warm bath, music, alcohol, take a walk, etc.)
7. Tobacco use (yes/no) Per day? How long? Time of day of your last use?
8. Alcohol use (yes/no) How many drinks per day/week/month? Time of day of last drink?
9. Caffeinated beverages (yes/no) How many per day? Time of day of last drink?
10. Any history of sleep walking, nightmares, snoring, talking in sleep, grinding teeth?
11. Any family history of sleep problems? (If yes, please describe)
12. Current medications, reason taken, how long taken (including all prescription and OTC medications as well as all herbal substances and anything taken for sleep).
13. Personal medical history.
14. Family medical history
- Turkoski, Beatrice B.; Managing Insomnia; Orthopaedic Nursing, Sep/Oct2006, Vol. 25 Issue 5
Reflection Exercise #5
The preceding section contained information
about behavioral tips for clients with insomnia. Write
three case study examples regarding how you might use the content of this section
in your practice.
What are Turkoski’s behavioral tips for insomnia? Record the letter of the correct answer