28.2 Factors Affecting Sleep and Rest

Development Stage

Sleep patterns change at different times in a life span. Neonates for example, fall directly into REM sleep, and sleep in rather short episodes for up to eighteen hours a day (Figure 28.5) (Johnson, 2024). As growth and developmental stages continue through childhood, adolescence, and adulthood, more outside influences such as the demands of school, hormonal changes and growth spurts, and employment expectations affect sleep. Quality may be influenced by stress, worry, or poor health; quantity may be affected by the addition of a baby to the family, personal or family obligations, or the need to get up early or stay up late for work.

Figure 28.5 A baby falls directly into REM sleep, and may sleep up to eighteen hours a day. (credit: “Safe Infant Sleep for SIDS Awareness Month” by NIH Image Gallery/Flickr, Public Domain)

Another developmental consideration is pregnancy, during which physical changes may include gastrointestinal discomfort (e.g., heartburn or reflux), causing wakefulness and the need for position changes. Fetal growth can lead to more frequent urination, difficulty finding a comfortable sleep position, and shortness of breath for the childbearing person.

Some of these developmental effects on sleep, such as hormonal changes with adolescence, excessive fatigue during a growth spurt, or poor sleep while pregnant are temporary. Other effects may become longstanding, as natural aging processes affect sleep over time, or when poor sleep perpetuates further sleep problems and chronic issues develop (Nunez and Lamoreux, 2023).

Illness

Chronic illness or episodes of acute illness are frequent contributors to disruptions of normal sleep patterns. They can also create new sleep patterns as an adaptive mechanism (Table 28.3). Some of these circumstances increase sleep, such as when the immune system is combatting an infection or recovering from a surgery or trauma. Other circumstances involve less sleep, or poor-quality sleep, which does not achieve the rejuvenation and restful state normally associated with sleep. If a person is unable to spend adequate time in stage III’s SWS, and/or does not reach REM, the sleep is not as restorative.

Medications

There are some medications designed to assist with sleep and others designed to maintain alertness and stay awake. Medications for sleep work with the central nervous system (CNS) in some capacity, to improve entry to sleep, to help maintain sleep, or both. There are some over-the-counter (OTC) natural remedies available as well, and for some people they work as well as medications approved by the Federal Drug Administration (FDA). Nurses should engage patients in a discussion about use of such easily available choices, as combination of natural supplements or OTC medications with other sleep aids, or other medications of any sort, should be approved by the healthcare prescriber (physician, nurse practitioner, or physician’s assistant). An introduction to some of the sleep-related medications follows.

Examples of natural sleep aids include melatonin, valerian, and kava kava. Although easily available, they have many of the same potential side and adverse effects as OTC and prescription sleep medications. An example of a commonly used OTC is diphenhydramine (e.g., Benadryl), which is a first-generation antihistamine, but is used for its sedating side effect. It is generally considered safe for patients over 12 years old, and tends to work well as a sleep aid, particularly for inducing sleep. If enough time for sleep is not provided, some people find themselves drowsy when they need to wake and start the day. Major CNS side effects are not common. Some of the common side or adverse effects of diphenhydramine include the following:

• Drug hangover: This includes difficulty waking the morning after taking the medication; may include slower reactions and residual sleepiness.
• Respiratory depression: This is typically dose-related, with higher doses, or if combined with certain other drugs (e.g., opioids), potentially affecting the respiratory center.
• REM rebound: This may manifest as nightmares or other brain activities associated with REM sleep.

Benzodiazepines, also known as anxiolytic drugs, are drugs commonly prescribed to reduce anxiety; some are prescribed as sleep aids. Insomnia is sometimes associated with anxiety, which can make the choice of this class of drug ideal in certain circumstances. Because of the possibility for more significant side effects, especially if they have been used for a long period and are suddenly discontinued, most benzodiazepines (e.g., diazepam, lorazepam, midazolam) are not used as often as in years past for treatment of insomnia. When they are prescribed, they tend to be for a limited duration. An exception, though still not recommended for long-term use, is temazepam, which is perhaps the benzodiazepine most used as a sleep aid and marketed with an associated brand name, Restoril.

Benzodiazepines have the potential to affect the CNS more than some other drugs, and may result in effects such as tolerance (taking a higher dose in order to achieve the anticipated effect) and dependence (caused by chronic use and development of an addiction to the drug; a withdrawal syndrome results from discontinuation).

There are several nonbenzodiazepines that have become commonly used as sleep aids over the past few years. These fall into the class of sedative-hypnotics. Following is a list of these drugs, with their brand names:

• eszopiclone (Lunesta)
• ramelteon (Rozerem)
• suvorexant (Belsomra)
• zaleplon (Sonata)
• zolpidem (Ambien, or Ambien CR [controlled-release])

Although these are more specifically designed for sleep (induction, maintenance, or both), they do have CNS effects and are therefore associated with a variety of side effects. Specific effects depend on the mechanism of action (MoA); for example, ramelteon initiates results similar to those of melatonin; the MoA of eszopiclone and zaleplon involves gamma-aminobutyric acid (GABA).

Whether a medication is being used for its primary effect or a desired side effect, nurses should be aware of the properties, including the MoA. This medication knowledge allows nurses to review individual patients’ use of medications; anticipate drug-to-drug interactions and side or adverse effects; and assess whether or not the desired effects are achieved. See Table 28.7 located later in the chapter.

Treatment for difficulty sleeping, including sleep aids, is often adequate to improve patients’ sleep and resolve problems with feeling sleepy while awake or falling asleep during the day. There are circumstances, however, when hypersomnolence (excessive feelings of fatigue and sleepiness, or episodes of sleep during normal times to be awake) is severe enough that medications are indicated to promote wakefulness. Medications range from caffeine to prescription drugs. Caffeine is available in tea and coffee beverages, energy drinks, and chocolate (Peters, 2023). There are also specific caffeine preparations available. There are several prescription medications that also promote wakefulness. Stimulants assist the brain’s ability to focus and be attentive (Peters, 2023). Examples of prescription stimulants include the following (Drugs.com, 2024b; Peters, 2023):

• methylphenidate (Ritalin, Concerta)
• amphetamine and dextroamphetamine (Adderral)
• armodafinil (Nuvigil)
• modafinil (Provigil)

Central hypersomnolence disorders, such as narcolepsy, are discussed later in the section and frequently require prescription therapy. Drug treatment tends to start with stimulants. Some patients may not respond well to first-line treatment so may be prescribed selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or tricyclic antidepressants (TCAs). See Table 28.8 later in the chapter.

Physical Activity

Physical activity supports sleep and prevents insomnia. Exercise tends to have general health benefits and promote psychophysiological homeostasis. Physical activity contributes to a body’s normal functioning by maintaining flexibility, improving oxygenation and perfusion, and fostering other metabolic actions and reactions. The revitalizing effects of sleep involve toxin clearance from the body and the restorative capabilities that are especially associated with SWS (Shafiq et al., 2024). Additionally, physical activities lead to physical fatigue and therefore a desire and need for the recuperation and rejuvenation that occurs during sleep.

Although an appropriate amount of physical activity is usually associated with positive results, excessive activity may lead to strained muscles or injuries that may cause pain, which can disrupt sleep patterns. Recommended exercise includes 150 minutes weekly. Many people incorporate that into three fifty-minute sessions, but for sleep promotion it may be better to work out five times weekly for thirty minutes each session (Nunez, 2020). Timing of activity can be important, as too much physical activity close to bedtime can actually inhibit falling asleep or interfere with quality sleep. It is typically recommended to avoid exercise within approximately five hours of anticipated sleep, but some recent evidence indicates only one hour from bedtime is enough of a buffer for moderate physical activity (Nunez, 2020).

Caffeine, Nicotine, and Alcohol Intake

Stimulants, such as caffeine and nicotine, are common contributors to insomnia. Although there are some people who drink coffee or other caffeinated beverages with or after the evening meal, many avoid them as a way to promote good quality sleep. In addition to the potential for caffeine to directly inhibit sleep through stimulation, its diuretic effects may cause frequent urination, which can also prevent sleep. For those who partake of just a cup of post-dinner coffee, recent research indicates only a minimal impact on insomnia (Krans, 2019; Spadola et al., 2019).

Nicotine has been implicated as having more of a negative impact on sleep than caffeine (Krans, 2019; Spadola et al., 2019). No matter the form (e.g., cigarettes, smokeless tobacco, or vapes), nicotine can impede sleep by minimizing the feelings of sleepiness and readiness for bedtime. Patients should avoid nicotine within two hours of planned sleep. Nicotine is also associated with waking earlier in the morning. The early awakening is a result of the addictive nature of nicotine and the effect on the brain as it withdraws from the chemical overnight (Krans, 2019).

Another chemical associated with insomnia is alcohol. Although alcohol is typically identified as a depressant, there is a stimulant effect involved with its metabolism (Krans, 2019; Spadola et al., 2019). This is why drinking an alcoholic beverage may assist someone in falling asleep, but within a relatively short time, the person is likely to awaken from the stimulant effects of alcohol metabolism (Krans, 2019). It can be difficult to fall asleep again. Recommendations are to limit alcohol to one or two drinks around the evening meal, then to avoid alcohol for three or four hours prior to bedtime (Krans, 2019; Spadola et al. 2019).

Life Stressors

The stress response involves activation of the sympathetic nervous system and hormones associated with the fight-or-flight response (see Stress, Adaptation, and Homeostasis for more information). Hormones such as cortisol, epinephrine, and norepinephrine cause physical responses of stimulation. These physical responses may include tachycardia, tachypnea, hypertension, an increase in release of glucose, and even anxiety. When stressors affect patients’ lives, it can be difficult to slow down the mind as well as the physical reactions. This can make falling asleep difficult, and even for those who are able to fall asleep, they may wake prematurely and find it hard to return to sleep. Control of stress, and learning techniques for appropriately coping with stressful situations, can help with insomnia caused by such life events.

Culture

Cultural influences and practices may impact the quality and quantity of sleep. Culture may influence how people think about sleep throughout the life span. For instance, some cultures frown upon naps in adulthood. Yet other cultures embrace naps throughout life’s stages and even build such afternoon breaks into the workday. Some cultures are more or less likely to include and encourage health and wellness activities, such as exercise, immunizations, and preventive visits to healthcare providers. Such preventive measures tend to contribute to health promotion and disease prevention. This can contribute to improved health or to peace of mind. Those whose cultural mores and practices encourage participation in such actions may be more likely to experience adequate, restorative sleep.

Dietary choices are also frequently culturally based, not only as to specific foods and drinks, but also in terms of timing and withholding. For instance, some cultures and religions include periods of fasting or a single daily meal later in the evening. Others may discourage drinking alcohol. By way of example, fasting may affect sleep quality or quantity because an individual may be hungry, have gastrointestinal discomfort, or altered bladder or bowel patterns.

Grief, also influenced by culture, can affect sleep. Cultural norms and practices often dictate the availability and amount of support a grieving person has from family and community. Sadness can be overwhelming, and may affect sleep patterns; depression can lead to a lack or excess of sleep.

Insomnia

Insomnia is an inability to fall asleep, to stay asleep, or to achieve good quality sleep. Lack of sleep results in feeling fatigued and sleepy, often throughout the day, and can hinder the ability to complete activities and obligations. Insomnia may also be a consequence of a physical or psychological disorder or condition. Insomnia often affects concentration, moods, and energy levels (Roddick & Cherney, 2024). Sleep disruptions are also associated with some cognitive disorders, including Alzheimer disease. Keep in mind that sleep is necessary to maintain clear thinking, to prompt reactions, and to process complex thoughts and circumstances.

Insomnia can be acute or chronic. Acute, or short-term, insomnia is temporary and may occur in response to a stressful situation, or a change to a person’s sleep schedule, such as a later night than usual or having to get up earlier than expected. Jet lag is commonly associated with acute insomnia because it changes normal sleep cycles and patterns. Chronic insomnia, on the other hand, lasts longer than three months and/or occurs more than three nights per week. The risk for developing certain disorders, such as hypertension, coronary artery disease, diabetes mellitus, cancer, depression, and anxiety, is higher for those who experience chronic insomnia.

Parasomnias are abnormal behaviors while a person is asleep (Table 28.4). These manifest in dreams, movements, and vocalizations that occur as a person is falling asleep, while asleep, or as they wake up (Schwab, 2022). With many of the parasomnia behaviors, the person does not remember the activities. Associated dreams may be recalled immediately upon waking, but most are not remembered long term. There is an almost cyclical relationship between insomnia and parasomnias, as lack of sleep can contribute to the occurrence of parasomnias, and parasomnias may result in a lack of sleep.

Sleep-Related Breathing Disorders

Breathing disorders associated with sleep include obstructive, central, and mixed sleep apneas; sleep-related hypoventilation; and sleep-related hypoxemia. Obstructive sleep apnea (OSA) is common and involves relaxation of the muscles of the posterior pharynx (back of the throat) (Figure 28.6). If these muscles relax excessively, they do not support structures within the mouth and throat, including the soft palate, tongue, and sides of the throat, resulting in the airway being blocked or narrowed (Mayo Clinic, 1998–2024; Newsom, 2023a).

Figure 28.6 Airflow through the normal airway is free and unobstructed through the nasal and oral airways; with OSA (shown here), the flow of air is impeded by structures within the mouth and throat, such as the tongue, soft palate, and sides of the throat. (credit: “Obstruction ventilation apnée sommeil” by Habib M'henni /Wikipedia, Public Domain)

The impaired breathing causes an accumulation of carbon dioxide (CO₂), which, upon reaching a certain level, causes the brain to waken the individual, open the airway, and take a deep breath. Depending on the level of CO₂ and oxygen (O₂), it may take a few deep breaths to normalize the blood gases. Many people have no recollection of the frequent awakenings, as they return to sleep quickly. Nonetheless, if their sleep is disrupted several times each hour, it fragments their sleep, and they may be very drowsy during the day, have mood swings, and find it difficult to concentrate on tasks and thoughts.

Central sleep apnea (CSA) is less common than OSA. It involves a lack of communication between the brain stem and the muscles involved in breathing (Mayo Clinic, 1998–2024; Newsom, 2023a). The airway remains open, but the impaired messaging causes frequent apneic episodes throughout a sleep cycle. Patients with CSA tend to experience the same fragmented sleep as those with OSA, but they also may notice nighttime discomfort in the chest, headaches in the morning, and insomnia (Mayo Clinic, 1998–2024; Newsom, 2023a). Mixed sleep apnea, as the title indicates, is simply a combination of obstructive and central sleep apnea. Therefore, both disorders occur in the same person throughout sleep.

There are several other breathing disorders associated with sleep as well. Sleep-related hypoventilation means shallow and unusually slow respirations while asleep. Such inadequate breathing allows for the patient to develop hypercapnia, or elevated blood CO₂. Sleep-related hypoxemia (low level of O₂ in the blood) is typically not a primary disorder but the result of another condition, usually respiratory, such as chronic obstructive pulmonary disease (COPD).

Sleep-Related Movement Disorders

Although some of the parasomnias discussed earlier do involve repetitive motions while asleep, such as jaw clenching, teeth grinding, and head banging, this section focuses on three sleep-related movement disorders: restless legs syndrome (RLS), periodic limb movement disorder (PLMD), and sleep-related leg cramps.

RLS, as the name indicates, involves leg movements that tend to begin in the evening and become acute when a person lies down to sleep. The sensation of the need to move the legs can become uncontrollable, and may even be painful, with the person moving not only the legs, but frequently repositioning in an attempt to calm the urge for movement. For some, arms and neck may become involved in the restless feelings (Newsom, 2023b).

Nutrition and medications may contribute to episodes of RLS. Alcohol, nicotine, and caffeine are sometimes involved in RLS symptoms, and deficiencies in iron, zinc, vitamin D, and magnesium may also be apparent in those who experience RLS (National Institute of Neurological Disorders and Stroke [NINDS], 2023; Pacheco, 2024). Antihistamine use may cause RLS symptoms and there is a genetic component for some patients; for many it is idiopathic. Some conditions that may lead to RLS include neuropathy, pregnancy, renal disease/failure and hemodialysis (NINDS, 2023).

RLS is not curable, but there are symptomatic treatments, which may include lifestyle adjustments and medications. If particular foods or drinks are identified as contributing to the symptoms, reducing or eliminating these is helpful (NINDS, 2023). Sleep hygiene and improved sleep patterns can prove helpful, as can regular moderate exercise; massage of the legs may also reduce symptoms (NINDS, 2023; Pacheco, 2024). Depending on the patient, medication therapy for RLS may include iron, dopamine agonists (e.g., pramipexole, rotigotine, ropinirole), opioids, and benzodiazepines (NINDS, 2023).

PLMD is associated with movements of the arms, legs, or feet while asleep. PLMD occurs with RLS for more than 80 percent of those who experience it (Newsom, 2023b; NINDS, 2023). Movements are involuntary and are typically repetitive; twitching is common, though patients may also kick. These episodes of movement can be very short term (five seconds) or may last more than a minute, and they may occur more than fifteen times hourly, which leads to awakening and a very fragmented sleep (Newsom, 2023b). Unlike with RLS, people experiencing PLMD do not notice pain, nor do they feel the deliberate need to move their extremities. As with RLS, nutritional imbalances and medications may contribute to episodes of PLMD, and some of the same treatments for RLS may help patients; no medications are recommended specifically for PLMD (Newsom, 2023b).

Cramps and muscle spasms can be quite painful; for some people, they occur while asleep and are therefore identified as sleep-related leg cramps (Newsom, 2023b). Such cramping can last from seconds to minutes, and they can wake a person up or prohibit falling asleep. Sleep-related leg cramps are associated with tired muscles and certain diagnoses, such as electrolyte abnormalities, dehydration, and nerve problems (Newsom, 2023b; Sumner, 2024). Application of heat and massage of cramping muscles may relieve the cramps, and medication therapy is typically focused on identifying and treating underlying conditions (Newsom, 2023b; Sumner, 2024).

Central Disorders of Hypersomnolence

Hypersomnolence is characterized by an inability to stay awake during waking hours. The sleepiness related to hypersomnolence is out of proportion to an individual’s need for sleep. In other words, getting what should be enough sleep overnight does not change the daytime hypersomnolence (Cleveland Clinic, 2024). Hypersomnolence disorders often negatively affect work and relationships, and patients are at risk for accidents, such as falling or motor vehicle accidents (MVAs). Central nervous system hypersomnias include narcolepsy, Kleine-Levin syndrome, and idiopathic hypersomnia (Cleveland Clinic, 2024; Moawad, 2024). These are considered primary hypersomnia, as the hypersomnia is not caused by something else; these are quite rare. Levels of neurotransmitters (e.g., orexin, histamine, dopamine, serotonin, and GABA) may be implicated in narcolepsy (Cleveland Clinic, 2024). Low orexin levels have been noted with type 1 narcolepsy (Cleveland Clinic, 2024). Individuals with type 1 narcolepsy are liable to experience cataplexy (muscle weakness) after exposure to an emotional situation involving stress, fear, excitement, and even laughter. Type 2 narcolepsy involves the same sort of sudden episodes of sleep but without cataplexy or low orexin levels (Cleveland Clinic, 2024). Treatment for narcolepsy includes stimulant drugs, SNRIs and SSRIs, and TCAs.

Kleine-Levin syndrome (KLS) involves occurrences of hypersomnia, behavioral or cognitive disorders, hypersexuality, and compulsive eating (Shah & Gupta, 2023). The cause of KLS has not been identified, though possible contributors include

• abnormal levels of neurotransmitters (e.g., dopamine, serotonin),
• infection,
• mental health disorder(s),
• toxins, and
• trauma (Shah & Gupta, 2023).

Treatment for KLS is multifaceted and may include psychiatric and pharmaceutical approaches (Shah & Gupta, 2023). As with treatment of narcolepsy, stimulants are used to directly address the hypersomnia, but they do not improve the cognitive and behavioral aspects of the syndrome (Shah & Gupta, 2023). Although there has not been one particular drug or class of drugs identified as particularly effective in treating the behavioral and mental health aspects of KLS, drug classes used include anticonvulsants, antidepressants, and mood stabilizers (Shah & Gupta, 2023).

Idiopathy indicates there is not a particular cause identified for a disorder.

Idiopathic hypersomnia therefore involves daytime sleepiness, in spite of adequate sleep, without a specific cause. Identification may take time and involve trial and error. Various treatment options may similarly be tried over time, in an effort to find the right drug or drug combination for individual patients.

Secondary hypersomnia occurs as a result of something else, such as a disease process or use of substance(s). Hypersomnolence disorders are not common and typically affect women more than men (Table 28.5) (Cleveland Clinic, 2024). Some of the medical conditions associated with secondary hypersomnia include

• depression
• multiple sclerosis (MS),
• neurological damage or trauma, and
• sleep apnea (Stubblefield, 2023).

Treatment of secondary hypersomnia may involve at least temporary treatment with medications such as stimulants used to treat narcolepsy. Treating the source of the problem, however, is more definitive, so the primary cause of the daytime drowsiness (medical diagnosis, drugs, or alcohol) becomes the focus of treatment.