Kathy P. Parker

Sleep in infants and young children: Part one: normal sleep.

The importance of sleep to overall health and well-being is becoming increasingly appreciated; however, clinicians may not have a sound understanding of the fundamentals of sleep. This review of normal pediatric sleep is meant to provide a foundation for the pediatric nurse practitioner to develop and use in clinical practice. Key concepts such as normal sleep physiology including biological rhythms and stages of sleep are discussed. Developmental changes in sleep seen in the transition from infancy to young childhood are highlighted, and strategies for instituting and maintaining normal sleep behaviors are recommended. Part 2 of this series will address common sleep problems experienced by young children.

Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment.

PURPOSE/OBJECTIVES To provide an overview of normal sleep, describe common sleep disorders, and discuss underlying sleep regulatory processes and how cancer, cancer treatment, and associated patient responses may adversely affect sleep. DATA SOURCES Published peer-reviewed articles and textbooks. DATA SYNTHESIS The duration, structure, and timing of sleep have a profound impact on health, well-being, and performance. Patients with cancer may be at risk for disturbances in sleeping and waking resulting from disease- and nondisease-related circumstances that interfere with normal sleep regulation, including demographic, lifestyle, psychological, and disease- and treatment-related factors. CONCLUSIONS Patients with cancer are at high risk for sleep-wake disturbances. IMPLICATIONS FOR NURSING An understanding of normal sleep, sleep pathology, and the factors that can precipitate sleep disturbance provides a context for nurses to interpret sleep complaints in their patients, evaluate responses to sleep-promoting interventions, and guide decision making regarding referrals.

Modulation of Vigilance in the Primary Hypersomnias by Endogenous Enhancement of GABAA Receptors

A component of cerebrospinal fluid in excessively sleepy people activates an inhibitory signaling pathway and mimics the actions of sedative-hypnotics. Awake and Refreshed A spindle prick on the finger, and Princess Aurora couldn’t keep her eyes open; one hundred years later, Sleeping Beauty was awakened with a kiss. But persistent daytime sleepiness—hypersomnolence—is no fairy tale, and neither the cause nor a cure is apparent. Now, Rye et al. begin to illuminate, in patients with primary hypersomnias, the neurobiology that underlies sleepiness of unknown etiology. A disabling condition, primary hypersomnia is characterized by lethargy, trance-like states, and “sleep drunkenness” even after prolonged, deep, nonrestorative sleep. The authors showed that cerebrospinal fluid (CSF) from these hypersomnolent subjects contains a small (500 to 3000 daltons) trypsin-sensitive substance that stimulates the in vitro function of selected γ-aminobutyric acid (GABA) receptors only in the presence of GABA—an inhibitory neurotransmitter that stimulates GABA receptors, quells consciousness, and induces sleep. GABA receptors are known to bind a class of psychoactive sedating drugs called benzodiazepines (BZDs). Hypersomnolent CSF samples mimicked the effects of BZD on GABA receptors but did not compete with BZD binding in human brain tissue, suggesting that the newly identified substance functions by a distinct mechanism. Furthermore, the BZD receptor antagonist flumazenil reversed hypersomnolent-CSF activation of GABA signaling, even though the drug is known to be a competitive antagonist of BZD and blocks BZD action by binding to the classical BZD-binding domain of GABA receptors. Most importantly, flumazenil restored vigilance in some hypersomnolent subjects. Together, these mechanistic studies pinpoint a potential new neuropharmacological pathway for a 25-year-old drug. The current study suggests that one of the “spindle pricks” that puts hypersomnolent subjects to sleep is a substance in CSF that augments inhibitory GABA signaling. A deeper understanding of the neurobiology of primary hypersomnia should help scientists discover new “kisses” that restore wakefulness—in fewer than 100 years. The biology underlying excessive daytime sleepiness (hypersomnolence) is incompletely understood. After excluding known causes of sleepiness in 32 hypersomnolent patients, we showed that, in the presence of 10 μM γ-aminobutyric acid (GABA), cerebrospinal fluid (CSF) from these subjects stimulated GABAA receptor function in vitro by 84.0 ± 40.7% (SD) relative to the 35.8 ± 7.5% (SD) stimulation obtained with CSF from control subjects (Student’s t test, t = 6.47, P < 0.0001); CSF alone had no effect on GABAA signaling. The bioactive CSF component had a mass of 500 to 3000 daltons and was neutralized by trypsin. Enhancement was greater for α2 subunit– versus α1 subunit–containing GABAA receptors and negligible for α4 subunit–containing ones. CSF samples from hypersomnolent patients also modestly enhanced benzodiazepine (BZD)–insensitive GABAA receptors and did not competitively displace BZDs from human brain tissue. Flumazenil—a drug that is generally believed to antagonize the sedative-hypnotic actions of BZDs only at the classical BZD-binding domain in GABAA receptors and to lack intrinsic activity—nevertheless reversed enhancement of GABAA signaling by hypersomnolent CSF in vitro. Furthermore, flumazenil normalized vigilance in seven hypersomnolent patients. We conclude that a naturally occurring substance in CSF augments inhibitory GABA signaling, thus revealing a new pathophysiology associated with excessive daytime sleepiness.

Sleep-wake disturbances and quality of life in patients with advanced lung cancer.

PURPOSE/OBJECTIVES To examine the scope and severity of subjective sleep-wake disturbances in patients with lung cancer and compare them to a group of healthy adults who were similar in age, gender, and race, and to examine the impact of sleep-wake disturbances on measures of health-related quality of life (QOL). DESIGN Descriptive, comparative. SETTING University-based and private urban ambulatory care clinics. SAMPLE 43 patients with advanced non-small cell or small cell lung cancer and 36 healthy adults. All participants were cognitively intact, and none had any known neurologic disorder, polysomnographically diagnosed sleep disorder, mood or anxiety disorders, or cerebral metastasis. METHODS Questionnaires, interview, and medical record review. MAIN RESEARCH VARIABLES Nocturnal sleep (quality, quantity, and disturbance), daytime sleepiness, and health-related QOL (physical, mental). FINDINGS Patients with lung cancer had poor perceived nocturnal sleep quality and excessive daytime sleepiness that differed significantly from the comparison group. Sleep disturbances in the group with lung cancer were characterized by breathing difficulty, cough, nocturia, and frequent awakenings. Sleep-wake disturbances were significantly associated with poorer health-related QOL after controlling for group. Excessive daytime sleepiness was associated most often with decreases in mental health, whereas poor nocturnal sleep was associated most often with decreases in physical health. CONCLUSIONS Findings suggest that sleep-wake disturbances are common in patients with lung cancer and that the disturbances are significantly associated with health-related QOL. Patients with lung cancer may be at risk for sleep-disordered breathing. IMPLICATIONS FOR NURSING The magnitude of nocturnal sleep disturbance and daytime sleepiness identified in this study reinforces the importance of ongoing screening and effective intervention for sleep-wake disturbances in patients with lung cancer.

Sleep-Wake Disturbances in People With Cancer Part II: Evaluating the Evidence for Clinical Decision Making

PURPOSE/OBJECTIVES To evaluate the quality of evidence on sleep-wake disturbances in people with cancer as a basis for clinical decision making and to discuss implications of the evidence for oncology clinicians, educators, and researchers. DATA SOURCES Published, peer-reviewed articles. DATA SYNTHESIS Members of the 2001 Oncology Nursing Society (ONS) Advanced Practice Nurse Retreat Evidence-Based Practice Sleep Working Group selected and evaluated data sources using criteria and processes outlined by ONS. CONCLUSIONS The development of nursing science related to sleep-wake disturbances among people with cancer and the application of research findings to clinical decision making are limited by the quantity and quality of published evidence. IMPLICATIONS FOR NURSING Clinicians are challenged to develop a plan of care that includes the assessment of sleep-wake disturbances and interventions to address them. Nurse educators are challenged to include sleep-wake content and skills to evaluate empirical data and interventions for sleep-wake disturbances in degree and continuing education curricula. Nurse researchers are challenged to specify consistent conceptual and operational definitions of key variables in sleep-wake models, use measurement instruments with evidence of reliability and validity, and design clinical trials to test interventions for sleep-wake disturbances among people with cancer.

Treatment of Weight Gain with Fluoxetine in Olanzapine-Treated Schizophrenic Outpatients *

Significant weight gain is a side effect associated with olanzapine treatment in some patients. We investigated the efficacy of high-dose fluoxetine as a weight-reducing agent for patients who develop early weight gain with olanzapine treatment. Patients that gained ⩾3% of their baseline weight in the initial 8 weeks of olanzapine treatment (n=31) were randomized to double-blind treatment with placebo or fluoxetine (60 mg/day). Clinical, weight, and weight-related measures were assessed. Fluoxetine failed to demonstrate weight-reducing effects (fluoxetine group: baseline mean 80.5 kg, SD=19.1, last mean=83.5 kg, SD=19.8; placebo group: baseline mean=77.1 kg, SD=12.1, last mean=78.8 kg, SD=10.6; F=1.3; df=1, 18; p=0.3). There were no differential effects in psychopathology, extrapyramidal side effects or weight-related measures between the placebo and fluoxetine groups. Serotonin reuptake inhibitors are probably not a practical option to counteract weight gain induced by atypical antipsychotics. Atypical-induced weight gain may result from mechanisms other than 5HT reuptake blockade.

Hemodialysis disrupts basic sleep regulatory mechanisms: building hypotheses.

BACKGROUND The proposition that hemodialysis may induce alterations in the sleep-wake cycle is based on two clinical observations: (a) Patients on dialysis frequently sleep during and after dialysis, and (b) the procedure often is associated with temperature elevations. A review of pertinent literature showed that sleepiness and temperature are physiologically related, and that these two variables are important indicators of sleep and circadian regulatory processes. OBJECTIVES To describe possible associations among hemodialysis, body temperature, and sleepiness; to assist in building hypotheses; and to provide direction for future research. METHODS Three exploratory studies were performed to investigate (a) dialysis-associated elevations in body temperature, (b) changes in body temperature patterns across the day, and (c) alterations in daytime sleepiness. RESULTS The current study demonstrated that many patients manifest dialysis-associated episodic elevations of body temperature, changes in the circadian pattern of body temperature, and increases in daytime sleep propensity. In the context of the Two-Process Model of Sleep Regulation, these alterations provide a parsimonious explanation for the poor subjective sleep quality, prolonged sleep latency, and daytime sleepiness reported by these patients. CONCLUSIONS These preliminary studies lead to the suggestion that hemodialysis may disrupt basic sleep regulatory mechanisms, and that further investigation in this area is warranted.

Age Changes in Timing and 24-Hour Distribution of Self-Reported Sleep

OBJECTIVE Aging has been associated with increased nocturnal awakenings, increased napping, earlier bedtimes and wake-up times, and more regular sleep-wake schedules. These patterns have often been ascribed to both psychosocial and medical factors, but nearly all studies to-date have been cross-sectional. METHODS The authors present self-reported sleep data from 31 elderly subjects followed over a decade. RESULTS With aging, the number of nightly awakenings and daytime napping increased over time. Exploratory analyses suggested that individuals who lived with another person had earlier bedtimes, later wake-up times, and greater daytime napping. Intervening medical comorbidities also appeared to be associated with increased napping. CONCLUSION These results confirm previous cross-sectional studies and suggest a complex biopsychosocial matrix for the timing and placement of sleep in elderly persons within the 24-hour day.

Sleep in infants and young children

Approximately 25% of children younger than 5 years experience some type of sleep problem. Whether the problem is acute or chronic, significant disruption to the childs sleep can occur and have a negative impact on the child and family. This article is the second in a two-part series on sleep in infants and young children. The purpose of this article is to provide fundamental information regarding common pediatric sleep problems for the clinician to use when assessing a childs sleep behaviors or addressing parental concerns. The definition, impact, and clinical evaluation of sleep problems are discussed.

Lowering dialysate temperature improves sleep and alters nocturnal skin temperature in patients on chronic hemodialysis

Hemodialysis (HD) induces physiological changes that may affect the ability to dissipate heat and adversely affect sleep. We studied the effects of altering dialysate temperature on polysomnographic measures of nocturnal sleep and the time course of proximal skin temperature. The sample included seven stable HD patients. The three‐phase randomized trial was conducted in a research facility. After one acclimatization night, subjects were readmitted in the evening on two additional occasions for 42 h and received HD the next morning in the warm condition (dialysate 37 °C) and cool condition (dialysate 35 °C) in random order. Continuous proximal skin temperature (axillary, Tax) and polysomnographic measures of sleep were recorded the nights before and after HD was administered. Highly significant findings included that the time course of Tax was markedly affected by dialysis temperature. There was a greater drop of Tax in the early morning following the warm condition than during the baseline nights or in the cool condition. Logistic regression indicated that the odds for the occurrence of sleep and its deeper stages were strongly and positively associated with Tax. Time of sleep onset was earlier in the cool condition (P = 0.03) with trends toward longer total sleep times (P = 0.09) and shorter rapid‐eye‐movement latencies (P = 0.09). These observations suggest that the use of cool dialysate during HD may improve nocturnal sleep by decreasing sympathetic activation and sustaining the normally elevated nocturnal skin temperature until later into the morning hours.