Sleep waking checklist

AIM :

Preparing and maintaining a sleep-waking checklist (for two weeks) of the oldest family member in the family based on a sample sleep diary provided by the National Institute of Health, US.  

INTRODUCTION:

It is the sleep that soothes and nourishes after a long day. Sleep is largely determined by the body’s internal clock, which also takes into account external factors such as weather and sunlight. The natural sleep-and-wake cycle of the body is attuned fairly closely to a 24-hour period.  

Fluctuations within the sleep cycle are disruptive to the functioning of many-body systems. Sleep duration and quality affect health, performance, learning, memories mood, and stamina. Getting a good night’s sleep can be difficult for some people. Most people, at some point, have trouble falling or staying asleep. Consistently poor sleep may lead to obesity, cardiovascular disease, and diabetes. Mental acuity and judgment may also be affected by sleep deprivation.  

Different people and age groups require different levels of sleep. Some people need eight full hours of sleep, while others can function with less rest. A great deal of progress has been made in the treatment of sleep disorders. Each age group has varying sleep requirements, and within each age group, there are variations. However, in general, these are the recommended daily sleep guidelines from the National Sleep Foundation:  

  • The infant (4-11 months) needs 12-15 hours of sleep
  • Those of school age (6-13 years): 9-11 hours
  • The hours for teens (14-17 years) are 8-10 hours
  • The young adults (18-25 years  ) needs 7-9 hours
  • Adults (26-64 years): 7-9 hours
  • Older adults (65+ years): 7-8 hours

THE NEURAL BASES OF SLEEP

Several parts of the brain are involved in sleep and wakefulness. Areas such as the thalamus, hypothalamus, basal forebrain, pineal gland, and parts of the brainstem are included in these regions. Circadian rhythm and sleep homeostasis interact to determine when a person sleeps. This circadian rhythm is used to control the body’s internal clock, and its rhythm is controlled by cells in the suprachiasmatic nucleus of the hypothalamus. Though external light and temperature affect it, the sleep cycle is roughly 24 hours long. Sleep drive/homeostasis determines how long a person stays awake and how much sleep he or she needs. Even though the exact mechanism controlling this phenomenon is not known, it is believed that it is related to the release of the neurotransmitters GABA and adenosine from the basal ganglia and other areas.  

In addition to the thalamus, basal forebrain, and brainstem that release stimulatory hormones, the hypothalamus in particular drives wakefulness with glutamate, histamine, and orexin. The hypothalamic signal is decreased when the time for sleep approaches based on the circadian rhythm and sleep drive. Through the sleep drive, the central autonomic system and pineal gland also work in coordination to appropriately affect the sympathetic and parasympathetic nervous systems, and so impact the changes in bodily functions during sleep.  

STAGES OF SLEEP

Each sleep stage has four stages; one for rapid eye movement (REM) sleep, and three for non-REM sleep (NREM). These stages are determined by analyzing patterns of brain activity that are distinctive to each stage during sleep.  

  The process of breaking down a person’s sleep into various phases and cycles is known as sleep architecture. The sleep architecture can be visually represented in a hypnogram if someone has undergone a sleep study. According to the American Academy of Sleep Medicine (AASM), the classification of sleep stages was updated in 2007. Previously, sleep experts generally referred to five stages of sleep, but today, the four AASM stages are the most accepted definition of the sleep cycle.  

Patterns of NREM sleep

The NREM sleep cycle consists of three stages. When a person sleeps in a stage called non-relaxation, waking them from sleep is more difficult.  

Stage 1 / N1

Stage 1 is basically when you doze off and lasts for one to five minutes. The body hasn’t fully relaxed by N1 sleep, but we start to see short periods of movement (twitches) as the body and brain begin to slow down. As sleep occurs, there are some changes in brain activity. During this sleep stage, it’s easy to wake a person up, but if they aren’t disturbed, they can move quickly into stage 2. An uninterrupted sleeper won’t spend much time in stage 1 as they move through the night.  

Stage 2 / N2

In stage 2, the body enters a more relaxed state with lowered body temperatures, relaxed muscles, and slower breathing and heart rates. A new wave pattern appears in the brain and eye movements cease. During sleep, brain activity slows overall, but short bursts of activity can help the brain resist being aroused by external stimuli. During the first sleep cycle, stage 2 can last from 10 to 25 minutes and N2 stages can become longer throughout the night. On average, a person spends about half their sleep time in N2 sleep.

Stage 3 / N3

During Stage 3 sleep, which is also called deep sleep, it is harder to wake someone up if they are in this phase. During N3 sleep, muscle tone, pulse, and breathing rate decrease as the body relaxes even more. This period of time has an identifiable pattern of brain activity called delta waves. Therefore, stage 3 may also be called delta sleep or short-wave sleep (SWS). This phase of sleep enables the body to recover and grow, so it is critical to restorative sleep. Additionally, it may aid in body functions such as the immune system. There is evidence that deep sleep enhances creativity, memory, and insightful thinking, even though brain activity is reduced. Deep sleep occurs most often during the first half of the night. During the early sleep cycle, the N3 stages typically last between 20 and 40 minutes. This process gets shorter as you sleep, and you spend more time in REM sleep.  

REM Sleep Patterns

When you’re asleep, your brain activity doubles, nearing levels that are seen when you’re awake. Additionally, the body has atonia, which is a temporary paralysis of muscles aside from the muscles that control breathing and the eyes. This stage is so named because even though the eyes are closed, they move rapidly. Memory, learning, and creativity are thought to be enhanced by REM sleep. A significant increase in brain activity during REM sleep explains why REM dreams are the most vivid. Even though dreams are possible in all sleep stages, they are less prevalent and less intense during NREM periods. Sleeping for 90 minutes or more usually induces REM sleep. REM sleep stages get longer over the course of the night, especially in the second half of the night. In contrast to the initial cycle of REM, which may last just a few minutes, the later stages may last up to an hour. An adult’s REM sleep accounts for about 25% of the total amount of sleep.

SLEEP MECHANISM

Circadian rhythm and homeostasis are two internal biological mechanisms that regulate when you are awake and asleep.    

The Circadian Rhythm controls a wide range of functions, including sleep, body temperature, metabolism, and hormone release.  During the night, they cause us to feel sleepy and influence our tendency to wake up without an alarm.  Circadian rhythms are regulated by our body’s biological clock, which runs on a 24-hour cycle.  The circadian rhythms are synchronized with environmental cues about the actual time of day (light, temperature), but they continue even with no environmental cues.   

The sleep-wake homeostasis tracks how much sleep you need.  This sleep drive is responsible for reminding and regulating sleep intensity after a certain time.  When you are sleep-deprived, this sleep drive intensifies with every hour you are awake. This leads to deeper sleep and longer sleep.  

Aspects that affect your sleep-wake cycles needs such as medical conditions, medications, stress, sleep environments, and what you eat and drink.  One of the greatest influences is exposure to light.  A special type of cell in your retina processes light in order to tell the brain if it is day or night, which helps to regulate sleep-wake cycles.  Exposure to light can interfere with falling asleep and returning to sleep after waking up.  

Because the circadian rhythm and sleep-wake cycle are disrupted, night shift workers often have difficulty falling asleep and staying awake at work.  People suffering from jet lag experience a mismatch between their internal clock and the actual clock when they cross time zones. Their circadian rhythms become out of sync with the time of day when they fly across time zones.   

ROLES OF GENES AND NEUROTRANSMITTERS

Sleep chemicals: The number of sleep-promoting neurons increases in many parts of the brain during the ante-bedtime ritual.  A chemical called a neurotransmitter can turn off or dampen activity in the cells that signal arousal or relaxation.  The chemical GABA is related to sleep, muscle relaxation, and sedation.  While we are awake, norepinephrine and orexin (also called hypocretin) keep some parts of the brain active.  Additionally, acetylcholine, histamine, adrenaline, cortisol, and serotonin are neurotransmitters that regulate sleep and wakefulness.  

Sleep and genes: The amount of sleep we need may be influenced by our genes.  Researchers have identified several genes involved in sleep and sleep disorders, as well as genes controlling neuron excitability and “clock” genes. Per, tim, and Cry which influences circadian rhythms and sleep timings.  A genome-wide association study found that sleep disorders can be linked to numerous chromosomes.  Furthermore, various genes have been linked to such sleep disorders as a familial advanced sleep-phase disorder, narcolepsy, and restless legs syndrome.  There are some genes expressed in the cerebral cortex and other brain areas that change their level of expression between sleep and wakefulness.  A variety of genetic models, including worms, fruit flies, and zebrafish, are helping scientists identify the genetic components and molecular mechanisms that control normal and pathological sleep.   

Studies of sleep: To diagnose a sleep disorder, your physician may recommend a polysomnogram or other test.  Polysomnograms require spending the night at a sleep clinic or sleep lab.  Your breathing, oxygen levels, eyelid and limb movements, heart rate, and brain waves are recorded all night long.  Video and audio recordings of your sleep are also captured.  Having this data can help a sleep specialist determine if you’ve reached each sleep stage and are proceeding properly through them.  Depending on the results, a treatment plan may be developed or additional tests ordered.   

WHAT AFFECTS SLEEP STAGES?

 In general, sleep stages follow a given pattern, but individual variations will vary based on factors such as:  

  • Age: As a person’s life progresses, the amount of time spent in each stage changes. A newborn spends the majority of their sleep time (around 50%) in REM sleep and may enter the REM stage as soon as they fall asleep. By the time they reach 5 years of age, their sleep has become comparable to that of adults. In contrast, elderly people tend to sleep less in REM.
  • Current sleep patterns: It is possible for someone who gets insufficient or irregular sleep over a longer period to develop an abnormal sleep cycle.
  • Alcohol consumption: Some drugs and alcohol can affect sleep architecture. For example, an initial decrease in REM sleep following alcohol consumption is followed by a rebound in REM sleep with long REM stages.
  • Sleep disorders: The presence of sleep apnea, restless legs syndrome (RLS) and other conditions that wake you up multiple times can interrupt a healthy sleep cycle. 

DISORDERS OF SLEEP

Insomnia a lack of sleep or difficulty falling asleep is reported by 20-30% of the population. Insomnia can be defined subjectively. Studies demonstrate that people can function well on as little as one hour of sleep a day. People who report sleeping little or not enough are often found to sleep much more than they thought. The reason people describe themselves as insomniacs is that they feel that they should sleep more than they do. People suffering from these conditions may show alterations in their daytime behavior and performance. Emotional arousal often results in insomnia. For example, both positive and negative thoughts about upcoming events can cause sleep disturbances. Psychologically, anxiety is often a factor in difficulty falling asleep, and depression is frequently a factor in frequent wakings  

Sleep apnea is a particular type of insomnia. . In this scenario, the sleeping person ceases breathing and is awakened when the rising amount of carbon dioxide in their blood stimulates their central chemoreceptors. The sufferer may not recall this when they are awake, and may simply report feeling tired throughout the day. There are two main causes of sleep apnea:  

  • Having a restricted airway (snorers tend to have sleep apnea);
  • The inability of the brain to initiate breathing with a normal concentration of CO2.

Sleepwalking often occurs during SW sleep, during which narrative dreams are least likely, so it isn’t what we think of as the enactment of dreams. It is most common among children, and its cause is unknown; however, it is not indicative of any underlying pathology.  

Enuresis or bed-wetting is often observed during early childhood. Most of the time, its persistence is the result of the child’s inability to wake up when the bladder is stimulated. It may also indicate anxiety-related conditions. The most common treatment is a ‘pad-and-bell’ device, in which a moisture-sensitive pad is placed underneath the sheets. An electrical circuit is completed with the first drop of urine, which results in the bell ringing and waking up the child. The child quickly learns that he or she must awaken in response to bladder stimuli before bedwetting occurs.  

Night terrors are also commonly reported in children. SW’s sleeping child wakes suddenly, terrified. This is not a nightmare (which is a very frightening dream in REM sleep). Without treatment, night terrors typically disappear with age.  

During narcolepsy, an irresistible urge to fall asleep suddenly takes over sufferers while awake. The situation may occur at any time, but it most frequently occurs during monotonous times. Typically, the sleep lasts around 5 – 10 minutes, and the person feels refreshed when they wake up. Unlike the normal sleep cycle, narcoleptics often fall into REM sleep as soon as they fall asleep.  

In cataplexy, some narcoleptics may collapse suddenly and with all muscle tone, usually fully conscious. In REM sleep, paralysis is similar to what happens normally. An animal breed with narcolepsy has been developed. There are genes associated with narcolepsy in dogs, and one gene has been found to cause it. In spite of this, genetic factors in humans are more complex. The source of the problem seems to be excessive excitability of cholinergic neurons in the peribronchial area, stimulating the cells in the magnocellular nucleus that produce the muscular paralysis of REM sleep (Nishino et al., 1994). The tricyclic antidepressants used in narcolepsy create an effect called REM sleep reduction.  

Adult sleepwalking also called REM sleep behavior disorder (RSBD) different from childhood sleepwalking. The condition is characterized by the absence of atonia during REM sleep and by dreaming abnormally, often acting out the dreams violently (Mahowald et al., 1990). RSBD may be the result of interference with the mechanism that normally produces REM sleep atonus in the magnocellular nucleus in the medulla. This situation can arise for a variety of reasons, which differ in different cases (Ferini-Strambi and Zucconi, 2000).  

As a result of flying across time zones, or working night and day shifts, our internal clocks are often out of sync with the local time. For example, our peak alertness and other functions are delayed by a minimum of six to seven hours when flying east across the Atlantic Ocean known as phase advance, in which zeitgebers are advance of the previous formed cycle. Jet lag causes to have a loss of concentration, disturbance in mood and sleep during local waking hours. In each case, the internal rhythm and the zeitgebers are not synchronized. The process of recovering from jet lag involves resynchronizing the internal and local rhythms. The westward flight (phase delay) results in less jet lag than eastward flight since we are able to adjust to it more quickly because of the shorter night during the transition. To sync the new zeitgebers we have to sleep late while going west and early in the case of the east. Getting to sleep earlier is more difficult than delaying sleep. For every hour of the time difference, an eastbound flight might require approximately one day of the adjustment. In a similar fashion, moving to a later work shift results in fewer problems than moving to an earlier shift. You can minimize jet lag by adjusting your wake-up time earlier in the morning, which helps your circadian rhythm catch up and enhances entrainment. Intense light exposure in the morning, along with intense exercise, facilitates rapid resynchronization (Boulos et al., 1995). Adjustment to phase shift can also be treated with melatonin, a hormone produced by the pineal gland(Deacon and Arendt, 1996).  

SLEEP DIARY

A sleep diary is a way to track your sleep and gather details about your insomnia symptoms. If you work with a sleep specialist or are a patient in a sleep disorder clinic, your doctor will probably ask you to fill out a sleep log for one to two weeks to get a better understanding of your sleep troubles. Even if you talk to your regular doctor (rather than a specialist) about sleep troubles, this log will provide a more comprehensive picture of your recent sleep patterns. Your doctor may use the information collected in your sleep diary along with other tests to diagnose and decide on a treatment recommendation for insomnia. To get the most accurate information, fill out the sleep diary as early in the morning as you can (so your bedtime routine and night-time sleep are fresh in your memory). 

The sleep diary includes the following points:

  1. A person’s desired or intended wake-up time,
  2. Awakening time,
  3. If the individual woke up spontaneously, as a result of an alarm clock, or due to another (specified) disturbance,
  4. The moment the person woke up,
  5. The person’s general mood and drowsiness during the day (usually from 1-5), and the major cause.
  6. When any naps or exercises begin and end during the day,
  7. Any drugs used, such as medication, sleep aids, caffeine, and alcohol, as well as their dosage and time of administration,
  8. An evening meal’s timing, type, and heaviness,
  9. Last hour activities, such as meditation, watching TV, playing computer games, etc.
  10. The level of stress before bedtime, often rated on a scale of 1 to 5, and its main source,
  11. While the person was attempting to fall asleep,
  12. The time that the person believes sleep began,
  13. The likelihood, number, time, and duration of any nighttime awakenings that took place,
  14. The quality of sleep,
  15. Any comfort level associated with a dream recalled.

Assessing and treating sleeping disorders relies heavily on sleep diaries. The sleep assessments help quantify the severity of a sleep disorder, are essential for a correct diagnosis, and guide the intervention by tracking the changes in sleep. In addition, they enable reliable measurement of treatment outcomes. They can also provide insight into how the patient adheres to their prescribed sleep schedule. Its simplicity and low cost make sleep diaries an attractive alternative to other measures. They provide essential information, can be online-based, and are easy to use. Sleep diaries have the disadvantage of inaccurate or incomplete data provided by patients.  

METHODOLOGY

MATERIAL REQUIRED :

Sample sleep diary

PROCEDURE TO FIND THE PARTICIPANT-

Keeping in mind the aim of the practical the oldest family member was been approached in order to prepare and maintain a sleep-waking checklist of two weeks duration.

INFORMED CONSENT-

The participant was first given a brief description of the test. He was also informed that this test would be conducted entirely at his own discretion which implies that he could decline his participation in this experiment if it was not convenient.

She was then given a consent form and all the relevant details related to the form was explained before soliciting the signature.

___________________________________________________________________________

INFORMED CONSENT FORM

This form seeks to take your consent to participate in a study. The following will provide you with information about the study that will help you in deciding whether or not you wish to participate. If you agree to participate, please be aware that you are free to withdraw at any point throughout the duration of the experiment.

All information you provide will remain confidential and will not be associated with your name. If for any reason during this study you do not feel comfortable, you may leave the laboratory and your information will be discarded.

When this study is complete you will be provided with the results of the experiment if you request them, and you will be free to ask any questions. Please indicate with your signature on the space below that you understand your rights and agree to participate in the experiment.

Your participation is solicited, yet strictly voluntary. All information will be kept confidential and your name will not be associated with any research findings.

xyz

SIGNATURE OF THE APPLICANT

___________________________________________________________________________

RAPPORT FORMATION-

To begin forming rapport and making the participant comfortable, the participant was told about the test, the purpose of testing, and given assurance of confidentiality and informed consent. It was ensured that the study outline and all the other necessary details were discussed in the language that the participant was comfortable with, the participant was made aware of his freedom to participate voluntarily and drop out of the study at any point. All the concerns and queries of the participant were readily addressed including confidentiality and informed consent to gain complete trust from the participant. After taking the consent form, further proceedings with the study were made.

DEMOGRAPHIC DETAILS-

  • Name- xyz
  • Age– 72 years
  • Gender- female
  • Date– 30 November 2020

INSTRUCTIONS

  • You will collect some important information regarding your sleep patterns. We will use this information to understand your sleep problem and to measure your progress in improving it.
  • Please answer all 10 questions when you wake up in the morning. It is crucial that you complete the diary every morning when it is fresh in your mind.
  • Often, it is difficult to determine the duration of wakefulness (numbers 3 and 4). Please provide as accurate an estimate as you can. Please do not watch the clock!
  • You should record unusual events (such as an illness, emergency, or phone call) that may have impacted your sleep, note it with the date.
  • The DAY and DATE refer to the morning that you are filling in the information. For example, DAY: Tuesday DATE: November 27, 2020 would head the column for information on Monday night’s sleep.

PROCEDURE

Fill the sample sleep diary after taking the consent of the oldest family member. The sleep diary should be filled for 2 weeks. After explaining all the instructions to the oldest family member fill the sleep diary for morning and evening. Record the sleep routine as follows-

  1. Napping: This should include the time subject went to bed and wake up in the morning and how long was the duration of sleep
  2. Number of awakenings: this includes how many times did the subject woke up in the night due to certain reasons.
  3. How long did the patient took to fall asleep- includes the time that the patient took before he was slept.
  4. How awake was the patient feeling after he got up- 1-wide awake, 2- awake but little tired, 3- sleepy. Choose the most appropriate option as per the subject.
  5. Number of caffeinated drinks- this includes tea, coffee, cola and how has the patient consumed and at what time.
  6. Alcoholic drinks: Specify time, type and amount taken (yesterday).
  7. Naptimes: duration of the sleep during the day
  8. Exercise time and length- this includes for how long the subject exercised
  9. How sleepy did the patient feel during the day: this includes 1- so sleepy had to struggle to stay awake, 2- somewhat tired, 3- alert, 4- wide awake. Choose the most appropriate option as per the patient.
  10. Sleep medicines: The list should include both prescriptions and over-the-counter medications. Indicate when what, and how much was taken (yesterday or last night).

RESULT

We experience changes in our sleep patterns as we age. People find aging makes them have difficulty falling asleep. Awakenings occur more frequently during the night and earlier in the morning. There is no change or a slight decrease in the total amount of sleep.  

INTERPRETATION AND DISCUSSION

  With aging, our bodies produce less growth hormone, which negatively affects slow-wave or deep sleep (a part of sleep that is especially refreshing). Adults tend to sleep less deeply (slow-wave sleep) with age. As people age, the proportion of slow-wave sleep and rapid eye movement (REM) sleep decreases, while the proportion of NREM stage 1 and stage 2 sleep increases. As you age, you tend to have difficulty establishing and maintaining sleep. Furthermore, sleep physiology deficits, including those associated with non-rapid eye movement (NREM) sleep, are important in later life. Even though disrupted sleep is one of the hallmarks of “normal aging”.  

According to the sleep diary, the subject is usually drowsy and sleeps 4-5 hours per night. Over the course of two weeks, the subject slept a maximum of 10 hours and a minimum of 5.  The subject wakes up at night and takes longer to get to sleep.  On average, the subject drinks 1-2 cups of caffeine-filled beverages daily. There is no alcohol consumption by the subject. Over the course of two weeks, the subject did not take a nap in the evening. Few meditation techniques are used by the subject. Most of the time, the subject feels exhausted.  

CONCLUSION

There is no change in sleep time or a slight reduction. The subject may have difficulty falling asleep and spend more time in bed. The period between waking up and going to sleep is often abrupt, so older people feel like they sleep less than they did when they were younger. A lesser amount of time is spent sleeping deeply and dreamlessly. The average older person awakens three to four times a night. Additionally, they are more aware of being awake. As a result of sleeping less, they tend to get up more often. Another reason is the need to urinate (nocturia), anxiety, and long-term (chronic) illness-induced discomfort or pain.  

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