Sleep Disturbances and Fatigue in Critically Ill Patients

Sleep disturbances and fatigue are significant problems for critically ill patients. Existing sleep disorders, underlying medical/surgical conditions, environmental factors, stress, medications, and other treatments all contribute to a patient's inability to sleep. Sleep disturbance and debilitating fatigue that originate during acute illness may continue months after discharge from intensive care units (ICUs). If these issues are unrecognized, lack of treatment may contribute to chronic sleep problems, impaired quality of life, and incomplete rehabilitation. A multidisciplinary approach that incorporates assessment of sleep disturbances and fatigue, environmental controls, appropriate pharmacologic management, and educational and behavioral interventions is necessary to reduce the impact of sleep disturbances and fatigue in ICU patients. Nurses are well positioned to identify issues in their own units that prevent effective patient sleep. This article will discuss the literature related to the occurrence, etiology, and risk factors of sleep disturbance and fatigue and describe assessment and management options in critically ill adults.

     

Child sleep disorders: Associations with parental sleep duration and daytime sleepiness.

This study examined the associations between childhood sleep disorders and mothers' and fathers' sleep duration and daytime sleepiness. One hundred seven families of children (ages 2-12 years) presenting to a pediatric sleep disorders clinic completed questionnaires assessing the sleep symptoms of the mother, father, and child. Parents of children with more than 1 type of sleep disorder experienced more daytime sleepiness than parents of children with a single sleep disorder. The pattern of results suggested more associations between maternal and child sleep than between paternal and child sleep. Within families, mothers reported significantly more daytime sleepiness than fathers, although there were no parental differences in sleep duration. Results provide preliminary evidence for an association between child sleep problems and parental daytime sleepiness, which may, in turn, extend previous research linking young children's sleep problems and parental functioning. Implications for treatment of both children and adults with sleep problems are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age.

Meta-analyses support the effectiveness of behavioral interventions for the treatment of insomnia, although few have systematically evaluated the relative efficacy of different treatment modalities or the relation of old age to sleep outcomes. In this meta-analysis of randomized controlled trials (k = 23), moderate to large effects of behavioral treatments on subjective sleep outcomes were found. Evaluation of the moderating effects of behavioral intervention type (i.e., cognitive-behavioral treatment, relaxation, behavioral only) revealed similar effects for the 3 treatment modalities. Both middle-aged adults and persons older than 55 years of age showed similar robust improvements in sleep quality, sleep latency, and wakening after sleep onset. A research agenda is recommended to examine the mechanisms of action of behavioral treatments on sleep with increased attention to the high prevalence of insomnia in older individuals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The two-factor structure of sleep complaints and its relation to depression and anxiety.

Although sleep complaints are common in depression and anxiety, there is little agreement as to how they should be organized and assessed. It is also unclear whether sleep complaints show specificity with certain disorders or whether they are nonspecific symptoms. The authors examined the structure of sleep complaints and the relations of these complaints to depression and anxiety in 3 samples: college students, older adults, and psychiatric patients. Exploratory and confirmatory factor analyses indicated that sleep complaints consistently defined 2 distinct dimensions: Insomnia and Lassitude. The Insomnia factor included indicators of early, middle, and late insomnia, as well as poor sleep quality. The Lassitude factor included measures of hypersomnia, fatigue, and sleepiness. Both factors were significantly related to symptoms and diagnoses of depression and anxiety. However, Lassitude was more strongly related to symptoms of depression and anxiety than was Insomnia. In addition, Lassitude showed specificity to measures and diagnoses of depression compared with anxiety disorders. This specificity can be explained by Lassitude's relation with negative and positive emotionality, both of which are components of depression. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronic illness, pain and health behaviors of community behavioral health clients.

Persons with comorbid medical disorders, along with substance use disorders and mental illness, present complex treatment needs that are seldom addressed. Chronic physical illness negatively affects treatment participation and retention, decreasing effectiveness. Studies documenting higher medical morbidity and mortality in such persons have long been available. Less is known about their health behaviors. Respondents (n = 418) at a community behavioral health center were surveyed for prevalence of illness, pain, health behaviors, and interest in lifestyle change. A total of 73% reported at least one chronic health problem, and nearly half rated their health between fair and very poor. Most reported at least one negative health indicator or behavior (e.g., smoking). Encouragingly, nearly 50% desired lifestyle changes including smoking cessation, exercise, and stress management. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Considering sleep in a family context: Introduction to the special issue.

The special issue addresses the importance of sleep considered within a family context in relation to a broad range of behavioral, emotional, and physical health issues. The collection of articles provides several excellent examples of studies that emphasize a family context for understanding various aspects of sleep in infants, children, adolescents, and adults. Taken together, these studies raise a set of compelling questions for future research in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Sommeil, insomnie et psychopathologie.

Sleep plays a critical role in psychological well-being and adaptation. Not surprisingly, sleep disturbance is a frequent problem among individuals facing situational psychological difficulties as well as among those with more chronic psychopathology. This article examines the relationship among sleep, insomnia, and psychopathology. In the first section, we address the issue of comorbidity by examining prevalence rates of sleep disturbances in the general population and among subgroups of individuals with selected psychopathologies and, conversely, rates of psychological symptoms/syndromes among individuals with and without sleep disturbances. The data indicate high rates of psychological syndromes (40%) associated with insomnia among community-based samples, and even higher rates (80%) of sleep disturbances among selected samples of patients with psychopathology. Comorbidity is particularly high among patients with insomnia, major depression, and generalized anxiety disorder. Although insomnia is often a symptom of an underlying psychopathology, longitudinal studies show that it can also be an important risk factor for a new onset major depressive disorder. The second section of this article summarizes the main subjective and EEG sleep impairments in selected anxiety disorders, mood disorders, and schizophrenia. Insomnia is a common clinical feature or even a diagnostic criterion of several of those disorders. Other related symptoms such as fatigue, low energy and poor concentration are shared across insomnia, major depression, and generalized anxiety disorder, suggesting some common mechanisms among those conditions. In addition to subjective sleep complaints, there is also evidence of EEG sleep abnormalities, such as impairment of sleep continuity, reduced slow wave sleep, and altered REM sleep patterns, with the latter two features being more specific to mood disorders. The third section of this article examines the effects of insomnia treatment on co-existing psychological symptoms or disorders and, conversely, the effects of treatment of selected anxiety and mood disorders on sleep. These results indicate that treatments of depression and anxiety may produce some sleep improvements but, in many cases, residual sleep disturbances persist and may actually increase the risk of subsequent relapse. The main implication is that treatment should directly target both co-existing conditions. Additional implications for the treatment and prevention of comorbid sleep disturbances and psychopathology and for future research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of Childhood disorders: Behavioral-developmental approaches.

Reviews the book, Childhood disorders: Behavioral-developmental approaches edited by Robert J. McMahon and Ray Dev. Peters (1985). This volume includes 11 original chapters from the 1983 Banff International Conference on Behavioral Sciences. Together, these chapters provide an overview of a number of high-quality programmes of research in the area of childhood disorders. The editors state that the purpose of the current offering is to focus on recent advances in the conceptualization, assessment, and treatment of childhood behaviour disorders, with particular attention being given to the role of developmental processes. The book contains two major sections. The first provides an overview of the conceptual foundations for a "behavioural-developmental" approach to childhood disorders. The second, which constitutes approximately 80% of the volume, illustrates programmes for the assessment and treatment of childhood disorders spanning the developmental spectrum from infancy to adolescence. Although this volume's attempt to bridge the gap between behavioural and developmental work may fall short, it is nevertheless a worthwhile contribution that nicely illustrates a range of outstanding programmes of clinical research for a variety of childhood disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health status of preweaned dairy heifers in the United States

Chronic fatigue and chronic fatigue syndrome (CFS) have become increasingly recognized as a common clinical problem, yet one that physicians often find difficult to manage. In this review we suggest a practical, pragmatic, evidence-based approach to the assessment and initial management of the patient whose presentation suggests this diagnosis. The basic principles are simple and for each aspect of management we point out both potential pitfalls and strategies to overcome them. The first, and most important task is to develop mutual trust and collaboration. The second is to complete an adequate assessment, the aim of which is either to make a diagnosis of CFS or to identify an alternative cause for the patient's symptoms. The history is most important and should include a detailed account of the symptoms, the associated disability, the choice of coping strategies, and importantly, the patient's own understanding of his/her illness. The assessment of possible comorbid psychiatric disorders such as depression or anxiety is mandatory. When the physician is satisfied that no alternative physical or psychiatric disorder can be found to explain symptoms, we suggest that a firm and positive diagnosis of CFS be made. The treatment of CFS requires that the patient is given a positive explanation of the cause of his symptoms, emphasizing the distinction among factors that may have predisposed them to develop the illness (lifestyle, work stress, personality), triggered the illness (viral infection, life events) and perpetuated the illness (cerebral dysfunction, sleep disorder, depression, inconsistent activity, and misunderstanding of the illness and fear of making it worse). Interventions are then aimed to overcoming these illness-perpetuating factors. The role of antidepressants remains uncertain but may be tried on a pragmatic basis. Other medications should be avoided. The only treatment strategies of proven efficacy are cognitive behavioral ones. The most important starting point is to promote a consistent pattern of activity, rest, and sleep, followed by a gradual return to normal activity; ongoing review of any 'catastrophic' misinterpretation of symptoms and the problem solving of current life difficulties. We regard chronic fatigue syndrome as important not only because it represents potentially treatable disability and suffering but also because it provides an example for the positive management of medically unexplained illness in general.     

The esophageal temperature gradient in anesthetized children

Radical changes in the health care system, including the paradigm shift from an acute to chronic illness model, and advances in managing major neuroscience patient populations are redefining neuroscience nursing practice in the 1990s. For example, advances in management mean that many more neurotrauma patients and patients with cerebrovascular disorders survive. Once stabilized, illness may become chronic and require long-term management. There are also promising developments in managing major neurological diseases. The decade of the 90s will require more collaboration, new practice models and a greater focus on rehabilitation. Research and education must support practice in reshaping neuroscience nursing.     

Treatment of sleep-maintenance insomnia in older adults: Sleep period reduction, sleep education, and modified stimulus control.

We evaluated a behavioral treatment package consisting of sleep period restriction, sleep education, and modified stimulus control in the treatment of sleep-maintenance insomnia in older adults. A multiple baseline design was used with 4 chronic insomniac subjects, ages 59, 65, 65, and 72. Sleep diaries and an objective behavioral measure of sleep were used to monitor improvement. Results revealed clinically significant reductions in time awake after sleep onset in 3 subjects, coincident with the initiation of treatment. These improvements were maintained at 2- and 6-month follow-ups. The 4th subject showed little improvement; however, a polysomnogram conducted on this subject at the end of the study revealed a fragmented sleep pattern secondary to periodic movements of sleep (nocturnal myoclonus). These encouraging but preliminary results call for further controlled evaluations of the efficacy of this behavioral treatment package for sleep-maintenance insomnia. The importance of conducting polysomnographic studies on elderly insomniacs is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral and cognitive-behavioral approaches to chronic pain: Recent advances and future directions.

Behavioral and cognitive-behavioral approaches to chronic pain are receiving increasing attention from researchers and clinicians. This article reviews and highlights recent research advances and future research directions. Assessment research reviewed includes studies examining the social context of pain, the relationship of chronic pain to depression, cognitive variables affecting pain, and comprehensive assessment measures. Treatment outcome studies reviewed are those evaluating the effects of behavioral and cognitive-behavioral treatments for chronic pain. These studies focus on comparisons of behavioral treatment with control conditions, comparisons of 2 behavioral treatments, and prevention of chronic pain. Future directions for assessment and treatment research are outlined. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Metabolism of an anionic fluorescent dye, 1-anilino-8-naphthalene sulfonate (ANS) by rat liver microsomes

OBJECTIVE: To examine the association between chronic illness and functional status change during a 3-year period in older people enrolled in an in-home comprehensive geriatric assessment (CGA) and preventive care program. DESIGN: Secondary analysis of data from a longitudinal cohort study. SETTING: Santa Monica, California. PARTICIPANTS: Two hundred two community-dwelling older persons (mean age at baseline was 81 years, 70% were women, and 72% reported good health) randomized to the intervention group in a trial of in-home comprehensive geriatric assessment and preventive care. MEASUREMENTS: We studied 13 common chronic illnesses/conditions determined clinically from an annual comprehensive evaluation by gerontologic nurse practitioners (GNPs) in consultation with study geriatricians. These target conditions included hypertension, osteoarthritis, coronary artery disease, obesity, undernutrition, urinary incontinence, sleep disorders, falls, gait/balance disorders, hearing and vision deficits, depression, and unsafe home environment. The dependent variable was functional change as measured by instrumental activities of daily living (IADL) and basic activities of daily living (BADL) assessed at baseline and annually for 3 years by independent research personnel. Potential confounding variables, including comorbid conditions and other subject characteristics, were controlled for in the analyses. RESULTS: Although functional status was similar at baseline, the presence of certain target conditions in this sample was associated significantly with functional decline in IADL and BADL during the 3-year period. Four conditions (gait/balance disorders, depression, unsafe home environment, and coronary artery disease) were associated with significant declines in IADL, and four conditions (gait/balance disorders, depression, hypertension, and urinary incontinence) were associated with significant declines in BADL. Conversely, subjects with obesity had no significant change in IADL or BADL throughout the study period and had less decline in IADL compared with nonobese subjects. CONCLUSIONS: Certain chronic conditions, particularly gait/balance disorders and depression, are associated with significant decline in functional status in older persons who receive CGA. These findings may help identify older persons at risk for greatest functional decline despite participation in CGA and may also suggest the need for more effective intervention strategies in these individuals.     

Cognitive–behavioral treatment of insomnia secondary to chronic pain.

Sixty participants with insomnia secondary to chronic pain were assigned randomly to either a cognitive–behavioral therapy (CBT) or a self-monitoring/waiting-list control condition. The therapy consisted of a multicomponent 7-week group intervention aimed at promoting good sleep habits, teaching relaxation skills, and changing negative thoughts about sleep. Treated participants were significantly more improved than control participants on self-report measures of sleep onset latency, wake time after sleep onset, sleep efficiency, and sleep quality, and they showed less motor activity in ambulatory recordings of nocturnal movement. At a 3-month follow-up assessment, treated participants showed good maintenance of most therapeutic gains. These results provide the 1st evidence from a randomized controlled trial that CBT is an effective treatment for insomnia that is secondary to chronically painful medical conditions. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Children's sleep and school psychology practice.

Much contemporary research has demonstrated the multiple ways that sleep is important for child and adolescent development. This article reviews that research with an emphasis on how sleep parameters are related to school adjustment and achievement. Five areas of sleep research are reviewed to discern implications for practice with children using an evaluation rubric of strong, moderate, and weak evidence. The research has implications for assessment of sleep and sleepiness in the schools, for primary and secondary prevention activities, and for interventions by school psychologists targeting children and adolescents with sleep problems that affect their school functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Professional psychologists in general health care settings: A review of the financial efficacy of direct treatment interventions.

Research is reviewed that evaluates the extent to which psychologists can reduce medical costs of health problems while still maintaining treatment effectiveness. Specific areas on cost-effectiveness include the following: preparation for anxiety provoking medical procedures, smoking cessation, detection and treatment of somatizing patients, psychological intervention in general rehabilitation, rehabilitation of chronic pain patients, behavioral treatment of cardiovascular disorders, and adherence to medical regimens. Major conclusions on these areas are presented. Difficulties with the research are discussed along with areas for future research. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diurnal cortisol secretion and 2-year changes in older adults' physical symptoms: The moderating roles of negative affect and sleep.

Objective: This study examined whether the association between cortisol secretion and changes in physical health symptoms would depend on other factors in a person's life. The authors expected that physical health effects would emerge particularly when cortisol disturbances co-occur in the context of high levels of trait negative affect or poor sleep. Design: Physical symptoms, diurnal cortisol secretion, affective tendencies, and sleep efficiency were assessed in a 2-yr longitudinal study of 184 older adults. Main Outcome Measure: Two-year changes in physical symptoms. Results: High cortisol levels were associated with increases in physical symptoms, but only among participants who experienced high negative affect and poor sleep. Conclusion: Elevated levels of cortisol secretion contribute to older adults' physical symptoms if they co-occur in the context of other emotional and behavioral problems. By contrast, cortisol disturbances may not influence physical symptoms among people who are emotionally well or engage in efficient sleep behaviors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comorbidity of Chronic Pain and Mental Health Disorders: The Biopsychosocial Perspective.

An exciting period in mental and physical health research is beginning, resulting from a paradigm shift from an outdated biomedical reductionism approach to a more comprehensive biopsychosocial model, which emphasizes the unique interactions among biological, psychological, and social factors required to better understand health and illness. This biopsychosocial perspective is important in evaluating the comorbidity of mental and physical health problems. Psychiatric and medical pathologies interface prominently in pain disorders. Important topics in the biopsychosocial approach to comorbid chronic mental and physical health disorders, focusing primarily on pain, are presented. Though this biopsychosocial model has produced dramatic advances in health psychology over the past 2 decades, important challenges to moving the field forward still remain. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical assessment and treatment of insomnia.

Insomnia is characterized by problems initiating and maintaining sleep—problems that often go unrecognized by psychotherapists as well as physicians. This article addresses central questions related to the diagnosis, assessment, and treatment of this problem. Differential diagnosis is focused upon as well as the comorbidity with psychiatric and organic disorders. The Assessment of Insomnia section covers different subjective measures of sleep: sleep diaries, sleep questionnaires, and sleep interview. Additionally, central objective sleep measures are included. In the Treatment of Insomnia section, the 6 most common behavioral interventions are presented together with the most current pharmacological approaches. (PsycINFO Database Record (c) 2010 APA, all rights reserved)