Sleep is a Vital Sign : Why Assessing Sleep is an Important Part of Women's Health Care

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http://nwh.awhonn.org 2010, AWHONN 243WeLLWOMANdDo you take for granted your ability to sleep and wake up refreshed? Or is the pursuit of suf-ficient and effective sleep a challenge you face each night? What about your patients? Wheth-er theyre pregnant, new mothers or perimeno-pausal women, they likely face their own sleep challenges. And what can the quality of a wom-ans sleep tell us about her general state of physi-cal, mental and emotional well-being? After all, its not just hormones and babies that can in-terfere with sleep. Medications, chronic illness, sleep disorders and our 24/7 digitally enhanced lives provide very real barriers to the quest for consistent, restorative sleep. Sleep is essential to good health, adequate daily performance and disease prevention. Its as vital to our functioning as adequate nutrition and, on any given day, perhaps more important than obtaining adequate physical activity. Its so often taken for granted as a part of life that clinicians may forget to include a basic sleep evaluation as part of an annual physical exam. Nutrition and exercise are recommended to be Sleep is essential to good health, adequate daily performance and disease preventionSleep is a Vital SignWhy Assessing Sleep is an Important Part of Womens Health CareCatherine Ruhl, CNM, MS244 Nursing for Womens Health Volume 14 Issue 3routinely assessed in the primary care of chil-dren and adults, but sleep is not specifi ed as an essential function to assess (U.S. Department of Health and Human Services, Health Resources Services Administration, Bureau of Health Pro-fessions, Division of Nursing, 2002). National Sleep AnalysisTh e Centers for Disease Control and Preven-tion (CDC) just released their fi rst-ever analy-sis of data on insuffi cient rest or sleep from the Behavioral Risk Factor Surveillance System for all 50 states in October of 2009 (CDC, 2009). Th ey found that 11.1 percent of adults surveyed reported insuffi cient sleep every day for the 30 days preceding the survey and that women were more likely than males, and non-Hispanic blacks were more likely than other groups, to report in-suffi cient rest. Age also made a diff erence, with those ages 25 to 34 reporting the most days of insuffi cient sleep and those over 65 reporting the fewest. Even geography was a factor. A high prevalence of insuffi cient sleep was concentrated in the southeastern United States. Th e research-ers hypothesized that this fi nding could be relat-ed to the regions higher concentration of chron-ic diseases associated with sleep disturbances. Th e CDC, while pointing out that few clinical guidelines for assessing and treating sleep insuf-fi ciency exist, concluded that health care provid-ers should routinely assess sleep quality so they can advise and refer their patients as needed. Consequences of Inadequate SleepTh e CDC states that the importance of chron-ic sleep insuffi ciency is underrecognized as a public health problem even though its associ-ated with chronic physical and behavioral health problems, injury, loss of productivity and mor-tality. Sleep-related problems aff ect 50 to 70 mil-lion American of all ages (Hunt, 2004; Institute of Medicine [IOM], 2006). Inadequate sleep and sleep disorders increase the risk of hyperten-sion, diabetes, obesity, depression, heart attack and stroke (IOM; Patel & Hu, 2008). Sleep disorders include insomnia, restless leg syndrome (RLS) and sleep apnea. Chronic sleepi-ness can adversely aff ect the immune system and infl ammatory response (Hunt, 2004). Chronic sleep restriction of 6 hours or less per night has been shown to decrease cognitive performance to the same degree as two total nights of sleep depri-vation (Van Dongen, Hans, Maislin, Mullington, & Donges, 2003). Close to 20 percent of serious car crashes are associated with driver sleepiness Catherine Ruhl, CNM, MS, is director of womens health at AWHONN in Washington, DC. Address correspondence to: cruhl@awhonn.org.DOI: 10.1111/j.1751-486X.2010.01546.x WeLLWOMANMedications, chronic illness, sleep disorders and our 24/7 digitally enhanced lives provide very real barriers to the quest for consistent, restorative sleepJune | July 2010 Nursing for Womens Health 245WeLLWOMANAwareness of the risks of sleep restriction may motivate a woman to make sleep a priority in her lifeand billions of dollars are spent on the direct med-ical costs of treating sleep disorders (IOM, 2006).Women need to be educated about the very real consequences of inadequate sleep. Wom-en who restrict their sleep due to the demands of their daily lives need to consider the cost, in terms of their own health, their productivity and the potential effects of their sleeplessness on oth-ers when it comes to making errors in the work-place or operating cars or machinery. Awareness of the risks of sleep restriction may motivate a woman to make sleep a priority in her life.Women and Sleep Womens health care providers need to under-stand the sleep challenges specific to women in order to work with women to create personal-ized plans for better sleep. Women commonly experience family and occupational interference with obtaining sufficient and restful sleep. Women entered the workforce in rising numbers in the latter half of the 20th century, but their child care and domestic duties did not neces-sarily decrease, leaving them with fewer hours for other activities, including sleep. Infants and children often have interrupted sleep schedules that affect their mothers sleep. Economic pres-sures may lead women to have multiple jobs out-side the home. Those who do shift workthat is, working rotating shifts or at nightare espe-cially at risk for poor sleep quality. The schedules involved with shift work often do not coincide with the bodys natural circadian rhythms. Shift work sleep disorder is defined as experiencing a recurrent pattern of sleep interruption resulting in excessive sleepiness, insomnia and irritability. It can cause poor concentration, errors, accidents and injuries (National Sleep Foundation, 2009).A womans life stage, hormonally, also af-fects her sleep quality and length. Women may average 300 to 450 menstrual cycles in their re-productive years, depending on age at menarche and menopause, number of pregnancies, length of lactation and hormonal contraceptive use. This monthly hormonal cycling, plus the effects of pregnancy, postpartum and perimenopausal hormonal fluctuations, can lead to years of sleep challenges. Educating women about how hor-mones influence sleep and strategies to manage these effects may help women feel that they have more control, or at least know what to expect, while living with interrupted sleep at certain times in their lives (see Box 1). Sleep and Chronic ConditionsChronic conditions that cause respiratory problems, difficulty moving or pain generally Box 1. Hormonal States and Sleep Symptoms Sleep Disorders Affecting Sleep Hormonal Changes In This StageMenstrual cyclePregnancyPerimenopauseRLS = restless leg syndrome Sources: Wolfson (2001); Hunt (2004)PMS: bloating, cramping, mood disorderReflux, shortness of breath, leg cramps, urinary frequency, backachesHot flashes espe-cially at nightAbrupt progester-one decrease with onset of menses or day before menses beginsIncreased progester-one causes fatigue in the first trimesterFluctuations in estrogen and pro-gesteroneInsomnia (day 27-day 1), RLS (if anemic)RLS (if anemic), sleep apnea (associated with increased risk of pre-eclampsia)Sleep apnea increases in incidence and severity at this time246 Nursing for Womens Health Volume 14 Issue 3described in the literature, women also seem to have higher rates of restless leg syndrome (Hunt). Nursing Interventions Nurses can assist women to develop and implement plans for better sleep and assess and refer them for treatment for sleep disorders. A womans health history, including a sleep assessment, can help the nurse and patient identify whether lifestyle and occupational fac-tors, hormonal fluctuations, social and emotional stress, chronic illness, medi-cations or a combination of factors are contributing to disrupted sleep. Long-term strategies should address mitigat-ing the effects of these underlying fac-tors on sleep and may require referral to specialists for disease management or sleep disorder evaluation. All wom-en with sleep disturbances can benefit from changing unhealthful sleep habits and improving sleep routines. Adher-ing to regular and consistent hours of sleep, avoiding large meals in the hours before bedtime and developing relax-ing presleep rituals are helpful for many half of sleep, causing multiple awak-enings and reduced total amount of sleep. Caffeine causes sleep fragmenta-tion and its half-life of between 3 and 7 hours means that even consuming bev-erages containing caffeine in the after-noon may interfere with sleep at night (Elliott). Stressful life events frequently cause sleep disruptions, but when sleep is af-fected despite resolution of the event, it may be a sign that coping strategies are ineffective. Intimate partner violence (IPV) affects women disproportionately and can interfere with sleep due to con-cerns for safety and mental and emo-tional stress. Insomnia and daytime fatigue occur at high rates in women who experience IPV (Campbell, 2002). Basic assessments for sleep disor-ders can be made in the primary care setting and are especially important in womens health (see Box 2). The rate of sleep apnea triples after menopause and becomes equivalent to the rate in men (Hunt, 2004). Women have higher rates of insomnia compared with men, at all ages, and although this is not well-interfere with sleep. Certain chron-ic conditions affecting sleep are more common in women, including fibro-myalgia, chronic fatigue syndrome, os-teoarthritis and depression. More wom-en than men report sleep disturbances connected with a depressive episode, so sleep complaints may help identify women with depression or at increased risk of depression. Depression is the most frequent cause of chronic insom-nia (Hunt, 2004). Certain chronic illnesses known to adversely affect sleep may require medications that may also affect sleep quality and duration. Examples of these medications are beta-blockers, bron-chodilators, stimulating antidepres-sants, thyroid supplements and decongestants (Elliott, 2001). Substance use and abuse assessment is impor-tant when assessing sleep. Nicotine is a stimulant and can cause insomnia and sleep-disordered breathing, due to ir-ritation of respiratory passages. Alcohol is used by many people to help them fall asleep, but it decreases rapid eye movement (REM) sleep in the second Box 2. Sleep Disorder Assessment Questions What do you think is the problem with your sleep? What is your average total sleep time? Do you have difficulty falling asleep or maintaining sleep? Do you feel rested when you wake up? Do you feel excessively sleepy during the day? Are you or those who share your environment aware that you snore or have apneic episodes? Do you wake up at night with leg cramps or calf pain?Source: Elliott (2001).Adhering to regular and consistent hours of sleep, avoiding large meals in the hours before bedtime and developing relaxing presleep rituals are helpful for many womenJune | July 2010 Nursing for Womens Health 247WeLLWOMANInstitute of Medicine. (2006). Sleep disorders and sleep deprivation: An unmet public health prob-lem. Retrieved from http://books.nap.edu/open-book.php?record_id=11617&page=1National Library of Medicine. (2009). Melatonin. Retrieved from http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.htmlNational Sleep Foundation. (2009). Shift work and sleep. Retrieved from http://www.sleepfounda-tion.org/article/sleep-topics/shift-work-and-sleepPatel, S.R., & Hu, F. B. (2008). Short sleep duration and weight gain: A systematic review. Obesity, 16(3), 643653.U.S. Department of Health and Human Services, Health Resources Services Administration, Bu-reau of Health Professions, Division of Nursing. (2002). Nurse practitioner primary care compe-tencies in specialty areas. Retrieved from http://www.nonpf.com/associations/10789/files/ PrimaryCareComps02.pdfVan Dongen, Hans P.A., Maislin, G., Mullington, J.M., & Donges, D.F. (2003). The cumulative cost of additional wakefulness: Dose-response effects of neurobehavioral function and sleep physiol-ogy from chronic sleep restriction and total sleep deprivation. Sleep, 26(2), 117126.Wolfson, A. R. (2001). The womans book of sleep. Oakland, CA: New Harbinger Publications.women. Creating a dedicated sleep space that is free of distractions can promote sleep (Wolfson, 2001). Sleep diaries can help women pinpoint patterns of sleep disturbances and evaluate progress in achieving better sleep. Depending on the underlying cause, or if there is no apparent underlying cause, sleep aids may be helpful. Benzodiazepines, nonbenzo-diazepines, antidepressants and antihistamines are various categories of drugs that can improve sleep when prescribed for short-term use. Tol-erance and rebound insomnia may be side ef-fects (Wolfson, 2001). Melatonin is a naturally occurring hormone produced by the pineal glad that can be bought over-the-counter as a dietary supplement. It has shown promise in treating jet lag and there is limited evidence that melatonin can decrease the time it takes to fall asleep and increase duration of sleep. Melatonin should be avoided by women who are trying to become pregnant, are pregnant or are breastfeeding (Na-tional Library of Medicine, 2009). Conclusion Dont miss the opportunity to educate wom-en about the importance of sleep, and inquire about their sleep quality and quantity. Even if they dont experience sleep problems, they will appreciate your concern. And if they are suf-fering from sleep disturbances, solutions exist that can improve, if not solve, their sleep issues. NWHReferencesCampbell, J.C. (2002). Health consequences of inti-mate partner violence. Lancet, 359, 13311336. Centers for Disease Control and Prevention. (2009). Perceived insufficient rest or sleep among adultsUnited States, 2008. Morbidity and Mor-tality Weekly Report, 58(42), 11751179. Re-trieved from http://www.cdc.gov/mmwr/pre-view/mmwrhtml/mm5842a2.htmElliott, A.C. (2001). Primary care assessment and management of sleep disorders. Journal of the American Academy of Nurse Practitioners, 13(9), 409417.Hunt, C. (2004). Sleep problems and sleep dis-orders. Clinical updates in womens health care. Washington, DC: American College of Obstetri-cians and Gynecologists.Get the FactsCDChttp://www.cdc.gov/Features/SleepNational Sleep Foundationhttp://www.sleepfoundation.orgNational Womens Health Resource Centerhttp://www.healthywomen.orghttp://nwhTalk.awhonn.org

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