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Poststroke Sleep Disorders

An Executive Summary

Park, Da-In; Choi-Kwon, Smi

Journal of Neuroscience Nursing: December 2018 - Volume 50 - Issue 6 - p 314–317
doi: 10.1097/JNN.0000000000000404
Executive Summary

ABSTRACT Background: Poststroke sleep disorders (PSSDs) are common manifestations that may lead to adverse outcomes that pose a negative impact on the daily lives of stroke survivors. However, PSSD is poorly understood in terms of etiology, assessment, treatment, and nursing management. The purpose of this executive summary is to provide an overview to broaden our understanding of PSSDs. Method: The electronic databases EMBASE, PubMed, CINAHL, Cochrane Library, and Google Scholar were searched to identify any available relevant studies. Results: The 3 main sleep disorders among stroke survivors are sleep apnea, nighttime sleep disturbances, and excessive daytime sleepiness. The PSSD prevalence ranges from 13.2% to 94.0%. Conclusion: The causative mechanism seems to be multifactorial, but occurrence may differ depending on the stroke stage. Combined use of subjective and objective assessment methods may increase PSSD detection and early treatment.

Da-In Park, MSN RN, is PhD Student and Adjunct Instructor, College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea. Smi Choi-Kwon, PhD RN, is Professor, College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea.

Questions or comments about this article may be directed to Smi Choi-Kwon, PhD RN, at smi@snu.ac.kr. She is a Professor at the College of Nursing, The Research Institute of Nursing Science, Seoul National University, Seoul, Republic of Korea.

The authors declare no conflicts of interest.

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Background

Stroke is a common cause of death worldwide, and even if one survives, it may have unfavorable effects on quality of life.1–3 Although medical advancements have increased the stroke survival rate, patients are more likely to experience poststroke disabilities.2,4 Past investigations identified sleep disorders only as a prestroke risk factor, not a stroke complication.5 Recent studies have indicated that stroke survivors commonly experience poststroke sleep disorders (PSSDs) that may lead to various adverse outcomes.3,6 However, PSSDs often go underdiagnosed and undertreated. Considering the rapidly increasing stroke survivorship, it is crucial to establish increased PSSD understanding and effective nursing implications. As neuroscience nurses, knowledge on prompt PSSD screening and management should be obtained to provide the best care and to prevent from further deterioration. Therefore, this executive summary aims to address the research evidence on PSSD definition, etiology, assessments, treatment, and nursing management.

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PSSD Definition

Caring for patients with PSSDs can be challenging because of lack of a clear consensus on the definition specific to the stroke population. Sleep researchers have defined sleep disorders in the general population as “any disturbed or altered breathing and ventilation during sleep.”7 For stroke care nurses, this definition, combined with other common symptoms of stroke survivors, is likely to be the most useful. Additional symptoms that stroke patients commonly experience include high frequency of sleep-wake cycle alterations, short sleep duration, feelings of nonrestorative sleep with a poor corresponding sleep efficiency, and frequent daytime dozing behaviors.4 In summary, PSSDs can be categorized into 3 types including sleep apnea (SA), nighttime sleep disturbances (NSDs), and excessive daytime sleepiness (EDS).

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Etiology

Recent studies indicate that the absence of airflow and ventilation while asleep is one of the most commonly observed sleep problems after stroke, with prevalence ranging from 52% to 94%.8–13 The 3 subtypes of SA among poststroke patients are obstructive SA (OSA), central SA (CSA), and mixed apnea. OSA presents as a consequence of mechanical narrowing in the airway system, CSA refers to loss of ventilator drive as a consequence of changes within the respiratory centers in the brain, and mixed apnea is a combination of central and peripheral breathing cessation.14 Stroke survivors are highly likely to develop upper airway obstruction during the first 24 hours after stoke onset, which may lead into OSA.12,13 Strokes affecting the brainstem, medulla, or bilateral hemispheres have a high possibility of presenting symptoms of CSA and mixed apneas.4

NSDs refers to difficulties initiating and maintaining sleep, unintended early morning awakenings and nonrestorative sleep, which causes impaired daytime functioning.15 Studies have found that 21.3% to 70.6% of stroke survivors complain of NSDs.3,6,16–20 Diabetes mellitus has been reported to be an independent predictor of NSDs caused by sympathetic arousal and hypothalamic pituitary adrenal axis activation.3 Studies showed disturbed emotional status such as depression and anxiety to be a contributing factor of NSDs.3,16–18,20 As for organic factors, left-hemisphere cortical area lesions affecting anterior circulation may be related to poorer sleep quality.3 Interestingly, damage to this area increases the likelihood of developing depression.21 It may be that poststroke NSD occurrence is significantly related to organic factors such as lesion location in the acute stage but emotional factors such as depression and anxiety in the chronic stage.3,20

Excessive daytime sleepiness refers to dozing behaviors due to irresistible desire to sleep during the day that may decrease overall daytime functioning, cognitive performance, and general well-being, which occurs in 11.9% to 49.5% of stroke survivors.12,20,22 Many argue that thalamic and subcortical lesions attribute to EDS, but the results are still debatable.3,20,22 Early studies showed that stroke survivors experience EDS in the earlier poststroke phase, but recent studies suggested it may persist into later phases, becoming a chronic problem.17,22 Depression and fatigue are closely related factors in all stages compared with lesion locations.20,22 Although the cause-and-effect relationship remains open to question, presence of SA and/or NSDs are also related to EDS development as evidenced by EDS patients having a higher number of apneic pauses during sleep, poor nighttime sleep quality, and feeling fatigued.20,22 Therefore, poststroke EDS may be a multidimensional phenomenon that is a consequence of SA, NSDs, and fatigue.

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Assessment Tools

Although a lack of gold standard assessment tool that captures complex aspects of PSSDs makes it difficult for nurses to accurately identify and diagnose symptoms in the poststroke population, several objective and subjective tools are suggested for nursing practice. For SA, polysomnography is a standard method to indicate apneic episode frequencies and severity by measuring apnea-hypopnea index.9,10,13,22–24 Although it is an ideal method for recording and interpreting biophysical data, it requires overnight testing in a specialized laboratory environment, which may cause unfamiliarity and discomfort to the PSSD patients resulting in inaccurate data readings. Polysomnography can also be very time consuming and expensive, making it impractical to apply to a wide range of poststroke patients who receive outpatient-based medical care. Portable respiratory polygraphy (RP) may be more suitable because it allows usage in various settings including hospitals and patient homes.25 However, researchers should take into consideration that RP may overestimate or underestimate the apnea-hypopnea index recordings. Considering this possible limitation, combined use of RP and subjective measurements such as the Berlin questionnaire and STOP-BANG is suggested. These tools are appropriate for clinical nursing use because they are feasible and easy to use and show good validity and sensitivity by including SA-specific questions such as habitual snoring behavior.12,19

Actigraphy, a wrist-sized activity sensor worn on the nondominant wrist, measures sleep patterns, sleep efficacy, and time in bed to determine NSDs.3 Until recent years, researchers have been hesitant to use actigraphy despite its high correlation with polysomnography results.26 As studies have shown its validity, reliability, and convenience, its use in poststroke patients is increasing to evaluate NSDs.3,26 The Karolinska Sleepiness Scale, Verran and Snyder-Halpern (VSH) Sleep Scale, Stanford Sleepiness Scale, and Pittsburgh Sleep Quality Index are used to capture respondents’ subjective NSDs at different time points: a specific time of the day, the previous night, the past 7 days, or the past month, respectively.12,17,19,20 The VSH may be the best option for NSD screening because it scores multiple aspects of sleep on a visual analog scale from 0 to 10 to indicate quality of sleep, and it may apply to a wider range of stroke subjects including those with a severe stroke. A combined use of actigraphy and VSH may be the best to capture objective and subjective poststroke NSDs.

Although there is no well-established diagnostic protocol, the Multiple Sleep Latency Test has been the most widely incorporated in EDS identification.22 The Multiple Sleep Latency Test can be achieved via actigraphy, which allows gross body movement detection at 30-second intervals to determine dozing behaviors during the day.3 Combined implementation of actigraphy and the Epworth Sleepiness Scale (ESS), a subjective tool that measures anticipated dozing behavior in 9 hypothetical situations, is recommended for poststroke EDS. The ESS well interprets stroke survivors’ sleep behaviors during daily activities.20 However, it should be noted that the ESS scores may be influenced by psychological factors such as depression and anxiety and, therefore, neuroscience nurses should separately assess these factors.

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Treatment and Nursing Management

In the respect that PSSD is a multifactorial stroke sequelae, an integrated and multidimensional approach is required in providing nursing care. Studies have indicated that limited medical treatment options are available for PSSDs, and they are similar to those of non–stroke-related sleep disorder treatments.8,9,11,12,23,24 Depending on the type of PSSD, pharmacological treatments involving sedative-hypnotic drug prescriptions or oxygen treatments involving positive airway pressure application are considered.4 However, these treatments are limited to physiologic symptom management and pose patient compliance and ineffectiveness issues longitudinally.4,15,27 It has been reported that, in the stroke population, treatment compliance is as low as 30% to 50% in the short term, and it decreases even further to as low as 15% on a long-term basis, which may be related to emotional disturbances.4 As NSDs and EDS are also closely related to depression and fatigue, proper assessment and preventative measures to manage the emotional symptoms of PSSDs are advised to provide a reliable and lasting improvement. These measures include combinations of cognitive-behavioral therapies, environmental stimulus control, sleep restrictions, positional therapy, and sleep hygiene.7 In addition, PSSD management educational programs that promote health and provide different coping and relaxation skills may lead to a reduction of sleep disorders.

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Conclusion

Poststroke sleep disorders are a persistent and debilitating condition that stroke survivors commonly endure. Although compelling evidence suggests that identification and treatment may be challenging because of the multifaceted aspects of PSSDs, poststroke-specific nursing assessment and management skills are critical in enhancing poststroke quality of life. Further evaluation according to different stages of stroke survival will open pathways to enhancing PSSD management. We advise future researchers to establish adequately powered, large-scale population-based studies and to develop poststroke-specific sleep measurement tools to expand our knowledge on PSSDs while maintaining optimized application of currently available instruments in nursing care.

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Keywords:

depression; excessive daytime sleepiness; executive summary; fatigue; nighttime sleep disturbance; sleep apnea; stroke

© 2018 American Association of Neuroscience Nurses