CorrectCare

'I Can't Sleep': Treating Complaints of Sleep Disturbance in Corrections

by Joyce Rackauskis-Anderson, MSN, ARNP

The first patient of the day has written a sick-call slip stating, “I need something for sleep.” When asked about her major problem, she immediately responds, “I can’t sleep and need something to help me sleep.” In the past, my immediate response was, “I don’t give medications for sleep.” Eventually, I realized that the therapeutic relationship with my patients was compromised by this response, and I needed to change how I dealt with complaints about insomnia in the jail.

Practitioners often become frustrated when trying to deal with inmate complaints about sleeping problems and feel pressured to prescribe sleeping medications, which may not be the optimal treatment for insomnia in the correctional setting. However, untreated sleep disturbances may cause symptoms of depression, irritability, impaired cognitive function, fatigue, difficulty with concentration and focus, and daytime sedation.

In the correctional environment, a variety of factors may cause difficulty with sleep, including medical issues, psychological problems and poor sleep hygiene practices. Primary insomnia occurs in 25% of patients and is related to poor sleep environment, poor sleep hygiene, rebound insomnia from sleeping aids, side effects to medications and shift work. Secondary insomnia occurs in the remaining 75% of the patients and is directly related to medical and/or mental health illnesses.

To deal effectively with an inmate’s sleep disturbances, the practitioner should obtain a comprehensive medical, psychological and sleep history and then identify any factors interfering with sleep and develop treatment plans to resolve identified problems.

Medical Comorbidities
The psychiatric/medical evaluation should include an identification of the patient’s medical comorbidities as virtually any medical comorbidity can cause insomnia. These include respiratory problems such as COPD, asthma, allergic rhinitis, sleep apnea and acute respiratory infections, which can interfere with the ability to sleep by compromising adequate air exchange; rashes and infections, which cause pain and itching; gastrointestinal problems such as heartburn, diarrhea, acute gastritis and irritable bowel syndrome; cardiac problems, including angina, irregular heart rates, lower extremity pain or ulcerations from poor circulation; and uncontrolled hypertension. Additionally, any cause of chronic or acute pain may interrupt sleep patterns. Arthritis, fibromyalgia, neck and back pain from old or new trauma, and neuropathy from diabetes or chronic alcoholism will prevent the patient from falling asleep and being able to stay asleep. All of the above need to be adequately treated to minimize effects on sleep.

Mental Health Factors
Psychological factors that interfere with sleep include bipolar disorders, anxiety, depression, psychosis and PTSD, along with addiction and withdrawal from drugs and alcohol. The bipolar patient in the manic phase will report difficulty with sleep, often obtaining only 3 to 4 hours of sleep a day. Rapid speech, flight of ideas and restlessness significantly interfere with the normal sleep pattern in these patients. A psychotic patient who is actively having auditory or visual hallucinations and paranoid delusions will demonstrate inappropriate behaviors, irritability and restlessness such that sleep may be nonexistent.

Depressed patients may complain of fatigue and difficulty staying awake, as well as the desire to remain in bed all the time. Alternatively, they may complain of fatigue but with an inability to sleep, along with feeling restless and overwhelmed most of the time. PTSD causes nightmares about previous traumatic experiences and thus interrupts the patient’s sleep. Anxiety causes restlessness, irritability, feelings of being overwhelmed with life stressors and difficulty maintaining a normal sleep pattern.

Practitioners can control psychological symptoms that interfere with the patient’s sleep by identifying the mental health disorder and prescribing appropriate medications. In addition, the practitioner should make appropriate referrals to self-help programs offered by the facility. Narcotics Anonymous, Alcoholics Anonymous, church groups, therapeutic counseling, trustee work, educational courses and group therapy enable the patient to develop healthy coping skills, institute healthy lifestyle changes and identify mechanisms to reduce life stressors.

Sleep patterns may be disrupted by substance abuse, and these patients may need treatment for the symptoms of withdrawal. Amphetamines, crystal methamphetamine and cocaine will cause prolonged episodes of wakefulness with a period of sleepiness and drowsiness when the patient stops using the drug. Opiates can cause sedation with significant withdrawal symptoms when the opiates are discontinued. Alcohol addiction may cause alcoholic withdrawal seizures or life-threatening delirious tremors requiring immediate treatment with a benzodiazepine taper.

Patients should be educated regarding the deleterious effects of drugs and alcohol on the normal sleep pattern. Furthermore, patients should be encouraged to make healthy lifestyle changes by avoiding future use of alcohol and illegal drugs.

Medication Effects
Various medications (e.g., steroids, hormone replacement medications, beta blockers, beta-agonists, antidepressants, antipsychotics, amphetamines, decongestants, antineoplastic agents, bronchodilators, diuretics, Dilantin and thyroid medications) can interfere with a patient’s ability to sleep and should be considered when determining the etiology of an individual’s sleep disturbances. Psychiatric medications associated with insomnia include Abilify, Celexa, Effexor, Lexapro, Luvox, Paxil, Pristiq, Prozac, Sinequan, Wellbutrin and Zoloft. Patients admitted to the correctional facility also may experience rebound insomnia when their prescribed sleeping medications are discontinued.

The practitioner should obtain a list of current medications and evaluate each for its potential to be the cause of the sleep disturbances. Adjustments in medication dosage or administration times may be needed to alleviate insomnia or somnolence associated with prescribed medications.

Sleep Hygiene
In addition, practitioners should assess sleep hygiene practices. A comprehensive sleep history will assist in understanding the patient’s sleep behavior. It should seek to identify problems with insomnia prior to incarceration, what the patient has done in the past to get to sleep and stay asleep, factors that have caused sleep problems in the past and current causes of the patient’s insomnia in the correctional environment.

Lastly, practitioners must be vigilant in monitoring who are patients attempting to obtain sedative medications for self-gain.

Treatment of verified sleep disturbances is three pronged and includes education in appropriate sleep hygiene practices, self-help in identifying causes that preventing adequate sleep and changing behavior as outlined below.

— About the author: Joyce Rackauskis-Anderson, MSN, ARNP, works at the Charlotte County Jail, Punta Gorda, FL. This article was reprinted with permission from the Summer 2009 issue of CorrDocs, the newsletter of the Society for Correctional Physicians. This version has been modified for CorrectCare and adds the recommendations and resources shown in More Information.

[This article first appeared in the Winter 2010 issue of CorrectCare.]