Robert Ford
Narcolepsy
Psychiatric Nursing
MCI-ECPI

Recent statistics show that almost one percent of the American population is affected by narcolepsy. Only a quarter of that one percent has been medically diagnosed with the disorder, whereas others continue to mistake the disorder for other illnesses such as epilepsy, depression, and side effects of different medicines. While many have not heard much about Narcolepsy, it’s just as common and proliferating as other common diseases such as Parkinson’s disease and multiple sclerosis and appears in every ethnic group in the world. To date, many people are unaware of what narcolepsy is and the side effects of such a quiet and mysterious disorder. If one experiences irrepressible periods of sleepiness through the day, even during your most intense activities today, then perhaps Narcolepsy is something to consider and something that’s need to be research so proper diagnosis and treatment can take place. This is hard to do, when Narcolepsy is so easily overlooked and are mistaken for other illnesses. But even when a person hears the word Narcolepsy, it’s doubtful that they are even sure of what it is or they possess any extensive knowledge on the disorder (Khan, Hazin, & Iqbal, 2009).
Narcolepsy is a chronic neurological disorder in which the brain lacks the ability to regulate normal sleep-wake cycles. People with narcolepsy experience uncontrollable spells of sleep at any time throughout the day. Individuals will fall asleep for periods ranging from a couple of seconds to minutes. There are also instances were individuals remain sleep for hours at a time. There are three additional symptoms that frequently characterize narcolepsy other than excessive daytime sleepiness. They include clear hallucinations during sleep onset or just before awakening, short episodes of complete paralysis at the beginning or end of sleep, and cataplexy, or the abrupt loss of voluntary muscle tone. Patients are not definitively diagnosed with narcolepsy until approximately 10 to 15 years after the first symptoms emerge. The exact cause of narcolepsy is unknown. It is believed that narcolepsy involves several factors interacting to trigger sleep disturbances and neurological dysfunction (National Institute of Health, 2010). People with narcolepsy do not spend a considerably larger amount of time asleep during a 24-hour period than normal individuals. A large amount patients experience repeated awakenings during the night in addition to involuntary sleep episodes and daytime drowsiness which is why it is considered to be a disorder of the natural boundaries between sleeping and waking states. A normal night's sleep lasts approximately 8 hours for most adults, and is composed of four to six individual sleep cycles. A sleep cycle is a sector of non-rapid eye movement (NREM) sleep proceeded by a period of rapid eye movement (REM) sleep (National Institute of Health, 2010).
Narcolepsy is a more complex and disturbing condition than a sleep disorder. The exact etiology of narcolepsy is not clear, but recent studies indicate a blend of abnormal neurotransmitter functioning and sensitivity, genetic predisposition, and abnormal immune modulation contributing to the development of the disorder (Khan, Hazin, & Iqbal, 2009). The hereditary foundation of the disorder stems from findings which associate human leukocyte antigen (HLA) subtypes as predisposing individuals to narcolepsy. There seems to be a link between deviations on HLA genes on chromosome 6 and the development of narcolepsy(Khan, Hazin, & Iqbal, 2009). Human leukocyte antigen (HLA)-DR2 and DQB1*0602 antigens have been connected to the onset of narcolepsy, particularly in cataplectic patients(Khan, Hazin, & Iqbal, 2009). The deviations in HLA complexes that go along with these genetic alterations are thought to initiate an autoimmune response against neurons in the central nervous system that are responsible for making hypocretin, a peptide neurotransmitter that plays a critical role energy homeostasis, sleeping patterns, neuroendocrine regulation, and in regulating appetite(Khan, Hazin, & Iqbal, 2009) . Studies have revealed a reduction in the number of hypocretin-producing neurons and levels of hypocretin in narcoleptic patients. A similar mutation on chromosome 12 in canines display similar dysfunction in hypocretin production, but no such mutation has been connected to the development of human narcolepsy(Khan, Hazin, & Iqbal, 2009). Although a strong association between genetic changes and narcolepsy exist, hereditary transmission is not the only cause in the development of narcolepsy. No form of inheritance has been identified in patients with familial forms of narcolepsy where genetic transmission is the principal cause(Khan, Hazin, & Iqbal, 2009).
Other neurochemical dysfunctions include malfunctions in the dopamine system. The brains of narcoleptic patients normally show monaminergic (norepinephrine and dopamine) hypoactivity. Canine studies have shown that cholinergic stimulation can induce cataplexy in narcolepsy (Khan, Hazin, & Iqbal, 2009). These neurochemical provide insight into why recent trials using the anticholinergic agent, atropine and a monoamine oxidase B inhibitor, selegiline, have shown potential in treating narcoleptic patients. “Selegiline increases the release of dopamine by blocking monamine oxidase B, and concomitantly protects dopaminergic neurons by increasing the levels of cyclic adenosine monophosphate (AMP) with the net effect of improved symptoms in narcoleptic patients (Khan, Hazin, & Iqbal, 2009).” The decreased cataplexy in canine models are attributed to atropine's inhibition of cholinergic pathways, which demonstrated promise for future treatment of narcoleptic patients with similar clinical findings (Khan, Hazin, & Iqbal, 2009).
A narcolepsy diagnosis requires several tests. The physician will perform a physical exam and an in-depth medical history to rule out other diagnosis. Several specialized tests, which can be performed in a sleep disorders clinic, are typically required before a diagnosis can be made. Two tests that are crucial in substantiating a diagnosis of narcolepsy include the polysomnogram (PSG) and the multiple sleep latency test (MSLT). Questionnaires, such as the Epworth Sleepiness Scale, are also used to assess excessive daytime sleepiness. For the Epworth Sleepiness Scale test, the patient is asked to answer eight questions using a scale from zero (not at all likely to fall asleep) to three (very likely to fall asleep). The total score is between 0 and 24. A cumulative score of 0 to 10 are normal and a score above 10 generally requires further examination (Chanin, 2010).
Polysomnogram, a sleep study, is a test that electronically transmits and records precise physical actions of the body while sleeping. Patient is to arrive at the sleep lab two hours before bedtime and the patient is not to deviate from normal daily routine. The patient is assigned to a private room in the sleep center and there is a central monitoring area where professional staff will monitor the patient throughout the night. The patient is hooked up to specialized equipment so special movements can be recorded. These movements include breathing patterns, brain activity, and muscle movement. The results are examined by a qualified sleep specialist to establish whether or not you have a particular sleep disorder (Chanin, 2010).
The multiple sleep latency tests are completed the morning after the overnight polysomnogram. This test measures how long it takes for the patient to fall asleep during the day. Prior to the test, the patient is asked to keep a journal of the time they awake, nap times, and bed times. The physician will use the journal to initiate a plan to eliminate medications that may affect the sleep test results. The patient is asked to take four or five planned naps every two hours during the test. The first nap will begin two hours after awakening that morning. Individuals with normal sleep and alertness take approximately 10-20 minutes to fall asleep. People with narcolepsy and other abnormal sleep patterns take a much shorter time to fall asleep (Chanin, 2010).
There is currently no available cure for narcolepsy. The most disabling symptoms of narcolepsy, excessive daytime sleep and cataplexy, however, can be controlled with medication regimens. The treatment regimen is customized to the change in symptoms (National Institute of Health, 2010).
For the past several years, physicians have used central nervous system stimulants-amphetamines such as, dextroamphetamine, pemoline, methamphetamine, and methylphenidate to reduce the incidence of sleep attacks and alleviate excessive day time sleep. The majority of patients indicate that these medications are very effective in improving levels of alertness and reducing daytime drowsiness. Like other medications however, there are several less appealing side effects that must be monitored. These side effects include upset stomach, night time sleep disturbances, irritability, shakiness, anorexia, nervousness, and disturbances in heart rhythm. There is also the risk of the body becoming tolerant when there is long term use. When tolerance occur the dosage of medication must be increased to maintain therapeutic effectiveness. There is also a high potential for abuse with amphetamines (National Institute of Health, 2010).
A new non-amphetamine wake-promoting drug called modafinil was approved by the Food and Drug Administration in 1999 for the treatment of excessive daytime sleep. Modafinil showed to be effective in lessening excessive daytime sleep and showed fewer, less serious side effects than amphetamines in clinical trials. The most commonly reported side effect was headache. There also appears to be no risk for tolerance when the drug is used for long periods of time (National Institute of Health, 2010). The Food and Drug Administration also approved xyrem on July 17, 2010, for treatment of cataplexy in patients that suffer from narcolepsy. This drug is currently restricted due to safety concerns associated with its use (National Institute of Health, 2010).
There are two groups of antidepressant drugs that have proved to be effective in managing cataplexy in patients. They include selective serotonin reuptake inhibitors (SSRI) (sertraline and fluoxetine and) and tricyclics (clomipramine, desipramine, protriptyline and imipramine). Side effects that must be addressed with this medication include high blood pressure, irregular heart rhythm, and impotence (National Institute of Health, 2010).
The nurse plays an important role in the care of an individual with narcolepsy. It is important to provide as many resources as possible to patients and explain what narcolepsy is and how it may affect their lives. The information should be provided to match the literacy level of the patient. Assess patient’s usual sleep habits and recent sleep quality as part of the initial nursing history. The nurse would make whatever immediate changes are possible to accommodate the patient. The nurse would also explore with patient, feelings about the disorder and the need for ongoing treatment (Varcarolis RN, 2010).
Narcolepsy can be complicated if a set sleep period cannot be formed or regulated. Certain substances such as caffeine, alcohol, and nicotine can also interfere with sleep during set sleep periods and can complicate the tantrums of narcoleptic episodes. It is important also to stay in safe environments replete with people and out of harm’s way so that episodes cannot result in unintentional fatalities of any sort. Narcolepsy is a disease that should be taken seriously and without the help of professionals such as doctors and nurses, can be catastrophic to the health of the patient and those around the patient. Close observation and individualistic approach is needed for each patient to ensure good health and safety.

References

Bozorg MD, A. M., & Benbadis MD, S. R. (2010, 02, 19). Narcolepsy. Retrieved Oct. 17, 2010, from EMdeicine from Web MD: emedicine.medscape.com
Chanin, M. ,. (2010, 03 03). Diagnosing Narcolepsy. Retrieved Oct. 17, 2010, from WebMD: www.webmd.com/sleep-disorders/guide/diagnosing-narcolepsy
Khan, M. F., Hazin, M. ,., & Iqbal, M. ,. (2009). Narcolepsy: Clinical Decision Making for the Primary Care Physician: Pathophysiology. Retrieved Oct. 17, 2010, from Medscape from WebMD: www.medscape.com/viewarticle/715634_2
National Institute from National Institute of Neurological Disorder and Stroke: www.ninds.nih.gov of Health. (2010, 05 14). NINDS Narcolepsy Information Page. Retrieved Oct. 17, 2010. Varcarolis, M.E. (2010). Annual of psychiatric nursing care planning (4th ed.). New York, NY: Saunders Elsevier.