SLEEP QUALI TY I N TYPE 2 DI ABETI CS
Maria Carolina Belo da Cunha1
Maria Lúcia Zanet t i2 Vanderlei José Hass3
Cunha MCB, Zanet t i ML, Hass VJ. Sleep qualit y in t ype 2 Diabet ics. Rev Lat ino- am Enferm agem 2008 set em bro-out ubr o; 16( 5) : 850- 5.
Sleeping disorders in t ype 2 diabet ic pat ient s const it ut e risk fact ors for aggravat ing diabet es since t hey can affect t he m et abolic cont rol t hrough insulin resist ance syndrom e. This was an observat ional, cross- sect ional st udy. The m aj orit y ( 52% ) of subj ect s had scores indicat ing poor sleep qualit y. The Pit t sburgh Sleep Qualit y I ndex ( PSQI ) scor es show ed pat ient s w it h a t im e aft er diagnosis ov er 10 y ear s and hy per t ension had t he poor est sleep qualit y. For t hose w it h hem oglobin A1c > 7% t aking sleeping m edicines and t hose w ho had norm al body m ass index ( BMI ) , t he sleep qualit y was even poorer. The findings of t he present st udy reinforce t he relevance of t his t opic since t here are no specific t ools for sleep evaluat ion of t ype 2 diabet ics m aking it difficult t o m ake any assert ions on t he sleep qualit y of t hese pat ient s.
DESCRI PTORS: sleep disorders; diabet es m ellit us, t ype 2; qualit y of life
CALI DAD DEL SUEÑO EN DI ABÉTI COS TI PO 2
Los dist urbios del sueño en diabét icos del t ipo 2, const it uyen fact ores de riesgo para el agravam ient o de la diabet es, pues pueden int erferir en el cont rol m et abólico a t ravés del síndrom e de la resist encia a la insulina. El estudio fue del tipo observacional- transversal. La calidad del sueño fue investigada en 50 diabéticos del tipo 2, a quienes se aplicó el Í ndice de Calidad del Sueño de Pit t sbur gh ( PSQI ) . La m ay or ía ( 52% ) pr esent ó punt uaciones del PSQI , que indican calidad del sueño m ala. Aquellos con t iem po de diagnóst ico superior a 10 años y con hipertensión poseían peor calidad del sueño. Para aquellos con valores de Hem oglobina A1c > 7% , que usaban m edicam entos para dorm ir y los que presentaron I MC norm al, la calidad del sueño se m ostró peor. Lo encont r ado en est a invest igación r efuer za la r elevancia de la t em át ica, ya que no exist en inst r um ent os específicos para evaluar el sueño del diabét ico del t ipo 2, dificult ando afirm aciones sobre la calidad del sueño del diabét ico.
DESCRI PTORES: t ranst orno del sueño; diabet is m ellit us t ipo 2; calidad de vida
QUALI DADE DO SONO EM DI ABÉTI COS DO TI PO 2
Dist úrbios do sono em diabét icos do t ipo 2 const it uem fat ores de risco para o agravam ent o do diabet es, pois podem int erferir no cont role m et abólico at ravés da síndrom e da resist ência à insulina. O est udo foi do t ipo observacional- t ransversal. A qualidade do sono foi invest igada em 50 diabét icos do t ipo 2, sendo aplicado o Í ndice de Qualidade do Sono de Pit t sburgh ( PSQI ) . A m aioria ( 52% ) apresent ou escores do PSQI que indicam qualidade do sono ruim . Aqueles com t em po de diagnóst ico superior a 10 anos e com hipert ensão possuíam pior qualidade do sono. Para os out ros com valores de hem oglobina A1c > 7% , que usam m edicação para dor m ir , e aqueles que apr esent ar am I MC nor m al a qualidade do sono m ost r ou- se pior . Os achados dest a invest igação reforçam a relevância da t em át ica, pois não exist em inst rum ent os específicos para a avaliação do sono do diabét ico do t ipo 2, dificult ando afirm ações acerca da qualidade do sono do diabét ico.
DESCRI TORES: t ranst ornos do sono; diabet es m ellit us t ipo 2; qualidade de vida
Universit y of Sao Paulo at Ribeirao Pret o College of Nursing, WHO Collaborat ing Cent er for Nursing Research Developm ent , Brazil:
1 RN, M.Sc. in Nursing, e- m ail: carolindabelo@yahoo.com .br; 2 RN, Free Lect urer, Associat e Professor, e- m ail: zanet t i@eerp.usp.br; 3 St at ist ician, Free Lect urer, e- m ail: haas@eerp.usp.br.
I NTRODUCTI ON
D
iabet es m ellit u s is a ch r on ic con dit ion of public healt h concer n due t o it s high m or bidit y andm or t alit y and significant loss of qualit y of life.
I n Br azil it is est im at ed t h at t h er e w ill b e
ar ound 1 1 . 3 m illion diabet ic pat ient s by 2 0 3 0 , ov er
1 0 0 % in cr ease com p ar ed t o t h e cu r r en t 5 m illion
diabet ic pat ient s( 1).
St udies point t he aging of diabet ic pat ient s,
incr eased r isk fact or s t hat ar e dir ect ly associat ed t o
m oder n life habit s and im pr ov ed diagnost ic cr it er ia( 2)
as causes for such growt h. Prolonged unhealt hy eat ing
h a b i t s, sm o k i n g , p h y si ca l i n a ct i v i t y, o b e si t y, a n d
alcohol abuse( 2) are am ong t he m ost invest igat ed risk
fact or s for diabet es m ellit us.
Diabet es r isk fact or s such as obesit y, or gan
fat , advanced age now have been associat ed t o
sleep-relat ed respirat ory disorders( 3). New fact ors t hat m ay
predispose t o t he developm ent of diabet es as well as
t he associat ion bet ween im paired glucose m et abolism
a n d r e d u c e d s l e e p h o u r s h a v e b e e n r e c e n t l y
in v est ig at ed .
Dur ing sleep, indiv iduals ex per ience a r ange
of changes in t heir cognit iv e and sy st em ic funct ions,
su ch as r ed u ct ion of car d iac ou t p u t an d p er ip h er al
v ascu lar r esist an ce an d con seq u en t ly r ed u ct ion of
blood pr essur e due t o r educed sy m pat het ic act iv it y,
h y p o - a n d h y p e r v e n t i l a t i o n , h y p o t h e r m i a a n d
h or m on al secr et ion( 4 ).
Melat onin is a horm one produced during sleep
secret ed by t he pineal gland. I t act s in sleep regulat ion
an d h as an an t iox idan t act ion as w ell. Lept in , also
secr et ed du r in g sleep, is a h or m on e t h at act s as a
sat iet y m od er at or b alan cin g ou t t h e n eed f or f ood
int ak e and ener gy consum pt ion( 4).
Du r in g sleep depr iv at ion , h y per secr et ion of
l e p t i n l e a d s t o i n cr e a se d f o o d i n t a k e , e sp e ci a l l y
car bohydr at es, w hich can pr edispose t o or aggr avat e
o b e si t y. No t a b l y, o b e si t y p r e d i sp o se s t o ch r o n i c
degener at iv e diseases such as diabet es m ellit us( 5).
I n ad d it ion , sleep d ep r iv at ion is k n ow n t o
inhibit insulin product ion by increasing cort isol levels.
I n t he long run it m ay induce t o a pre- diabet es st at e
or ev en t o full- blow n diabet es( 6).
Wh i l e sl eep i n g , n o r m al i n d i v i d u al s k eep a
balance bet ween insulin secret ion and glucose upt ake,
wit hout showing high or low blood glucose levels. But
in diabet ic pat ient s such balance is im pair ed due t o
low blood glucose lev els( 6).
Sleep depr iv at ion has been show n t o cause
i n cr e a se d g l u co se l e v e l s d u e t o r e d u ce d g l u co se
m e t a b o l i s m a n d h i g h c o r t i s o l l e v e l s . B e s i d e s
aggr av at ing diabet es by incr easing glucose lev els, it
c a n p o s e a h i g h e r r i s k f o r t h e d e v e l o p m e n t o f
diabet es( 7 ).
The inabilit y of diabet ic pat ient s t o m aint ain
a norm al sleep pat t ern can involve m ore t han feeling
t i r e d t h e n e x t d a y s i n c e t h e m e t a b o l i c c o n t r o l ,
product ion of glucocort icoids and blood glucose cont rol
ar e af f ect ed lead in g t o t h e d ev elop m en t of in su lin
r esist an ce.
S t u d i e s h a v e d e s c r i b e d i n t r i n s i c ( s l e e p
a p n e a , i n so m n i a , p e r i o d i c l i m b m o v e m e n t s) a n d
ex t r i n si c sl eep d i so r d er s ( ci r cad i an r h y t h m , sl eep
h y g i e n e a n d p sy ch o a ct i v e d r u g u se ) i n d i a b e t i c
p at ien t s. Th e m ost com m on d isor d er seen is sleep
apnea( 8- 9).
I ndividuals wit h sleep apnea have shown high
levels of lept in associat ed wit h resist ance t o it s act ion.
This st at e is aggr av at ed b y obesit y, pr edisposing t o
t he developm ent of ot her diseases such as diabet es( 5).
Lept in n ot on ly r egu lat es appet it e bu t also
act s on ch em or ecept or s t h at can det ect ch an ges in
ox y gen and car bon diox ide lev els. The pat hogenesis
of vent ilat ory dysfunct ions in diabet ic pat ient s is also
associat ed t o changes in t he chem orecept ors involved
in t he cent r al r espir at or y funct ion.
Sleep deprivat ion in diabet ic pat ient s has also
been associat ed t o ey e pr oblem s. Ret in opat h y m ay
b e in it iat ed or ag g r av at ed b y h y p ox ia t h at occu r s
dur ing sleep hour s in t he dar k . Ret inal blood flow in
n o r m a l i n d i v i d u a l s i s a d e q u a t e d u r i n g sl e e p . Bu t
diabet ic pat ien t s w it h r et in opat h y w h en ex posed t o
reduced light ness in a dark room during sleep do not
hav e adequat e ox y gen supply t o t he r et ina.
I t should be not ed t hat sleep fr agm ent at ion
due t o noct ur ia and ev en fr equent ur inat ion at night
m ay be a r eflex of poor blood glucose cont r ol( 10).
I n addit ion t o high blood glucose t hat affect
t h e sleep p at t er n of t y p e 2 d iab et ic p at ien t s, low
noct urnal blood glucose is oft en seen in 29% t o 56%
of insulin- dependent t ype 1 or t ype 2 diabet ic pat ient s
a n d m a y g o u n n o t i c e d o r a c c o m p a n i e d b y
m anifest at ions t hat affect sleep qualit y.
Psy ch op h y siolog ical in som n ia, d ef in ed as a
difficult y in failing asleep or st aying asleep, is anot her
int rinsic sleep disorder com m only report ed in diabet ic
Rest less leg syndrom e, anot her int rinsic sleep
disor der, is char act er ized by uncom for t able sensat ion
t hat occur s m ost ly dur ing sleep. The developm ent of
t his syndrom e is associat ed t o advanced age, urem ia,
p oly n eu r op at h y, r h eu m at oid ar t h r it is, an em ia, an d
m et abolic dist ur bances including diabet es m ellit us( 11).
Ex t r i n si c sl e e p d i so r d e r s a r e p a r t i cu l a r l y
associat ed t o en v ir on m en t - r elat ed f act or s su ch as
noise, act iv it ies such as m usic list ening, r eading, TV
w at ch in g , m an u al w or k , am on g ot h er s, as w ell as
excessive consum pt ion of food and drinks before sleep
t im e causing delay in sleep init iat ion.
I nt r insic and ex t r insic sleep disor der s affect
t o som e ext ent t he qualit y of life and t o great er ext ent
t he sleep qualit y of diabet ic pat ient s.
Given t hat sleep- relat ed ext rinsic and int rinsic
disorders in diabet ic pat ient s have been lit t le explored
in t he nursing area, furt her invest igat ions of reliable,
s p e c i f i c i n s t r u m e n t s t h a t c a n p r o v i d e o b j e c t i v e
i n f o r m a t i o n o n sl e e p q u a l i t y a r e n e e d e d . Th e se
in st r u m en t s can p r ov id e in p u t t o d ev elop ef f ect iv e
st r a t eg i es f o r q u a l i f i ed n u r si n g i n t er v en t i o n s a n d
t herapeut ic approaches for sleep prom ot ion in diabet ic
pat ient s as par t of t heir com pr ehensiv e car e.
OBJECTI VES
To assess sleep qualit y in a group of diabet ic
pat ient s at a universit y research and ext ension cent er
of a cit y of t h e in t er ior of t h e St at e of São Pau lo,
Br azil.
MATERI ALS AND METHODS
Ob s e r v a t i o n a l , c r o s s - s e c t i o n a l s t u d y
conduct ed bet w een May 20 and June 20, 2005 at a
univ er sit y r esear ch and ex t ension cent er in a cit y of
t he int erior of t he St at e of São Paulo. The st udy sam ple
c o m p r i s e d 5 4 d i a b e t i c p a t i e n t s e n r o l l e d i n t h e
St andard Diabet ic Pat ient Care Program at t he cent er.
Of t hem , four pat ient s were excluded due t o im paired
c o g n i t i o n a s s e s s e d b y t h e M i n i - M e n t a l S t a t e
Exam inat ion ( MMSE) . The final st udy sam ple included
50 diabet ic pat ient s.
Th e Pit t sb u r g h Sleep Qu alit y I n d ex ( PSQI )
was used in t he assessm ent of sleep qualit y. PSQI is
an inst r um ent t hat assesses subj ect iv e sleep qualit y
a n d r e l a t e d d i so r d e r s. Th e o r i g i n a l v a l i d a t e d( 1 2 )
i n s t r u m e n t h a s 8 9 . 6 % s e n s i t i v i t y a n d 8 6 . 5 %
specificit y. The validat ed Brazilian Por t uguese ver sion
sh ow s t h e sam e h igh sen sit iv it y ( 8 0 % ) bu t sligh t ly
low er specificit y ( 68.8% )( 13).
PSQI com p r ises sev en d om ain s: su b j ect iv e
sleep qualit y ; sleep lat ency ; sleep dur at ion; habit ual
sleep efficiency ; sleep dist ur bances; use of sleeping
m edicat ion; and dayt im e drowsiness and dysfunct ion.
I t includes 10 quest ions, of which quest ions 1 t o 4 are
open and 5 t o 10 are sem i- open.
Th is in st r u m en t com es w it h in st r u ct ion s for
t he scoring of each dom ain. PSQI scoring scale ranges
fr om zer o t o 2 1 an d scor es gr eat er t h an 5 in dicat e
p oor sleep q u alit y. Each d om ain h as a set w eig h t
bet w een zero and t hree and global score is given by
t he sum of t he scores in t he seven dom ains. A sem
i-st r uct ur ed guide w as used for collect ing infor m at ion
on sociod em og r ap h ic ( g en d er, ag e, m ar it al st at u s,
y ear s of st u dy, occu pat ion an d f am ily in com e) an d
clinical v ar iables ( dur at ion of diagnosis, diagnosis of
h igh blood pr essu r e, n oct u r ia, m edicat ion s, lev el of
hem oglobin A1c, w eight and height ) .
Dat a was collect ed during int erviews wit h t he
i n v e st i g a t o r a t t h e st u d y ce n t e r o n Tu e sd ay a n d
Wedn esday s, fr om 1 pm t o 5 pm . Th ese in t er v iew s
t ook p lace in a p r ev iou sly p r ep ar ed , p eacef u l an d
com fort able room . Subj ect s were asked t o sign a free
i n f o r m e d c o n s e n t f o r m b e f o r e t h e i n t e r v i e w . A
dat abase w as cr eat ed in Window s Ex cel t o or ganize
dat a an d t h en m ov ed t o t h e St at ist ical Pack age for
t he Social Science ( SPSS, v er sion 13.0 for Window s)
for dat a an aly sis. Absolu t e v alu es, per cen t ages an d
a b so l u t e f r eq u en cy a n d m ed i a n d i st r i b u t i o n w er e
descr ibed accor ding t o t he nor m alit y of dat a.
RESULTS
Most subj ect s w er e fem ales ( 76% ) , m ar r ied
( 52% ) , ret ired or hom em akers ( 88% ) , had a m edian
f o u r y ear s o f st u d y an d i n co m e o f t h r ee m o n t h l y
m in im u m w ages ( 5 2 % ) . Th eir age r an ged bet w een
4 4 and 7 9 y ear s, w it h m edian 6 2 y ear s old. Of all,
38% had been diagnosed wit h diabet es for m ore t han
1 0 y ear s, 7 0 % w it h h igh blood pr essu r e, 3 6 % h ad
hem oglobin A1c great er t han 7% , 72% had noct uria,
8 5 % h ad b od y m ass in d ex ( BMI ) cor r esp on d in g t o
obesit y and 22% t ook sleeping m edicat ions.
Ta b l e 1 sh o w s g l o b a l PSQI sco r e s o f t h e
Table 1 – Pit t sburgh Sleep Qualit y I ndex ( PSQI ) scores
of t ype 2 diabet ic pat ient s. São Paulo, Br azil, 2005
e r o c S l a b o l G I Q S
P N %
5 > I Q S
P 26 52%
5 < I Q S
P 24 48%
l a t o
T 50 100%
Table 1 show s 26 ( 52% ) of all subj ect s had
PSQI scores low er t han 5, indicat ing t hat m ost could
be cat egorized as having adequat e sleep qualit y, and 24 ( 48% ) had poor sleep qualit y. I t should be st ressed
t hat dat a from t he different PSQI dom ains cannot be int er pr et ed separ at ely and t hat only t he PSQI global
sco r e a l l o w s t o a ssessi n g sl eep q u a l i t y i n t y p e 2 diabet ic pat ient s.
Fo r 3 0 % o f s u b j e c t s s l e e p q u a l i t y w a s
im pair ed. I n r egar d t o sleep lat ency, 62% t ook less t h an 1 5 m in u t es t o fall asleep; 1 6 % t ook 1 6 t o 3 0
m inut es; 12% t ook 31 t o 60 m inut es; and 10% t ook m or e t h an 6 0 m in u t es. As f or sleep du r at ion , 3 8 %
report ed sleeping m ore t han seven hours a night , 22% r epor t ed six t o sev en hour s; 18% fiv e t o six hour s,
and 22% less t han five hours. Six percent had sleep ef f icien cy gr eat er t h an 8 5 % ; 2 2 % bet w een 7 5 an d
84% ; 28% bet ween 65 and 74% ; and 44% lower t han 6 5 % . Th e m o s t c o m m o n s l e e p d i s o r d e r s w e r e :
n oct u r ia, cou g h in g or in t en se sn or in g , d if f icu lt y t o
br eat h, feeling hot , cold and pain. Most subj ect s did not t ake any sleep m edicat ions. And t he m aj orit y did
n ot r ef er an y p r ob lem s of d ay t im e d r ow sin ess an d d ist u r b an ces.
The analy sis of PSQI scor es and dur at ion of diagnosis show ed sleep qualit y w as m or e affect ed in
t hose subj ect s who had been diagnosed wit h diabet es f or m or e t h an 1 0 y ear s. I t is k n ow n t h at d iab et es
com plicat ion s becom e m or e f r equ en t af t er t h e f ir st 10 y ear s of disease ( Table 2) .
Tab le 2 – Dist r ib u t ion of su b j ect s accor d in g t o t h e Pit t sbu r gh Sleep Qu alit y I n dex ( PSQI ) an d du r at ion
of diagnosis. São Paulo, Br azil, 2005
l a b o l G I Q S P e r o c S s i s o n g a i d f o n o i t a r u D s r a e y 0 1 < s i s o n g a i d f o n o i t a r u D s r a e y 0 1 >
N % N %
5 > I Q S
P 12 42.9% 12 54.5%
5 < I Q S
P 16 57.1% 10 45.5%
l a t o
T 38 100% 22 100%
When PSQI scor es and lev els of hem oglobin
A1c were correlat ed, 33% of subj ect s wit h hem oglobin
A1c great er t han 7% had im paired sleep qualit y, i.e.,
poor sleep qualit y ( Table 3) .
Tab le 3 – Dist r ib u t ion of su b j ect s accor d in g t o t h e
Pit t sbur gh Sleep Qualit y I ndex ( PSQI ) and lev els of
glycosylat ed hem oglobin ( A1c) . São Paulo, Brazil 2005
e r o c S l a b o l G I Q S
P HemoglobinA1c>7% HemoglobinA1c≤≤≤≤≤7%
N % N %
5 > I Q S
P 6 33.3% 18 56.2%
5 < I Q S
P 12 66.7% 14 43.8%
l a t o
T 18 100% 32 100%
The analysis of BMI and PSQI scores showed
4 7 . 6 % o f o b ese d i a b et i c p a t i en t s h a d p o o r sl eep
qualit y. The sam e was found for t hose who had been
diagnosed for m ore t han 10 years and had high blood
p r essu r e.
DI SCUSSI ON
The assessm ent of sleep qualit y is a valuable
appr oach t o t y pe 2 diabet es car e as m an y pat ien t s
can becom e aw ar e t heir sleep qualit y is not as good
as t hey t hought . I n t he pr esent st udy, sleep qualit y
w as assessed based on inform at ion obt ained from all
PSQI dom ains t oget her. Thus, t he pat ient s’ percept ion
a b o u t t h e i r s l e e p q u a l i t y w i l l n o t n e c e s s a r i l y
correspond t o a PSQI global score indicat ing adequat e
sleep qualit y.
Sleep lat ency, i.e., difficult y in falling asleep
and st aying asleep, is associat ed t o st ress and anxiet y
in t he daily life. I n part icular in t ype 2 diabet ic pat ient s,
t hese problem s can affect t heir m et abolic cont rol since
horm ones involved in vit al processes of body funct ion
ar e pr oduced dur ing t he sleep cy cle( 4).
An adult needs seven hours of sleep per night ,
and t he num ber of hour s of sleep t ends t o decr ease
w it h age. The num ber of hour s necessar y for r est ing
v ar ies in div idu ally an d som e people m ay be r est ed
aft er a r educed num ber of hour s of sleep( 1 4 ). Giv en
t hat , in t he pr esent st udy, 60% of diabet ic subj ect s
were elderly, t he st udy findings m ay be reflect ing t heir
n eed of sleep du r in g agin g an d t h e v er y ch an ge of
int r insic sleep pr ocesses at t his phase of life.
The fact t hat 44% of subj ect s had less t han
65% habit ual sleep efficiency is concer ning because
sleeping is a pr im e phy siological need for a healt hy
life and for phy sically r est or ing t he body.
I n addit ion t o hor m onal changes associat ed
irrit abilit y, reduced abilit y for planning and perform ing
t ask s, m ood sw ings and difficult y in concent r at ion in
t he short run and prem at ure aging, t he developm ent
o f ca r d i o v a scu l a r a n d g a st r o i n t est i n a l co n d i t i o n s,
obesit y and diabet es m ellit us( 6) in t he long run.
Giv en t hat 66% of t he subj ect s st udied had
sleep pr oblem s such as w ak ing in t he m iddle of t he
night or very early in t he m orning, it can be assum ed
t h e se p a t i e n t s’ h a b i t u a l sl e e p e f f i ci e n cy m a y b e
im p air ed . How ev er, f u r t h er st u d ies ar e r eq u ir ed t o
bet t er est ablish t his associat ion.
No ct u r i a i s a m a j o r cl i n i ca l si g n o f p o o r
m et ab olic con t r ol. Diab et ic p at ien t s ar e at r isk of
d eh y d r at i o n d u e t o o sm o t i c d i u r esi s. Ad d i t i o n al l y,
episodes of noct uria can lead t o frequent awakenings
w h i ch a f f e ct sl e e p q u a l i t y, l a t e n cy, d u r a t i o n a n d
habit ual efficiency( 15).
Sym pt om s such as coughing, int ense snoring,
and difficult y t o breat h are associat ed t o sleep apnea.
During an episode of sleep apnea, t he passage of air
t hr ough t he t r achea is obst r uct ed pr oducing sev er al
sou n ds ch ar act er ist ic of sn or in g. I t is gen er ally n ot
per ceiv ed by t he snor er but r at her by som eone w ho
sleeps in t he sam e room( 16).
Du r in g an ep isod e of ap n ea p at ien t s h av e
h y p ox ia an d as a r esu lt t h ey can d ev elop g lu cose
int oler ance w it h m et abolic im pair m ent( 17). Ther efor e,
f u r t h e r st u d i e s a r e r e co m m e n d e d t o t h o r o u g h l y
d escr ib e sleep d isor d er s f or t h e d iag n osis of sleep
ap n ea i n t h ose d i ab et i c p at i en t s w h o h av e sl eep
-r elat ed cou g h in g , in t en se sn o-r in g , an d d if f icu lt y t o
b r eat h .
Dr u g s f or t h e t r eat m en t of sleep d isor d er s
m ay cau se sl eep p at t er n d y sf u n ct i o n as t h ey can
depr ess or r edu ce br ain cor t ex r espon se t o st im u li
a n d p r o d u c e a s t a t e o f a l e r t n e s s , a n x i e t y a n d
depr ession . Most sleep in du cer s depr ess REM sleep
so t h ose t ak in g t h ese m ed icat ion s h av e an alt er ed
sleep cy cle( 15).
O n e s h o u l d a l s o b e a r i n m i n d t h a t t h e
t r eat m en t of sleep disor der s is n ot alw ay s f ollow ed
u p b y a m ed ical p r ov id er as f or t h e class of d r u g
t a k e n , d o se a n d t i m e o f a d m i n i st r a t i o n . On t h e
ot h er h an d, w h en dr u gs ar e pr escr ibed by a doct or,
t r eat m en t com plian ce is of t en poor. Bot h sit u at ion s
ca n a f f e ct sl e e p q u a l i t y a n d l e a d t o a n a d v e r se
e f f e ct .
Drug t herapy for im proving t he sleep pat t ern
of diabet ic pat ien t s m ay do m or e h ar m t h an good.
Elder ly pat ien t s w it h diabet es u su ally t ak e m u lt iple
dr u gs f or diabet es m an agem en t , dy slipidem ia, h igh
b l o o d p r essu r e, am o n g o t h er s, an d t h e co m b i n ed
effect of m ult idrug t herapy m ay negat ively affect t heir
sl eep p at t er n . Th u s, d r u g s h av e t o b e j u d i ci ou sl y
prescribed t o diabet ic pat ient s and followed up by t he
m edical pr ov ider( 18- 20).
Ex cessiv e d ay t im e d r ow sin ess is t h e m ost
co m m o n co m p l ai n t asso ci at ed t o sl eep d i so r d er s.
Day t im e dr ow siness m ay be m ist ak en w it h laziness,
lack of int er est or ev en alcohol int ox icat ion( 15).
But in diabet ic pat ient s it m ay associat ed t o
signs and sym pt om s of m et abolic decom pensat ion due
t o noct uria; pain; t ingling in t he lower lim bs, sweat ing,
palpit at ion, am ong ot her s.
Th er e is st ill n o con sen su s bu t episodes of
dozing and ev en fr equent aw ak enings at night seem
current ly t o be part of a pat t ern t ypical of t he
sleep-w a k e cy cl e. An ex p er i m en t a l st u d y sh o sleep-w ed sl eep
d ep r iv at ion can p r ed isp ose t o g lu cose in t oler an ce.
Sl e e p d i so r d e r s a r e b e l i e v e d t o r e su l t f r o m t h e
d e l e t e r i o u s e f f e c t o f d i a b e t e s o n t h e c e n t r a l
m echanism of r espir at or y cont r ol; t hus diabet es m ay
be t he cause or effect of sleep disorders( 3). How ever,
w e w er e n ot ab le t o con f ir m t h at h em og lob in A1 c
g r eat er t h an 7 % af f ect ed sleep q u alit y sin ce m ost
subj ect s ( 66.7% ) wit h t his condit ion were cat egorized
as hav ing adequat e sleep qualit y.
CONCLUSI ON
Glob al PSQI scor e sh ow ed 4 8 % of t y p e 2
d iab et ic p at ien t s h ad p oor sleep q u alit y. PSQI is a
t ool t hat pr ov ides dat a about sleep qualit y in t hese
pat ient s and im pr ov es dat a collect ion for suppor t ing
ev id en ce- b ased n u r sin g in t er v en t ion s. Th e f in d in g s
of t h e p r esen t st u d y st r ess t h e im p or t an ce of t h is
su b j ect sin ce t h er e ar e n o sp ecif ic in st r u m en t s f or
sleep assessm ent in diabet ic pat ient s. They also allow
nurses t o broaden t heir knowledge on fact ors affect ing
s l e e p t h a t c a n b e a p p l i e d i n e f f e c t i v e n u r s i n g
int er vent ions for im pr oving sleep pat t er ns of diabet ic
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