CIRCADIAN

RHYTHM
PREPARED BY:
MISS DIPTI K. PUNJAL
FIRST YEAR M.Sc. NURSING STUDENT
ROLL NO.: 02
SUBJECT: MENTAL HEALTH NURSING
GIMH
 The term "circadian", was
coined by
Franz Halberg
of the University of
Minnesota, widely considered
the
"Father Of American
Chronobiology."
 MEANING
• The term circadian comes
from two Latin words namely

“circa” means around

“diem/dies” means day

Circadian means
“approximately one day’’.
FUNCTION OF CIRCADIAN RHYTHM:
Helps to regulate:
Sleep schedule, appetite
and body temperature
Hormone levels, alertness
and daily performance
Blood pressure
What are biological clocks?
Biological clocks are organisms’
natural timing devices, regulating the
cycle of circadian rhythms.
They’re composed of
specific molecules (proteins) that
interact with cells throughout the body.
 Every tissue and organ contains
biological clocks.
BIOLOGICAL RHYTHMS:
There is main four biological
rhythms:
Diurnal (night and day)
Circadian (24 hours)
Ultradian (less than 24 hours)
Infradian/Circalunar (1 month)
Circannual (1 year)
 Diurnal rhythms
A biological rhythm that is
synchronized with the
day/night cycle.
Circadian (24 hours)
The 24-hour cycle that
includes physiological and
behavioural rhythms like
sleeping.
 Ultradian (less than 24 hours)
◦ Recurrent period or cycle repeated throughout a 24-
hour day.
◦ It includes blood circulation, blinking, pulse,
hormonal secretions, heart rate, thermoregulation,
micturition, bowel activity, appetite.
Infradian/Circalunar (1 month)

◦Biological
rhythms that last
more than 24
hours, such as a
menstrual cycle.
 Circannual cycle

◦A biological process that occurs in living

creatures over the period of approximately one
year like breeding cycle.
What is the master clock?
• A master clock in the brain coordinates all
the biological clocks in a living thing,
keeping the clocks in sync.
• In vertebrate animals, including humans, the
master clock is a group of about
20,000 nerve cells (neurons) that form a
structure called the suprachiasmatic
nucleus, or SCN.
• The SCN is in a part of the brain called the
hypothalamus and receives direct input
from the eyes.
 CHRONOBIOLOGY
 Chronobiology comes from
the ancient Greek
◦ chrónos, meaning "time"

◦ Biology which pertains to

“the study, or science,
of life.”
 Chronobiology is “The formal study of
biological temporal
the study of rhythms, such as daily,
circadian rhythms. tidal, weekly, seasonal,
and annual rhythms, is
called chronobiology.”
•One example of a light-
related circadian
rhythm is sleeping at
night and being awake
during the day.
 DEFINITION
“Circadian
rhythms are
physical, mental
and behavioural
changes that
follow a 24-hour
cycle.”
 DEFINITION
“Circadian rhythm or circadian cycle, is a natural, internal
process that regulates the sleep–wake cycle and repeats
roughly every 24 hours.”
 ◦“A circadian rhythm is any biological
process that displays an endogenous,
entrainable oscillation of about 24 hours.
These 24-hour rhythms are driven by a
circadian clock, and they have been widely
observed in plants, animals, fungi and
bacteria.”
 CONTROL OF CIRCADIAN RHYTHM:
Hormonal influences:
Melatonin:
 Most commonly associated with the sleep-wake cycle.
 Levels of melatonin vary throughout the day (and night) which helps regulate
circadian rhythms in the body.
 Melatonin levels are high at night (during sleep) and low during the day (during
wakefulness).
 The levels of melatonin are regulated by the suprachiasmatic nucleus of the
hypothalamus which reacts to the amount of light in the environment.
 So, the darker it is outside of the body,
the more melatonin there is.
Cortisol:
◦Steroid hormone and
is often released in
response to stress.
◦Disruption of regular
cortisol production
can cause insomnia.
Growth hormone-releasing
hormone (GHRH):
 GHRH's main activity is causing
the anterior pituitary gland to
release growth hormone.
 It also promotes slow-wave
sleep.
 When production of GHRH is
increased slow-wave sleep is
enhanced.
Corticotropin-releasing
hormone (CRH):
 a peptide hormone involved in
stress response.
 injections of CRH promote
wakefulness and inhibit slow-
wave and REM sleep.
Leptin hormone:

 Leptin has specific receptors on the

hypothalamus and is released from
the main adipocytes.
 Serum leptin levels peak at night.
 Disruption of circadian balance can
affect leptin secretion, thermogenesis.
 Ghrelin is closely related to hunger
while leptin is tied to feeling full. A
lack of sleep triggers increased levels
of ghrelin and decreased levels of
leptin, leading to increased hunger
and appetite.
 NEUROCHEMICAL INFLUENCES:

Acetylcholine:
 Acetylcholine (ACh) is a neurotransmitter
that is often associated with the activation of
muscles but is also involved in the
cholinergic system which often results in
inhibitory actions.
 Ach has the distinction of being identified as
the first neurotransmitter for the regulation of
circadian rhythms; located in the pons and
basal forebrain.
 ACh neurons in these areas are very
important for the initiation of REM sleep.
 ACh levels are at their highest during REM
sleep and waking states.
Serotonin:
 Serotonin is a neurotransmitter that is
commonly associated with depression
(or the lack of serotonin is associated
with it).
 Serotonin is produced almost solely in
the Raphe nuclei.
 Serotonin has similar effects on the
sleep-wake cycle to those of
norepinephrine.
 Serotonin helps to maintain arousal
and cortical responsiveness as well as
inhibiting REM sleep.
Norepinephrine:
 act as both a neurotransmitter and a hormone.
 best known as a stress hormone and one of the main components in the flight-or-
fight response.
 Norepinephrine activity in the locus coruleus (LC) is the most important with
regards to the sleep-wake cycle .
 This is one of the main areas involved in arousal from sleep.
 Increased norepinephrine also decreases REM sleep.
◦ GABA:

 Is usually responsible inhibition of nerve

transmission.
 GABA release is to shut down or down
regulate neurons.
 One of the main areas GABA is involved in
for the sleep-wake cycle is the posterior
hypothalamus (PH).
 The stimulation of the neurons in the PH
are known to contribute to wakefulness.
 Increased levels of GABA in this area
contribute to inducing sleep.
Glutamate:

◦ the most common neurotransmitter in the brain and the main excitatory
neurotransmitter.
◦ It is also the precursor for GABA which is the main inhibitory
neurotransmitter in the brain.
◦ glutamate in the brain stem regulates the brain activity and maintains muscle
tone during the wakefulness,

◦ participate in initiation and maintaining of sleep and wakefulness.

Adenosine:
• inhibitory neurotransmitter that is involved
in promoting sleep.
• After waking up, adenosine levels begin to
build up in the brain throughout the day
which cause more and more sleep.
• Eg. when you drink caffeine, it achieves
its stimulating effects by blocking your
brain's adenosine processing.
◦ Dopamine:

 Dopamine is a neurotransmitter that is

best known for its role in the regulation
of motor function as well as it's
depletion during Parkinson's Disease
which leads to motor dysfunction.

 Dopamine (basal ganglia) regulate

sleep-wake states.

 Dopamine down regulates melatonin,

which is partly responsible for causing
sleepiness, which greatly contribute
towards waking up from sleep.
Orexin (hypocretin):
 Orexin is a neurotransmitter that is linked to
arousal and wakefulness and is almost
exclusively produced in the hypothalamus.
 Orexin is responsible for regulating many
different systems involved with sleep and
stabilizing both awake and sleep states.
 Some of the systems orexin regulates are
dopamine, norepinephrine, histamine, and
acetylcholine systems.
◦ Orexin system is responsible for integrating
different influences such as metabolic, circadian
and sleep debt to decide what state the body
should be in (asleep or awake).
 How it works?
SCN:
 The primary circadian clock in mammals is located in
the suprachiasmatic nucleus (or nuclei) (SCN) master clock
(pacemaker), a pair of distinct groups of cells located in
the anterior hypothalamus.
 The preeminent roles of the SCN in locomotor, hormonal, and
feeding circadian rhythms.
 The SCN receives information about illumination through
the eyes.
 the retina of eye contains specialized ganglion cells that
are directly photosensitive, and project directly to the
SCN, where they help in the entrainment
(synchronization) of this master circadian clock.
 These cells contain the photopigment melanopsin and
their signals follow a pathway called
the retinohypothalamic tract, leading to the SCN.
 The SCN takes the information on the lengths of the day and
night from the retina, interprets it, and passes it on to the pineal
gland, a tiny structure shaped like a pine cone.
 In response, the pineal secretes the hormone melatonin.
 Secretion of melatonin peaks at night and ebbs during the day
and its presence provides information about night-length.
◦ For example, receptors in the eyes detect darkness and pass that
signal along to the suprachiasmatic nucleus, which then
stimulates the production of melatonin, the hormone that causes
sleepiness.
 SLEEP CYCLE
 The sleep cycle is an oscillation between the slow-wave and REM
(paradoxical) phases of sleep.
 It is sometimes called the ultradian sleep cycle, sleep–dream cycle,
or REM-NREM cycle, to distinguish it from the circadian alternation
between sleep and wakefulness.
 In humans this cycle takes 70 to 110 minutes (90 ± 20 minutes).
 The average length of the sleep cycle in an adult man is 90 minutes.
 Sleep:
Sleep is divided into two broad types:
1. non-rapid eye movement (non-REM or NREM) sleep and
2. rapid eye movement (REM) sleep.
 Non-REM sleep occurs first and after a transitional period is called slow-wave
sleep or deep sleep.
 During this phase, body temperature and heart rate fall, and the brain uses less
energy.
 REM sleep, also known as paradoxical sleep, represents a smaller portion of total sleep time.

 It is the main occasion for dreams (or nightmares), and is associated with desynchronized and fast brain
waves, eye movements, loss of muscle tone, and suspension of homeostasis.

 NREM is divided into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-
wave sleep.
 The whole period normally proceeds in the order: N1 → N2 → N3 → N2 → REM.
 REM sleep occurs as a person returns to stage 2 or 1 from a deep sleep.
 There is a greater amount of deep sleep (stage N3) earlier in the night, while the proportion of REM sleep
increases in the two cycles just before natural awakening.
 The cycle can be defined as lasting from the end of one REM period to the end of the next, or from the
beginning of REM, or from the beginning of non-REM stage 2.
 Sleep can be measured by the types of brain waves that occur during various stages of sleep activity.
◦ Awakening:
 It can mean the end of sleep, or simply a moment to survey the environment and
readjust body position before falling back asleep.
 Sleepers typically awaken soon after the end of a REM phase or sometimes in the
middle of REM.
 Internal circadian indicators, along with a successful reduction of homeostatic
sleep need, typically bring about awakening and the end of the sleep cycle.
 PROBLEMS RELATED TO CIRCARDIAN
RHYTHM:
Sleeping problems:

 struggle to fall asleep,

 wake up during the night, or
 be unable to sleep as long as they want into the morning.
 Their total sleep can be reduced, and a disrupted circadian rhythm
can also mean shallower, fragmented, and lower-quality sleep.
◦ Airline pilots and cabin crew: Due to
the work nature of airline pilots, who
often cross several time zones and
regions of sunlight and darkness in one
day, and spend many hours awake both
day and night, they are often unable to
maintain sleep patterns that correspond
to the natural human circadian rhythm;
this situation can easily lead to fatigue.
◦ Metabolic disorders:
 Obesity and diabetes are associated with lifestyle and
genetic factors.
 Among those factors, disruption of the circadian
clockwork and/or misalignment of the circadian timing
system with the external environment (e.g., light–dark
cycle) might play a role in the development of metabolic
disorders.
 Shift work or chronic jet lag have profound consequences
for circadian and metabolic events in the body.
 In humans, shift work that favours irregular eating times is
associated with altered insulin sensitivity and higher body
mass.
 Shift work also leads to increased metabolic risks for
cardio-metabolic syndrome, hypertension, and
inflammation.
◦ Effect of drugs:
 Changes to the circadian rhythm and sleep occur
once an individual begins abusing and stops using
drugs and alcohol.
 Circadian rhythms and clock genes expressed in
brain regions outside the suprachiasmatic
nucleus may significantly influence the effects
produced by drugs such as cocaine.
◦ Others:
 Disruption to rhythms usually has a negative
effect. Many travellers experience the
condition known as jet lag, with its associated
symptoms of fatigue, disorientation,
and insomnia.
 Bipolar disorder and seasonal affective
disorder is also associated with irregular
functioning of circadian rhythms.
 TREATMENT OF DISTURBED CIRCADIAN RHYTHM:

Bright light therapy:

 Bright light therapy is used to advance or delay sleep.
 The timing of this treatment is critical and requires
guidance from a sleep specialist.
 Bright light therapy works by resetting the circadian clock
to be more in sync with the earth’s cycle of light and dark.
◦ A high intensity light (2,000 to 9,500 lux) is required and
the duration and timing of exposure varies from one to two
hours.
Chronotherapy:
 In chronotherapy, an attempt is made to move
bedtime and rising time later and later each day,
around the clock, until a person is sleeping on a
normal schedule.
 This treatment can be used by people
with delayed sleep phase disorder (DSWPD),
who generally cannot reset their circadian
rhythm by moving their bedtime and rising time
earlier.
Sleep hygiene:

 Use heavy curtains or an eye mask to prevent light from interrupting

your sleep.
 Use natural sleeping aids:
Melatonin supplements improve sleep quality.
Valerian root: a popular supplement improves sleep quality and sleep
disorder symptoms.
Magnesium has a relaxing effect on the body and brain, which
improve sleep quality.
Lavender aromatherapy also helps to improve sleep.
Glycine Consuming glycine immediately before bedtime help fall
asleep faster and improve the overall quality of sleep.
Tryptophan, ginkgo biloba, and L-theanine may also help promote
sleep.
Lifestyle and behavior therapy:
 This approach encourages changes to improve sleep and
to develop good sleep habits.

◦ Good sleep habits include maintaining regular sleep-wake

times (even on weekends and vacations);
◦ avoiding naps (exception: shift workers);
◦ developing a regular routine of exercise (avoid high-
intensity exercise within one hour of bedtime); and
◦ avoiding alcohol, caffeine, nicotine, and stimulating
activities within several hours of bedtime.
Medications:
 Medications such as melatonin (available over-the-
counter), wake-promoting agents (such as modafinil) or
caffeine, and short-term sleep aids may be used to adjust
and maintain the sleep-wake cycle to the desired schedule.
NURSING MANAGEMENT OF PATIENT HAVING
DISTURBED CIRCADIAN RHYTHM

• Obtain a thorough and careful sleep history both from

patient.
• Ask patient to maintain a sleep diary which include all
sleep histories.
• Advice patient to maintain a regular and consistent bed
time and wake time that is similar to both workdays and
non-work days.
• Instruct patient to develop a regular relaxing bed time
routine about 1 to 2 hours before sleep onset and use natural
sleeping aids.
• Advice patient to establish comfortable sleeping conditions
most conducive to good sleep. (Cooler room temperature,
darkness, and low noise levels)
• Instruct the patient to exercise regularly, but….
Instruct the patient to
avoid vigorous
exercise within 2 to 3
hours of sleep onset
• Advice the patient to spend some time outside each day.

• Instruct patient to avoid exposure to bright light in the evening before bed and
encourage exposure to bright light in the morning.

• Instruct patient to avoid stimulants in the evening.

• Instruct patient to avoid use of alcohol to facilitate sleep initiation; this is likely to
result in sleep fragmentation later in the night as blood alcohol levels fall.

• Refer patient to a sleep specialist.

• Administer medications as per doctor’s order: Melatonin and wake-promoting agents

(such as modafinil) to reset circadian rhythm.
 ASSIGNMENTS
1. Circadian Rhythm
2. Nursing management of patient having disturbed
Circadian Rhythm