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Sleep: geriatric self-learning module.

The Geriatric Resource Nurses at the University of Virginia developed the Self-Learning Modules in Geriatric Care. The SPPICEES pneumonic addresses the eight distinct modules, each targeting a commonly encountered health concern of older adults across health care settings. These include:

S: Sleep

P: Problems with eating and nutrition

P: Pain

I: Immobility

C: Confusion

E: Elimination

E: Elder abuse

S: Skin

The modules were designed using a case study approach in order to encourage the learner to gain new knowledge as well as apply this knowledge. Each module includes two case studies, one applicable to the care of an older adult in the inpatient setting, and the other applicable to an older adult in the outpatient setting. Each module takes approximately 20 to 30 minutes to complete.

The completion of these self-study modules alone does not ensure the staff member is age-specific competent; this is determined through the observation and demonstration of behaviors while working directly with older adults. However, these modules will enhance the staff member's knowledge as a foundational step in developing competent behaviors.

Purpose

The purpose of this module is to provide age-specific educational information related to sleep problems in older adults for the patient care staff.

Target Audience

This self-study module was developed for use by a target audience of health care professionals who care for inpatient and outpatient older adults.

Directions

1. Read and review the learning objectives.

2. Read the self-study module information.

3. Answer the post-test questions.

Objectives

At the end of the module, the clinician will be able to:

* Describe common changes in sleep associated with age.

* Outline the common factors that can lead to sleep problems in older adults.

* Discuss interventions for coping with sleep disturbances in older adults.

Overview

Humans need rest and sleep to conserve energy, prevent fatigue, provide organ respite, and relieve tension. Sleep can be a major health issue for many older adults, who commonly report disturbed or inadequate sleep. The sleep-wake cycle is a human characteristic that displays a circadian rhythm (about 24 hours). Rhythms are generated by a "clock" in the brain but the cycle is influenced by external events, including the light-dark cycle, eating, and activity routines such as going to work. Sleep itself is a complex, active process that follows a pattern of well-defined cycles--non-rapid eye movement (NREM) and rapid eye movement (REM)--which alternate throughout the night with an average cycle of 90 minutes each in healthy adults.

Inpatient Case Study

Mrs. J. is an 80-year-old woman admitted to the CCU for insertion of a temporary pacemaker. She has stage 2 Alzheimer's disease. She cannot remember why she is in the hospital or call the nurse for help. She tries to climb out of bed, looking for her daughter or needing to urinate, about once an hour throughout the night.

* What are some of the factors that are influencing the patient's restlessness?

* What information would you like to know from the family about the patient's routines?

* What interventions would you suggest to help Mrs. J. sleep?

Outpatient Case Study

Mr. B. is a 70-year-old man with a sleep disorder who consequently was lethargic during the day and lonely at night. His wife of 40 years had recently insisted on moving into the guest room because she could no longer cope with his loud snoring and periods of interrupted breathing. She has been taking diphenhydramine (Benadryl[R]) for sleep but it isn't helping anymore. Mr. B. often awakes abruptly with a feeling of drowning and gasping for air. However, he simply tolerated it because he thought nothing could be done about it. Now that it had become a threat to his marriage, he became more motivated to investigate possible solutions.

* What objective and subjective data would you want to obtain from him?

* What would you teach Mr. and Mrs. B. about changes in sleep related to aging?

* What suggestions would you make to him?

Age-Related Changes in Sleep

Nearly half of Americans age 65 or older report occasions of poor sleep. Up to two-thirds of institutionalized older adults have disturbed sleep and receive sedative/hypnotic medications. The incidence of sleep disorders is high but because only one in five patients seeks treatment, health care practitioners could easily underestimate the incidence of sleep disorders in their patients. Age-related changes in sleep patterns are so common they are thought to be a normal part of aging. However, chronologic age by itself does not correspond closely with poor sleep. Rather, acute and chronic illness play a larger part in changed sleep patterns. Age-related sleep changes include the following:

* The total sleep time is decreased until age 80, then increases slightly.

* Time in bed increases, with decreased time spent sleeping.

* Onset to sleep is lengthened.

* Awakenings are frequent, increasing with age and leading to less restful sleep.

* A number of co-morbid conditions lead to noctural awakening (nocturia, orthopnea, etc.).

Sleep Disturbances

There are nearly 100 known sleep disorders. The categories include the following:

* Insomnia. Difficulty in initiating or maintaining sleep.

* Hypersomnia. Excessive sleep usually in daytime or at inappropriate times, including sleep apnea (characterized by loud snoring with transient, brief, intermittent breathing cessation lasting greater than 10 seconds).

* Parasomnias. Unusual behaviors during sleep including nightmares, sleep talking, sleep walking.

* Noctural movement disorders. Restless legs or nocturnal myoclonus.

Sleep concerns reported by older adults regarding quality and quantity of sleep usually result from individual and environmental factors. These include:

* Loneliness caused by loss of partners, friends, or relatives.

* Hospitalization or institutionalization in long-term care.

* Changes in lifestyle or residence.

* Prescribed and over-the-counter medications including methylxanthines (caffeine and thorphylline), sympathomimetics (pseudephedrine), alcohol, corticosteriods, thyroxine, neuroleptics, and certain antidepressants.

* Diuretics administered late in the afternoon.

* Medical or psychiatric illness including any problem which causes pain or discomfort, difficulty breathing, frequent urination or defecation, anxiety, or an increased level of arousal.

* Poor sleep habits.

* Primary sleep disorders.

* Other stressful life events.

Sleep disorders occur more commonly among older people than younger adults, especially among institutionalized older adults, and can be disruptive to patients and caregivers. Sleep apnea prevalence increases with aging, affecting males predominately. However, after menopause in women, careful attention to screening is warranted. Sleep apnea affects 24% of independent-living older adults, 33% of acute care inpatients, and 42% of older adult nursing home residents. Sleep apnea is characterized by episodes of no breathing for more than 10 seconds. It is often due to occlusion of the upper airway (obstructive sleep apnea), usually associated with snoring and complaints of excessive daytime sleepiness. It can also result from a lack of brain-initiated signals to the diaphragm and other respiratory muscles (central apnea). In the latter type, snoring is not associated but insomnia is a chief complaint.

Periodic leg movements (rhythmic jerks of the lower legs), myoclonus, and restless leg syndrome are common in older adults, with prevalence estimated to range from 60% to 92% as age increases. Contributing causes may include diseases of the spine, degenerative joint disease, peripheral vascular disease, and iron deficiency anemia. These disorders of muscle movement result in arousal and awakenings that disrupt sleep depth and continuity. People are often unaware of the cause of sleep disruption, and movements are reported by a bed partner.

Patients with dementia often experience significant sleep/wake cycle disturbances called sundowning. The degree of disturbance parallels the severity of the dementia. The altered circadian rhythm may not trouble patients themselves, but can be a serious problem for caregivers or staff because patients' sleep rhythm may not match the daily routine of the caregivers or the institution. This mismatch may culminate in the prescription of hypnotic medications, virtually all of which can further impair cognition and can worsen restlessness. If sundowning occurs, health care providers should assess the patient for hunger, thirst, pain, discomfort, need to eliminate, and safety/security needs.

Sleep History

While it may seem obvious when a patient complains of difficulty sleeping, the clinician's first task is to decide if the patient does indeed have a sleep-related problem. Simply keeping a daily sleep diary can have positive effects on how a person views sleep and can help alter behaviors. It is also important to determine how long the symptoms have been present, because this may give a clue to the pathogenesis or relation to recent medication use. The sleep problem should then be classified into one of the four categories listed earlier in order to assist in determining the underlying causes and to determine the most appropriate treatment.

Questions to ask can include:

1. How long have you been having trouble sleeping?

2. How much sleep do you get?

3. Do you get up early or stay up late?

4. Do you have trouble failing asleep?

5. Do you have nightmares?

6. Do you have trouble staying asleep?

7. Do you wake up refreshed in the morning?

8. Do you use prescription or over-the-counter drugs, or alcohol to obtain sleep?

9. How much caffeine, fluid, and/or alcohol do you consume?

10. How much exercise do you get in a day?

11. What is your normal bedtime routine?

Treatment

Careful assessment, correction of treatable problems, and a trial of good sleep hygiene can improve sleep for many patients.

Behavioral interventions. Sleep hygiene behaviors can impact positively on an elder's sleep. Nurses can provide education and support to manipulate the environment to promote sleep.

Interventions include:

* Avoiding behaviors that interfere with sleep (for example, caffeine, alcohol, exercise near bedtime).

* Performing behaviors to encourage sleepiness (for example, small snack, relaxation preparation).

* Strengthening circadian rhythm cues (for example, waking at consistent time everyday, developing and using a bedtime routine, short or no naps, using the bed only for sleeping).

* Using deep relaxation techniques including verbal training, meditation, biofeedback, cognitive structuring, or imagery.

* Ensuring treatment for underlying medical or psychiatric conditions.

* Screening for sleep-related disorders (especially sleep apnea) and referring for specialized treatment.

* Supporting patients through major loss or transitional events.

* Manipulating the environmental to enhance sleep propensity (decreased noise and light, orientation to surroundings, organized nighttime awakenings for treatment, medications, and procedures).

For sundowning, the nurse maintains continence and comfort, controls pain with nonpharmacologic measures and nonnarcotic analgesia, ensures privacy and darkness, and provides diversion and distraction. Research also shows that the use of light has been beneficial. Exposure to 2 hours of bright light or sunlight, especially in the morning, increased the amount and quality of sleep at night.

Pharmacologic treatment. Drugs that promote sleep are called soporific, and those that inhibit sleep are called antisoporific. Both prescription and over-the-counter drugs can contribute to sleep disturbances. Pharmacologic treatment of sleep disturbances in older adults is complicated by age-related drug kinetic and dynamic changes. Decreased total body water and increased total body fat alter drug distribution. Fat-soluble drugs, such as sedative hypnotics (flurazepam [Dalmane[R]]), have an increased volume of distribution. Drug metabolism generally is slowed and elimination is reduced secondary to decreased liver and renal function. This results in longer drug half-lives with potentials for accumulation and toxicity. For reasons not well understood, the receptor sensitivity for some drugs is changed. For example, older adults are more sensitive than younger adults to depression of the central nervous system by sedative hypnotics. Therefore, drug therapy should be initiated at a low dose and gradually increased as necessary.

Benzodiazepines are the most widely used prescription drugs for insomnia in all ages. However, older people are susceptible to side effects of these drugs such as confusion, agitation, impaired motor performance, and amnesia. Older individuals with cognitive decline are especially sensitive to the sedating effects of drugs and to the amnesia/memory loss effects of some benzodiazepines. For older people, short-acting benzodiazepines (triazolam [Halcion[R]]) rather than longer-acting preparations are most appropriate.

Because sleep disturbances often accompany depressed mood in older adults, tricyclic antidepressants can help both problems. The more sedating tricyclic amines (amitryptiline [Elavil[R]]) are used to assist in initiating and maintaining sleep but must be monitored carefully due to anticholinergic side effects. Neuroleptic (antipsychotic) medications with strong sedating properties are often used to induce sleep in older adults with cognitive impairments. These drugs, however, often remain sedating for only 2 to 3 weeks and have side effects that include alarming involuntary body movements (extrapyramidal effects) and daytime somnolence.

Alcohol is probably the most commonly used self-treatment sleeping medication. However, it fragments sleep and decreases total sleep time. Over-the-counter products such as diphenhydramine (Benadryl[R]) and acetaminophencombination products (Tylenol PM[R]) usually contain antihistamines and may be effective for sleep initiation. However, they are not effective for sleep maintenance because tolerance occurs quickly, and they may produce delirium and anticholinergic side effects (for example, urinary retention).

When to refer to a specialist? Referral to a physician specializing in sleep disorders is warranted if:

* The diagnosis is not clear and a formal sleep study is desired.

* Symptoms are refractory to empiric treatment.

* Sleep apnea is present or strongly suspected.

* A noctural seizure disorder is suspected.

* Periodic limb movement disorders or other parasomnias are suspected.

Formal sleep study involves overnight polysomnography. This consists of direct observation of the sleeping patient; continuous EEG monitoring; recording of eye, muscle, or body movements; and monitoring of respiratory function, nasal and oral air flow, and blood oxygen saturation. It allows for documentation of the true sleep disorder present.

Conclusion

The two case studies have provided the framework for understanding problems related to sleep in older adults. The prevalence and significance of sleep problems in older adults cannot be underestimated, especially in those with medical illness. Nighttime sleep disturbances in patients add considerable physical and emotional stress. Nurses can make a real difference in the quality of health and life for older adults and their caregivers by careful assessment and intervention for sleep disturbances.

Sleep: Geriatric Self-Learning Module Post-Test

1. Poor sleep may be a symptom related to:

a. Depression.

b. Major life change.

c. Pain.

d. Sleep disorder.

e. All of the above.

2. The approximate percentage of older Americans who report problems with sleep is:

a. 15%.

b. 33%.

c. 50%.

d. None.

3. Sleep apnea:

a. Is characterized by greater than 10 second cessation of breathing during sleep.

b. Decreases with age.

c. Results in decreased daytime sleepiness.

d. Is accompanied by stereotypical leg movements.

4. Physiologic changes of sleep with aging include:

a. Increased time in bed.

b. Decreased deep sleep.

c. Decreased REM sleep.

d. All of the above.

5. Good sleep hygiene includes all of the following except:

a. Correct environment (proper temperature, decreased light and noise).

b. Increasing alcohol, caffeine, and nicotine,

c. Using relaxation techniques.

d. Daily exercise but not just before bedtime.

Post-Test Answers

1. e

2. c

3. a

4. d

5. b
Sleep: Geriatric Self-Learning Module
MODULE EVALUATION--Date

We are interested in your evaluation of this module. Please use the
"comments" section at the end to make suggestions for any low ratings.
Thank you for your cooperation.

PART I--OBJECTIVES

The learner objectives for this module are listed below. Evaluate the
extent to which you have achieved each of these objectives
by circling the appropriate number using the following scale:

3 = Achieved
2 = Partially achieved
1 = Not achieved
NA = Not Applicable

OBJECTIVES

Describe common changes in sleep associated with age.   3   2   1   NA
Outline the common factors that can lead to sleep
 problems in older adults.                              3   2   1   NA
Discuss interventions for coping with sleep
 disturbances in older adults.                          3   2   1   NA

PART II--MODULE EVALUATION

The following statements refer to the module as a whole. Read each
statement and circle the number, which corresponds, to the ONE
response that best expresses you opinion about that statement.

5 = Strongly agree 4 = Agree 3 = Neutral 2 = Disagree
1 = Strongly disagree

1. The content was relevant
 to my practice.                   5   4   3   2   1   NA
2. The sophistication of the
 content was appropriate for me.   5   4   3   2   1   NA
3. I feel competent to perform
 my job related to --.             5   4   3   2   1   NA

Content inappropriate/omitted from this module?

PART III--COMMENTS


Resources

Sleep

Dowling, G. (1995). Continuing education program: Integrating an understanding of sleep knowledge into your practice. Part 5: Sleep problems of older adults. The American Nurse, 27(3), 24-25.

Foreman, M.D., & Wykle, M. (1995). Nursing standard-of-practice protocol: Sleep disturbances in elderly patients. Geriatric Nursing, 16(5), 238-243.

Smyth, C. (2003). The Pittsburgh sleep quality index. MEDSURG Nursing, 12(4), 261-262.

General Aging

Beers, M.H., & Berkow, R. (Eds.) (2000). Merck manual of geriatrics (3rd ed.). Whitehouse Station, NJ: Merck Research Laboratories.

Ebersole, P., & Hess, P. (Eds.) (2003). Toward healthy aging: Human needs and nursing response (6th ed.). St. Louis: Mosby.

Ham, R.J.., & Sloane, RD. (Eds.) (2001). Primary care geriatrics: A case-based approach (4th ed.). St. Louis: Mosby.

Lueckenotte, A.G. (Ed.) (2000). Gerontologic nursing (2nd ed.). St. Louis: Mosby.

Cindy Westley, MSN, RN-BC, NP-BC, is a Community Care Manager, University of Virginia Health System, Charlottesville, VA.

Note: Copyright [c] 2002 by the Rectors and Visitors of the University of Virginia. Reprinted here with permission. The Sleep: Geriatric Self-Learning Module is based on an original module by Allene Brighton, RN.
COPYRIGHT 2004 Jannetti Publications, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Clinical Practice
Author:Westley, Cindy
Publication:MedSurg Nursing
Date:Oct 1, 2004
Words:2847
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