Point for Practice

Consider older adults in a residential or nursing home setting. What measures might you employ to ensure good sleep hygiene in your clients?

Assessment of sleep

Assessment of older people’s sleep patterns should include a thorough sleep history. Questions should include the following areas:

• Ask the person to describe a typical night’s sleep.
  
• Identify how well the person functions during the day? This can include asking about daytime naps and how they feel as the day progresses.
  
• Identify any prescribed or over-the-counter drugs taken and typical alcohol intake (many of these can interfere with sleep).
  
• Ask if the person uses sleep-inducing medications.
  
• Identify the usual time of going to bed.
  
• Ask how long the person feels they lie awake before falling asleep.
  
• How many times does the person feel they awaken during the night? Is this in relation to any symptom of disorders such as breathing difficulties, pain, nocturia or palpitations? Dreams or nightmares may precipitate more frequent awakenings.
  
• Identify the normal time for awakening in the morning.
  
• A sleep diary can be kept for several weeks to help identify sleep patterns – this can be particularly helpful.

(Adapted from Linton and Matteson, 1997)

Other questions to consider asking include:

• Do you experience any problems in staying asleep?
  
• Identify how the person rates their quality of sleep.
  
• Identify if the environment affects quality and quantity of sleep. Has the sleeping environment changed of recent?
  
• Are caffeine containing beverages consumed after late afternoon?
  
• Is a night-time ritual followed before retiral for the night?

(Adapted from Roach, 2001)

Personal beliefs about sleep should also be explored as the person may place much importance on an arbitrary number of hours sleep each night (McConnell and Murphy, 1997). When assessing a person’s sleep patterns and habits, the nurse should also remember to consult family members and seek their input and assistance.

As use of medications increase with age, including over-the-counter medications and prescription drugs, it becomes important to take a careful drug history which includes both these categories of drugs (Roach, 2001). Older people may be more susceptible to the stimulatory effects of some chemicals including caffeine, the stimulatory effect of which can be as much as 8–14 hours. The effects of caffeine may be even more pronounced in older adults due to possible decreased liver function impairing caffeine clearance.

Schoenfelder and Culp (2001) suggest that a visual analogue scale (VAS) may be useful when assessing the quality of sleep in older adults. This scale works along the same lines as the VAS associated with assessing pain which most nurses will be familiar with. Such scales, for example, require the person to place a mark on a 100-mm horizontal line that ranges from one end for the best sleep ever to the other end with the worst sleep ever. The distance of the mark along the line is then measured and this can be compared to other night’s sleep.

Sleep disorders in older adults

Apnoea

Sleep apnoea is a common disorder amongst older adults. Obstructive sleep apnoea is an upper respiratory disorder where the upper airway is repeatedly obstructed during sleep, which reduces airflow–hypopnoea or stops it–apnoea (Wolkove et al., 2007a). Sleep apnoea therefore involves interruptions to breathing during sleep. Relaxation of the pha- ryngeal muscles during sleep causes the tongue and palate to fall backwards resulting in an obstruction of the airway. These obstructive incidents result in interrupted, poor-quality sleep, nocturnal oxygen desaturation and a considerable reduction or absence of REM sleep (Wolkove et al., 2007a). This sleep disorder is far more likely to occur in overweight men. A pattern of loud snoring followed by varying lengths of silence is typical of this condition and any comments or changes in sleep patterns, including episodes of loud snoring made by partners should be followed up.

Periods of apnoea or hypopnoea (cessation or slowing of respiration) increases with age from an average of five disturbances per night at 24 years of age to about 50 per night at the age of 74 (Timiras, 2003). Apnoea results from a collapse of muscles in the upper airway resulting in a total airway blockage. This typically lasts for around 10 seconds and is reversed on wakening, where the upper respiratory muscles regain their activity. Hypopnoea is a partial blockage of the upper airways where the amount of oxygen entering the lungs is considerably reduced. Again, this episode typically lasts for around 10 seconds before the person wakes up and begins to breathe normally again. These incidents account for the disturbed sleep experienced by many older adults. This disturbance to the night’s sleep contributes to tiredness, drowsiness and fatigue the next day (Wolkove et al., 2007a), which has been shown to increase the risks of falls and involvement in road traffic accidents (Timiras, 2003).

Leg movements during sleep

Sleep-related leg movements during sleep are also common in the older adult. The prevalence of leg movements when sleeping increases with age. Thirty-three per cent of older people experience twitches or leg discomfort every two to three times, every minute during much of the night. These movements often lead to a brief arousal from sleep and they appear to be related to loss of coordination between motor excitation and inhibition (Timiras, 2003). As with sleep apnoea, these movements disturb a night’s sleep which leads to daytime drowsiness and fatigue in many older adults.

Restless leg syndrome is a very different sleep disorder from periodic leg movement disorder described earlier. Patients with restless leg syndrome can experience tingling, unpleasant cramps and painful sensations before the onset of sleep. These are usually felt in the lower extremities. A crawling feeling under the skin is also described. When the symptoms occur the person is likely to move or massage their legs. Typically, these symptoms are experienced not long after getting into bed and contribute to a delay in sleep onset. This syndrome occurs in ~ 10–35% of people over 65 and is more likely to occur in women compared to men (Wolkove et al., 2007a). The onset of this condition appears to be linked to a reduction in dopamine production and administration of levodopa or dopamine agonist can decrease the symptoms associated with this disorder.

Insomnia

Insomnia is defined as difficulty in falling asleep with episodes of wakening during the night followed by difficulty in falling asleep again (Mauk, 2006). Insomnia affects ~50% of all older people, with older women more likely to report greater difficulties in falling asleep when compared to older men. Insomnia in women may be linked to a reduction in the hormone oestrogen post menopause (Roach, 2001).

Roach (2001) identifies two categories of insomnia in older people. They are:

1.Transient insomnia.

2.Chronic insomnia.

Transient insomnia is normally a temporary condition where the sleep problem is related to a situation which increases stress levels. Examples of stressful situations include admission to hospital, financial concerns, health worries, bereavement or grief. The insomnia is commonly self-limiting and should resolve relatively quickly, lasting no more than 5–7 days. Medication is not usually necessary; however, if it is required, then hypnotics or sedatives should not be prescribed and administered for longer than 2–3 days and the smallest effective dose possible should be given.

Chronic insomnia normally lasts much longer than transient insomnia. It is described as a sleep pattern disturbance that has been present for more than 1 month. This category of insomnia is associated with the additional symptoms of anxiety, irritability, fatigue and impaired mental functioning (Roach, 2001).

There are a number of reasons why insomnia is common among older people.

Frequent awakenings during the night may also be related to medical conditions. Common and well-recognised causes of insomnia include depression and anxiety disorders. Older adults are particularly at risk of depression related to, for example, the loss of a partner, social isolation, underlying disease and onset of dementia.

Adults with dementia are prone to sleep disturbance and those diagnosed with Alzheimer’s disease are especially likely to have sleep disturbances. Not only is dropping off to sleep difficult, but regular and frequent episodes of wakening through the night are also experienced. It is not unusual for these sleep disturbances to increase in their severity as the dementia progresses with sufferers also sleeping for longer periods throughout the day. Agitation is common especially in the late afternoon and evening where symptoms such as confusion, disorientation and restlessness are experienced. These can result in inappropriate vocalisations, expressions of violent behaviour and a tendency to wander. These symptoms are collectively referred to as ‘sundowning’ relating to the time of day when they are first expressed.

Insomnia is common in patients with Parkinson’s disease (PD) who may also experience frequent awakenings with difficulty returning to sleep. However, adults who are diagnosed with PD also commonly experience vivid dreams, nightmares and leg jerks, all of which upset a night’s sleep.

Other factors including retirement which results in a change of routine and which may utilise less energy during the day can lead to insomnia as an individual may be in the process of transforming from a more active work lifestyle to a more sedentary retired lifestyle. This alone may lead to an abrupt change in demand for daily physical activity and energy and can lead to change in demands for sleep. Until adjustments are made, the individual may suffer from insomnia.

REM sleep disorder

REM sleep disorder commonly affects people over the age of 60. Dreaming usually occurs during REM sleep. At this time, voluntary muscles are normally inhibited which prevents typical skeletal muscle movement during dreaming. However, REM sleep disorder is typified by the loss of this normal muscle inactivity so that there is an increase in movement at this time. During REM sleep disorder, the person may engage in a number of different body movements some of which can be forceful and damaging to either themselves or their bed partner. It is possible for the person to get out of bed and walk about. They may also thrash their arms and legs while in bed, and it is this range of movement that put partners at risk of being kicked or punched. Ninety per cent of older people who suffer from this condition are men (Wolkove et al., 2007a), and it is often linked with neurodegenerative disorders including PD, multiple sclerosis and Alzheimer’s disease. Interestingly, where PD is concerned, REM sleep disorder may be a precursor to the development of Parkinson’s as it may be present for a number of years before the signs and symptoms of PD are obvious (Wolkove et al., 2007a).

General interventions

When identifying appropriate interventions relating to sleep disorders for older people, changes associated with the ageing process need to be taken into consideration. The sleep patterns of older people differ from those of younger people for the reasons already identified (McConnell and Murphy, 1997). However, older people continue to require the same amount of sleep but it may be distributed differently over a 24-hour period when compared to younger people and this may include the need to nap during the day (Roach, 2001). Roach also identifies that sleep requirements may increase with advancing age. Therefore, it is important to explain to older people the ageing changes and how they will influence their sleep pattern.

Interventions should be implemented after a thorough sleep history has been taken. The aim of the nursing interventions should include:

• A decrease in the overall length of time spent in bed.
  
• A reduction in the number or frequency of naps.
  
• Advice relating to re-organising the structure of daytime activities and increasing daytime energy levels to enhance sleep at night.
  
• Education on the use of relaxation techniques.
  
• A combination of all of the above.

The outcome of nursing interventions is therefore to promote sleep in older people in such a way that they will awaken refreshed and energised. There are a number of simple measures that can be implemented to achieve this outcome.

Nursing interventions should include informing older people of normal ageing changes associated with sleep. The environment should be modified to provide ambience that is conducive to sleep. The room that is being used for sleeping should not be too warm; however, it should be kept above 60°F. The bedclothes and pillows should be kept clean and comfortable. It is also recommended that the bed is only used at night and activities that occur in bed should be restricted to sleep and sex (Linton and Matteson, 1997).

Exercise should be actively encouraged at any time during the day within limits of level of the person’s mobility. Roach (2001) suggests morning or early evening exercise, and Linton and Matteson (1997) suggest afternoon or early evening as times for exercise. Increasing levels of daytime activity should encourage an individual to feel pleasantly tired and sleepy at night. Naps during the day should be reduced or avoided although this may be difficult to achieve if normal sleep patterns are being redistributed.

It is useful for older people to try and follow a similar sleep routine each night, so that the individual goes to bed at approximately the same time each night and rises at approximately the same time each morning. These practices are known as developing good sleep hygiene. Additionally, older people should develop sleep rituals to try and aid sleep. The rituals can include having a warm bath, taking a light snack before bedtime or drinking a glass of warm milk. Warm milk aids sleep as it contains a substance called tryptophan which acts as a natural sedative. Tryptophan enhances production of melatonin produced by the pineal gland. Melatonin promotes and enhances sleep.

There are a number of relaxation strategies that may be useful to add to the sleep ritual to try and improve sleep patterns. These include meditation, visualisation, music or reading a book at bedtime (Roach, 2001). If an individual awakes during the night, they should be encouraged to engage in monotonous activities to try and induce sleep again. The concept of counting sheep probably falls into this category. If falling back to sleep continues to be a problem, then the following advice should be given.

If an individual cannot sleep after 10–15 minutes of lying awake, then they should use diversionary strategies to try and aid a return to sleep. Diversionary strategies include turning on the light so that the individual can read or watch television until they feel sleepy again. Additionally, it is important to rise from bed at approximately the same time each morning in order to promote a regular pattern that supports the circadian rhythm (Linton and Matteson, 1997).

Advice should be given to older people regarding both caffeine and alcohol intake. Caffeine is a stimulant and should therefore be avoided after 5 pm or at least 3–4 hours before bedtime. Alcohol in moderation often causes sleep disturbances in that an older person will fall asleep but they are often awake during the night as the sedative effects of alcohol wear off. Moderate to high alcohol intake may also lead to the need to rise in order to void. Alcohol should therefore be limited to no more than one drink prior to going to bed.

Medications to promote sleep whether they are prescribed, that is hypnotics or sedatives, or over-the-counter sleeping aids should be avoided or used for no more than 2–3 days as they can cause rebound insomnia. Rebound insomnia is the inability to fall asleep or stay asleep after discontinuing medications to help with sleep.

Benzodiazepines have traditionally been the most commonly prescribed hypnotics for use by older people. They work by depressing stages 3 and 4 of NREM and REM sleep and by increasing stage 2 NREM sleep. However, if there is a requirement to prescribe and administer hypnotics, the starting dose should be half the dose prescribed for younger people. Remember that ageing changes reduces the efficiency of the liver in metabolising drugs. These drugs can cause increased daytime sleepiness and a lack of motor coordination leading to a reduction in mobility, an increased risk of falls and subsequent fractures and a decreased ability to carry out activities of living. Older people therefore need to be monitored for these unwanted effects if they are prescribed these groups of drugs. There are other possible side effects including confusion, forgetfulness, wandering at night, paradoxical agitation (where an opposite reaction to the medication occurs such as restlessness and agitation after taking a sedative) and differing levels of cognitive impairment (Wolkove et al., 2007b).

If the person is admitted to hospital or long-term care, a number of issues need to be taken into account. In hospital, the patient should be encouraged to adhere to their normal sleep rituals as much as possible. Any symptoms that make sleep more difficult such as pain or breathlessness should be managed appropriately. Staff should plan to have minimum disruptions during the night (Roach, 2001).

In institutional settings, effort should be made to consolidate all nursing activities in order to reduce the number of interruptions to patients who are asleep. When patients are checked hourly overnight, interventions should be made when patients are awake. However, if a patient has been sleeping for three rounds of checks, they should be wakened if they require nursing interventions. In this way, a patient’s night’s sleep is disturbed as little as possible within an institutional setting.

Specific interventions

Staff should note how much sleep individuals actually achieve during the night. Patients who are suspected of having sleep apnoea should have their oxygen saturation levels monitored during the night (McConnell and Murphy, 1997). Patients should be advised to sleep upright or on their side to reduce the risk of sleep apnoeic episodes. If overweight, then weight loss is advisable.

Continuous positive airway pressure is a method of respiratory ventilation which has been used to treat sleep apnoea. This method of ventilation delivers a stream of compressed air which keeps the pharyngeal airway open, thus preventing airway obstruction. By adjusting the applied air pressure appropriately, the airflow acts as a pneumatic splint. Patients are required to wear a nose or full-face air mask which many older adults have difficulty in accepting, especially if the person has to rise in order to void as they must then remove and reapply the air mask each time they rise. Compliance can be improved by educating the person how to carry out this procedure (Wolkove et al., 2007b). The use of sedatives or hypnotics is not recommended for older adults who have sleep apnoea.

Phototherapy in the form of evening light therapy may be effective for early morning insomnia. Use of evening light can increase total sleep time, REM sleep and slow-wave sleep, all of which contribute to a good night’s sleep and increase the likelihood of the person waking up feeling refreshed. Evening light exposure may also help some patients with Alzheimer’s disease by helping to reduce disturbances to their sleep-wake cycle.

Summary

Sleep – all of us know and appreciate the value of a good night’s sleep. However, for many older people, getting a good night’s sleep seems elusive. In this chapter, we have identified a number of problems that may prevent the older adult from sleeping well. We go on to consider a range of strategies that may be employed to improve the quality and quantity of an older person’s sleep.

Health-care professionals who work in residential or other institutional settings need to give careful thought to how the environment may or may not be conducive to sleep. All health-care professionals should be familiar with the concept of good sleep hygiene and how they may promote good sleep hygiene in their clients/patients.

References and further reading

Related posts:

Growing Older Controlling Body Temperature Theories of Ageing Eating and Drinking Eliminating Breathing

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