Sleep

Although normal aging is accompanied by decreased “deep sleep,” sleep efficiency, and increased time awake after sleep onset, these changes should not result in excessive daytime sleepiness, increased risk of falls, or insomnia. Impaired sleep results in decreased health and functional outcomes in the older adult.

BACKGROUND

A.  Definition

  1. Sleep disorders involve problems with the quality, timing, and amount of sleep, which cause problems with functioning and distress during the daytime.
  2. Sleep disorders can affect overall health, safety, and quality of life. In the older adult, OSA, insomnia, restless legs syndrome, and REBD are common. These disorders result in excessive daytime sleepiness, cognitive dysfunction, nocturia, high risk of falls, and increased morbidity and mortality.

B.  Etiology and epidemiology

  1. There are many types of sleep diagnoses, and the most common disorders reported by older adults are OSA, insomnia, and RLS.
  2. Approximately 5% to 31% of older adults have insomnia, 18% have obstructive sleep apnea (Punjabi, 2008), and 9.4% to 15% of adults older than 40 report RLS (Ohayon, O’Hara, & Vitiello, 2012).

PARAMETERS OF ASSESSMENT

A.  A sleep history (see Exhibit 30.1) should include information from both the patient and the family members. People who share living and sleeping spaces can provide important information about sleep behavior that the patient may not be able to convey.

B.  The Epworth Sleepiness Scale (Johns, 1991) is a brief instrument to screen for severity of daytime sleepiness in the community setting. It can also be found under “Resources” at consultgerirn.org/resources.

C.  The Pittsburgh Sleep Quality Index (Buysse et al., 1989) is useful to screen for sleep problems in the home environment and to monitor changes in sleep quality. This instrument can be found under “Resources” at consultgerirn.org/resources.

D.  Insomnia Severity Index (Bastien, 2001) is a seven-item self-report questionnaire used to screen for insomnia severity. This single measure allows a clinician the ability to assess the mismatch between sleep opportunities and sleep ability, and the effects of treatment.

NURSING CARE STRATEGIES

A.  Vigilance by nursing staff in observing patients for snoring, apneas during sleep, excessive leg movements during sleep, and difficulty staying awake during normal daytime activities (Ancoli-Israel & Martin, 2006; Avidan, 2005)

B.  Management of medical conditions, psychological disorders, and symptoms that interfere with sleep, such as depression, pain, hot flashes, anemia, or uremia (Ancoli-Israel & Martin, 2006; Avidan, 2005)

C.  For patients with a current diagnosis of a sleep disorder, ongoing treatments, such as CPAP should be documented, maintained, and reinforced through patient and family education (Avidan, 2005). Nursing staff should reinforce patient instruction in cleaning and maintaining positive airway pressure equipment and masks.

D.  Instructions for patients and families regarding sleep-hygiene techniques to protect and promote sleep among all family members (see Box 30.1; Avidan, 2005)

E.  Review and, if necessary, adjust medications that interact with one another or whose side effects include drowsiness or sleep impairment (Ancoli-Israel & Martin, 2006), referring also to the Beers Criteria for potentially inappropriate medications for older adults (Fick et al., 2019; Ancoli-Israel & Martin, 2006).

F.   Referral to a sleep specialist for moderate or severe sleepiness or a clinical profile consistent with major sleep disorders such as OSA or RLS (Avidan, 2005)

G.  Aggressive planning, monitoring, and management of patients with OSA when sedative medications or anesthesia are given (Avidan, 2005)

H.  Ongoing assessment of adherence to prescriptions for sleep hygiene, medications, and devices to support respiration during sleep (Avidan, 2005)

I.   Hospital staff should avoid waking a patient for routine care, such as baths, vital signs, and routine blood tests (American Academy of Nursing, 2014).

EVALUATION AND EXPECTED OUTCOMES

A.  Quality-assurance actions

  1. Provide staff education on the major causes of sleep disorders (i.e., OSA, insomnia, RLS).
  2. Provide staff with in-services on how to use and monitor CPAP equipment.
  3. Have individual nursing units conduct environmental surveys regarding noise level during the night hours, and then develop strategies to reduce sleep disruption caused by noise and care patterns.
  4. Add sleep as a parameter of the admission assessment for patients, and provide written instructions for patients using CPAP at home to always bring the equipment with them to the hospital. Include sleep quality (e.g., see PSQI tool; www.hartfordign.org) in the assessment.
  5. Use posthospital surveys of patient satisfaction with sleep while in the hospital, and provide feedback for nursing staff (see www.hartfordign.org, Sleep topic).

B.  Quality outcomes

  1. Improved quality of sleep during normal sleep intervals as reported by patients and staff.
  2. Improved quantity of sleep during normal sleep intervals as reported by patients and staff.

FOLLOW-UP MONITORING

A.  Depending on the diagnosis, follow-up may include long-term reinforcement of the original interventions along with support for adhering to treatments prescribed by a sleep specialist. For example, patient compliance with CPAP therapy for OSA is critical to its efficacy and should be assessed during the first week of treatment (Weaver et al., 2012). All patients benefit from positive reinforcement while trying to acclimate to nightly use of a positive airway pressure device.

B.  CPAP masks may require minor adjustments or refitting to find the most comfortable fit. Most such changes are needed during the acclimation period, but patients should be encouraged to seek assistance if mask problems develop (Weaver et al., 2012). In the acute care setting, respiratory care technicians are valuable in-house resources when staff from a sleep center are not readily available.

C.  During the initial treatment phase of insomnia, sleep deprivation may cause rebound sleepiness, which should subside over time. Follow-up should include ongoing assessment of napping habits and sleepiness to track treatment effectiveness (Avidan, 2005).

D.  If obesity has been a complicating health factor, weight loss is a desirable long-term goal. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include weight loss and regular exercise, which is also consistent with cardiovascular health and long-term diabetes control (Ancoli-Israel & Ayalon, 2006).

ABBREVIATIONS

CPAP          Continuous positive airway pressure

OSA            Obstructive sleep apnea

PSQI           Pittsburgh Sleep Quality Index

RLS             Restless legs syndrome

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

American Academy of Nursing. (2014). Twenty-five things nurses and patients should question. Retrieved from https://www.choosingwisely.org/wp-content/uploads/2015/02/AANursing-Choosing-Wisely-List.pdf. Evidence Level VII.

Ancoli-Israel, S., & Martin, J. L. (2006). Insomnia and daytime napping in older adults. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 2(3), 333–342. doi:10.1016/j.jsmc.2006.04.011. Evidence Level 1.

Avidan, A. Y. (2005). Sleep in the geriatric patient population. Seminars in Neurology, 25(01), 52–63. doi:10.1055/s-2005-867076. Evidence Level 1.

Bastien, C. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2(4), 297–307. doi:10.1016/S1389-9457(00)00065-4. Evidence Level IV.

Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & -Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. doi:10.1016/0165-1781(89)90047-4. Evidence Level IV.

Fick, D. M., Semla, T. P., Steinman, M., Beizer, J., Brandt, N., Dombrowski, R., … Sandhu, S. (2019). American Geriatrics Society 2019 Updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767. Evidence Level I.

Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14(6), 540–545. doi:10.1093/sleep/14.6.540. Evidence Level IV.

Ohayon, M. M., O’Hara, R., & Vitiello, M. V. (2012). Epidemiology of restless legs syndrome: A synthesis of the literature. Sleep Medicine Reviews, 16(4), 283–295. doi:10.1016/j.smrv.2011.05.002. Evidence Level I.

Punjabi, N. M. (2008). The epidemiology of adult obstructive sleep apnea. Proceedings of the American Thoracic Society, 5(2), 136–143. doi:10.1513/pats.200709-155MG. Evidence Level V.

Weaver, T. E., Mancini, C., Maislin, G., Cater, J., Staley, B., Landis, J. R., … Kuna, S. T. (2012). Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: Results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial. American Journal of Respiratory and Critical Care Medicine, 186(7), 677–683. doi:10.1164/rccm.201202-0200OC. Evidence Level II.