Promoting quality sleep in older people: the nursing care role

Sleep is a basic activity of living. Its restorative properties in healthcare settings--both hospital and community--should be considered by healthcare workers. Its significance in gerontological nursing should not be underestimated. As older people are prone to multiple pathology, disease processes may mask their need for effective sleep and rest. "Sleep architecture" is a term that applies to the mechanics of sleep or its stages and clinicians may fail to identify when this is disrupted. "Sleep hygiene" refers to measures or interventions used to promote sleep and a person-centred approach is necessary, with support from specialist agencies to achieve effective sleep hygiene. The need for long periods of sleep may diminish owing to ageing. However, the quality of the sleep experiences, i.e. feeling rested and refreshed, should be the same. Several factors have been identified in the causation of insomnia. In healthcare settings, environmental factors such as noise and light pollution are the commonest features. Other issues that may be present in both healthcare and community settings are related to varied perspectives, such as physiological, psychological and spiritual-religious. Providing a climate conducive to health sleep in all settings becomes a requisite in the planning of care.

Insomnia, depression and anxiety disorders and their association with benzodiazepine drug use among the community-dwelling elderly: implications for mental health nursing

Benzodiazepine (BZD) drug use among seniors is an important public health issue because the benefit from their use is moderate and of short duration and numerous adverse events have been linked to their use. Furthermore, there is a significant discrepancy between the prevalence of mental health disorders and BZD drug use in the elderly population, which can be attributed to a measurement issue. The goal of this cross-sectional descriptive study was to determine the prevalence of mental health disorders among seniors using BZD and living in the community, basing this information on both a thorough face-to-face interview and a pair of self-reported validated instruments. Among the 216 seniors recruited in our study, nearly 20 % were users of BZD and over three quarters of them had been using this drug for more than a year. Thirteen subjects were recognized as depressed according to a self-report measure compared to 18 according to the interview. Likewise, 13 seniors were categorized as anxious, based on a self-report questionnaire compared to 39 based on the interview. Among self-reported measures of mental health variables, logistic regression indicated that insomnia increases by 7 the likelihood of using BZD (odds ratio: 7.2) and is the only statistically significant variable associated with BZD consumption. Based on thorough interviews, logistic regression showed that insomnia (odds ratio: 6.9) is still the dominant symptom associated with BZD drugs. In conclusion, our results clearly support the assertion that mental health status is influenced according to how it is measured. Finally, nurses should be aware that not all individuals are capable of expressing their mental health problems using either psychological or emotional terminologies. They may opt for expressing their psychological suffering as a physical symptom such as sleeping problems.

A study on the experience of insomnia in a psychiatric inpatient population

Complaints of insomnia among psychiatric inpatients are high. Many technical studies about insomnia are available in the literature, but few make reference to individual experience. This study examines the subjective experience of insomnia for psychiatric patients in one mental health unit. A random purposive sample of seven subjects was selected from the population of patients complaining of insomnia. Subjective experience was examined using a tape-recorded semistructured interview. The data were analysed using Burnard's content analysis framework. Ten categories were identified: control, wants and desires, holistic, assessment, individualisms, beliefs, conflict, communication, resignation and sleep signatures. Biographical data, and data from clinical notes about sleep were also collected. Results show that the impact of insomnia should not be underestimated and that attention to this aspect of a patient's experience could have a general effect on their mental health and well-being.

Sleep promotion in hospitalized elders

Older adult patients often have poor, fragmented sleep when they are in the hospital. The factors contributing to sleep disturbance in hospitalized elders will be explored, and interventions for promoting sleep among these patients will be discussed.

Developmental stages of sleep from birth to adolescence, common childhood sleep disorders: overview and nursing implications

Sleep is an important physiological process with profound impact on the body. Sleep undergoes normal developmental changes and common sleep problems are seen in general pediatric practice. This article discusses normal developmental changes related to sleep, common sleep disorders experienced by children and how nurses can assist parents in coping with these changes and disorders.

Management of chronic insomnia in the elderly

Insomnia is a common complaint in the elderly. It is not a disease in and of itself, but a symptom of an underlying problem with the potential for medical, psychological, and functional complications. Approximately one half the persons aged 65 years and older experience insomnia. However, few mention their sleep problems to their primary care providers. Because of the prevalence of insomnia in the elderly and the potential for complications, it is important for primary health care providers to understand the cause, assessment, and management of chronic insomnia. Both pharmacologic and behavioral therapies are effective in the treatment of insomnia. Early recognition and treatment may increase the quality of life for the elderly insomniac.

Correlates of sleep quality in persons with HIV disease

This study used the Symptom Experience dimension of the revised UCSF Symptom Management Conceptual model to examine correlates of sleep quality in HIV-infected persons. According to this model, person, health/illness, and environment categories influence perception of a symptom. The average person in the sample (N = 58) reported being HIV-infected for 8.5 years and was 46 years old, not working, and a person of color. Depending on the level of data, either chi square or Pearson correlations were computed between the person, health/illness, and environment categories and the dependent variable, sleep quality, as measured by the Pittsburgh Sleep Quality Index. Person variables significantly related to sleep quality were employment status, trait anxiety, and general well-being. Health/illness variables significantly related to sleep quality were length of time living with HIV disease and five health status measures (depressive symptoms, state anxiety, symptom severity, daytime sleepiness, and functional status). The environmental variables associated with sleep quality were sleeping alone, having a separate bedroom, and sleeping in a noisy room. Correlates of better sleep quality are positive general well-being, less anxious personality trait and emotional state, less daytime sleepiness, less depressive symptoms, and less symptom severity. Correlates of worse sleep quality are impaired functional status and longer duration of living with HIV disease.

Sleep promotion in adults

Insomnia is among the most frequent health complaints brought to the attention of primary care providers. The prevalence estimates are highest in women, older adults, and patients with medical or psychiatric disorders. Clinical researchers have studied many barriers to sleep as well as some sleep promotion interventions for the ill and aging adult. Environmental, personal, and person-environment rhythm factors have been identified as correlates of poor sleep. All interventions studied by nurse researchers are non-pharmacological and have been classified as interventions that (a) create an environment more conductive to sleep, (b) relax the sleeper, or (c) entrain the circadian sleep-wake rhythm. This chapter summarizes results of published research on correlates of poor sleep and interventions to promote sleep. The chapter includes the relevant studies conducted by researchers in related disciplines as well as nurses' research. The arcs software package was used to facilitate summarization of intervention studies. It was concluded that correlates of poor sleep are well described, but theories of sleep promotion are not well explicated. Also, the research base for sleep promotion interventions for use with clinical populations other than those with chronic insomnia is sparse. Gaps in knowledge are identified and conceptual and methodological issues are discussed as the basis for future directions in sleep promotion research.

Health visitor-run adult sleep clinics

Two sleep clinics run by health visitors were set up in Dundee to provide a brief, time-limited programme of advice and treatment for adults with insomnia and referred by their GPs. This article describes the clinics and reports the clinical features and outcome of the first 100 patients referred.

A nonpharmacologic sleep protocol for hospitalized older patients

OBJECTIVES

To evaluate the feasibility of and adherence to a nonpharmacologic sleep protocol targeted to nurses for acutely ill older patients and to test the effectiveness of the protocol on enhancing sleep and reducing sedative-hypnotic drug (SHD) use.

DESIGN

Prospective cohort study.

SETTING

A 34-bed general medical unit in a university-affiliated teaching hospital.

PARTICIPANTS

A total of 175 consecutive admissions aged 70 years or older.

INTERVENTION

A nonpharmacologic sleep protocol consisting of a back rub, warm drink, and relaxation tapes was administered by nursing personnel to patients who complained of difficulty initiating sleep or who requested a SHD. After 1 hour, if the patient still requested it, the nurse administered the SHD.

MEASUREMENTS

The main outcomes of sleep quality and SHD use were measured by patient interview and chart abstraction. Feasibility and adherence to the protocol were tracked daily by patient and nurse interviews and chart abstraction.

RESULTS

A cohort of 111 patients, mean age 79.3 (+/- 6.4), 68% women, received the sleep protocol. Patients required the protocol for a mean of 4.9 days per patient, totalling 539 patients-days. The overall adherence rate was 400/539 (74%) patient-days. The rate of complete nonadherence was 139/539 (26%), with reasons for nonadherence including nurse nonadherence in 30 (6%), patient refusal in 104 (19%), and medical contraindications in five (1%). The quality of sleep correlated strongly with the number of parts of the protocol received, suggesting a dose-response relationship, with the highest correlation for receiving two to three parts (p = .64, P < 0.001). The sleep protocol was successful in reducing SHD use from the baseline preintervention rate of 51/94 (54%) to 34/111 (31%) (P < .002). The sleep protocol had a stronger association with quality of sleep (p = .75, P = .001) than did SHDs (p = .07, P = .45). However, chronic SHD users were more likely to refuse the protocol than nonusers (64% vs 41%, P < .03) and received SHDs 4.5 times more often than nonusers (67% vs 15%, P = .001).

CONCLUSION

The nonpharmacologic sleep protocol provides a feasible, effective, and nontoxic alternative to SHDs to promote sleep in older hospitalized patients. Use of the protocol can substantially decrease use of SHDs.

Insomnia, alcohol, and over-the-counter drug use in old-old urban women

Insomnia is a common complaint of older adults. Historically, alcohol and over-the-counter (OTC) medications have been used as sedatives. Yet, there is a lack of information regarding the use of these substances by old-old urban women. A volunteer sample of 155 urban women over the age of 85 participated in a two-part structured interview to obtain data related to their health, sleep patterns, use of alcohol and OTC medication to improve sleep, awareness of hazards associated with use of these substances, and reason for seeking health care for insomnia. Findings indicate that all of the women had health problems and difficulty in sleeping. The majority used alcohol, OTC medication, or both on a regular basis in an effort to improve their sleep. Nurses who work with very old women need to assess clients' use of these substances and the side effects associated with them.

Insomnia and mental health

The night care team's role in promoting mental health is not simply administering hypnotics. This paper describes the knowledge base needed and identifies several behavioural and cognitive strategies to aid patient empowerment.

An investigation into primary nursing and its effect upon the nursing attitudes about and administration of prn night sedation

This study aims to explore the administration of prn night sedation by qualified night nurses on primary nursing and team nursing wards using a quasi-experimental design. The purpose of the study was to examine the attitudes of qualified nurses (n = 20) about sleep problems in hospital and sleep medication and compare these attitudes with behaviour (the administration of prn night sedation) reporting any differences between wards using team and primary nursing philosophies of care. Ten nurses from team nursing wards and 10 nurses from primary nursing wards were interviewed about the amount of night sedation they had administered during one night shift. This was followed by a questionnaire aimed at examining their attitudes about sleep and night sedation using several visual analogue scales. Findings proved to be significant in that results confirmed that team nurses gave out almost three times as much prn night sedation as nurses on primary nursing wards and held attitudes that closely correlated with more of a 'medical model' approach such as an emphasis on the advantages of night sedation and the need for its continued use in the clinical area.

Effect of the use of sleep medication in Dutch hospitals on the use of sleep medication at home

Insomnia is an important nursing problem in hospitals. Although the use of sleep medication is often criticized, it is one of the commonest interventions with regard to sleep problems. In this study, the effect of the administration of sleep medication in Dutch hospitals on the use of sleep medication at home is investigated. Only patients were included who had never used sleep medication before admittance in hospital. Results show that patients who used sleep medication for at least 5 days in hospital (n = 233) used sleep medication more often at home after discharge than patients who did not use sleep medication in hospital (n = 55). Furthermore, the study showed that those patients who used at least 5 days' sleep medication, especially those patients who used sleep medication more often in hospital, also used sleep medication more often at home. This is in line with the addictive effects of sleep medication. From these results it can be concluded that the administration of sleep medication is not without danger. Therefore, it is recommended to search for alternative interventions, especially for patients who are in hospital for a longer period.