Several factors contribute to sleep disorders in older adults. Firstly, medical conditions are a contributing factor of sleep disorders. A few examples of medical conditions that affect sleep are heart conditions (angina and congestive heart failure), asthma, cancer, chronic fatigue syndrome, chronic pain syndrome, gastro esophageal reflux disorder, degenerative disease, chronic obstructive pulmonary disease, hyperthyroidism, pregnancy, and stress (Reeve and Bailes, 2010). Due to the physiology associated with these conditions, different effects on sleep exist, contributing to sleep disorders in older adults. Secondly, psychiatric conditions can also contribute to sleep disorders. Examples include a variety of mood disorders (major depressive disorder, bipolar mood disorder, and dysthymia), anxiety disorders (generalized anxiety disorder, panic disorder, post traumatic stress disorder, and obsessive-compulsive disorder), psychotic disorders (schizophrenia, schizoaffective disorder), amnestic disorders (Alzheimer disease, dementias), attention-deficit disorder, personality disorders, bereavement, and stress (Reeve and Bailes, 2010). Different psychiatric conditions have effects on sleep due to the nature of their physiology and involvement with hormones and psyche, contributing to sleep disorders. The third factor that contributes to sleep disorders is associated with the medical and psychiatric factors. With all of these conditions that older adults are prone to having (many with comorbidities), medical management of these conditions results in medicine, which has side effects that affect sleep disorders. Medication side effects is the third factor that affect sleep and are “another cause of sleep disturbance,” with older adults consuming roughly five to nine daily medications according to Subir (2016). These medications interfere with sleep and wakefulness. Some medications include sedative antidepressants and antipsychotics, which can contribute to daytime drowsiness. In turn, daytime drowsiness and napping in the day interferes with sleep at night. Beta-blockers “can cause difficulty falling asleep, an increased number of awakenings, and vivid dreams” as suggested by Subir (2016). Also of note are theophylline and caffeine, which are stimulant drugs known to increase wakefulness, decreasing total sleep time. Subir suggests, “caffeine’s effect can last as long as 8-14 hours and may be more pronounced in older patients… [and] over-the-counter pain relievers, cold or allergy remedies, appetite suppressants, and tonics may contain caffeine” (Subir, 2016). Fourthly, the phenomenon called “sleep stress” also contributes to sleep disorders in older adults. The premise of sleep stress is that there are fluctuating periods of stress that result in poor sleep, effecting maladaptive behaviors in trying to get to sleep. Kelso states:
“These include (1) a vicious cycle of trying harder to sleep and becoming more tense (i.e., patients “trying too hard to sleep”) and (2) bedroom habits and routines (e.g., brushing teeth) that actually condition the patient to become frustrated and aroused. Patients often report “racing thoughts” and sensitivity to their environment”(2014).
Sleep stress in the older adult creates anxiety, which compounds the effects of ineffective sleeping, acting as a contributor to sleep disorders. Lastly, there are lifestyle and social factors that contribute to sleep disorders in older adults. Subir states that “many older people are less active, and their bodies are not as ready for sleep at the end of the day” (2016). In addition, alcohol and smoking habits interrupt sleep. Another lifestyle factor to consider is daytime sleeping, or napping, which interferes with sleep. As the older adult is prone to stress, Subir believes that “everyday stress can make sleep more difficult” (2016). With changes in lifestyle and habits that have physiologic effects on sleep, sleep disorders may occur.
As a gerontologic nurse, promoting effective sleep for Mr. Hayes must be included in his care plan. He came to the gerontology wellness clinic and made several complaints regarding sleep, seeking out advice for effective sleep promotion.
Firstly, we would discuss light reduction. Light reduction can be achieved by encouraging the use of an eye mask since “light exposure is the primary external cue for circadian rhythm” (Hu, Jiang, Zeng, Chen, & Zhang, 2010). In a study by Hu, Jiang, Zeng, Chen, and Zhang, they conclude, “eye masks promote sleep … [in] simulated… light” (2010). Light is a contributor to the circadian rhythms in the body, which influences how people sleep, the times of sleep, the quantity of sleep, and the quality of sleep. The Cleveland Clinic states “these rhythms might be altered… especially [with] exposure to light” (2014). Further, the suprachiasmatic nucleus (SCN) initially arranges its intrinsic, rhythmic oscillations to roughly twenty-five hours. Reeve and Bailes state that these “rhythmic oscillations become synchronized to a 24-hour period based on the light-dark cycle entrained through the retinohypothalamic tract and actions of various neurotransmitters” (2010). The cycle then repeats with low and high levels, with the lowest point coordinating with early morning- resulting in the fostering of sleep, followed by a surge to encourage wakefulness (Reeve and Bailes, 2010).
Secondly, to promote effective sleep, we can suggest the use of earplugs, to reduce noise levels. In the same study of light by Hu et al, earplugs were also tested for noise reduction. The conclusion is that earplugs did promote sleep, making their use reasonable (Hu et al, 2010). Several studies show that exposure to noise is a cause of sleep disturbance by Topf et al. (1996), Wallace et al. (1999), Freedman et al. (2001), and Christensen (2007) and “patients also frequently report excess noise as one of the most disturbing factors in other ward areas in hospital” (as cited by Richardson, Thompson, Coghill, Chambers & Turnock, 2009). Richardson et al suggest that nurses contribute to developing interventions for noise reduction in hospitals (2009). Using evidence from these studies, noise reduction can be applied to the home setting for Mr. Hayes. The suggestion of earplugs is supported and may have an effect on sleep promotion.
Thirdly, the promotion of comfort can affect sleep effectiveness. Comfort can be achieved in several ways, according to the preferences of the patient, with Mr. Hayes as the focus in this case. In a study by Eliassen and Hopstock, they determined that patient comfort strategies include “foot or hand massages, holding the patient’s hand, sitting within visual distance if the patient was anxious, or offering television, radio or music if the patient desired such entertainment before sleeping… [and] bed adjustments, patient position, adequate pain relief, massage, mouth care” were important to the patient (2011). Encouraging a patient to find a comfortable room temperature is also important. The scientific background for comfort promotion regards what happens during sleep. The ability to regulate body temperature is lost in some people during REM sleep and temperature sensitivity occurs, and “abnormally hot or cold temperatures in the environment can disrupt this stage of sleep” (American Sleep Association, 2007). The American Sleep Association further contends that if “REM sleep is disrupted one night, our bodies don’t follow the normal sleep cycle progression the next time we doze off… [and] we often slip directly into REM sleep and go through extended periods of REM until we “catch up” on this stage of sleep, contributing to sleep disorders (American Sleep Association, 2007). All in all, an “increase [in] comfort of sleeping position, enhancing relaxation… will promote a sleep state” (Potter & Perry, 2011).
Fourthly, allaying anxiety with the use of relaxation techniques can contribute to more effective sleep. LaReau suggests that patients have a device for music because “soothing music blocks out sounds from the environment, promotes relaxation, and decreases the time to sleep onset” (as cited by Potter & Perry, 2011). Additionally, encouraging a patient to read before bed with their favorite materials is good for sleep promotion since “reading before bedtime is a rest-promoting pre-bedtime activity” (Potter & Perry, 2011). According to the Cleveland Clinic, psychological stressors (a contributor to anxiety) interfere with sleep (2014). The Cleveland Clinic suggests:
“Develop some kind of pre-sleep ritual to break the connection between stress and bedtime… some people find it helpful to make a list of all the stressors of the day, along with a plan to deal with them. In addition, periods of relaxation (meditating or taking a hot bath) can help a person relax and get to sleep” (2014).
Anxiety and stress involve two systems- the corticotrophin-releasing hormone (CRH) system and the LC-autonomic nervous (AN) system. Staner suggests, “in humans, there is a close temporal relationship between HPA [hypothalamic-pituitary-adrenal] activity and sleep structure” (2003). In shortwave sleep, sympathetic activity is decreased and a positive correlation exists between REM sleep amount and the activity of the hypothalamic-pituitary-adrenal conglomerate. Staner contests that “patients with complaints of insomnia show electrophysiological and psychomotor evidence of increased daytime arousal, as well as indications of increased HPA activity and increased sympathetic tone (2003). Allaying anxiety and promoting relaxation will decrease HPA activity and contribute to better sleep.
Lastly, to promote effective sleep, we can support an exercise regimen. We can encourage Mr. Hayes engage in regular exercise because “regular exercise improves sleep quality by slightly increasing the amount of stage 3 and stage 4 sleep” as suggested by Tucker (as cited by Potter & Perry, 2011). With a structured exercise plan, Mr. Hayes may have better sleeping patterns, decreasing his sleep complaints.
One complementary modality for sleep promotion is relaxation. The objective of relaxation therapy is to promote “mental relaxation secondary to physical relaxation, [with] meditation, progressive muscle relaxation, biofeedback, imagery” (Reeve and Bailes, 2010). As mentioned earlier, relaxation has physiological effects on sleep. Kelso states “patients with insomnia often display high levels of arousal (physiologic and cognitive) at night and during the daytime” (2014). Relaxation interventions aim to deactivate the arousal system, which contributes to sleep disorders. Techniques suggested by Kelso include “(1) progressive muscle relaxation, (2) biofeedback, and (3) imagery training and thought stopping” (2014). The Cleveland Clinic contends that progressive muscle relaxation works by helping an individual relax sequentially, focusing on the different sensations of tension and relaxation (2014).
A second complementary intervention is stimulus control. The objective of this intervention is to develop a regular sleep cycle, promote the association of the bedroom with rapid onset of sleep, and to use the bed for only sleep (or sex) (Reeve and Bailes, 2010). This treatment is used to “reestablish the connection between the bed and sleep by prohibiting the patient from engaging in non-sleep activities while in bed” (Reeve and Bailes, 2010). The patient is instructed to only go to bed if sleepy, use the bedroom and bed for intimacy and sleep, avoiding sleep stress (for example, changing rooms if unable to fall asleep within twenty or thirty minutes, prompting return to bedroom when sleepy again), having a regular wake schedule regardless of how much the patient slept the previous night, and to avoid daytime napping (Kelso, 2014). Scientifically, stimulus control comes from the acceptance that insomnia may have a relationship between the bedroom becoming associated with other things (examples include stressful situations, work, leisure) other than sleep and sex (Cleveland Clinic, 2014).
The third complementary treatment for sleep promotion is sleep restriction. Sleep restriction aims to reduce the amount of time in bed and to limit the time in bed to actual sleep. In addition, “mild sleep deprivation promotes more efficient sleep” (Reeve and Bailes, 2010). The sleep deprivation will build up, enabling speedy sleep onset. Once sleep improves, the patient is then encouraged to gradually increase time in bed by intervals of fifteen to thirty minutes (Kelso, 2014).
Fourthly, paradoxical intention is used as a complementary sleep promotion intervention. The objective of this intervention is to “change unrealistic sleep expectations [and] decrease anxiety about falling asleep by staying awake as long as possible” (Reeve and Bailes, 2010). It has roots to psychology and this intervention encourages the patient to stay awake, which is a feared behavior to the patient with sleep disorders. By doing this, paradoxical intention “serves to eliminate performance anxiety so that sleep may come more easily” (Kelso, 2014). This has ties to sleep stress prevention as mentioned earlier. The cycle of trying harder to sleep is ineffective and results in less sleep. By facing the fear of not being able to sleep by staying up, the sleep state may come more naturally instead of accumulating performance anxiety to sleep and failing.
Fifth and lastly, cognitive behavior therapy is used complementary in sleep promotion. Cognitive behavior therapy aims to “replace identified dysfunctional attitudes about sleep with adaptive substitutes” (Reeve and Bailes, 2010). Cognitive behavior therapy will attempt to correct unrealistic expectations sleeplessness and it’s consequences, identify coping responses, aid in restoring balance to “anxious autonomic thoughts”, and shift attention (Reeve and Bailes, 2010). Kelso also writes that cognitive behavior therapy uses the patient to identify specific dysfunctional sleep perceptions and challenge their validity to replace them with other substitutes using “reattribution training” and reappraisal. (Kelso, 2014). Cognitive behavior therapy works psychologically. It helps break down problems (such as sleep disorders) into smaller, more manageable parts by situation, thoughts, emotions, physical feelings, and actions. Cognitive behavior therapy stops negative thought cycles. Exposure therapy is a part of CBT “to face your fears in a methodical and structured way” (National Health Service of England, 2014). After a couple of exposures to the problem (inability to sleep in this case), the anxiety will not escalate as much as before, making sleep come easier. (National Health Service of England, 2014)
Over-the-counter (OTC) sleep aids are used to promote sleep. The discussion of over the counter sleep aids will include three examples- diphenhydramine, doxylamine succinate, and melatonin.
Firstly, Diphenhydramine (Benadryl, Unisom SleepGels, etc.) is an antihistamine with drying (anticholinergic) and sedative effects. The action of is to compete with histamine for cell receptor sites on effector cells. According to Chattem, diphenhydramine “works by blocking the effects of a natural occurring neurotransmitter made by your body called histamine… [and] when histamine is reduced, you experience drowsiness, which allows you to both fall asleep faster and stay asleep (2015). Diphenhydramine is used as an antihistaminic, for motion sickness, anti-Parkinson’s, and nighttime sleep aid (Pharmaceutical Associates, Inc., 2012). There are several adverse effects related to diphenhydramine. General adverse effects include a rash, anaphylactic shock, chills, excess sweating, photosensitivity, and drying of the mouth, throat, and nose. The most frequent adverse reactions are extra systoles, agranulocytosis, sleepiness, sedation, dizziness, disturbed coordination, paresthesia, epigastric distress, and thickening of nasal secretions. Nursing implications include teaching to not use in neonates or premature infants. Diphenhydramine is contraindicated in nursing mothers. Patients should be taught signs and symptoms of hypersensitivity reactions to antihistamines or to avoid this medication if there is a history of previous hypersensitive reaction. Diphenhydramine should be used with caution in several conditions including stenosing peptic ulcer, narrow-angle glaucoma, pyloroduodenal obstruction, symptomatic hypertrophy, and bladder-neck obstruction. Of special note, Pharmaceutical Associates, Inc. states, “antihistamines are most likely to cause dizziness, sedation, and hypotension in elderly patients” (2012). Patients taking diphenhydramine should be cautioned to avoid activities that require concentration such as driving and operating machinery to decrease accidents since diphenhydramine has the sedative effects. (Pharmaceutical Associates, Inc., 2012)
Secondly, another over-the-counter drug used to help sleep is Doxylamine succinate (Unisom Sleeptabs). Doxylamine is also a sedating antihistamine, with similar side effects to diphenhydramine (Mayo Clinic Staff, 2014). The difference is that doxylamine succinate not only blocks just histamine, it blocks acetylcholine as well to cause drowsiness and sleep (Chattem, 2015). Doxylamine succinate is used for insomnia and allergic rhinitis. The most common adverse effect is excessive drowsiness, in addition to the side effects of diphenhydramine as listed previously. Nursing implications involve managing the effects of marked drowsiness. Patients are taught to avoid alcohol and to be cautious when driving and operating machinery. Patients are also urged to disclose any medications they are currently taking since there are interactions between drugs. Of note, if patients are already taking sedatives or tranquilizers, a clinician must be consulted as the effects of sedation may be enhanced and life threatening. Also, pregnant women and women planning to become pregnant must be counseled by a clinician regarding the effects of the medication on breast milk. Disease and other medical conditions must be considered when taking doxylamine succinate. Due to the possibility of anticholinergic effects (indicated by dry mouth, nose, and throat, painful urination, and urinary retention), patients with conditions such as glaucoma, emphysema, chronic bronchitis (or any other respiratory illnesses), or prostatic hypertrophy should see a clinician before the start of doxylamine succinate. Specifically in the geriatric population, there is “possible increased risk of dizziness, sedation, and hypotension” (American Society of Health-System Pharmacists, 2015). Hypotensive effects need to be monitored to prevent fainting, falls, accidents, and injury. (American Society of Health-System Pharmacists, 2015)
Thirdly, Melatonin is used as an over-the-counter sleep aid. Melatonin is a hormone that contributes to the natural sleep-wake-cycle. According to Mayo Clinic Staff, there is “some research [to] suggest that melatonin supplements might be helpful in treating jet lag or reducing the time it takes to fall asleep” (2014). Melatonin is N-acetyl-5-methoxytryptamine, produced by pinealocytes in the pineal gland during the dark hours of the day and night cycle. Oral melatonin has been reported to induce phase-setting effects on circadian rhythms (sleep-wake cycle and rest-activity). Melatonin is used for such as the sleep-wake cycle and rest-activity (Truven Health Analytics, 2016). There are several adverse reactions related to melatonin. Some of them include nausea, headache, daytime sleepiness, uncontrolled urination, dizziness, and depression (Wolters Kluwer Health, 2009). According to Mayo Clinic Staff, headache and daytime sleepiness are known side effects (2014). In addition, there are several nursing implications associated with melatonin. There are a handful of interactions between melatonin and other drugs/substances. Melatonin is elevated by caffeine and counselors must teach patients taking melatonin to watch their caffeine intake. For patients taking fluvoxamine, melatonin metabolism may be inhibited, increasing the effects of melatonin. This means that there is a higher risk for marked drowsiness. Melatonin may decrease the effect of nifedipine, which will result in an elevated blood pressure. Patients need to be taught that when taking melatonin and nifedipine need to monitor their blood pressure carefully. Also, for patients taking Coumadin and melatonin, there may be a risk for potentiating the effects of Coumadin. This means there is a higher risk for bleeding and melatonin use in patients taking anticoagulants must be monitored or reconsidered. In addition, as melatonin is a sleep aid, marked drowsiness needs to be monitored. Patients are taught to avoid driving and operating machinery to reduce injury risk. (Wolters Kluwer Health, 2009).
References
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