N117sleep.docx

University of the Philippines Manila The Health Sciences Center COLLEGE OF NURSING WHO Collaborating Center for Leadership in Nursing Development Commission on Higher Education Center for Excellence Sotejo Hall, Pedro Gil St., Ermita, Manila

Geriatric Syndrome: Sleep Disturbances A Written Report

Submitted in Partial Fulfillment of the Requirements of N-117: Nursing Care of the Chronically-Ill and the Aged (Older Persons)

Submitted by: BAYONITO, Karl Aaron D. DELOS SANTOS, Jose Raphael MEJIA, Robert L. MORENO, Keena S. NABONG, Earl Bradley A. TUBERA, Sophia A. VILLANUEVA, Mary Grace B.

4th May 2017

I.

Sleep Sleep is one of the simplest and most-convenient way of preserving one’s health and

well-being. It provides rest and gives our body time to regenerate and reserve energy to fulfill our activities of daily living. With aging comes different changes in every aspect of life. These may be in terms of physical, social, psychological, emotional, spiritual or other aspects. Older persons also face the struggle of the need to adapt to certain changes in their life that may be an effect of the different changes that they experience and one good example of a change that’s an effect of different aspects of aging is the occurrence of sleeping disturbances/ sleeping disorders. Research has suggested that the elderly have a decreased ability to sleep (Ancoli-Israel 1997; Bliwise 1993). In addition to this, certain normal processes that are used to be fully functional for a normal adults tends to deteriorate or degrade as one approaches old age. Common manifestations of this include the increased arousals and awakenings at night, non-REM sleep is also affected by being reduced or even non-existent at times although REM sleep tends to be preserved (Neubauer, 1999), changes in time and duration of sleep and reports of difficulty in falling asleep. According to Reid, et’ al (2006). one of the most commonly reported sleeping disorders among older persons is insomnia which is defined as the prolonged and usually abnormal inability to get enough sleep (Webster, 2017). Cooke and Ancoli-Israel identified 3 major factors affecting the sleeping patterns of the elderly. These include: (1) Depression and psychological distress, (2) Co-existing medical illnesses, and (3) medications taken. We can also notice and observe by simply living with older persons that their sleep cycles are also different from normal adults, The National Sleep Foundation described the gradual

change in circadian rhythms of older persons as “Advanced Sleep Phase Syndrome”. The evident sign of this syndrome is the tendency of the older persons to fall asleep early and wake up very early in the morning. The consequence of this is decrease in the quality of sleep, longer time to fall-asleep and increase in sleep fragmentation (repetitive waking up at night). The prevalence of NCDs among older persons and the severity of their effects also majorly contributes to the quality of sleep of the older persons. Neubauer (1999) also identified other primary sleep disorders among older persons such as: (1) sleep apnea, (2) restless legs syndrome, (3) periodic limb movement disorder, and (4) REM-behavior disorder. Given all of these common problems faced by older-persons in terms of getting a quality and enough sleep, the importance of being an advocate of sleep and providing ways to improve sleeping practices and patterns cannot be over-emphasized.

II.

Impact of Syndrome Some studies perceived the effects of decreased amount of sleep of older persons as

nothing to harm the systems of the body. A study conducted by Bonnet (1988) revealed that older individuals may require less sleep than younger ones and can be less sensitive to its effects. Healthy older clients are likewise or more resistant to the effects of decreased amount of sleep as compared to young adults as evidenced by decreased sleepiness during the day of the older persons compared to younger ones. Also, it is mentioned that there is an improved psychomotor performance of the older persons compared to younger ones even under lack of sleep. Cognitive function of older persons is also noted to tolerate basic functions like addition. However, it is important to note that these results are from healthy older persons.

On the other hand, due to chronic abnormal sleep in the elderly, which is caused by different sleep disturbances and conditions that leads to decreased amount of sleep and rest, negative effects could occur. A study by Cooke (2011) revealed that consequences of insomnia to older persons include poor health and mental status. Poor health status is seen in poor physical performance while decreased mental status is evident in development of depression and poorer cognition. Because of these, decreased sleep time can also increase incidents of falls which is common in frail older persons. Poor medication use is also prevalent in older persons with lack of sleep (Fragozo, 2007). This may be due to decreased mental and cognitive function that the older persons unintentionally forget to take their medications of time thus, results to progression of disease and other complications. In physical activity, it is reported that older persons with decreased sleep also has decreased physical activity and also disability in basic ADLs. Chronic decrease and tolerance for physical activity may branch to different problems and complications related to immobility like increase in pressure ulcer risk, DVT risk, respiratory infection risk, constipation, self-care deficit, and many more. Even if healthy older persons tolerate decreased amount of sleep hours, still, it is evident that lack of sleep affects older persons negatively, therefore, complete number of sleep hours is still essential.

III.

Pathophysiology There are two sleep stages classified by polysomnographic studies. These are the rapid-

eye-movement

(REM)

sleep

and

non-REM

sleep.

The REM sleep (ie, paradoxical desynchronized sleep) is the stage of sleep during which the muscle tone decreases markedly. It is associated with bursts of conjugate gaze and dreaming. Decline

in

this

stage

occurs

during

extreme

old

age

(Xiong,

2016).

The Non-REM sleep is further subdivided into 4 stages. Stages 1 and 2 constitute light sleep, and stages 3 and 4 are called deep sleep or slow-wave sleep (SWS). It was determined that in older people, there is a higher duration of stage 1 sleep because of the increased number of shifts in stage 1. Stages 3 and 4 decrease markedly as someone ages. In extreme old age (>90 years old), stages 3 and 4 may disappear completely. According to some studies, older women tend to have normal or even increased stage 3 sleep, whereas men have normal or reduced stage 3 sleep. This lead to older persons being more easily aroused from sleep by auditory stimuli, suggesting increased sensitivity to environmental stimuli (Xiong 2016). Aside from the normal process of aging, other causes of disturbed sleep pattern in older persons are poor sleep habits, medical illness, medications, and psychiatric disorders. Poor sleep habits is due to irregular sleep-wake patterns related to lifestyle or work requirements undermining the ability of the circadian system to effectively provide sleepiness and wakefulness at appropriate times. Consumption of caffeine-containing beverages in the afternoon and alcohol consumption in the evening can impair nighttime sleep. It also prevents deeper sleep and increases arousals during the latter part of the night (Neauber, 1999). Medical

illness

such

as

arthritis,

prostatic

hypertrophy

and

cardiovascular,

gastrointestinal and pulmonary diseases, may precipitate sleep disruption. Sleep may be delayed because of pain and discomfort. Neurodegenerative disorders also cause deterioration of the sleep-wake cycle (Neauber, 1999). Having medications and polypharmacy cause stimulating effects leading to sleep disruption. The potential sedating effects of medications (especially long-acting sedatives that are inappropriately used as sleep aids) should also be a consideration in patients who report excessive daytime sleepiness. Many of the medications that are prescribed for chronic medical

and psychiatric conditions can also contribute to, or even cause, insomnia, such as central nervous system stimulants (e.g. modafinil, methylphenidate), antihypertensives (e.g. β-blockers, α-blockers), respiratory medications (e.g. theophylline, albuterol), chemotherapy, decongestants (e.g. pseudoephedrine), hormones (e.g. corticosteroids, thyroid hormones) or psychotropics (e.g. SSRIs, atypical antidepressants, MAO inhibitors). Stimulating medications and diuretics should be taken earlier in the day and sedating medications should be administered prior to bedtime to facilitate

sleep

(Israel,

2009).

Psychiatric disorders promotes disturbed sleep. A classic example is insomnia in association with major depression. The tendency toward increased arousals and early-morning awakening in older person may be severely exacerbated in the presence of depression. Psychologic manifestations of the life changes that they often experience also contribute to a deterioration in the quality of sleep. Significant factors include physical limitations, loss of loved ones and leaving a familiar home to live in a more supervised setting. The two primary sleep disorders experienced by older persons are Obstructive Sleep Apnea (OSA) and Periodic Limb Movement in Sleep (PLMS). OSA happens when there is a lack of breathing during sleep. The causes may be obstructive (upper airway occlusion), central (primary neurologic disease), or mixed. The ability of the genioglossus muscle (the major pharyngeal dilator muscle) to respond to increases in pharyngeal negative pressure is impaired with aging, yielding a more vulnerable airway (Edwards, 2010)..The manifestations in people with OSA are waking with gasping, confused wandering in the night, and thrashing during sleep. Waking up the person resolves OSA so it is important to avoid sedatives and hypnotics in these patients because those agents can further relax the pharynx dilators, resulting in worsening the apnea. According to one study by Martin et

al among healthy older adults living in the community, the prevalence of OSA (defined by more than 5 apneas per hour) was 28% in men and 20% in women. OSA occurs in 42% of people with dementia who live in nursing homes and correlates with cognitive function. This is because sedative-hypnotic medications of people with will likely exacerbate sleep apnea which are not recommended in patients with OSA. Unmanaged OSA can lead to daytime hypersomnolence, systemic hypertension, cardiac arrhythmias, cor pulmonale, and even sudden death (Xiong, 2016). Another common sleep disorder in older persons is the Periodic Limb Movements in Sleep (PLMS) or nocturnal myoclonus. It is the repetitive, unilateral, or bilateral stereotyped leg jerks that arouse the patient from sleep.The incidence of nocturnal myoclonus increases with age, and the likelihood of an associated sleep-wake complaint is related to the absolute number and intensity of the leg movements. Soaking the legs and feet in a warm bath or engaging in regular exercise provides relief of restless legs syndrome in some patients (Xiong, 2016). IV.

Management A. Health Promotion In addressing sleep disturbance of the older persons, evidence-based nursing

interventions encompassing education, facilitating behavioral changes, manipulating the environment to make it more conducive to sleep, and planning care for relaxation and preservation of the normal circadian rhythms need to be done. Health education is still one of the basic and most important interventions to help them understand the nature of a sleep disturbance. These include teaching older persons how to recognize age-related changes in sleep, encourage them to write a sleep diary to be aware of the factors affecting sleep and therapeutic response to

treatment strategies,

and further assessment to those who present physical signs of sleep

deprivation, changes in behavior, performance, and cognition. Other specific interventions to promote sleep include sleep hygiene, stimulation of acupoints, relaxation, music, natural sound and vision, and aromatherapy. Sleep hygiene minimizes the factors that can disturb and disrupt sleep, both in the environment and on a personal level. Examples of those activities are regulation of room temperature for increased comfort, control of light and noise levels during the night, avoidance of daytime napping, engaging in physical activity during the day and abstaining from the consumption of caffeine and alcohol at late hours. Acupuncture has positive effects on sleep efficiency after stimulation of acupoints in the ear of primary insomnia patients (Suen et al. 2002). However, sleep promotion by acupuncture needs to have familiarity with the technique since some people may find the intervention painful. Different relaxation techniques are also used to promote sleep. The intervention consisted of audio-taped instructions for relaxation, mental imagery and music or oral relaxation instructions and mental imagery provided to the person (Richardson 2003). Teaching patients how to do progressive relaxation has been found to be effective by enabling them to decrease the time to sleep onset and the number of nighttime awakenings and to sleep more soundly (Hoffman, 2003). Music, common natural sounds and music videos can be done to create calm and promote sleep and this was found to be more effective in patients undergoing surgery (Zimmerman et al., 1996). Listening to relaxing music and using guided imagery (usually done with the help of a tape of ocean sounds, rain, waterfalls or other relaxing auditory sounds) can also promote sleep.

Additional research on the effectiveness of these interventions will improve their usefulness in evidence-based nursing (Hoffman, 2003). Lastly, aromatherapy uses calming and relaxing essential oils prior to bedtime that can potentially help a person fall asleep faster and stay asleep until the intended wake-up time.

B. Disease Prevention Insomnia proves to be the most common sleeping disorder among older people. In order to encourage a better night’s sleep. Melatonin helps in controlling sleep and wake cycles so naturally increasing it will be beneficial. The bedroom should be kept dark with a few or no lights. Artificial lights may affect the body’s production of melatonin causing a decrease in levels. Electronic devices such as televisions and smartphones should be turned off. If possible, the room should only be used for sleeping and must be kept clean, cool and dark with a comfortable bed. Sleeping problems may be caused by noise, light and heat. As older persons experience difficulty in falling asleep and are troubled by awakening after only a few hours of sleep, simple measures can be done in order to improve their quality of sleep. Sleep disturbed breathing may be avoided through sleep position modification. The older person must avoid sleeping in the supine position. Posture can cause structural changes in the upper airway such as elevation of the diaphragm when in the supine position and the reduction in upper airway muscle activity with the change from lateral to supine sleep position. Sleeping on the sides can can help prevent sleep disturbed breathing. Sleeping in this position can also help prevent neck and back pain, as well as acid reflux. For sleep disturbed breathing, weight reduction is also recommended. This is to reduce excess tissue that may be obstructing the airway.

Even though the cause of periodic limb movement disorder is unknown, there are steps that can be done to reduce its occurrence. Products containing caffeine should be avoided as caffeine is known to intensify PMLD. This includes coffee, tea, softdrinks, and chocolates. Rapid Eye Movement Sleep-Behavior Disorder causes a person to act out vivid and so safety measures should be done to prevent injury during an attack. Having a bedroom at the groundfloor is preferable especially for those who leave their beds during an episode. Doors and windows should be properly secured. Clearing the floor around the bed from any sharp objects is important. The family may consider placing paddings on bedrails and nearby furnitures.

C. Curative Sleep disorders or disturbances have been reported in the older adults and these causes daytime fatigue and sleepiness. Recognition of this problem has been increased markedly in the recent years because it has great effect on the quality of life of the older adults. (Stepanski, Rybarczyk, Lopez & Stevens, 2003) Physicians have been treating this with pharmacological interventions and most commonly, they use sedatives or hypnotics, antidepressants, antipsychotics and antihistamines; however, oftentimes, risks outweigh the benefits because of the metabolism changes in the body of the older adults. (Allen, Coon, Uriri-Glover & Grando, 2012) Older adults have decreased metabolism rate because of the changes in the way their body process various proteins, enzymes, substrates and other chemicals in the body. Drugs absorbed in the body needs to be reduced first or reach their half-life in order to be excreted in the body. However, as a result of the metabolic changes, drugs takes more time to be excreted in from the body. To add, as a result of the decreased resting metabolism, they accumulate fats

more in the body and obesity is linked in old age. Due to this, fat-soluble medications are excreted longer from the body. Also, changes in their gastrointestinal function has been noted which may then affect the absorption of the drugs. The older persons have decreased secretion of gastric acids and reduced gastric acids reduce the absorption of the drugs taken orally. However, their gastrointestinal motility is decreased and this increases the absorption of drugs. Net result is great alterations in the absorption of the drugs and as well as, the time needed for them to take effect. (Wooten, 2012) In addition to this is the polypharmacy of the older persons. Older persons often times have many comorbidities and are required to take many medications such as maintenance medicines for different diseases. Usually polypharmacy results in adverse drug reactions, effects on geriatric syndromes, cognition and physical function, thus, choosing the right medications are really important among older persons taking medications, including if the older person chooses to take medications to treat sleeping disorders and disturbances. (Hilmer & Gnjidic, 2009) Because of these changes in the older adults, giving medications for sleep disorders must be with strict precaution. For decreasing risks and the after-effects of the drugs, medications for sleep disorders are usually given before bedtime and stimulants and diuretics are usually given in the morning. (Cooke & Ancoli-Israel, 2011) Hypnosedatives and antipsychotics are associated with impairments in cognition, memory, coordination and balance with acute use but long-term use is associated with tolerance of insomnia. Antidepressants may cause possible impaired performance and daytime drowsiness, and decreased REM sleep. And, antihistamines may impair daytime performance and increase drowsiness. (Allen, Coon, Uriri-Glover & Grando, 2012)

D. Rehabilitation Sleep is a very important physiologic process that helps in restoring bodily functions that are important for us. And there is a notable decline in both quality and quality of sleep that occur as we age. Older persons need as much as sleep as those who are younger, but they often do not get it because the brain is less sensitive to the drive to sleep. Evidences and scientific knowledge about the effective rehabilitation techniques for sleep disorders in older persons has increased dramatically. Gooneratne (2008) studied the effectiveness of complementary and alternative medicine for sleep problems in older adults. It showed in her review that meditation, specifically mindfulness meditation, has been one of the most commonly studied for insomnia. It demonstrated improved sleep during meditation therapy and this result can be from the fact that this type of therapy can also reduce stress which gives beneficial effects on sleep. Yoga has also shown to reduce anxiety and physiologic arousal. Yoga is a holistic practice involving physical activity associated with specific postures, breathing exercises, and positive attitude towards life. A study of Manjunath et. al. (2005) comparing yoga to a control group showed that there was an increase in total sleep time relative to pre-treatment by one hour. Lastly, Gootneratne (2008) described that Tai Chi, a Chinese exercise that includes a meditational component, improved sleep duration by 48 minutes in 118 older adults. It was also noted that general health-related quality of life and daytime sleepiness levels also improved. On the other hand, there is an increasing number of evidence showing nonpharmacological interventions for management of older persons with sleep disorders. The most common treatment has been multicomponent cognitive-behavioral therapy (CBT) which was found to meet evidenced-based treatment criteria for sleep problems in older persons (Allen et al., 2012). Two of the components of CBT are stimulus control and sleep restriction therapy.

Stimulus control, in essence, increases the association of being in bed and being asleep. It aims to make the bed a cue for sleeping based on operant behavioral techniques by instructing older persons to limit their activities in the bed and bedroom, as they may only sleep in bed; and any other activities in bed, such as watching television, reading, eating, worrying, and working are prohibited. Sleep restriction therapy, on the other hand, involves limiting the amount of time an individual spends in bed to actual average time spent sleeping each night aiming to strengthen the homeostatic sleep system, which declines with increasing age. This therapy is appropriate for persons with insomnia who nap frequently during the day or who spend a lot of time in bed at night. Results showed that sleep has been consolidated and the time spent awake during the night has decreased.

V.

Conclusion As a person ages, it is accompanied by a variety of sleep complaint and sleep disorders

and poor sleep quality constitutes one of the most common difficulties faced by older persons. Generally, sleep becomes more fragmented and lighter with increased arousals and awakenings. As the amount of sleep in stage 3 and 4 are reduced beginning in the middle age, the body compensates by increasing amount of stage 1 and 2 sleep which are also the lighter stages of sleep. These changes in sleeping pattern leads to daytime sleepiness causing napping that may be intentional or unintentional. Previous studies have been made reporting that older persons have a decreased ability to sleep that is reported as insomnia which is caused by a variety of factors. These factors include psychological distress, medical illnesses, and medications. In order to manage sleep disorders behavior treatment and pharmacologic treatment are utilized.

VI.

References

Aging and Sleep. (n.d.). Retrieved May 03, 2017, from https://sleepfoundation.org/sleeptopics/aging-and-sleep/page/0/2 Allen, A. M., Coon, D. W., Uriri-Glover, J., & Grando, V. (2013). Factors associated with sleep disturbance among older adults in inpatient rehabilitation facilities. Rehabilitation Nursing, 38(5), 221–230. https://doi.org/10.1002/rnj.88 Bonnet, M. H. (1989). The effect of sleep fragmentation on sleep and performance in younger and older subjects. Neurobiology of Aging, 10(1), 21–25. https://doi.org/10.1016/S01974580(89)80006-5 Cooke, J. R., & Ancoli-Israel, S. (2011). Normal and abnormal sleep in the elderly. Handbook of Clinical Neurology Sleep Disorders, 653-665. doi:10.1016/b978-0-444-52006-7.00041-1 Geriatric

Sleep

Disorder.

(2017,

March

09).

Retrieved

May

03,

2017,

from

http://emedicine.medscape.com/article/292498-overview#a2 Gooneratne, N. S. (2008, February). Complimentary and Alternative Medicine for Sleep Disturbances in Older Adults. Clinics in Geriatric Medicine, 121-viii. Hilmer, S. N. & Gnjidic, D. (2009). The effects of polypharmacy in older adults. Discovery, 85(1), 86 - 88. Retrieved from http://www.isdbweb.org/documents/file/1486_4.pdf Manjunath, N. K. & Telles S. (2005). Influence of Yoga and Ayurveda on self-rated sleep in a geriatric population. Indian J Med Res May; 121(5):683–690. [PubMed: 15937373] Miner, B., & Kryger, M. H. (2017). Sleep in the Aging Population. Sleep Medicine Clinics, 12(1), 31–38. https://doi.org/10.1016/j.jsmc.2016.10.008 Neubauer, D. N. (1999, May 01). Sleep Problems in the Elderly. Retrieved May 03, 2017, from http://www.aafp.org/afp/1999/0501/p2551.html

Sleep

disorders

in

older

adults.

(n.d.).

Retrieved

May

03,

2017,

from

https://medlineplus.gov/ency/article/000064.htm Stepanski, E. et al. (2003). Assessment and treatment of sleep disorders in older adults: A review for

rehabilitation

psychologists.

Rehabilitation

Psychology,

48(1),

23–36.

https://doi.org/10.1037/0090-5550.48.1.23 Vaz Fragoso, C. A., & Gill, T. M. (2007). Sleep complaints in community-living older persons: A multifactorial geriatric syndrome (See editorial comments by Dr. Michael V. Vitiello on pp 1882-1883). Journal of the American Geriatrics Society, 55(11), 1853–1866. https://doi.org/10.1111/j.1532-5415.2007.01399.x Wooten, J. (2012). Pharmacotherapy considerations in older adults. Disclosures, 105(8), 437 445. Retrieved from http://www.medscape.com/viewarticle/769412_2

University of the Philippines Manila The Health Sciences Center COLLEGE OF NURSING WHO Collaborating Center for Leadership in Nursing Development Commission on Higher Education Center for Excellence Sotejo Hall, Pedro Gil St., Ermita, Manila

Creative Intervention on Sleep Disorders A Written Report

Submitted in Partial Fulfillment of the Requirements of N-117: Nursing Care of the Chronically-Ill and the Aged (Older Persons)

Submitted by: BAYONITO, Karl Aaron D. DELOS SANTOS, Jose Raphael MEJIA, Robert L. MORENO, Keena S. NABONG, Earl Bradley A. TUBERA, Sophia A. VILLANUEVA, Mary Grace B.

4th May 2017

I.

Intervention In order to promote sleep for the older person, the SLEEP bundle will be implemented.

The SLEEP bundle is an abbreviation of interventions that alleviates or helps sleep disorders in the older persons. The SLEEP bundle consists of: S - Stimulus Control Therapy L - Loosening techniques E - Exercise (Tai Chi Chih) E - Education on Sleep Hygiene P - Position II.

Type of Creative Intervention The type of creative intervention proposed is a care bundle. A care bundle is a set of

interventions when used together significantly improves patient outcomes (McCarron, K., 2011). The steps of the care bundle are carefully selected, well-established practices that are packaged together and scientifically supported (McCarron, K., 2011). This care bundle created is a health promotion intervention. As World Health Organization (n.d.) defined, "health promotion is the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions." This care bundle includes lifestyle management nursing independent interventions as well as disease management.

III.

Rationale

Stimulus Control Therapy

A lot of individuals develop habits that are inappropriate during bedtime, such as watching the clock tick and counting down the time remaining before needing to start the day, or doing a lot of things that only extend periods of time in bed without sleeping like watching the television, reading, etc.; or worrying about the effects of having a bad night of sleep (Moorin et. al., 2006). Stimulus control therapy aims to break off the negative associations of the bed as a place of frustration. It has been described for more than 30 years ago and has showed many excellent results in treating sleep disturbances (Stepanski, 2003). The main goal in stimulus control therapy is to reduce the anxiety or conditioned arousal individuals may feel when attempting to go to bed. Stimulus control, in essence, increases the association of being in bed and being asleep. It aims to make the bed a cue for sleeping based on operant behavioral techniques. Specifically, a set of instructions designed to reassociate the bed/bedroom with sleep and to re-establish a consistent sleep schedule are implemented.

Loosening Techniques Before bed, older persons tend to think of the past experiences, the day’s scenario or a long time problem that contributes to the client’s difficulty in sleeping. Because the client’s thoughts are pre-occupied, it is continued to be stimulated. Loosening techniques involves relaxation techniques which aids in the older person’s inducement of sleep. A study conducted by Stepanski (2003) mentioned that relaxation techniques works by decreasing the older person’s anxiety and decreasing cognitive and physiological stimuli. Relaxation techniques could include listening to soothing music like sounds of nature and piano instrumentals, administering soft massage, and deep breathing exercises. However, there may be instances where relaxation techniques may not be fully applicable to everyone. Extreme depression, anxiety or older persons

with certain mental health problems may find loosening techniques not really helpful and might even worsen their conditions that’s why consulting with the physician regarding relaxation techniques with patients with special mental health conditions ar

Exercise (Tai Chi Chih) Generally, physical exercise was thought to be beneficial to enhance sleep quality. However, among older persons, moderate-intensity exercises or aerobic exercises may not be able to be tolerated because of their age-related physical limitations. In a study by Li et al, two forms of exercise, Tai Chi and stretching exercises, were compared for better sleep quality outcomes and Tai Chi, a slow-moving meditation, has demonstrated a positive impact on sleep quality. (Irwin, Olmstead & Motivala, 2008) This also improves sleep as this form of exercise alleviates painful joints and relaxes the body. (Scott, 2008)

Education on Sleep Hygiene Many people with sleep disturbances do not realize that a lot of factors affect sleep quality and quantity. These factors include caffeine intake, smoking, use of alcohol, physical exercise, napping, and keeping a regular wake-up time. As most of us know, caffeine is a stimulant that can disrupt sleep induction. Nicotine from tobacco is also a stimulant, and smoking has been tied to sleep difficulties as well (Stepanski et. al., 2003: Phillips & Danner, 1995). In fact, smokers experience more difficulty in falling asleep and have more disruptions in nighttime compared to nonsmokers. Older adults mistakenly believe that drinking alcohol can help them fall asleep faster, but research proves that alcohol can cause disruptions resulting to a poor sleep overall. Research has shown that exercise that is performed 4-8 hours prior to bedtime

produces the most enhancement of sleep. This is due to the effect of exercise in body temperature which is conducive to sleep. Napping is another habit among older adults that can affect nighttime sleep. Older adults tend to develop a habit of urinating during nighttime causing awakenings due to the urge to urinate. Thus, education for sleep hygiene directed to the older persons is needed to ensure good night sleep.

Position As people ages, they tend to adapt a right lateral position for sleep (Gordon et al, 2009). According to researchers at Stony Brook University, compared to sleeping supine or on prone, sleeping on side lying position, may more effectively remove brain waste and prove to be an important practice to help reduce the chances of developing Alzheimer’s, Parkinson’s and other neurological diseases (Benveniste et al, 2015). Sleeping on your back or stomach can cause structural changes in the upper airway such as elevation of the diaphragm when in the supine position and the reduction in upper airway muscle activity with the change from lateral to supine sleep position. Sleeping on the sides can help prevent sleep disturbed breathing. Sleeping in this position can also help prevent neck and back pain, as well as acid reflux. The brain’s glymphatic pathway clears harmful wastes, especially during sleep. This lateral position could prove to be the best position for the brain-waste clearance process (Benveniste et al, 2015).

IV.

Nursing Diagnosis(es) Disturbed sleep pattern This is state in which a client experiences a change in the quantity or quality of one’s rest

pattern that causes discomfort or interferes with desired lifestyle (Carpenito, 2013). The major

characteristic for this nursing diagnosis would be difficulty of falling or remaining asleep. For the older persons, certain geriatric considerations must be noted. Research has found that sleep efficiency declines with advancing age, so more time is needed in bed to achieve restorative sleep. Sleep time decreases with age Stages 3 and 4 and REM sleep decrease with aging (Hammer, 1991). Sleep pattern disturbances are the most frequent complaint among older adults (Hammer, 1991). Older adults have more difficulty falling asleep, are more easily awakened, and spend more time in the drowsiness stage and less time in the dream stages than do younger people (Miller, 2009). Miller (2009) reports that approximately 70% of older adults complain of sleep disturbances, usually involving daytime sleepiness, difficulty falling asleep, and frequent arousals. Insomnia Defined as the state in which a client reports a persistent pattern of difficulty falling asleep and frequent awakening that disrupts daytime life (Carpenito, 2013). A defining characteristic of a report of persistent difficulty falling or remaining asleep. Sleep deprivation Sleep deprivation is defined as prolonged periods of time without sleep (sustained natural, periodic suspension of relative unconsciousness). (Carpenito, 2013) Defining characteristics include difficulty of sleeping at night or being not able to sleep and being sleepy or drowsy in the day. Studies have found that chronic sleep deprivation, for whatever reason, significantly affects your health, performance, safety, and pocketbook. Readiness for enhanced sleep This is defined as a pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle and can be enhanced (Carpenito, 2013). Defining

characteristics for this diagnosis include amount of sleep is congruent with developmental needs, expresses a feeling of being rested after sleep, expresses willingness to enhance sleep and follows sleep routines that promote sleep habits.

V.

Expected Outcomes Goal: After the nursing interventions, the client/s will be able to achieve optimal amount

of quality sleep as evidenced by complete seven to eight hours of sleep a day which is the recommended of sleep for older persons. Objectives: After the nursing interventions, the client/s will be able to: ● Have an adequate sleeping pattern. ● Verbalize the feeling of being well-rested. ● Report an optimal balance of rest and activity ● Describe factors that prevent or inhibit sleep.

VI.

Methodology

Stimulus Control Therapy Specifically, a set of instructions designed to reassociate the bed/bedroom with sleep and to reestablish a consistent sleep schedule are implemented. These include: 1) Going to bed only when sleepy; 2) Getting out of bed when unable to sleep; 3) Using the bed/bedroom only for sleep (i.e., no reading, watching TV, etc); 4) Arising at the same time every morning; and 5) Avoiding naps. ● Step 1: Go to bed only when you feel sleepy. It is important to wait to feel ‘sleepy’ before going to bed. Feeling fatigued or exhausted is different from feeling ‘sleepy’. Feeling exhausted is not an indicator that you’re ready to fall asleep.

● Step 2: Don’t stay in bed if you do not fall asleep quickly! Waiting to go to bed when you are sleepy will increase your chances of falling asleep quickly but will not guarantee it. So if you go to bed feeling sleepy, but you are not asleep within about 15 minutes (guess – don’t use the bedroom clock), get up, go into another room, and do something relaxing until you feel sleepy again. ● Step 3: Return to bed when sleepy again. Once you feel sleepy again, go back to bed. If you still can’t sleep, keep repeating the process until you fall asleep within a quarter hour. You will eventually fall asleep quickly at some point during the night. ● Step 4: Do have a fixed getting-up time. Getting up at the same time every day is probably one of the most important things you can do to help regulate your sleep pattern and help you to get to sleep earlier. ● Step 5: Do not sleep during the day.

Loosening Techniques This loosening technique will consist of aroma therapy combined with music therapy and massage to help relax and improve sleep quality. Step 1: Choose the right environment (lighting, noise, music) The environment affects the sleep quality of the older person. Stimuli around the sleeping environment must be minimal to help relax the patient. Lighting must be dimmed. No unnecessary noise. Low, relaxing music. Step 2: Choose the right aroma and essential oil.

Using essential oils in aromatherapy can be a great way of assisting the general health of elderly people, yet some points have to be kept in mind when mixing essential oil blends for older people. Since older people may be frail, it is best to use a lower dilution rate for essential oils in the carrier oils and due notice must be taken of any medical conditions, medications taken or illnesses. With older people there may be a higher incidence of health problems, so it is imperative to check the profiles of each essential oil, to ascertain that it is not contra-indicated for a particular health problem, and that there are no contraindications with certain medications. Step 3: Ask the older person to choose a comfortable position. Step 4: Massage the arms of the older person using the essential oil. Apply slow kneading motions to soothe the tensed muscles of the arms of the older person. Applying effleurage first will prepare the muscles for the deep muscle work up using the petrissage, which are applied pressure to the deep muscles and compression to the underlying muscles.

Exercise This Tai Chi will consist of two parts, namely Balancing the Heart Qigong, and the Balancing the Qi and Settling the Mind (Rochford, 2009) Exercise one:: Balancing The Heart Qigong The following exercise works to restore balance in the heart and reduce the unwanted effects of exhaustion. Using the energy points Lao Gong (Palace of Weariness) - an acupuncture point used for exhaustion on the Heart Protector Meridian and Yong Quan (Bubbling Spring) - a point used

to ground energy and bring people into their bodies, this exercise works to strengthen internal qi and calm the nervous system. It is also fantastic for helping us melt away some of the psychological baggage that prevents us from sleeping. 1) Stand with you feet at shoulder width in a comfortable upright position. Bend your knees slightly so you feel more connected to the ground and gently "rooted". Imagine a thread of golden light from your crown gently lifting you up to align your spine and tuck your chin gently in until your head feels comfortably placed. Place your tongue gently on the roof of your mouth (to connect the pathways of Qi in your body). Relax your shoulders and imagine/feel any tension in your body melting away through the soles of your feet. 2) Create a smooth and gentle pulse of movement from your feet and up through your body. Your knees will unbend slightly, then raise your arms to shoulder height. Turn your palms in towards each other to align the Lao Gong energy points. Breath: Breathing in. 3) Tilt the body gently forwards, opening the arms out to the sides and increasing the pressure on the front of the feet slightly (massaging the Yong Quan energy points). Breath: Breathing out. 4) Tilt gently back as you bring the arms back in again and come back into a more upright relaxed stance. Breath: Breathing in. 5) Relax the body, bend the knees slightly and bring the arms back down to waist height again. Breath: Breathing out Tips: focus gently on the sensations in the palms to harmonize the energy in the Lao Gong points and the Heart Protector Qi Pathway (meridian). Stay connected with the sensations in the body, if you mind wanders just gently bring it back. If you notice any tensions in the body, try to

imagine and feel them melting away into white light/pure Qi. Any disturbances you experience in your mind also imagine are melting away into pure white light/Qi. Exercise Two:: Balancing the Qi and Settling The Mind This exercise is designed to bring peace to the heart and to activate healing on a deeper level – bringing relaxation and balance into the body and mind. It works with what is known as the middle Dan Dian (an energy centre around the heart) and and the Lower Dan Dian (around the navel). It will make you feel calm, centred and relaxed. 1) Stand with you feet at shoulder width in a comfortable upright position. Bend your knees slightly so you feel more connected to the ground and gently "rooted". Imagine a thread of golden light from your crown gently lifting you up to align your spine and tuck your chin gently in until your head feels comfortably placed. Place your tongue gently on the roof of your mouth (to connect the pathways of Qi in your body). Relax your shoulders and imagine/feel any tension in your body melting away through the soles of your feet. 2) Palms facing up and the waist, breath in and rise up gently. Bring the palms to the height of your heart. 3) Turn the palms to face the floor, relax and breath out. Bring your feet flat to the floor again. Allow any tensions to melt away. Bring the palms to waist level again. 4) Turn the palms to face up and repeat the exercise gently six or seven times. 5) Finish by placing the palms on the belly and visualise healing light at the center of your body.

Education on Sleep Hygiene

Getting a good sleep is essential for maintenance of both physical and mental health. One important practice in sleep hygiene is to spend an appropriate amount of time asleep in bed, not too little or too excessive. Other practices include: ● Avoiding stimulants such as caffeine and nicotine close to bedtime. It is typically recommended that caffeine-sensitive individuals not ingest caffeine after noon and that others not ingest it after late afternoon. Studies have found that older adults are especially sensitive to the effects of caffeine. ● Practice physical exercise 8-4 hours prior to bedtime. Exercising to promote good quality sleep. ● Limiting daytime naps. Napping does not make up for inadequate nighttime sleep. ● Steering clear of food that can be disruptive right before sleep. Frequent nighttime awakenings can be helped by advising the individual to restrict fluid intake during the several hours prior to bedtime but to be sure to drink an adequate amount earlier in the day.

Position Position self on the side while using pillows to support the head and neck. The right and left side of the body must be kept as symmetric as possible. A pillow may be placed on the abdomen and in between the legs for more support. For those with wide hips, a space may be present between the waist and the bed. A small pillow or a rolled towel may be paced to prevent the upper body from sagging downwards and straining the upper back. The knees should be bent and may use a pillow in between for support. A bigger pillow that is hugged between the arms and legs may also be used. The left upper leg should not cross over the right lower one as this

would lead to the left upper knee to drop and the left hip to be rolled forward. This twists the lower spine and may cause to lower back ache.

VII.

Constraints

Stimulus Control Therapy A challenge for this type of therapy is adherence. Older adults often feel entitled to sleep and rest in bed as much as they like especially if they are ill. And they have more time to do so since most of them are already retired. In this kind of therapy, it is very important to follow each aspect and this adherence can be achieved through clear and simple explanations of the rationale for each step and by social support. Loosening Techniques Medical condition, medications that may have contraindications for the aroma used. Also, consider the physical condition of the older person in the amount of essential oil used. Too much may cause trippings and falls. Exercise Although Tai Chi was designed for the older people, it is still important to not force the individual to the exercise. Encourage them to participate but emphasize that they can only participate as much as he/she can tolerate. Education on Sleep Hygiene

Almost all sleep hygiene practices include modifications of lifelong habits. Thus, it is challenging for the older persons to change these habits and comply readily to these sleep hygiene practices. Therefore, it is necessary to provide them the best evidences and enough rationale for these practices. Position Although sleeping on the right side lying position is recommended it should not be imposed on the older person. He is still encouraged to sleep in a position that he feels the most comfortable in. Proper body alignment must be maintained at all times. Sleeping positions should always be individualized according to the health condition and needs of the older person.

VIII.

References

Benveniste, H. et al. (2015). The Effect of Body Posture on Brain Glymphatic Transport. The Irwin, M., Olmstead, R. & Motivala, S. (2008). Improving sleep quality in older adults with moderate sleep complaints: a randomized controlled trial of tai chi chih. SLEEP, 31(7), 1001 - 1008. Journal of Neuroscience, 35(31), 1034 –11044. DOI:10.1523/JNEUROSCI.1625-15.2015 McCarron, K. (2011). Understanding Care Bundles. Nursing Made Incredibly Easy, 30-33. Morin, C., Bootzin, R., Buysse, D., Edinger, J., Espie, C., & Lichstein, K. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29, 1398-1414. Rochford,

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