Sleep Disturbancesand

What to Do About ThemCommon but not trivial,all sleep disordersrequire assessment,and most respondto nursing intervention.

CAROLYN HOCHCHARLES REYNOLDS. 3rd

Sleep is an active and complexrhythmic state that may be af­fected by the aging process.Changes in sleep are particularlyfrequent concerns among the elder­ly(l-3). In the varied settingswhere nurses work with olderadults, there are many opportuni­ties to observe changes in sleep be­havior or to hear patients describethem. Knowledge of sleep charac­teristics and of the sleep distur­bances that may occur with agingis the basis for assessment and ra­tional intervention.

Sleep is a set of complete physiol­ogical processes involving a pre­dictable sequence of operatingstates within the central nervoussystem. This sequence is identified

Carolyn Hoeb, RN, PhD, is research pro­gram coordinator, Geriatric Sleep Re­search, Western Psychiatric Institute andClinic, University of Pittsburgh School ofMedicine, PA. Charles Reynolds. 3rd, MD,is associate professor of psychiatry and neu­rology, and director, Sleep Evaluation Cen­ter, Western Psychiatric Institute andClinic, University of Pittsburgh School ofMedicine.

The authors' work on sleep disturbanceswas supported in part by NIMH grants00295-06 and 37869-03.

24 Geriatric Nursing January/February t986

by specific behaviors and electroen­cephalographic patterns. The twokinds of sleep are non-rapid-eye­movement (NREM) and rapid eyemovement (REM).

NREM sleep is composed of fourstages. Stage 1, a transition be­tween wakefulness and sleep, lastsonly a few minutes. The person isvery relaxed and drowsy, yet some­what aware of surroundings. EEGpatterns show low-voltage waves ofthree to seven cycles per second.

True sleep begins in Stage 2.Thoughts are short, mundane, andfragmented. The person is unawareof surroundings but wakes easily.EEG waves show characteristicsleep spindles (bursts of 13-voltagesharp waves shaped like the letterK). Stage 2 generally lasts fromfive to 20 minutes as sleep pro­gresses to Stage 3.

In Stage 3, or deep sleep withslow delta waves of one to four cy­cles per second, muscles relax,pulse rate slows, and temperaturedecreases. If this stage is not inter­rupted, the sleeper usually movesinto the deepest NREM sleep.Stage 4. where there is little move­ment of the body and arousal is dif­ficult.

Stage 4 occurs about 40 minutesafter the start of Stage 1. Stages 3and 4 combined last from 15 to 30minutes, a period thought to relaxand restore the body(4-5).

At the end of about 90 minutes ofsleep, the individual gradually re­turns through the lighter stages ofsleep. Instead of reentering Stage 1or awakening, however, the person

enters rapid eye movement sleep.During REM sleep, the pulse,

respiration, blood pressure, andbasal metabolic rate increase andfluctuate while head, neck, andgeneral skeletal muscle tone anddeep tendon reflexes are depressed.Vivid dreams are reported fre­quently after arousal from REMsleep. While EEG and biologicalactivity appear similar to wakeful­ness, the individual is even moredifficult to arouse than in NREMdeep sleep. REM sleep lasts 10minutes and is thought to be impor­tant to learning, memory, and ad­aptation(4-5).

The number of cycles of NREMand REM sleep is related to the to­tal time spent asleep, but individu­als ordinarily have four to five com­plete sleep cycles each night. Theearly sleep cycles are dominated byNREM Stages 3 and 4; as thenight continues, NREM periodsdecrease and REM periods in­crease. About 20 percent of sleeptime is spent in REM(4-5).

Disturbances of sleep can begrouped according to cause: altera­tions in sleep-wake patterns, physi­cal illnesses, psychological factors,and medications.

Altered Sleep-Wake Patterns

The first group of sleep distur­bances result from alterations insleep-wake patterns and have beenidentified as consistent signs of bio­logical aging(6). Total sleep time ina 24-hour period may not actuallydecrease by more than one hourover an adult lifetime, but the stage

duration and quality of the sleepare altered.

The proportion of REM andNREM sleep time changes withage. There is an increased quantityof Stage 1 sleep and a 25 percentincrease in light sleep (Stage 2).However, slow-wave sleep (Stages3 and 4) decreases by 50 percent ormore. Some elderly have no Stage 4sleep. REM sleep occurs as often asin younger adults but the length ofeach episode shortens(3,6).

These changes are reflected inthe common sleep-related com­plaints of older adults:

• spending more time in bed• taking longer to fall asleep• awakening more often• being sleepy in the daytime• needing longer to adjust to

changes in the usual sleep-wakeschedule.

Accompanying these sleepchanges is an increased prevalenceof sleep-related breathing distur­bances, snoring, and periodic legmovements.

Physical Illness

The second cause of sleepchanges is physical illness. Approx­imately two-thirds of individualsover 65 have one or more chronicillnesses(3). As arthritic joints stif­fen during the inactivity of sleep,pain may awaken the person. Angi­na can be associated with coronaryartery vasoconstriction at the onsetof REM sleep(8).

In chronic obstructive lung dis­ease, oxygen saturation may pro­duce inadequate ventilatorychanges during sleep. Hence the in­dividual's frequent arousals may bea physiologically adaptive responseto improve ventilation in responseto hypoxia(4,9).

Epigastric pain that causesawakening can result from refluxof gastric acid into the esophagusor from the increase in gastric acidsecretion that is associated with ex­acerbation of peptic and duodenalulceration during periods of REMsleep(lO). Fluid accumulation inthe lungs of individuals who havecongestive heart failure producesdifficult breathing and resultantsleeplessness(ll). Benign prostatic

enlargement; prostatic disease; dia­betes mellitus; and urethritis, espe­cially in elderly women, can all pro­duce frequent awakening duringthe night to urinate.

Psychological Factors

Old age is a time of losses: job,physical capabilities, significantothers, and material belongings.These losses may evoke anxiety ordepression, which, in turn, maycause delay in falling asleep, earlierappearance of REM sleep, frequentawakening, increased total time inbed but feelings of having sleptpoorly, and early morning awaken­ings(3).

The intensity and duration ofemotionality increase with age.When elderly individuals are facedwith tense situations, they experi­ence more stress and take longer toreturn to baseline functioning thando younger adults. The effects ofincreased emotionality cause alter­ations in sleep(12). Organic brainchanges (for example, in Alzheim­er's disease) are associated with adecrease in total sleep time, lessREM sleep, and more frequentawakening(7).

Medications

Drugs or their side effects maycontribute to sleep disturbances.The elderly are particularly at riskbecause chronic illnesses and,therefore, medication use both in­crease with age. Age-dependentchanges in pharmacokinetics, espe­cially in the distribution, metabo­lism, and excretion of drugs, tendto interfere with the sleep-wake cy­cle(13-14).

The value of hypnotics for theelderly is questionable; althoughsuch medications may contribute tothe quantity of sleep temporarily,they often cause daytime hangov­er(6). Moreover, hypnotics mayworsen sleep apnea in the elderlyand decrease REM sleep.

Hypnotics are effective for onlyabout one week of consecutive use.After this period, a rebound effectleads to intense dreaming, night­mares, and more disturbed sleep.The elderly person is likely to have

more trouble falling asleep andstaying asleep than before usinghypnotics(7, IS).

Sleep Assessment

Sleep assessment is an integralpart of the genenil health assess­ment and seeks to identify, first,the type of sleep disturbance, ifany, and its duration; and second,its probable causes, physical, psy­chosocial, or medication-related.Sources of information include in­terviews with the elderly individualand his or her bedpartner, signifi­cant others, or caregivers; medicalrecords; physical and psychologicalassessment; and a sleep diary.

Nursing assessment should de­termine whether a sleep distur­bance requires medical referral orif it can be relieved through nursingintervention. Specific questions areasked. When did the sleeping prob­lem begin? How. often does it oc­cur? How is the problem per­ceived? Do the patient and partnerassociate any particular factorswith the problem?

It is important to explore how thepresent sleeping pattern differsfrom previous patterns, the severityof the disturbance and whether itinterferes with daily functioning,and how the person has tried to re­lieve the disturbance(l6-17).

The sleep environment and bed­time routines are investigated byasking the individual· and partnerto keep a sleep-wake diary for 14days. In it they note the distribu­tion and quality of the person'stime in bed and asleep during the24-hour day. Daily entries includephysical activities, meal times andintake (food, beverages, caffeine,alcohol), mental activities with thetime of day, time and length of day­time naps, evening and bedtime ac­tivities (TV, reading, exercises),presleep state of. mind, number ofnight awakenings, and wake-uptime in the morning(16).

Nursing Intenention

Analysis of the assessment datausually identifies the specific typeof sleep disturbance. If medical at­tention is not initially indicated,nursing intervention is planned to

GClriatric Nursing January/February 198615

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MEASURES TO IMPROVE SLEEP. -- -- - - - -- - - - --- .

alleviate the sleep disturbance bycorrecting its precipitating factors.

Elderly persons and their fami­lies need to know that some sleepdisturbances may be unavoidable.It is not that less sleep is needed butthat the ability to sleep seems todiminish with age. What is re­quired, therefore, is intervention tostrengthen the sleep-wake cyclerhythm and to combat the age­related tendency to develop severalbrief sleep episodes in a 24-hour pe­riod. This strategy can only be ef­fective with the cooperation of theindividual and caregivers.

Encourage the elderly person togo to bed only when sleepy, to worktoward a consistent bedtime, to getup at the same time each morning,and to shorten or eliminate naps.Suggest alternate activities such asreading, crafts, walks, or social in­teractions to fill in for naptime. If anap is necessary, advise taking it atthe same time each day to maintaina consistent schedule. Just lying inbed and thinking is discouraged iIiorder to maintain the bed as a pow­erful stimulus to sleep. If sleepingdoes not come, the person may getup but should remain inactive in or­der to preserve the 24-hour, rest­activity cycle.

Hayter's research suggests thatdaytime napping does not decreaseelders' total sleep time and shouldnot be discouraged(18). Neverthe­less, in the elderly, daytime nap­ping should be minimized if it is as­sociated with trouble consolidatingsleep at night.

The sleeping environment is ofprime importance. Elderly peoplemay sleep better with a dim lighton. This reduces the possibility ofconfusion and disorientation andhelps prevent falls enroute to thebathroom. Some individuals, how­ever, prefer a dark room.

Bed and mattress should providesupport and comfortable firmness.Position of the bed in the room maymake a difference. Room tempera­ture is adjusted to the person'spreference and loose-fitting gar­ments worn, to allow free move­mentduring sleep. Some elderlysleep better in complete silence;others desire soft background mu-

16 Geriatric Nursing January/February 1986

Nursing Intervention

explain th.at some SIeQPdisturbances are anunavoidable consequence ofaging.

Encourage going to bed onlywhen sleepy and getting up atthe same time each morning.

Discourage just lying In bedand thinking If sleep does notoocur. Advise to get up butremain Inactive or dosomething boring.

Reduce or eliminate naps.Encourage alternate activitiesto fill In for naptime. If a nap Isnecessary. take It at the sametime each day.

Individualize the sleepenvironment with regard tolight, temperature, bedfirmness and position.

Schedule exercise at least twohours before bedtime.

Omit caffeine drinks after thedinner meal.

Individualize dietary routinesbefore bedtime, e.g., snack,warm milk.

Omit alcohol before bedtime.

Teach relaxation techniquessuch as slow. deep breathingand rhythmic contracting andrelaxing of muscles.

Teach comfort measures If thesleep disturbance Is related tophysical Illness. e.g••prescribed analgesics,positioning. etc.

Discourage the use ofnonprescription sleepingmedications.

sic. A bedpartner can influencesleep and, for some elders, the lossof a spouse makes sleeping diffi­cult. For other couples, however,separate beds or rooms may be nec­essary.

Exercise contributes to physicalfatigue and thus invites sleep. But

RatiolUlle

To Inform that abUIlY to Sleepseems to dlmlnlsItwlthage.

To strengthen thflithythm Ofthe sleep-wake cYCle.

To prevent "condltloned"insomnIa and tomalntalo thebed as a powerful stimulus tosleep.

To strengthen th~rhythm ofthe sleep-wake; cycle.

To create atmosphereconducive to sleep.

To Increase physical fatigueand thus promote sleep butavoId excess stimulation beforesleep.

To avoid stimulation.

To provide comfort and easesleep onset.

To prevent Its Interference withsleep maintenance.

To Induce calm. alleviatetension. and prepare the bodyfor rest.

To promote sleep onset andmaintenance.

To Improve the quality of sleep. !

eliminate daytime hangover.and prevent Interactions Withprescribed drugs.

advise exercising at least two hoursbefore bedtime because too. muchstimulation-physical or mental­can prolong falling asleep.

Dietary habits also need consid­eration. Some individuals sleep bet­ter after a snack; others cannotsleep after eating. Warm milk may

improve sleep because it is comfort­ing or because of the L-tryptophanit contains, which has been identi­fied as a sleep inducer. Caffeinedrinks such as coffee, tea, or colaare stimulants and are best avoidedafter the evening meal. Alcohol, adepressant, may initially have hyp­notic effects, but it interferes withsleep maintenance.

Relaxation techniques can be­come part of the nightly routine.Slow, deep breating for a minute ortwo tends to induce calm, as doslow, rhythmic contracting and re­laxing of muscles. These measuresalleviate tension and prepare thebody to rest. Imagery can also betaught so that the individual imag­ines himself or herself in a restfulscene that evokes relaxing, serenefeelings. For some people, praying,meditation, and yoga are soothingand lead to sleep.

.If the sleep disturbance is relatedto physical illnesses, comfort mea­sures are important to ease fallingasleep and staying asleep. For con­ditions causing pain, appropriateanalgesics taken about one-halfhour before sleep and warm or coolapplications to an affected area of­ten increase comfort. Careful posi­tioning and proper support to pro­tect pressure points aid muscle re­laxation.

If breathing abnormalities inter­fere with sleep, prescribed medica­tion such as bronchodilators shouldbe used before bedtime. Sleeping ina semisitting or lateral decubitusposition or with two pillows alsoeases breathing.

Other medications, particularlydiuretics, are scheduled so as toprevent nocturnal awakenings. Ingeneral, if medically feasible, se­dating medication is best pre­scribed near bedtime rather thanduring the day.

The use of nonprescription sleep­ing preparations is not advisable.Rather, help the person to increasereliance on behavioral measures tocure sleep disturbances. The inter­ventions described here plus reas­surance can help many eldersachieve more control over sleep,thereby diminishing or eliminatingthe need for sleeping pills.

For patients in acute-care hospi­tals and for nursing home residents,particular attention is necessary toreduce noise throughout the sleephours, regulate room temperature,and control lighting. Individualiz­ing bedtime and wake-up time ismore difficult in such facilities, butit is possible. Simulating usual at­home patterns to the extent possi­ble and employing measures thatencourage sleep are essential tohelp individuals recuperate fromacute illness or cope with chronicconditions.

Polysomnographic Evaluation

How and when is formal sleeplaboratory evaluation helpful? Athorough medical evaluation andsubsequent referral to a sleep disor­ders specialist (clinical polysom­nographer) are indicated if the as­sessment raises a clinical suspicionof any of the following:

• a sleep-apnea syndrome (sug­gested particularly by heavy snor­ing and excessive daytime sleepi­ness)

• nocturnal myoclonus (sug­gested by a complaint of restlesslegs-or akathisia-like sensationsinterfering with sleep onset-kick­ing of bed partner, or bed covers intotal disarray every morning)

• narcolepsy-cataplexy (sug-gested by a history of irresistibledaytime sleep attacks and emotion­triggered loss of muscle tone;usually, the onset is before age 30but it occasionally begins in ad­vanced age)

• sleep-phase irregularity (theprominent advance of a majornighttime sleep period or an ex­tremely fragmented sleep-wakeschedule with multiple sleep peri­ods and awake periods throughoutthe 24-hour day). In addition, ifnursing interventions have not im­proved sleep after a two-to-three­week trial, referral is advisable.

There are about 100 sleep re­search centers in the UnitedStates. >4< Most are affiliated withlarge hospitals or medical centers.

-For the location of centers, write or phoneAssociation of Sleep Disorders Centers,P.O. Box 2604, Del Mar, CA 92014 (619)755-6566.

The polysomnogram is an electron­ic recording of brain waves, eye andmuscle movement, breathing, andother factors. Diagnosis may re­quire that the patient spend one ortwo nights at the sleep center.

Summary

Sleep disturbances in the elderly,while common, are not trivial. Age­related changes in sleep-wake pat­terns, concurrent medical or psy­chiatric disorders, and environmen­tal changes.may produce an arrayof sleep-related complaints in theelderly. Against this complex back­ground, comprehensive assessmentand individualized intervention canbe effective in the long-term care ofthese individuals.

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