Regulation of sleep and wakefulness occurs primarily in the hypothalamus.

Chapter 10

Sleep and Activity

Sleep is a state of consciousness characterized by the physiologic changes of reduced blood pressure, pulse rate, and respiratory rate along with a decreased response to external stimuli.

Biologic Brain Functions and Sleep

Sleep begins with the four stages of non-REM sleep, continues with a period of REM sleep, and then cycles through non-REM and REM stages of sleep for the rest of the night.

Variations in the REM and non-REM sleep stages occur with advancing age.

REM sleep is interrupted by more frequent nocturnal awakenings, and the total amount of REM sleep is reduced.

The amount of stage 1 sleep is increased, and stage 3 sleep and stage 4 sleep are less deep.

Stages of Sleep and the Older Adult

The sleep-wake cycle follows a circadian rhythm, which is roughly a 24-hour period.

The decrease in nighttime sleep and the increase in daytime napping that accompanies normal aging may result from changes in the circadian aspect of sleep regulation.

Sleep and Circadian Rhythm

Difficulty falling asleep, difficulty staying asleep, frequent nocturnal awakenings, early morning awakening, and daytime somnolence

May be transient, short term, or chronic

Affects the older adult’s quality of life with excessive daytime sleepiness, attention and memory problems, depressed mood, nighttime falls, and possible overuse of hypnotic or over-the-counter medications

Insomnia

Insomnia: the inability to sleep

Increased sleep latency, reduced sleep efficiency, nocturnal awakenings, increased early morning awakenings, and increased daytime sleepiness

Older adults awaken four or more times a night.

Daytime napping is common.

Daytime sleepiness may suggest underlying disease.

Other sleep changes are associated with chronic disease and other health problems.

Age-Related Changes in Sleep

Environment

Pain

Lifestyle

Dietary influences

Medication use and medical conditions

Depression and dementia

Factors Affecting Sleep

Schedule procedures and care activities to avoid unnecessary awakenings, modify environmental factors to promote a quiet, warm, relaxed sleep setting, and orientate older adults to the institutional setting.

Reduce noise: close doors, lower voices.

Reduce bright lighting at night.

Temperature: warmer is better than colder.

Nonpharmacologic and pharmacologic measures may be used to relieve pain.

Nursing Interventions for Sleep Environment

Loss of spouse

Retirement

Relocation

Having a roommate in long-term care facilities

Dietary influences

Depression

Dementia

Lifestyle Changes Affecting Sleep

Sleep is influenced by what we eat and drink.

Which of the following are true statements about sleep in the older adult? (Select all that apply.)

Reduced REM sleep causes irritability or anxiety the next day.

Insomnia leads to an increase in daytime falls.

Older adults commonly take naps during the day.

Cooler temperature at night is better for sleeping.

Acute or chronic pain interferes with falling asleep.

Quick Quiz!

ANS: A, C, E

Answer to Quick Quiz

Recurrent episodes of cessation of respiration

Apneic episodes may last from 10 seconds to 2 minutes and range from 10 to 100 per hour of sleep.

Three types: central sleep apnea (CSA), obstructive sleep apnea (OSA), and complex sleep apnea

OSA most common in older adults

Sleep Apnea

Due to complete or partial airway obstruction that blocks air flow increasing respiratory efforts

Risk factors: obesity, short or thick neck, jaw deformities, large tonsils, tongue or uvula, narrow airway, deviated septum, smoking, hypertension, and cardiac disease

Symptoms: daytime fatigue; waking with a headache and sore throat or dry mouth, and confusion; trouble concentrating and irritability; and sexual dysfunction

Treatment weight loss, positioning on side, CPAP, mandibular advancement devices and surgery

OSA

Repetitive kicking leg movements throughout the night

May occur every 5–90 seconds and each kick causes a brief disruption of sleep.

Report insomnia and excessive daytime sleepiness

Treatments: Drugs such as dopamine agonists and eliminate caffeine-containing products

Periodic Limb Movement in Sleep

Patient’s report of his or her sleep pattern and sleep-related problems

Determine quality and quantity of sleep.

Review the number of nocturnal awakenings and length of time awake at night.

Typical bedtime rituals or practices

Daytime sleepiness or a strong desire to nap

Assess consumption of alcohol, caffeinated beverages, sedative-hypnotics, OTC drugs, and other practices before bedtime.

Components of the Sleep History

Sleep diary

Sleep laboratory

Epworth Sleepiness Scale (ESS)

Pittsburgh Sleep Quality Index

Further Assessment of Sleep

Stable schedules and bedtime routines, a sleep-friendly environment, avoidance of any substances that would interfere with sleep, regular exercise (but not immediately before trying to sleep), and stress reduction

Nonpharmacologic interventions: relaxation therapies, stimulus control therapy, and sleep restriction therapy and cognitive behavioral therapy

Drug therapy may be necessary for a short time no more than one or two weeks.

Sleep Hygiene

Routine daily activities, diversional activities, and physical exercise

Changes occur in the activities pursued by older adults as they age or experience acute or chronic illness.

Physical exercise has health-promoting benefits for all older adults.

Activity and Older Adults

Activities that once were accomplished with ease may require modified approaches or the assistance of others.

Modification of routines and use of assistive devices help maintain independence.

Family members, friends, or paid caregivers may help with shopping and other tasks.

Dependency in basic ADLs increases the risk of relocation to a long-term care facility or to the home of a family member.

Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

Important to maintain health, preserve the ability to perform ADLs, and improve the general quality of life

Prevents of heart disease, reduces elevated blood pressure and risk of osteoporosis, promotes appropriate weight and more restful sleep

Preserves mobility and reduces the risk of falls by promoting muscle strength and joint flexibility

Physical Exercise

Moderate-intensity aerobic exercise for 150 minutes a week

Drink water before and after exercise

Clothing should allow for easy movement and perspiration.

Athletic shoes should provide both support and protection.

Outdoor exercise should be avoided in extremely hot or extremely cold weather.

Stop exercising and seek help for chest pain or tightness, shortness of breath, dizziness or lightheadedness, or palpitations during exercise

Physical Exercise Tips

Retirement, relocation, and the loss of a spouse

Alzheimer’s disease, when it progresses, cognitive impairment increases, which adversely affects the ability to initiate and participate in routine daily activities

Older adult with advancing dementia also loses the ability to initiate diversional activities and to participate in activities that were once enjoyed.

Lifestyle Changes that Affect Activity

Activities should be meaningful, have a purpose, and foster a sense of well-being for the participants.

Physical exercise is important for general physical well-being.

Exercise may reduce agitation or wandering.

Rhythmic movement of a rocking chair may reduce agitation.

Going for a walk may redirect the impulse to wander.

Activities that tap into the older adult’s past life experiences and interests may stimulate memory.

Activity and Alzheimer’s Disease and Other Dementias

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