Approximately one-third of a human's life is invested in sleeping; but sleep remains a most mysterious and baffling concept. Sleep, as a measure of health, is a fascinating entity and is currently capturing the attention of both researchers and clinicians. Scientific methodological designs to investigate this concept are being created in the pursuit of knowledge of the unknown components of this highly important element of wellness and good health.
The phenomenon of sleep has the potential for relieving an individual of stress and responsibility when a break is needed to recharge the person's spirit, mind and body; or, it can remain maddeningly aloof when it is needed most. ' Shakespeare, in his play Henry IV, describes this elusive quality of sleep when he notes:
How many thousand of my poorest subjects are/at this hour asleep! O'sleep, O'gentle sleep,/ nature's son nurse, How have I frightened thee,/that thou no more will weigh my eyelids down/and steep my senses in forgetfulness?
Many definitions of sleep are found in literature. Guyton defines sleep as "a state of unconsciousness from which a person can be aroused by appropriate sensory and other stimuli."2 Sleep is a natural occurrence having psychological and physiological functions that activate the restorative repair processes of the body.
Psychologically, sleep allows the individual to experience a sense of wellbeing, alertness and psychic energy to perform tasks adequately. If sleep deprivation occurs, adverse psychological effects for the individual may result. Such effects may include becoming forgetful, disoriented and confused resulting in mis identification of others, particularly if sleep deprivation has occurred over a prolonged period. Effects of sleep deprivation are reversible, however, when the proper proportion of the sleep/wakefulness patterns have been restored within a 24hour period.
Relationship exists between the amount of sleep obtained at night and the amount of wakefulness during daytime hours. Work performance, degree of alertness, level of activity, and wellness are affected when the sleep/ wakefulness ration falls below the required amount to replenish the psychological and physiological demands of the body adequately. Research has demonstrated that the brevity and length of sleep periods affect mortality rates. In a six-year study by the American Cancer Society, data supported the hypothesis that people who sleep for unusually long or short periods or use sleeping pills have a significantly higher mortality rate than others. People who slept only seven or eight hours a night enjoyed the lowest mortality rate.1
Sleep, as a rhythmic and cyclical behavioral state, occurs in four stages as identified on electro-encephalogram (EEG) tracings. In the waking stage, the tracings show an EEG alpha-wave pattern of 8 to 12 cycles/second. In the sleep cycle. Stage 1, the non-rapid eye movement (NREM), is identified by low voltage, 4 to 6 cycles/second activity on the EEG tracing. Within a few seconds of time, Stage 2 NREM sleep occurs, characterized by 13 to 15 cycles/second. The EEG shows sleep spindles and high voltage spikes known as K complexes (Kleitman, unpublished research). As Stage 3 NREM begins, delta waves (1 to 4 cycles/second) are identified on the tracing. In this stage, muscle relaxation, pulse rate slowing and temperature decreases are noted. If this stage is not disturbed by random stimuli, then the individual moves into Stage 4 NREM, the deepest sleep of the cycle.3
Research has demonstrated that in the general population, an individual will shift the sleep pattern every 90 minutes from Stage 4 to Stage 1 and then progress to the stage of REM, rapid eye movement. This stage produces the physiological effect of loss of muscle tonus, irregular pulse, and elevation of the blood pressure. This stage is essential for good health as dreaming takes place.3 Research has verified that a person usually enters REM sleep three to five times a night. REM sleep, identified as "paradoxical sleep" projects a pattern of electrical activity of the brain during REM that is identical to a pattern of a person fully awakek.1 Controversy abounds regarding the effect of REM deprivation in an individual and research remains inconclusive regarding this outcome of the particular aspect of the sleep cycle.
The Aging Process and Sleep Patterns
The aged may be considered to be chronically sleep-deprived when, in fact, their normal pattern of sleep/ wakefulness has changed over time. Researchers have found that neither the amount of sleep per 24 hours nor the need for sleep decreases with age. Total sleep time and proportion of REM to NREM remain constant from ages 20 to 60. However, Stage 4 sleep, the restorative phase, declines rapidly and by age 50 is reduced by one-half (50%). Awakenings from Stage 2 NREM sleep become more frequent beginning in the fourth decade with the amount of time spent in bed becoming longer. As the person ages, the awakenings continue to increase in terms of frequency and duration. More time may be required in bed by older people to achieve the same amount of restorative sleep as compared with young adults.4 Deep restorative sleep (delta wave) is lost to the older adult who may experience an awakening every hour during the sleep cycle.
Research has demonstrated that the elderly have an an increased total duration of Stage 1 sleep, and an increase in the number of shifts into Stage 1 sleep. The amount of sleep in Stage 2 is changed very little apparently in the elderly.5 According to researchers, sleep in Stage 3 tends to be normal or even increased in elderly women. In the aged, as noted previously, there is an absolute and relative reduction in the time spent in Stage 4 sleep. Little or no Stage 4 sleep may be found in twentyfive percent of the population in the sixth decade of life.6
Because aging changes involve many levels of psychological and physiological functioning in the total human organism, a high degree of stress may be placed on the human system and alterations in the sleep cycle may occur.7 When the sleep pattern allows less complete rest than psychologically or physiologically required, the elderly person may exhibit symptoms of fatigue, headache, visual disturbances, poor concentration, apathy, depression, and problems with musculoskeletal coordination.
Feinberg demonstrated that a decline in the proportion of REM sleep in the aged may follow the trend of reduced intellectual function, which could relate to changes in cerebral blood flow, organic brain syndrome symptomatology, and decline in alpha wave activity.4 A decline in the amount of REM sleep results in reductions in restoration of physiological changes associated with REM sleep. Muscular twitches, penile tumescence, rapid irregular respiration and heart rate, and increased cerebral blood flow are those symptoms sometimes observed.5 C i re ad i an rhythm of REM sleep in the elderly appears to shift to the earlier part of the night so that distribution of REM sleep throughout the night is unusually uniform.
Sleep Disorders of the Elderly
Numerous sleep disorders in aging populations have been noted by sleep researchers. The major disorders include:
Insomnia - Insomnia is defined as "a complaint denoting varied experiences of poor sleep with daytime fatigue."8 The complaint categories for insomnia include: inability fall asleep, frequent awakenings, inability to return to sleep, early morning arousal, and any other combination of the above.
A major complaint of elderly is that of hypersomnia; that is, complaints of excessive sleep, persistent daytime drowsiness, sleep "attacks", drug states, comatose states and postencephalitic drowsiness (Dement, Miles, Carskadon, 1982, p. 30). Individuals with this complaint experience fatigue, weakness, blackouts, learning and memory problems, inappropriate sleep and sleep attacks, hallucinations and lack of energy. Sleepiness in the daytime may be accentuated by alcohol use.
Unusual Nocturnal Behavior - Elderly persons may be prone to nocturnal wandering or disorientation, the "sundowner's syndrome" . Abnormal nocturnal behavior may include screaming, talking, moaning, regurgitating, belching, bedwetting, nocturnal ejaculation, scratching, tooth grinding and coughing (Dement, Miles, Carskadon, 1982, p. 30).
Snoring - A highly important symptom of abnormal sleep behavior is that of snoring. This behavior usually indicates some impairment of upper airway function which may have serious implications for the elderly client. Heavy snorers may have hemodynamic abnormalities during sleep which may develop into cardiovascular problems. Prevalence of snoring increases with age, according to researchers, partly as a result of relaxation of tissues . Clinical symptoms may include inordinately loud snoring, abnormal behavior during sleep (a result of the struggle to breathe), enuresis and morning headache. Conditions that may aggrevate sleep related apneas include: micrognathia, cervical cordatomy, myotonic dystrophy, paoiomelitis, arromegaly, hyperthyroidism with myxedema and macroglossia, amyloidosia, and hypertrophie tonsils in children (Dement, Miles, Carskadon, 1982, p. 34). Snoring, then, may be a precursor of sleep apnea.
Sleep Apnea - Respiratory regulation proceeds differently during sleep apnea as opposed to wakefulness. For the elderly person abnormal breathing at night is the result of respiratory pauses and/or apnea. Sleep specialists regard 30 episodes of apnea per night as the upper limits of normal. Upper airway sleep apnea is viewed by such specialists as a terminal illness which, if untreated, will sooner or later result in sudden death during sleep or decompensation of the impaired cardiovascular system at any time (Dement, Miles, Carskadon, 1982, p. 35).
Patterns in the Institutionalized
Sleep/wakefulness patterns, particularly of institutionalized elderly, are essential data for evaluation of the health status of individuals. The biorhythms as represented by the patterns reveal the circadian cycle that monitors body temperature, blood pressure, heart rate, respirations and central nervous system mechanisms. A relationship exists between sleep at night and the way an elderly person feels during the day. Daytime symptoms that usually are ascribed to the aging process, but may actually be responses to disturbed sleep, include loss of the ability to perform highly skilled tasks in a rapid fashion, to resist fatigue, to maintain physical stamina, to unlearn or discard old techniques, and to apply the rapid judgment needed in changing and emergency situations. For institutionalized elderly, it should be noted that restructuring of accustomed activity, boredom for lack of activity, and dependence on others may result in daytime sleepiness. Institutional care imposes strict living conditions on elderly clients which may have deleterious effects on their lifestyle. This situation has implications for the nursing staff; they should be challenged to provide a stimulating environment to avoid sheer boredom and maintain a zest for living.
The increased incidence of chronic illnesses over time may tend to add to the frequency and severity of sleep disorders that effect the sleep/ wakeful ness patterns of the aging. Researchers have found that a circadian rhythm disruption as a result of altered sleep patterns also effects rhythm changes in urine flow and potassium excretion.
Another interesting phenomenon is the effect of sleeping pills used for sleep induction in the elderly. Reportedly, 25 percent of the prescription drugs are used by the elderly (Dement, Miles and Carskadon, 1982, p. 39). Many institutionalized elderly are given sedativehypnotics that may aggravate sleep disorders and add to the confusion and drowsiness during daytime hours. Routine nocturnal sedation of patients is said to really be for the benefit of the staff (Dement, Miles, Carskadon, 1982).
The nursing profession is concerned with the comprehensive health care of institutionalized elderly adults throughout the 24 hour period. Since the elderly adult spends approximately one-third of this 24 hour period insleep behavior, knowledge of the sleep pattern and nighttime activities of the person is essential to the formulation of an individualized care plan and the wellbeing of the older adult.
In addition to the lack of information on the normal nocturnal behavior of institutionalized older adults, there is lack of precise information on possible causes of sleep disturbances. This situation stimulated Bahr and Gress, two nurse researchers, to undertake two descriptive studies to study a) the nocturnal sleep patterns (eight hour period) of elderly residents; and, b) 24 hour sleep/ wakefulness patterns of selected institutionalized elderly. These investigations were designed as pilot studies to generate hypotheses for further research of experimental design.
Nocturnal Behavior of Institutionalized Elderly - A descriptive pilot study of the nocturnal activity in the institutionalized elderly adult was conducted in a health care facility in a mid western metropolitan area on 11 subjects during nighttime hours 11:00 PM through 7:00 AM. Hourly observations of subjects were made independently and simultaneously by the two investigators who recorded observations on separate forms for a total of 297 observations during three data collection periods of eight hours each. Two consecutive week nights and one weekend night were used for sampling the nocturnal behaviors of the subjects. It was assumed that nocturnal behaviors might vary because of such variables as staffing patterns, scheduled activity programs and visiting patterns.
Data were listed into the following categories: I) sleep, 2) restlessness, 3) activity, and 4) out of bed. Data were further analyzed into subcategories in terms of activity, 1) physiological, 2) psychosocial, and 3) reasons for being out of bed. In addition, demographic data were collected via chart review with attention also given to use of prescribed sleep inducing medication.
Analysis of data demonstrated consistent individual patterns of nocturnal activity throughout the data collection period. No significant differences were found in the nocturnal activity in the comparison of data on week nights with the weekend night. While the number of subjects in this study do not allow generalization, findings raised questions about the extent to which variation in patterning of nocturnal behaviors in elderly institutionalized adults is an individual difference, rather than a general difference characteristic of all elderly persons.3
In addition, analysis showed that the majority of subjects had ingested one or more sleep inducing medications. Findings indicate that essentially the same subjects ingested sleep inducing medications during each of the observational periods. The question remains as to what the "normal" nocturnal activity patterns are in view of the ingested sleep inducing medication.9
24-Hour Sleep/Wakefulness Patterns of Institutionalized Elderly - A descriptive pilot study of the 24 hour sleep/ wakefulness patterns of institutionalized elderly was conducted in a health care facility in a midwestem metropolitan area on 12 subjects during a 24 hour period for three days.
Observations of each subject were made and recorded every 30 minutes during the 24 hour period by the research assistants. Three days, Monday, Wednesday and Saturday, were used for data collection to pick up any change that might occur between week days and a weekend day.
Gross analysis of data demonstrated the variability of sleeping patterns in these institutionalized ambulatory elderly adults. No trend of statistical significance was detected. These data reinforce the need for additional research by nurse investigators to understand the sleep/wakefulness patterns of elderly institutionalized clients.
Since variability of sleep patterns exist for elderly clients, it is essential for the nurse to assess the lifestyle patterns that may impact on the sleep behaviors. Lerner suggested the following self-assessment test that provides the nurse with excellent information about the client.3
After obtaining the client's history, the nurse should be able to formulate an individualized plan of care to meet the needs of the elderly adult. Exercise, involvement in activities and hobbies of various types, and a sense of wellbeing, aid the elderly individual in patterning a life that also is conducive to sound sleeping practices.
Illnesses can cause sleep alterations that are a challenge to the nurse as well. Lerner notes that such illnesses as arthritis, angina pectoris chronic obstructive pulmonary disease, congestive heart failure, diabetes mellitus, peptic ulcers, alcoholism, parkinsonism, altered sensory perception and depression have a major input or physiologic function which, in turn, affect the sleeping pattern of the elderly adult.3 When the sleeping pattern is so sufficiently disrupted as to create difficulties in functioning during daytime, a sleep disorder may result.
The challenge to nurses is to enhance sleep capabilities in the aged adult. A supportive milieu conducive to sleep and nursing practices will aid in more refreshing sleep and a more productive lifestyle. Lemer provides the following checklist that nurses may use in planning care for elderly in the realm of sleep.3 The checklist of health measures includes the following points:
1. The client and family should be instructed regarding the dangers of over-the-counter drugs for sleep. These may cause disorientation, bradycardia, delirium and/or blurred vision.
2. All drugs are to be checked for adverse interactions in terms of medical conditions (hypertension and glaucoma).
3. Regular activity to promote rest and relaxation is to be encouraged.
4. Night lights on in bedrooms and bathroom aid in the elimination of disorientation.
5. Clutter to and from bathroom and bedroom is to be avoided.
6. Urinal, bedpan or commode is to be placed near the bed if bathroom facilities are not easily accessible.
7. Siderails, on the beds of those whose condition warrants, should be removed to avoid accidents.
8. Nonuse of sedation allows for continence, alertness, participation in activities and decline of accidents.
9. Drinking a cup of warm milk with honey before bedtime may help induce sleep.
Other health measures that may be conducive to sleep induction are a soothing backrub, accompanied by soft conversation. These nursing measures, as well as nonuse of sedation, have invaluable results. To enhance the sleep milieu is a tremendous challenge, particularly in an institutional setting where many contraindications to it exist.
Sleep is a mysterious, elusive, natural ocurrence, related to the daily circadian rhythm patterns of humans and is essential to good health. Professional nurses are key persons to assist the institutionalized elderly in enjoying a higher qualify of life in the area of sleep. This professional practice is an outgrowth of employing knowledge about sleep problems in older adults and recognizing the sleep disorders that may occur when sleep is disrupted. Implementing nursing interventions when symptoms arise and using health measures for sleep enhancement are within our domain. Additional nursing research is needed in the area of sleep/ wakefulness patterns of elderly. Such clinical research by nurse investigators should improve the quality of life for elderly men and women and aid in reducing the risk of dying during sleep. More information about the nature of sleep and the aging process is needed. Findings should facilitate a more rational use of sleeping medication, effective diagnosis and treatment of sleep disorders, and improved circadian rhythm function, resulting in increases in daytime alertness, energy and zest for living among older adults.
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