Journal of Gerontological Nursing

The 24-Hour Cycle: RHYTHMS OF HEALTHY SLEEP (Developing Nursing Strategies!)

Rose Therese Bahr, PhD, FAAN; Lucille Gress, MA, RN

Abstract

Nursing is intimately involved in the care of elderly adults for whom institutional living is their customary setting. Since sleep and activity are important aspects of this care we need to investigate and identify sleep/wakefulness patterns of these older persons, and explore possible nursing strategies.1 The outcomes of these investigations would be judged with respect to the well-being of these individuals. Hence, this study (phase two of a three-phase study) was undertaken for the purpose of generating hypotheses for further study.

While information acquired about sleep and sleep/wakefulness patterns through laboratory research is important, it is insufficient for the nursing profession, which is concerned with care of the whole person in various nonlaboratory settings. In the holistic approach, professional nurses are concerned with the individual's response to an ever changing environment, internal and external. Thus, it is imperative that information be gathered about the sleep/wakefulness patterns of individuals in their customary settings.

Sophisticated laboratory studies have contributed to a body of knowledge about the physiological patterns of sleep and wakefulness.2 Documentation from the use of electrophysiological techniques, such as the EEG and EMG, has provided information on the patterns of electrical activity in the brain. It has shown dramatic changes that occur in individual patterns of sleep. Sleep may be referred to as active sleep (AS) and quiet sleep (QS).2

Active sleep is defined as a phase in which there is almost a complete relaxation of skeletal muscles and rapid eye movements (REM). This phase, frequently referred to as REM sleep, may also be referred to as paradoxical sleep, since it results in an ECG pattern similar to that of the awake state. Dreams are often reported to occur within the REM phase.

Quiet sleep (QS), on the other hand, may be defined by researchers with respect to the EEG characteristics, which include sleep further described in the identification of stages one through four.

Active sleep and quiet sleep patterns are components of the sleep/ wakefulness cycle. States of sleep and wakefulness, in turn, may be viewed as two ends of a continuum with respect to the levels of alertness and arousal.2

The purpose of this study was to determine the time increments of the various phases of sleep/wakefulness, and the 24-hour cycle pattern of sleep/ wakefulness of selected institutionalized elderly adults. Identifying these patterns is an essential step in the research process, ultimately aimed toward determining nursing strategies to facilitate appropriate intervention for elderly with sleep/wakefulness pattern disturbances.

Researchers have previously indicated that patterns of sleep change as part of the developmental process.36 The newborn has an ultradian QS-AS sleep cycle (less than 24- hour cycle) of approximately 60 minutes in the early postnatal period.3

The mature person, on the other hand, tends to exhibit a circadian rhythm (approximately 24 hours) of 90 minute cycles.

Furthermore, change in the sleep/ waking rhythm has been identified by Hay ter.7 Although the duration of the sleep/wakefulness phases of this rhythmic cycle continues to change over time, the cyclic period of approximately 24 hours does not.3

Kahn and Fisher indicate that stage four, or the stage of deep sleep, practically disappears in the elderly.8 Others indicate that sleep tends to be distributed throughout a 24-hour period, rather than limited to eight night-time hours.49

While knowledge of change in the stages of sleep is important, the critical issue is the distribution of the sleep/ wakefulness patterns over the 24-hour period.

Although the basis for alterations in sleep patterns of the elderly is not clear, it has been suggested the changes in the central nervous system, prominent in the autonomic and hypothalamic centers, could…

Nursing is intimately involved in the care of elderly adults for whom institutional living is their customary setting. Since sleep and activity are important aspects of this care we need to investigate and identify sleep/wakefulness patterns of these older persons, and explore possible nursing strategies.1 The outcomes of these investigations would be judged with respect to the well-being of these individuals. Hence, this study (phase two of a three-phase study) was undertaken for the purpose of generating hypotheses for further study.

While information acquired about sleep and sleep/wakefulness patterns through laboratory research is important, it is insufficient for the nursing profession, which is concerned with care of the whole person in various nonlaboratory settings. In the holistic approach, professional nurses are concerned with the individual's response to an ever changing environment, internal and external. Thus, it is imperative that information be gathered about the sleep/wakefulness patterns of individuals in their customary settings.

Sophisticated laboratory studies have contributed to a body of knowledge about the physiological patterns of sleep and wakefulness.2 Documentation from the use of electrophysiological techniques, such as the EEG and EMG, has provided information on the patterns of electrical activity in the brain. It has shown dramatic changes that occur in individual patterns of sleep. Sleep may be referred to as active sleep (AS) and quiet sleep (QS).2

Active sleep is defined as a phase in which there is almost a complete relaxation of skeletal muscles and rapid eye movements (REM). This phase, frequently referred to as REM sleep, may also be referred to as paradoxical sleep, since it results in an ECG pattern similar to that of the awake state. Dreams are often reported to occur within the REM phase.

Quiet sleep (QS), on the other hand, may be defined by researchers with respect to the EEG characteristics, which include sleep further described in the identification of stages one through four.

Active sleep and quiet sleep patterns are components of the sleep/ wakefulness cycle. States of sleep and wakefulness, in turn, may be viewed as two ends of a continuum with respect to the levels of alertness and arousal.2

The purpose of this study was to determine the time increments of the various phases of sleep/wakefulness, and the 24-hour cycle pattern of sleep/ wakefulness of selected institutionalized elderly adults. Identifying these patterns is an essential step in the research process, ultimately aimed toward determining nursing strategies to facilitate appropriate intervention for elderly with sleep/wakefulness pattern disturbances.

Researchers have previously indicated that patterns of sleep change as part of the developmental process.36 The newborn has an ultradian QS-AS sleep cycle (less than 24- hour cycle) of approximately 60 minutes in the early postnatal period.3

The mature person, on the other hand, tends to exhibit a circadian rhythm (approximately 24 hours) of 90 minute cycles.

Furthermore, change in the sleep/ waking rhythm has been identified by Hay ter.7 Although the duration of the sleep/wakefulness phases of this rhythmic cycle continues to change over time, the cyclic period of approximately 24 hours does not.3

Kahn and Fisher indicate that stage four, or the stage of deep sleep, practically disappears in the elderly.8 Others indicate that sleep tends to be distributed throughout a 24-hour period, rather than limited to eight night-time hours.49

While knowledge of change in the stages of sleep is important, the critical issue is the distribution of the sleep/ wakefulness patterns over the 24-hour period.

Although the basis for alterations in sleep patterns of the elderly is not clear, it has been suggested the changes in the central nervous system, prominent in the autonomic and hypothalamic centers, could effect changes in the sleep/ wakefulness pattern. Changes in sleep patterns are most difficult to manage by institutionalized elderly residents. according to Straberg.10 Older persons living in settings outside of institutions may establish and maintain sleep patterns in keeping with their particular need or situation, but older institutionalized adults have fewer opportunities to maintain their unique sleep patterns. Both non-institutionalized and institutionalized elderly adults commonly experience increasing difficulty in achieving restful sleep.

The Study

To help answer questions of concern in the clinical setting, this investigation addressed the collection of data on the sleep/wakefulness patterns of a convenience sample of 12 older adults, three male and nine female, ranging in age from 67 to 93 years. The study was conducted in a health care setting located in a large midwestern metropolitan area. The questions under study were:

1. What is the 24-hour sleep/ wakefulness pattern of selected ambulatory institutionalized elderly adults on a minimal care unit;

2. What differences, if any, occur in sleep/wakefulness patterns in these subjects over a 72-hour period (three 24-hour days);

3. What variation, if any, occurs in the sleep/wakefulness patterns of individual subjects in the study over a 72-hour period;

4. What is the relationship between sleep/wakefulness periods and the sleep medications used for the subjects?

Operational Definitions - Operational definitions used were as follows:

* Elderly - individual 60 years of age and over.

* Sleep/wakefulness patterns - intermittant periods of sleep and wakefulness occurring over the 24hour period.

* Sleep - is that behavior characterized by immobile posture and diminished but readily reversible sensitivity to external stimuli.11 Other characteristics include eyes closed, slowed respiration, relaxed musculature.

* Wakefulness - a state of alertness in which the individual carries out activities of daily living or assumes a non-sleep posture with eyes open.

* Institutionalized adult - an ambulatory individual 60 years of age and over whose physical and mental condition is such that she/he requires minimal supervision. This individual is housed on a minimal care unit in a health care center engaged primarily in the care of the elderly.

Data Collection - Observational methodology used for the data collection was similar to that used by other clinical researchers.12·13 These researchers were also concerned with data on the time and sequencing of sleep/ wakefulness patterns in clinical settings.

Three nurses were involved in the data collection process for this 24-hour sleep/wakefulness study, one for each of the 8-hour shifts of the 24-hour data collection periods.

During each of the 24-hour collection periods, the observer stepped into the room and observed the subject at close range for 30 seconds. Criteria for determining the sleep/wakefulness behavior was based upon the operational definitions presented previously. Observations were recorded by making a check mark in the appropriate space on the individual forms for recording data. Observations were made of each subject and recorded every 30 minutes over the 24-hour period of observation. Three days, Monday, Wednesday, and Saturday, were used for the observations as a means of determining whether changes in sleep/wakefulness patterns might occur between week days and the week-end day.

Interrater reliability was performed at specified intervals across the three 24hour data collection periods, including each of the three shifts. Out of a total of 144 observations, there were two areas of disagreement, representing a 98 percent reliability between observers.

Instrument - A modification of the Regestein - Barbiasz sleep/wakefulness checklist was used for recording observations.13 This is a simple "sleep chart," composed of 48 lines on a sheet of paper, a line for each one-half hour period during the 24-hour period of observation. A vertical line was used to separate the two columns, one for "Awake" on the right, and one for "Asleep" on the left. A form for each subject was labeled according to a preestablished code. The time frame used for this study began at 7:00 am and extended through 6:30 am the following morning.

Analysis - Analysis of variance (ANOVA) for repeated measurements was performed separately for 72-hours sleep during night time and 72-hours awake during day time. Exact location significance difference between the three days was found by the use of Duncan's Test. While some differences occurred, they were not statistically significant.

Table 1 reflects the sleep/ wakefulness patterns of individual subjects over the 72-hour observational period (three 24-hour days). These data include the breakdown on the individual states of sleep and wakefulness.

FIGURESUMMARY OF SLEEP BEHAVIORS OVER THREE 24-HOUR PERIODS

FIGURE

SUMMARY OF SLEEP BEHAVIORS OVER THREE 24-HOUR PERIODS

Table 2 reflects the group mean, standard deviation, variance and covariance for the 72-hour observational period. Although these data are not statistically significant, they are of interest in demonstrating a degree of individual variability in sleep/wakefulness patterns. ANOVA for repeated measures was performed on the variable: drugs, days one, two and three. Findings on the variable "drugs" were not statistically significant.

A summary of the findings on the sleep patterns of subjects for the three 24-hour days are reflected in the figure. This is reflected in two arbitrarily established 12-hour periods, since elderly may sleep at alternating periods over a 24-hour period, rather than at nighttime hours only.

Conclusions

While these findings in this study were not statistically significant, there are few clinical studies available for the purpose of comparison. Therefore, these data provide some baseline information on sleep/wakefulness patterns of elderly institutionalized adults, which may have heuristic value in stimulating further research. Such research is of vital importance to the nursing profession seeking to improve the quality of life for institutionalized elderly persons.

Sleep has long been considered to have restorative value; sleep patterns, known to change over time as a normal course of events in the aging process, need to be taken into account. Restoration is believed to encompass such areas as the repair process, biological rhythms, and hormonal activity, all of which contribute to the elder's sense of well-being. Because of the increasing numbers of older persons and the resultant increase in the incidence of chronic disease conditions among the institutionalized elderly, nurses need to be aware of the unique needs of these elderly persons.

Intervention for sleep/wakefulness variability is often the use of sedatives, tranquilizers, and hypnotics. Nurses using an holistic approach need to explore other strategies for supporting individual sleep/wakefulness patterns by manipulating the environment. Such manipulations include warm milk at bedtime, or during the night, serving a snack at bedtime, adequate temperature control and use of blankets, controlling the noise level and obtaining an adequate sleep history. The sleep history would allow the individual to indicate unique patterns based upon their perceptions and the action taken to promote sleep and rest.

Data from such a study also have implications with respect to staffing patterns and planned activity programs. If older adults have periods of wakefulness during the early morning hours, staffing patterns might be changed to accommodate these persons. Rather than resorting to the use of medications, nurses might offer nighttime snacks and allow the individual to be mobile, to read, to listen to the radio , and to visit with each other or the staff. This might accommodate their needs. Planned activities might be arranged for night-time hours, rather than having them grouped in the afternoon hours.

Table

TABLE 172 HOUR SLEEP/WAKEFULNESS PATTERN

TABLE 1

72 HOUR SLEEP/WAKEFULNESS PATTERN

Table

TABLE 272 HOUR SLEEP/WAKEFULNESS PATTERN

TABLE 2

72 HOUR SLEEP/WAKEFULNESS PATTERN

Data from phases I and II have demonstrated variability in sleep/ wakefulness patterns of elderly institutionalized adults. In phase III of this three-part study, data will be collected on the normal sleep/wakefulness patterns of an ambulatory, non-institutionalized sample. These data will be used for the generation of hypotheses in the development of an experimental research design.

Sleep is viewed as a vital component of health care for the elderly, and it is believed that manipulation of the environment can help maintain the unique sleep/wakefulness patterns of the elderly. Professional nurses should make a concerted effort to become knowledgeable of the sleep/ wakefulness patterns of individual older adults and to accept the challenge for determining nursing interventions having predictability and measurable outcomes.

References

  • 1. Yura H. Walsh MB: Human Needs and the Nursing Process New York, Appleton-Century-Crofts, 1978.
  • 2. Cotman CW, McGaugh JL: Sleep and activity rhythms. Behavioral Neuroscience, New York, Academic Press, 1980.
  • 3. Sterman MB: The basic rest-activity cycles and sleep: development consideration in man and cats. In Clements Cb, Purpura DP, and Mayer FE (eds.), Sleep and the Maturing Nervous System New York, Academic Press, 1972.
  • 4. Kaluger G, Kaluger MF: Human Development: The Span of Life. St. Louis. The CV Mosby Company. 1979.
  • 5. Feinberg I: Changes in sleep cycle patterns mthage.JPsychiatrRes 1974; 10:283-306.
  • 6. Renshaw DC: Why sleep? Chicago Medicine 1973;75:1038-1042.
  • 7. Hayter J: The rhythm of sleep, Am J Nurs 1980;80:456-461.
  • 8. Kahn E, Fisher C: The sleep characteristics of the normal aged male. J Nerv Ment Dis 1968; 148:477-494.
  • 9. Webb W: Sleep: the Gentle Tyrant. Englewood Cliffs, New Jersey, PrenticeHall, 1974.
  • 10. Straberg D: An overview of neuropsychiatrie disturbances in the elderly. J Am GeriatrSoc 1980; 28:422-425.
  • 11. Hobson JA: Sleep: physiologic aspects. New England Journal of Medicine 1969; 28:1343-1345.
  • 12. Hagemann V: Night sleep of children in a hospital, part II: sleep description. MaternChild Nurs J 1 98 1 ; 10: 1 27-141.
  • 13. Regestein QR, Barbiasz JE: Sleep disorders: recognizing them in patients. The Journal of Practical Nursing 1980; 30:21-22,62.

TABLE 1

72 HOUR SLEEP/WAKEFULNESS PATTERN

TABLE 2

72 HOUR SLEEP/WAKEFULNESS PATTERN

10.3928/0098-9134-19850401-06

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