The long-term goal of this investigation is to promote sleep as a restorative function for hospitalized elderly persons. As the first step in the achievement of this goal, the current investigation was a replication of the first phase of a two-phase study conducted by Gress, Bahr, and Hassanein.1 Gress et al, in their first phase, described the consistency and predictability of nocturnal behavior of institutionalized elderly. In the second phase, Gress et al described the consistency and predictability of 24-hour sleep-wake patterns of their sample.
This article will examine the consistency and predictability of nocturnal activity patterns of older adults admitted to an inpatient geriatric unit. Nocturnal activity patterns include sleep, restlessness, and wakefulness. Future studies will be designed to test nursing interventions.
Nursing is concerned with the comprehensive care of older adults and with implementing a plan of care in keeping with the individual needs of elderly persons. To do this, it is essential to have knowledge about the nocturnal activity patterns of older adults not only in the setting in which they usually reside, but also in an acute inpatient unit. To care for these patients during their increasingly shorter hospital stays, provide adequate staff to meet their needs during the night, and help them adapt to the major disruptions attributed to hospitalization, baseline data on nocturnal behavior patterns of hospitalized elderly are needed.
The predominant nocturnal behavior throughout the lifespan is sleep. Guy ton defined sleep as "a state of unconsciousness from which a person can be aroused by appropriate sensory or other stimuli."2 Sleep is considered to have restorative functions, to occur in highly individualistic rhythms, patterns, and variations, and to change in terms of requirements and ranges with age and activity.2"6 Sleep quality was the focus of a study by Snyder-Halpern and Verran.7 They evaluated the literature and concluded that the subjective indicators of sleep quality are fragmentation, length of sleep, delay in falling asleep, and depth of sleep.
Research on sleep is multidisciplinary and focused on identifying sleep stages, rhythms, and cycles; establishing the physiological and psychological benefits of sleep; documenting the defining characteristics of and problems associated with sleep disorders and deprivation; describing the changes in sleep patterns with age and illness; and suggesting strategies to promote sleep throughout the lifespan and in persons with alterations in health.815 Previous sleep investigators demonstrated that a reduction in hours of sleep is associated with increasing fatigue, irritability, and aggressiveness; decreased pain tolerance and increased corticosteroid and catecholamine output levels; and changes in mood and basic drives. 16"18
Sleep in hospitalized patients was reviewed by Collings19 and researched by DHn et al,20 Goodemote,21 Hilton,22 and Walker,23 who documented numerous sleep interruptions, reduced quantity, and poor quality of sleep in intensive care and postsurgical patients. Beyerman asked 100 patients (mean age 68 years) what disturbed meir sleep during hospitalization and found that 24% indicated noise, 10% indicated somatic complaints, 9% indicated taking medication, and 9% indicated the strangeness of the environment.24 The specific disturbances were difficulty falling asleep (20%), interrupted sleep (17%), early awakening (13%). and not feeling rested (10%).
DESCRIPTION OF THE SAMPLE IN TERMS OF AGE, LENGTH OF STAY, AND NUMBER OF MEDICALANP NURSING DIAGNOSES
Studies of nocturnal activity patterns in the elderly, that is, activity in addition to sleep, occurred only in long-term care institutions and critical care units.1·25*28 The consistency and predictability of nocturnal activity patterns of older adults who are hospitalized in acute care settings has not been studied. No doubt the usual pattern is altered, but what is the pattern during hospitalization?
The research design is a descriptive observational method. Older adults admitted to an inpatient nursing unit were observed for nocturnal activity patterns during 3 consecutive days of hospitalization to analyze similarities and differences in the patterns and to compare the findings with Gress et al. Nocturnal behavior patterns were defined as the activities that subjects engaged in between the hours of 1 1 PM and 7 AM.
Subjects were recruited on their admission to an inpatient geriatric unit in a large Midwestern teaching medical center. Inclusion criteria included: not rated critically ill by physician assessment: not considered confused or possessing a sleep disturbance by nursing assessment; 60 years of age or olden English speaking; able to provide consent; and expecting to stay in the hospital at least 4 nights.
The observed sleep and wakefulness patterns of the subjects were recorded on the Sleep Chart developed by Regestein and Barbiasz29 and adapted by Gress et al. The coding system had four major categories: sleeping, during which time the subject was observed to have eyes closed, muscles relaxed, and respiration pattern unchanged; restless, during which time the subject was observed to have eyes closed, respiration pattern unchanged, and moving extremities or turning in bed; awake, performing physiological activities such as eliminating, drinking, eating, complaining of pain, etc, or performing psychosocial activity such as expressing feelings, watching television, reading, etc; and up, performing physiological activity or psychosocial activity, such as standing or walking.
Other than inter-rater reliability studies, no prior testing to establish reliability of the instrument was reported. A pilot study was conducted to establish inter-rater nocturnal behavior reliability, and steps were taken throughout the study to monitor the reliability of observations. Validity of the instrument is limited to content validity and was established based on the sleep literature and the use of a panel of experts.29
The study procedures were developed by Gress et al and were applied in this investigation with hospitalized adults. At 30-minute intervals during each of the 8-hour data collection periods, the trained observer stepped into the room and observed the subject at close range for 30 seconds using the criteria described tor sleeping, restless, awake, and up. Close range meant inside the patient's room, approximately 5 feet from the subject. The observational conditions were such that doors were left open and night lights were on and, in some cases, lamps were left lit in the rooms by the subjects.
The observations occurred over 3 consecutive days and nights as outlined by Gress et al. Observations were recorded by making a check mark in the appropriate space on the individual forms for recording data. The observations were graphed for each subject for Day 1 . Day 2. and Day 3 to facilitate the examination of individual nocturnal behavior patterns.
Gress et al did not find significant] differences in nocturnal behavior between weeknights and weekend nights. Hartman reported a first night effect he termed mild insomnia associated with sleeping in a strange place; thus, no observations were conducted on the subjects' first nights of hospitalization.6 All observations occurred on the subjects' second, third, and fourth hospital nights.
Observations were accomplished by trained staff nurses. The training consisted of didactic presentation of the observation criteria and actual observations of patients who were willing to be in a pilot study. Staff were considered trained when inter-rater reliability between a pair of observers and one of the authors reached 0.85 on two or more occasions. Of the 4,464 observations (48 observations per day on 31 subjects x 3 days), approximately 20% were chosen randomly and conducted by two nurses to check for reliability of the data collection. Reliability among observers was maintained at 0.98. Based on the pilot study, the observational procedures were considered feasible.
Limitations of the Study
Scientific evaluation of sleep is often conducted in a laboratory setting using the direct physiological measurenents of electroencephalogram, elecro-oculogram, or electromyogram. Neither these technologies nor the raining to use them were available to the researchers; thus, the Gress et al global observational approach was used.
Twelve men and 19 women between the ages of 61 and 91 years (mean 15.1, SD = 8.0), were observed at 30-minute intervals during their second, third, and fourth nights of hospitalization. Characteristics of the sample are summarized in Tables 1 and 2. the subjects were an elderly, white, mostly widowed group with multiple nursing and medical diagnoses primarily involving the cardiorespiratory system who stayed in the hospital about 10 days. Four subjects received sleep inducing medication.
Pattern of Nocturnal Sleeping Behavior
Examination of the data reported in the Figure indicates that over the 3-day period, fewer subjects were sleeping at any given hour on the second night than on the first night. On the third night, fewer were sleeping at any given hour than on either the first or second night. By day 3, less than 50% of the sample were sleeping at any given hour. For example, at 3 AM on Day 1 , 72% of the subjects were asleep, compared with 56% on Day 2 and 47% on Day 3. In contrast, Gress et al reported that 82% of their sample were asleep at 3 AM on Days 1 and 2, and 91% were asleep at 3 AM on Day 3.
Pattern of Nocturnal Restlessness
Restlessness was the least reported behavior. Fewer than 1 0% of the subwere observed (except at 1 1 PM , 1 AM, and 4 AM on Day 3) in the restless state at any time. On the first observation night, there were three observation periods at which no one was observed to be in the restless state. By the third observation night, there were one to five subjects observed in the restless state at each observation except at 5 AM.
Pattern of Behavior for the Sample
Gress et al differentiated the awake state as the subject being awake and engaged in either psychological or physiological activity. Due to the small number of persons in either category in this study, the categories were combined and are reported merely as awake data. The percentages of subjects in this category increased from less than one third of the sample at any given hour on the first observation night to nearly half the sample on the third observation night. For example, at 3 AM on Day 1 , 19% of the subjects were awake. This percentage increased to 29% on Day 2, and 49% on Day 3.
DESCRIPTION OF THE SAMPLE IN TERMS OF GENDER, MARITAL STATUS, AND PRIMARY MEDICALAND NURSING DIAGNOSES
Pattern of Up Behavior
Few subjects, generally less than 10%, were in and out of their beds at any given hour during the night. In fact, the percentage up in the early hours of morning, such as 5, 6, and 7 AM, decreased over the 3-day period.
Examination of Medication and Treatment Interruptions at Night
After the data presented were analyzed, the coinvestigators returned to the subjects' hospital records to reconstruct the interruptions per subject per night. Three fourths of the sample were given a medication or treatment or underwent a procedure that interrupted their sleep during the night. Only 4 of the 32 subjects were not interrupted during the night for a medication, treatment, or procedure. Eleven subjects were interrupted three or more times during the night. Ten of these 1 1 subjects were interrupted twice within I hour. Most interruptions were for medication that was ordered on a 5- or 6-hour schedule or for vital signs. It was difficult to determine from the data, however, whether the subject or nursing staff initiated the activity that constituted the interruption.
Examination of the Consistency and Predictability of the Patterns
In no instance did any subject demonstrate consistency in his or her own pattern of behavior from the first night to the third night. In addition, subjects demonstrated considerable variation from one another in their patterns of nocturnal behavior. Examination of each subject's individual observational record led to the conclusion that each time sleep was interrupted, it took at least 30 minutes to achieve the sleeping state again.
SLEEPING BEHAVIOR OFTHE SUBJECTS
The major finding of this study was that the number of times hospitalized elderly subjects were observed sleeping between the hours of 1 1 PM and 7 AM decreased markedly over three nights, while the number of times they were observed awake increased markedly. These findings are in stark contrast to that of Gress et al, who demonstrate a highly consistent and predictable pattern for each institutionalized elderly subject. The study findings are in agreement with Hayter's5 finding that sleep patterns are highly individualistic and vary from subject to subject. More than 75% of the subjects in the current study had a minimum of two interruptions each night chiefly for medication administration or the monitoring of vital signs.
Nursing staffs possess considerable control over the patient's hospital environment during the night. There are fewer employees on duty and events are not routinely scheduled during the hours of 1 1 PM to 7 AM. However, the results of this study indicate that the environment is not conducive to sleeping. How can this situation be improved?
One recommendation that bears repeating is the timing of medications and treatments, including vital signs. They should be scheduled after considerable thought to the patient's daily schedule, prior sleep pattern, institutional monitoring policies, and medication and treatment interactions. Many times patients have a schedule of awakening during the night before hospitalization, and this "usual time" could be incorporated into the plan of care. It is the responsibility of the nurse to integrate the medication and treatment regimens with the patient's previous pattern of nocturnal behavior and aim for a restful night.
Preparations for diagnostic tests were found to be a major interference. The nurse needs to monitor the plans for testing and advocate change if the preparations will interfere with adequate rest. For example, a 68-year-olc woman in the current study was prepped for a colonoscopy at 9 PM with GoLy tely. She spent much of the night expelling the contents of hei bowel and received little or no restorative sleep that night.
The nurse must consider factors doc umented from other studies as well Beyerman documented noise as her pa tients' most frequently occurring cause of sleep disruption. Closing the door, lowering voices, and eliminating unnecessary equipment and distractiv« stimuli are a few examples of methods to adjust the environment. Beyermar further documented somatic discom forts, such as pain, that contributed tc sleep disruption. Adequate pain reliel prior to sleep with appropriate analgesia for the condition and age of the patient should be addressed in the piar of care. The investigators were re lieved to find that only four subjects received sleep-inducing medication, because this medication is currentl) discouraged among the geriatric population. I9 Because the nocturnal ac tivity patterns were highly individuai and because these four subjects wer« interrupted as often as the rest of the sample, no conclusions are drawr about the use of sleep-altering drugs.
There are many additional factors tc be measured in a comprehensive assessment of nocturnal behavior pat terns of hospitalized elderly, such ai the initiator of the interruptions (nurse or patient), the mental and emotiona state of the subject, usual bedtime routine and the potential for adherence tc it in the hospital, effects of various medications, nursing measures taken to promote sleep, daytime activity pat^ tern, nutritional habits, and the subjects' perceptions of their nocturnal bej havior.
The findings of this study reiterate the role of the nurse as advocate for the patient. Although it is unrealistic tc expect elderly individuals to sleep through the night at home or in the hospital, care must be planned to include the need for rest. Gress et al documented predictable and consistenl >atterns of nocturnal sleep behavior or institutionalized elderly. We documented progressively less predictable and consistent nocturnal sleep behavior and increasingly more awake belavior as the hospital stay progressed.
As a result of this study, it is recomlmended that at least two additional studies be conducted. The first should 3e designed to determine whether this less consistent and predictable nocturnal behavior pattern can be replicated and, if so, whether it is due merely to a change in environment attributable to Hartman's mild insomniac effect or if it is due to the numerous interruptions, noise, and health alterations. The second study should be designed to develop and test a sleep conducive environment in the acute care setting.
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DESCRIPTION OF THE SAMPLE IN TERMS OF AGE, LENGTH OF STAY, AND NUMBER OF MEDICALANP NURSING DIAGNOSES
DESCRIPTION OF THE SAMPLE IN TERMS OF GENDER, MARITAL STATUS, AND PRIMARY MEDICALAND NURSING DIAGNOSES