Case Study Sleep Disturbances in Older Adults

CASE STUDY SLEEP DISTURBANCES IN OLDER ADULTS1

Sergey Makov

New York City College of Technology

Geriatric Nursing

NUR 4090

Prof. Lynda M. Konecny

March 25, 2014

CASE STUDY SLEEP DISTURBANCES IN OLDER ADULTS1

Case Study Sleep Disturbances in Older Adults

1. As the individual moving through the life span the human body continues to experience changes. Sleep patterns, stages, and cycles continue to change with age across adulthood. Based on clinical research data from National Institute of Medicine two major age- related changes in older adults were identified: earlier wake time and reduced sleep consolidation. (Colten & Altevogt, 2007, p. 46). Researchers identified the hallmark changes with age is a tendency toward earlier bedtime and wake times. Older adults (approximately ages 65 to 75) typically awaken 1.33 hours earlier, and go to bed 1.07 hours earlier, than younger adults (approximately ages 20 to 30)(Colten & Altevogt, 2007, p. 46). Sleep stages are also affected by age. Older adults may experience the changes in the amount of time spent in each stage. After midlife the person will start to experience the reduction in non-rapid eye movement stage sleep and rapid eye movement (REM) stage sleep (Eliopoulos, 2014, p. 186). Older adults in comparison to younger people sleep less soundly and shift in and out of stage 1; also older adults spend more time in stages 1 and 2 sleep (Eliopoulos, 2014, p. 186). Researchers from Institute of Medicine stated that younger adults may experience brief periods of awakening but those periods considered to be minor and happen close to REM sleep transition, thus the integrity of sleep is not disturbed. Arousal from REM sleep in younger adults suggests on protective mechanism which keeps younger adults from awakening during NREM sleep (Colten & Altevogt, 2007, p. 46). However, this protective mechanism declines as the person advance with age. In addition to that, Slow-wave sleep declines with the age at rate of approximately 2 % per decade. As a result of this decline the older adults are mire likely to experience more frequent awakenings.

Five factors contributing to sleep disturbances in older adults:

1. Circadian Disruption. According to American Journal of Neurodegenerative Disease older adults are experiencing significant disruption in melatonin system (Costa, Carvalho, & Fernandes, 2013, p. 231). Older adults showing constant decrease in plasma level melaoting secretion with age. With the decreased plasma melatonin level older adults are more likely to experience difficulties with sleep, the need more time to adjust to dark environment, and need more time to fall asleep. It has been noticed that older adults show disturbance in circadian rhytmicity in comparison to younger adults. Age-related macular degeneration has been proposed as one of the reason associated with reduced melatonin secretion. Due to progressive loss of light transmission through the lens the photoreception to light will be diminished and the older adults will be more frequently affected by circadian instability. (Costa et al., 2013, p. 234)

2.Depression. Depression was identified as one of the key factors leading to sleep disturbances in the older adults (Costa et al., 2013, p. 234). Based on the research data from American Journal of Neurodegenerative Disease depressed older adults are more prevalent to experience insomnia. Insomnia was identifies as most frequent sleep disturbance in depressed older adults. Depressed older adults are more likely to experience the negative emotions, such as loneliness and fear of death. Moreover loss of sleep may be one of the reasons in alteration in neurobiological function that affects mood. Instabilities in mood regulations will prevent older adults from falling asleep easily (Costa et al., 2013, p. 239).

3. Restless Leg Syndrome. The older adults may experience disturbances because of the condition which cause uncontrollable urge to move the legs during the night time. (Eliopoulos, 2014, p. 187). In order to relive the symptoms the individuals must move the legs. Movement brings relief of the sensation but also interferes with sleep. According to the author the incidence of the condition increased with age. The individuals with the Parkinson’s disease, iron deficiency anemia, rheumatoid arthritis, and diabetes are the groups with an increased risk.

4. Parkinson’s Disease. Between 60 and 90 % of older adults suffering from the disease have sleep disturbances. The earliest and more common manifestations of the disease are difficulty to initiate and maintained sleep. (Costa et al., 2013, p. 237) Other abnormalities such as increased number of arousals and awakening, Parkinson- specific motor phenomena such as nocturnal immobility, rest tremor, eye blinking, and dyskinesias are reported as factors that affect the quality of sleep (Costa et al., 2013, p. 237).

5. Sleep apnea. Older adults suffering from the condition will not be able to get sufficient amount of night sleep and will display the signs of fatigue and sleepiness during the daytime. Older adults suffering from the condition will experience a blockage in the upper airway that interferes with normal air flow. Insufficient amount of oxygen will cause the older adults to experience the headache. If left untreated the sleep apnea might bring a lot of negative consequences to health and well being of older adults such as hypertension, cardiovascular disease (Eliopoulos, 2014, p. 187).

Nursing interventions that can be implemented for the older adults to improve sleep habits.

According to American Academy of Sleep non-pharmacological treatments for geriatric insomnia provide positive outcomes in chromic insomnias. The most widely used method is Cognitive Behavioral Therapy (CBT). CBT provides combination of stimulus control, sleep restriction, cognitive restructuring, relaxation and good sleep hygiene. (Krishnan & Hawranik, 2008, p. 595). As a geriatric nurse I will suggest to Mr. Hayes as well as other older adults to implement the following steps in their daily practice to promote sleep hygiene.

1 Stimulus Control. Since the majority of older adults spend their time in the bedroom with non sleep related activities. I will improve their sleep habits through reassociation. I will suggest using bedroom for sleep and sex only; to go to bed when sleepy; to leave the bedroom when unable to sleep after 20 min, will encourage engaging in relaxation activities until feel drowsy, and then will suggest returning to bed. Older adults should maintain regular morning rise time (Krishnan & Hawranik, 2008, p. 596 table 2).

2 Sleep hygiene educations. Older adults need to be educated about importance of healthy behaviors that will promote and enhance sleep. Some older adults did not pay enough attention to their activities of daily living or some of them simply belief that ADLs are not going to affect their sleep patterns. That is why I am going to concentrate on promoting of regular exercise, but not within 4 hours of sleep, will educate to avoid tobacco, stimulants, caffeine, alcohol within 4-6 hours before bed. Due to slower metabolism and peristalsis older adults need to avoid heavy liquids and meals 2-3 hours before bed (Krishnan & Hawranik, 2008, p. 596)

3 Relaxation therapies. Relaxation techniques will promote muscle relaxation, will slow down processes in the central nervous system and will bring a lot of benefits to older adults suffering from sleep disturbances. Progressive muscle relaxation, meditation, abdominal breathing, imaginary training showed positive effects on sleep quality and scientifically proven techniques to improve sleep patterns among elderly as evidence by electromyography, electroencephalography. Those older adult who engaged in relaxation techniques activates before bed showed improved sleep, less episodes of awakening during the night. (Krishnan & Hawranik, 2008, p. 597).

4. Environment. Older adults should be adequately instructed to get sufficient mount of sun light during the day to facilitate sleep at night. To promote muscle relaxation and to decrease the pain, older adults might be instructed to take a warm bath at bedtime. Bed rooms must be a quiet place to decrease the distraction and promote sleep (Eliopoulos, 2014, p. 190).

5. Cognitive Behavioral Therapy. To provide a sense of control and self-efficacy over sleep geriatric nurse must discuss the dysfunctional beliefs and attitudes about sleep. The maladaptive beliefs should be replaced with more adaptive attitudes such as decatastrophizing, reappraisal, and attention shifting showed as a positive intervention for sleep patterns improvement (Krishnan & Hawranik, 2008, p. 596).

Complementary modalities interventions for sleep promotion.

1. Manipulative and body based practices: Acupuncture. One of the forms manipulative non-invasive technique practices that involves stimulation on meridian or acupoints. Researchers from National Institute of Health stated that by applying pressure to certain parts may improve blood circulation to vital organs such as brain. The muscle tension is significantly reduced by using acupuncture. Scientific studies demonstrated the older adults who had practicing acupuncture showed increased nocturnal plasma melatonin level (Gooneratne, 2009, p. 7).

2. Meditation. Stress reduction techniques could be one of the mechanisms by which meditation can bring beneficial effect on sleep and most of the studies that have demonstrated improvedsleep during meditation therapy have been conducted as stress reduction studies. Studies conducted by NIH demonstrated the individual practicing medication have improved sleep pattern, the overall level of stress hormone cortisol was significantly low. In addition to stress reduction, there mayalso be differences in slow-wave sleep as a result of meditation (Gooneratne, 2009, p. 8)

3. Tai Chi. Is a low- to moderate-intensity Chinese exercise that includes a meditational component. Based o n research data from National Center for Complementary and Alternative Medicine (NCCAM) a study of the effects of Tai Chi (consisting of three 60 minutes sessions for 24weeks) in 118 older adults in comparison to low-impact exercise noted that Tai Chi improved self-reported sleep duration by 48 min. Tai Chi exercise also increase muscle strength, flexibility, and overall balance of older adults (Gooneratne, 2009, p. 8).

4. Yoga. This techniques improve the quality of sleep by improving physical strength and flexibility, improves breathing, reduce stress, and enhance mental focus. Yoga is a multicomponent practice that consists of physical activity associated with specificpostures, breathing exercises, and a specific philosophical attitude towards life. It has beenshown to reduce anxiety levels and physiologic arousal. Many older adults experience sleep disturbances because of other medical condition, such as fibromyalgia, arthritis, and depression. Yoga shows positive effect on sleep duration and sleep quality (Gooneratne, 2009, p. 8).

5. Individualized Music Therapy. Older adults who received music therapy at bedtime each night, showed significant improvement in terms of sleep quality. Music therapy achieves its therapeutic effect by elevating pain threshold. With the appropriate music older adults showed increased tolerance to painful stimuli. As a result the older adults with chronic pain might show increased sleep.

Pharmacological options for sleep.

A. Herbal Therapy. Valeriana.The plant species Valeriana, in particular Valeriana officinalis and to a lesser extent Valerianaedulis, is the source of the ingredients in valerian. These ingredients can be divided into thefollowing categories: valepotriates, sesquiterpenes (volatile oil components which account forvalerian’s unpleasant odor), and amino acids (such as GABA and glutamine). Putative sitesof action of valerian include the GABA receptor 78, binding at A (1) adenosine receptor, as more recently noted, the 5-HT-5a receptor(Gooneratne, 2009, p. 5)

Since valerian may act on GABA receptors, valerianmay potentiate the sedative effects of other central nervous system depressants. Nurse must carefully assess if the older client currently taking any prescribed medications. The daytime “hangover” cognitive effects found. There is also a case report of valerian withdrawal symptoms which werecharacterized by delirium in a patient who had been using one-half to two grams per dose upto five times daily for several years.

B.Kava kava. The kava are believed to have anxiolytic, analgesic, muscle relaxing, and anticonvulsant effects, mediated by effects on the limbic system, the part of the brain linked to emotions. The mechanism of action of the pharmacological effects of kava is not fully understood. The nurse must be aware of its hepsatotoxic adverse effects. The individual who is taking anticonvulsants, anti-anxiety agents, and diuretics should ask the primary health care provider about safeness to combine the herbal supplement with the prescribed medication("US National Library of Medicine," 2014).

C. St. Johns WartExtracts of St. John’s wort contain many polyphenols, including flavonoids (rutin, hyperoside, isoquercetin, quercitrin, quercetin and others), phenolic acids, naphthodianthrones (hypericin, pseudohypericin, protohypericin and others), and phloroglucinols (hyperforin, adhyperforin). The active principle responsible for the antidepressant effects of St. John’s wort is not known, the most likely candidates being hypericin, pseudohypericin and hyperforin. In controlled trials, St. John’s wort has shown evidence of an antidepressant effect in patients with mild to moderate depression. Side effects can occur with St. John’s wort including gastrointestinal upset, dizziness, confusion, fatigue, anxiety and photosensitivity.("US National Library of Medicine," 2013).

Over the counter sleep aid

A. Melatonin. Melatonin is a hormone produced by pineal gland. One of the major roleis regulating sleep-wake cycle. Serum melatonin level is relatively low in comparison to its nocturnal levels. The cases of hepatotoxicity were published. Nurse must be aware of the fact that certain medications such as beta-blockers, calcium channels blockers will decrease the natural serum level of melatonin in blood. Researchers did not find any significant changes in FSH, LH and thyroid stimulating hormones.

B. Diphenhydramine. Antihistamine act as histamine-1 (H1) receptor antagonist. The most common adverse reaction is CNS depression, which can produce sedation. Sedation can range from mild drowsiness to deep sleep. Because of the drag wide availability the older adults must be watched for the signs and symptoms of acute poisoning, such as hallucinations, excitement ataxia. Older adults must be monitored for signs of urinary retention, dry mouth, and constipation.

C. L-Tryptophan. It is a basic amino acid used in the formation of messenger serotonin. L-tryptophan is a byproduct of tryptophan, which the body can change into serotonin. The individual taking L-Tryptophan should be closely monitored for dizziness, dry mouth, drowsiness, and mood swings, unusual and inappropriate sexual urges.

Prescription medications

A. Zolpidem (Ambien). Belongs to class ofnonbenzodiazepines-nonbarbiturates. Effect not fully understood but their produce similar effect as barbiturates. Possible adverse reactions are similar to barbiturate withdrawal; dependence, tolerance; gastric irritation, nauseam vomiting, respiratory depression. Geriatric clients must be instructed to get a lower dose. Client must be closely monitored for signs and symptoms of respiratory depression (Pharmocology for Nurses 2005, p. 392).

B.Temazepam (Restoril). Belongs togroup of benzodiazepines. Work by stimulation GABA receptors in the ascending reticular activating system of the brain. The reticular activating system is responsible for wakefulness and attention. Possible adverse reactions are ataxia, amnesia, dizziness, muscle weakness, daytime sedation, fatigue, respiratory depression. Geriatric client must be closely monitored for idiosyncratic reaction, such as nervousness, restlessness, talkativeness. These effects occur because benzodiazepines with long half-lives are likely to accumulate in a geriatric client. (Pharmocology for Nurses, 2005, p. 290)

C. Triazolam (Halcion) Belongs to Benzodiazepines group. Work by stimulation of GABA receptors in the ascending reticular activating system of the brain. Possible adverse reactions are: amnesia, dry mouth, nausea, vomiting, rebound insomnia older clients must be monitored for hallucinations or violent behavior. Respiratory status must assess carefully.

References

(2005). Pharmacology A 2-in-1 Reference for Nurses. PA: Lippincott Williams& Wilkins.

Colten, H. R., & Altevogt, B. M. (2007). Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Institute of Medicine. The National Academies, 1-425.

Costa, I., Carvalho, H., & Fernandes, L. (2013). Aging, circadian rhythms and depressive disorders review. American Journal of Neurodegenerative Disease, 2 (4), 228-246.

Eliopoulos, C. (2014). Age-related changes in sleep. In Gerontological Nursing (8th ed., pp. 186-193-193). Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins.

Gooneratne, N. (2009). Complementary and Alternative Medicine for Sleep Disturbances in Older Adults. National Institute of Health, 24 (1)(), 1-19.

KAVA KAVA (PIPER METHYSTICUM). (2014). Retrieved from

Krishnan, P., & Hawranik, P. (2008). Diagnosis and management of geriatric insomnia: A guide for nurse practitioners. Journal of the American Academy of Nurse Practitioners, 20, 590-599.