Running head: CASE STUDY SLEEP DISTURBANCES IN OLDER ADULTS
Case Study Sleep Disturbances in Older Adults
Sergey Makov
New York City College of Technology
Geriatric Nursing
NUR 4090
Prof. Lynda M. Konecny
March 25, 2014
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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 agerelated 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:
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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
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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.
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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 46 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
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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
improved sleep 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 may also 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
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Medicine (NCCAM) a study of the effects of Tai Chi (consisting of three 60 minutes sessions for
24 weeks) 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 specific postures,
breathing exercises, and a specific philosophical attitude towards life. It has been shown 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 Valeriana edulis, is the source of the ingredients in valerian.
These ingredients can be divided into the following categories: valepotriates, sesquiterpenes
(volatile oil components which account for valerian’s unpleasant odor), and amino acids (such as
GABA and glutamine). Putative sites of action of valerian include the GABA receptor 78,
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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, valerian may 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 were characterized by delirium in a
patient who had been using one-half to two grams per dose up to 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 Wart Extracts 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
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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 role is
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
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A. Zolpidem (Ambien). Belongs to class of nonbenzodiazepines-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 to group 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.
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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.
http://dx.doi.org/http://www.ncbi.nlm.nih.gov/books/NBK19960/pdf/TOC.pdf
Costa, I., Carvalho, H., & Fernandes, L. (2013). Aging, circadian rhythms and depressive
disorders review. American Journal of Neurodegenerative Disease, 2 (4), 228-246.
http://dx.doi.org/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852564/pdf/ajnd00020228.pdf
Eliopoulos, C. (2014). Age-related changes in sleep. In Gerontological Nursing (8th ed., pp. 186193-193). 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.
http://dx.doi.org/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276624/pdf/nihms3670
1.pdf
KAVA KAVA (PIPER METHYSTICUM). (2014). Retrieved from
http://livertox.nlm.nih.gov/KavaKava.htm
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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. http://dx.doi.org/10.1111/j.1745-7599.2008.00366.x