Page Submenu

add to knowledge bank

print

email to a friend

SLEEP

The information in this "Want to know more" section is organized according to the following major components of the NURSING PROCESS:

• Goal
• Background
• Definitions
• Assessment/Screening Tools
• Nursing Care Strategies
• Evaluation/Expected Outcomes
• Follow-up monitoring

Goal

Optimal state of alertness while awake with optimal quality and quantity of sleep during the patient's preferred sleep interval.

Back to top

Background

Etiology and Epidemiology

• Excessive sleepiness may be due to difficulty initiating sleep, impaired sleep maintenance, or by waking after sleep onset and not being able to return to sleep, as well as sleep fragmentation.
• There are many types of sleep disorders associated with mental, neurologic or other medical disorders. Excessive sleepiness is primarily a function of both quality and quantity of sleep and has been documented in 20% of elders (n = 4578 over age 65) in the Cardiovascular Health Study (Whitney et al., 1998).
• Daytime sleepiness is the only sleep symptom associated with mortality, incident cardiovascular disease morbidity and mortality, myocardial infarction and congestive heart failure, particularly among women (Newman et al., 2000a).
• According to the most recent "Sleep in America" Poll drawn from a home telephone survey (National Sleep Foundation, 2002), 27% of older Americans categorize their sleep as fair or poor.
• Patients in acute care settings are more likely to have problems with excessive sleepiness and sleep disorders. For example, Ancoli-Israel and colleagues (1987, 1991) found undiagnosed obstructive sleep apnea (OSA) in 24% of independent living elders (over age 65), 33% of elders in acute care settings and 42% of elders in nursing home settings.

Back to top

Definitions

Excessive Sleepiness (Somnolence, Hypersomnia, Excessive Daytime Sleepiness) "A subjective report of difficulty in maintaining the alert awake state, usually accompanied by a rapid entrance into sleep when the person is sedentary" (American Academy of Sleep Medicine, 2001).

Excessive Daytime Sleepiness: Sleepiness that interferes with normal daily activities. A change from baseline (ask patient, family, or caregiver).

Insomnia: difficulty with falling asleep. Normal sleep latency is about 10 minutes.

Sleep apnea: cessation of respiration during sleep due to (1) airway obstruction caused by collapse of upper airway structures and/or (2) neurological dysfunction.

Restless leg syndrome: a condition where patients report uncomfortable crawly sensations in their legs when at rest that is often associated with motor hyperactivity and only relieved with activity. These patients find relief in getting up and walking around frequently at night.

Sleep changes with age: an increase in number of awakenings and arousals, decreased REM sleep, increased number of shifts in sleep stages, reduced sleep efficiency (percentage of time asleep compared to time spent in bed), and a tendency to go to bed earlier and awaken earlier.

Atypical Presentation
Daytime sleepiness is not normal-always assess for underlying causes. Restless leg syndrome may present with the patient observed walking in place next to the bed or wanting to climb out of bed or with leg thrashing at night. For many patients, the discomfort is only relieved by walking.

Back to top

Assessment/Screening Tools

Epworth Sleepiness Scale: http://www.umm.edu/sleep/epworth_sleep.html

Try this: The Epworth Sleepiness Scale (ESS) http://www.hartfordign.org/publications/trythis/issue06.pdf

Sleep History
Screening questions for patient or family members

• Usual bedtime and time of awakening
• Napping (when and where)
• Difficulty falling asleep
• Difficulty staying asleep or frequent awakenings
• Difficulty returning to sleep after waking during the night
• Waking too early
• Witnessed apneas
• Sleep walking or night time wandering, falling at night (when and where)
• Snoring
• Nocturia
• Obesity (BMI>30, neck size > 17/16)
• Uncomfortable sensations in the legs or frequent kicking during sleep
• Cognitive dysfunction
• Depression
• Recent history of car crashes or accidents due to sleepiness
• Current diagnosis of sleep disorder or Sleep Apnea and use of CPAP

Parameters of Assessment

• A careful history should be taken that includes both the patient and family members. People who share living and sleeping spaces can provide important information about sleep behavior that the patient may not be able to convey.
• Several strategies have been developed to take a sleep history and are outcomes of the Academic Sleep Awards program sponsored by the NHLBI. Two formats are included in table format to outline key points in obtaining key information from older patients and their family members (See Tables).
• For patients with a current diagnosis of a sleep disorder, documentation and continuation of ongoing treatments, such as CPAP, should be maintained and reinforced by patient and family education.

Excessive Sleepiness: Nursing Assessment and Interventions
Presenting Complaint Difficulty in:	Common Causes	Nursing Interventions
Going to sleep and returning to sleep after being awakened.	Insomnia Depression Psychological distress can interfere with sleep onset. Conversely, sleep deprivation can lead to depression and can also trigger exacerbation of other conditions (bipolar illness).	Primary prevention and treatment with morning bright light exposure and sleep hygiene techniques such as avoiding: caffeine, daytime napping, and exercise prior to bedtime; consistency in sleep schedule; and managing environmental factors in patient care setting: noise (quiet); temperature (cool); motion/vibration (avoid); light (complete darkness); and comfort/bedding (patient preference). When other measures have not been effective for insomnia provide appropriate medications short term only (<2 weeks). See Medication Topic. Screen for depression Evaluate for sleep deprivation as a source of recent onset insomnia and early awakenings.
Staying asleep.	Sleep apnea (by medical diagnosis or by nursing observation).	Obtain baseline sleep information from patient and family, past medical history of sleep apnea or witnessed apneas, gasping, choking during sleep along with O2 desaturations. If apneas are witnessed during care of patient with no current diagnosis of sleep apnea, recommend consultation with sleep specialist for sleep study. Most common treatment: continuous positive airway pressure (CPAP). Other treatments: weight loss or surgical techniques to reduce tonsils and/or soft palate. Avoid sedating medications or provide CPAP anytime the patient is sleeping while on sedating medications. Always be sure patients who use CPAP at home bring/use it every night at the hospital. Sleep apnea patients will require extra airway support during anesthesia and recovery.
Staying asleep.	Restless leg syndrome May be caused by iron deficiency anemia, floate/B12 deficiency, diabetes, hypothyroidism, medications (tricyclics, SSRIs, caffeine) and chronic renal failure. Diagnosed based on symptom report, does not require a specialist referral or a sleep study.	Evaluate labs: Ferritin, TIBC, folate, B12, fasting blood sugar, TSH, BUN, creatinine, Ca, Mg. Initiate pharmacologic treatment as appropriate. Consider discontinuing potential causative medications: tricyclics, SSRI's. Avoidance of caffeinated beverages. Validate and support recognition of condition and encourage daytime exercise. Evaluate and modify the environmental factors in patient care settings (noise, temperature, motion/movement, light, comfort/bedding).
Awakening too early	Aging changes Depression Early awakening is sign of depression. Sleep deprivation can lead to depression and can also trigger exacerbation of other conditions (bipolar illness).	Reinforce Sleep Hygiene practices. Avoid daytime naps. Maintain a regular sleep schedule. Aggressively screen and treat reversible conditions: hypothyroidism; iron or folate deficiency; poor sleep hygiene, environmental factors. Elders should be screened for depression Consider sleep deprivation as a source of recent onset insomnia and early awakenings.

Back to top

Nursing Care Strategies

• Management of medical conditions, psychological disorders and/or symptoms that interfere with sleep such as: depression, pain, hot flashes, anemia, or uremia.
• Review and/or adjust medications that have interactions and/or side effects that include drowsiness or sleep impairment.
• Instruction in and/or nursing delivery of Sleep Hygiene Measures.
• Medical referral to a sleep specialist for moderate and severe conditions of ES and/or a clinical profile consistent with major sleep disorders, such as obstructive sleep apnea (OSA) and restless legs syndrome (RLS).
• Aggressive planning, monitoring and management of sleep disordered breathing with anesthesia or when sedative medications may be used, especially when positive airway pressure devices are used at home.
• Ongoing assessment of adherence to prescriptions for sleep hygiene, medications and/or use of devices to support respiration during sleep.
• Instruction in and/or reinforcement of use, cleaning and maintenance of positive airway pressure equipment and masks.
• When other measures have not been effective for insomnia provide appropriate medications short term only (<2 weeks). See Medication Topic.

Back to top

Evaluation/Expected Outcomes

• Improved quantity and/or quality of sleep during normal sleep intervals.
• Reduction in ES and any sequelae.
• Improved cognitive functioning and functional status as well as improved social and occupational performance.

Back to top

Follow-up monitoring

Depending upon diagnosis, follow-up may include long-term reinforcement of the original interventions along with supporting the patient to adhere to prescriptions from the sleep specialist.

• Rebound sleepiness may also occur during the initial treatment phase. This occurs because of sleep deprivation and should subside over time. Follow-up should also include ongoing assessment of napping and sleepiness.
• If obesity has been a complicating health factor weight reduction may also be a desirable patient goal in the long term. With reduction in daytime sleepiness, the timing is ripe for increasing activity level. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include regular exercise, which is consistent with cardiovascular rehabilitation and long-term diabetic control.
• Sleep hygiene measures continually reassessed.

Reprinted with permission from Springer Publishing Company. Umlauf, M. G., Chasesn, E. R., & Weaver, T. E. (2003). Excessive Sleepiness. In M. Mezey, T. Fulmer, I. Abraham (Eds.), D. Zwicker (Managing Ed.), Geriatric nursing protocols for best practice (2nd ed., pp. 47-65). New York: Springer Publishing Company, Inc.

Sleep Hygiene Measures

Use the bed only for sleeping (or sex). Develop consistent and rest-promoting bedtime routines. Maintain the same bedtime and waking time every day. Exposure to bright sunlight is desirable upon awakening, but should be avoided just prior to bedtime. Upon awakening, get up out of the bed slowly, no matter what time it is. If awakening during the night, avoid looking at the clock; frequent time checks will heighten anxiety and make sleep onset more difficult (turn the clock around!). Avoid naps entirely or limit naps to 10 - 15 minutes duration. Sleep in a cool and quiet environment. Patients who cannot sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until they are sleepy again. (Don't watch television, which emits too bright a light.) Sleeping alone is more restful than sleeping with another person or pets. If pets or bed partners add to the problem, moving to the couch for a couple of nights might be useful or restricting pets from sharing the bed may be necessary. Prior to bedtime avoid the following: caffeine and nicotine after 12 noon; alcohol intake (> 3 drinks); large meals or exercise 3-4 hours before bedtime; emotional upset or emotionally charged activities.

(Mezey et al, 2003). Reprinted with permission from Springer Publishing Company 2004.

References

Johns, M.W. (1992). Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep, 15, 376-381.

American Academy of Sleep Medicine. (2001) International classification of sleep disorders, revised: diagnostic and coding manual. Rochester, Minnesota: American Academy of Sleep Medicine.

Ancoli-Israel, S., Kripke, D. F., & Mason, W. (1987). Characteristics of obstructive and central sleep apnea in the elderly: an interim report. Biological Psychiatry, 22, 741-750.

National Sleep Foundation. (2002) Sleep in America Poll. Accessed at http://www.sleepfoundation.org/2002poll.html.

Newman, A. B., Nieto, F. J., Guidry, U., Lind, B. K., Redine, S., Pickering, T. G., et al. (2000). Relation of sleep-disordered breathing to cardiovascular disease risk factors: The Cardiovascular Health Study Research Group. Journal of the American Geriatric Society, 8, 115-23.

Whitney, C. W., Enright, P. L., Newman, A. B., Bonekat, W., Foley, D. & Quan, S.F. (1998). Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study. Sleep, 21, 27-36.

Last updated - February 2005

Back to top