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Purpose of sleep and rest
- Sleep and rest help the body to"
- - conserve energy
- - prevent fatigue
- - provide organ respite
- - relieve tension
- sleep is a basic need, rest occurs with sleep
- - spend 1/3 lives sleeping
- - sleep deprivation /fragmented sleep is associated with risk to physical and emotional health
- healthy people 2020: sleep health goals
- as u age the needs for sleep does not reduce. u still need that deep sleep
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Biorhythm and sleep
- Circadian sleep-wake rhythm
- - circadian endogenous response (body temp, pulse, BP, hormonal levels awake for 16, sleep 8)
- - sleep architecture= stages
- * stage 1: lightest level, easy to awaken
- * stage 2: deeper stage of relaxation
- * stage 3: early phase of deep sleep
- * stage 4: deep sleep and relaxation
- * REM sleep- once every 90 mins of stage 4
- - 85% of dreaming occur
- the sleep cycle is repeated several times during the night
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Sleep and aging BOX 11-2
- Changes begin between 20-30yrs
- - less time in spent in stage 3+4
- 40-60 even less time is spent in 3/4 and more time is in stage 1+2 or awake
- - more sensitive to noise, light and room temp- easily awaken (keep it quiet and dark)
- - more difficult to fall asleep
- Circadian rhythm changes:
- - less responsive to external stimuli such as light- sleep times become altered- early bed early to rise
- increase in sleep fragmentation (waking in the middle of the night)
- REM sleep shorter, less intense more evenly disturbed
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Other considerations
- time spent in REM declines w/age- may not feel rested upon awakening
- day time naps may be needed to compensate
- ? frustration if elders are unable to stay awake during times when other family members are or wide awake when everyone is sleeping
- consider increasing natural light to push circardian rhythm back
- consider noise, lighting and room temp with elders in facilities
- sleep complaints are linked to other health problems or disorder
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Sleep disorders
- insomonia
- sleep apnea
- restless leg syndrome
- REM sleep behavior
- circadian rhythm sleep disorder
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Sleep problems in older adults: contributing
- age related changes in sleep architechure
- co-mobidities: CV, DM, pulmonary disease, MS disorders, CNS disorders (parkinson seizure, dementia), GI GERD hernia GU
- depression anxiety delirium, psychosis
- pain
- polypharmacy
- life stressors
- limited exposure to sun light
- environmental noises
- poor sleep hygiene
- lack of excerise
- excessive napping
- caregiver for a dependent elder
- sleep apnea
- restless leg syndrome
- periodic leg movement
- REM behavior disorder
- alcohol, smoking
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Insomnia
- disturbed sleep in presence of adequate opportunity and circumstance for sleep
- Dx: difficulty falling asleep at least one month
- w/resulting impaired daytime functioning
- May be:
- - primary insomnia (no other causes of sleep disturbance)
- - co morbid insomnia- more common
- nurse- schedule, relaxation technique (mediation), caffiene, eating before bed, foods that incre your dopamine/serotonin levels like protein/carbs crackers/milk, use bed for sleep only, no alcohol)
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Sleep Apnea
- 5 episode of no breathing for at least 10sec per hour of sleep with daytime sleepiness
- 3 types:
- - obstructive airway
- - central sleep apnea- the brain fails to signal the muscles to breath or cardiac dysfunction this is dangerous- u can see organ damage.
- - mixed
- Apnea: hypoxemia and hypercapnea- changes in ANS activity, incr systemic and pulmonary arterial pressure and changes in cerebral blood flow- fragmented sleep and excessive daytime sleepiness
- avoid sleeping on your back
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Effects of sleep apnea
- Affects 20% adult LTC 70-80%
- elders: significant cognitive decline
- - poor memory, irriablity, personality changes, difficulty concentrating
- Untreated sleep apnea can cause hypertension, stroke or heart failure
- excessive daytime sleepiness leads to increase accidents
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risk factors for sleep apnea
- increasing age
- increased neck circumference
- male
- anatomical abnormalities of the upper airway
- upper airway resistance/obstruction
- family hx
- excess weight
- use of alcohol, sedatives, tranquilizers
- smoking
- hypertension
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Dx and Tx of sleep apnea
- Sleep study (PMS) polysomnogram
- treatment depends on severity, type of apnea
- comorbid disorders
- - weight loss
- - avoid alcohol & sedative
- - smoking cessation
- - avoid alcohol & sedatives
- - smoking cessation
- - avoid supine sleeping
- - wearing CPAP (continous positive airway pressure device) allows to breath without obstruction
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Restless Leg Syndrome
- sensormotor neurological disorder
- - unpleasant leg sensations: paresthesia, creeping sensations, cramping burning pain, indescribable sensations
- May be:
- - primary (idiopathic)- affects younger aged
- - Secondary results from, iron deficiency, end stage renal disease, pregnancy, dopamine dysregulation
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Considerations
- prevalence: 10-20% more in women
- contributing factors:
- - BMI, caffeine and tobacco use, sedentary lifestyle
- Antidepressants and neuroleptic medication may aggravate RLS (avoid)
- Treatments include:
- - FE supplements, gabapentin (treat)
- - stretch, physical activity
- - hot baths, relaxation
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Implication for gerontological nursing
- Assessment includes sleep history:
- review sleep patterns
- - time spent in sleep and naps, quality of sleep
- - bed time routines
- Presence of sleep disturbances? length present?
- contributing factors to poor sleep?
- - pain, chronic illness
- - medication, alcohol use
- - depression, anxiety
- suggestion
- - be more active during the day
- - less time taking naps
- - good sleep hygiene- relaxation, avoiding screen time
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other pt consideration
- Nurses need to be aware of pt's
- - time he/she retires to bed time awakes
- - types of daily excerise sleep log
- - sleeping position
- - room environment- temp, lighting, noise
- - medications/management if any?
- management directed at identifiable causes
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Non pharmacological intervention
- stress management
- do not disturb periods
- usual bedtime routines
- use of white noise (background noise)
- **encourage patterns of equalizing activity and rest periods throughout the day
- exposure to sunlight
- pain management- heat/cold therapy. guided therapy
- good sleep hygiene box 11-6
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Pharmacological treatment
- benzo receptor agonist (drug of choice)
- - zolpidem (ambien), eszopiclone (zunesta) and zaleplon (sonata)
- --- full night sleep, no alcohol, no driving, avoid antichol or antihistamine, empty bladder before bed)
- - shorter half lives more favorable for older adults
- - rapid action take right before bed
- - ramelteon: melatonin receptor against DFA
- medications should be used short term
- avoid sedative, hypnotics (benzo and barbituriates)
- OTC:
- - avoid benadryl or tylenol PM- antihistamine and antichol side effects
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Activity
- improves health outcomes/emotional health, functional status and quality
- decrease chronic illness and functional limitations
- lack of physical activity leads to frail health and loss of function
- only 1/3 men, 25% 65-74yo engage in leisure time activity/strengthing activities
- - less participation with advancing age
- less likely to receive exerise counseling
- improves cognitive functioning
- health people 2020
- - increase participation in aerobic physical activity
- - decre # of adults who do not engage in physical activity
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Assessment
- functional abilities
- screenings:
- - to identify medical problems and maximize benefit
- - to identify functional limitations
- - minimize injury/others adverse effect
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Guidelines for physical activity
- all adults should:
- - 30 mins/24 hr of moderate intensity aerobic activity
- - even if 10 mins at a time
- Adults > 65 yo
- - 2 1/2 hours/week of moderate intensity aerobic activity
- - brisk walk, swim, bicycling
- and muscle stregthening at least 2x a weel
- - t'ai chi excerises- improves flexibility and balance
- - wii games, home programs
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Other consideration
- Physical activity can be adapted to all adults even those in wheelchair
- muscle weakness and atrophy primary concern
- exercise prescription
- - focus on endurance, strength, balance, flexibility
- - varied activities involving interaction with peers, fit person's lifestyle & culture
- - inform of community resources: YMCA COA
- benefits are immediate
- evidence- based interventions focus on adequate rest, activity and sleep
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