Elsevier

Geriatric Nursing

Volume 30, Issue 1, January–February 2009, Pages 53-60
Geriatric Nursing

Assisted Living Column
Sleepiness or Excessive Daytime Somnolence

https://doi.org/10.1016/j.gerinurse.2008.11.004Get rights and content

Excessive daytime somnolence (EDS) is associated with age-related changes, environment, circadian rhythm or sleep pattern disorder, insomnia, medications, lifestyle factors, depression, pain, and illness. The notion of “sleep architecture” connotes a structure that describes the sleep cycle (i.e., stages) and wakefulness during a single sleep period—that is, rapid eye movement (REM) and non-REM sleep. Circadian rhythms perform a variety of functions including regulation of the quality and distribution of the stages of sleep. Insomnia includes delayed sleep onset as well as premature wakening; sleep is nonrestorative. Comorbidities associated with insomnia are Alzheimer's disease and other dementias, delirium, depression, congestive heart failure, chronic obstructive pulmonary disease, gastroesophageal reflux disease, pain, degenerative diseases of the neurological system, and sleep apnea. Continuous inadequate sleep affects cognitive function, physical performance, overall well-being, and quality of life. There is a greater risk of falls from insomnia than is the use of hypnotics to manage it. Sleep disruption among older adults is underrecognized and undertreated. Assessment using valid tools can be performed rapidly. There are a variety of treatment options, including sleep hygiene and pharmacological and alternative modalities.

Section snippets

Background

EDS is associated with age-related changes, environment, circadian rhythm or sleep pattern disorder, insomnia, medications, lifestyle factors, psychological disorders, and medical illness. Yet many older adults as well as health care professionals regard “daytime sleepiness” as a normal companion of aging about which nothing can be done.1 This misperception prevents appropriate evaluation and treatment—many of which are quite effective.

At least 20% of all adults in the United States have sleep

Sleep Terminology

The terms defined in Table 1 can be useful in constructing a sleep profile even before specific measurements are taken and interviews conducted.

Sleep Architecture

“Sleep architecture” connotes a structure used to describe the sleep cycle (i.e., stages) and wakefulness during a single sleep period—that is, rapid eye movement (REM) and non-REM sleep (discussed later). Circadian rhythms (also known as biorhythms) perform a variety of functions: regulation of body temperature, metabolism, digestive processes, hormone secretion, and the quality and distribution of the stages of sleep. A circadian rhythm has an approximate daily periodicity but tends to be a

Sleep Stages

REM differentiates between the 2 stages of sleep: REM and non-REM (NREM). Research indicates that NREM is associated with the integrity and health of the immune and digestive systems. It consists of 4 stages:

  • Stage 1: “light sleep”; usually lasts about 5 to 10 minutes and occurs between being asleep and awake. Breathing is slow and regular, heart rate is slightly decreased, and eyes roll slowly back and forth. In young adults, this stage constitutes under 5% of total sleep time.

  • Stage 2: “true

Insomnia

The definition of insomnia includes delayed sleep onset as well as premature wakening or getting up so early that sleep is nonrestorative.1 Causes can be medical, functional, emotional, neurological, pharmacological, environmental, and psychosocial. Comorbidities in elder adults associated with insomnia are Alzheimer's disease and other dementias, delirium, depression, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), pain,

Sleep Hygiene Measures

In collaboration with the resident, sleep hygiene measures not only can restore effective sleep but can (re)establish health promoting/maintaining lifestyle practices.1, 7 The assisted living nurse is counselor and clinician for the older adult in advising and monitoring appropriate sleep (and lifestyle) measures. Several cognitive-behavioral theories can frame the approach taken with the resident: self-efficacy theory, motivation theory, the health belief model. Although sleep hygiene measures

Pharmacologic Treatment

As noted earlier, there is a greater risk of falls from untreated insomnia than from appropriate use of hypnotic medications. Dietary supplements and herbals (e.g., melatonin, valerian) are ineffective for treatment of insomnia, as far as the empiric data indicates.2 Pharmacologic treatment seeks to remove or treat the causes of EDS, particularly with regard to the progression of insomnia from an acute or transient status to chronic status. The medication selected varies with the goal of

Complementary and Alternative Medicine (CAM)

Slightly more than 40% of Americans use some type of CAM, but almost 90% of older adults do so, many of whom do not tell their primary care provider (i.e., physician, nurse practitioner). Defined as the use of products and practices that are not part of Western (allopathic) medicine, CAM is purportedly used for many chronic illnesses and conditions, many of which can cause sleep disturbances: cardiac disease, diabetes mellitus, arthritis, and back pain.4 The CAMs of choice for these conditions

Challenges in Assisted Living

The philosophy of assisted living is that of resident autonomy/self-determination and choice: residents are encouraged to set their own routine. In general, evening or night staffing in assisted living residences (ALRs) is less than 50% of daytime staffing. Residents who choose to retire at “unusual” times of day pose challenges to the regulatory requirements that ALRs monitor and supervise the residents. Most ALRs do not offer planned or social activities after 8 p.m.

Resident and family

Acknowledgement

The authors wish to thank Dr. Carolyn Auerhahn, EdD, APRN, FAANP, Clinical Associate Professor and Coordinator, Geriatric and Adult/Geriatric Nurse Practitioner Programs, College of Nursing, New York University for her thoughtful reading of this article.

ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, John A. Hartford Institute for Geriatric Nursing, New York University, New York, NY.

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ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, John A. Hartford Institute for Geriatric Nursing, New York University, New York, NY.

SANDI FLORES, RN, C, is executive director of the American Assisted Living Nurses Association and Education Director of Community Education, LLC (www.communityed.com), San Marcos, CA.

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