Excessive Sleepiness
Protocol 5.1: Excessive Sleepiness (cont.)
F. Referral to a sleep specialist for moderate or severe sleepiness or a clinical pro- file consistent with major sleep disorders such as OSA or restless leg syndrome (Avidan, 2005).
G. Aggressive planning, monitoring, and management of patients with OSA when sedative medications or anesthesia are given (Avidan, 2005).
H. Ongoing assessment of adherence to prescriptions for sleep hygiene, medica- tions, and devices to support respiration during sleep (Avidan, 2005).
VI. EVALUATION AND ExPECTED OUTCOMES A. Quality Assurance Actions
1. Provide staff education on the major causes of excessive sleepiness (i.e., OSA, insomnia, restless leg syndrome).
2. Provide staff with in-services on how to use and monitor CPAP equipment.
3. Have individual nursing units conduct environmental surveys regarding noise level during the night hours and then develop strategies to reduce sleep disruption caused by noise and care patterns.
4. Add sleep as a parameter of the admission assessment for patients and pro- vide written instructions for patients using CPAP at home to always bring the equipment with them to the hospital.
Include sleep quality (e.g., see PSQI tool; http://www.hartfordign.org).
5. Utilize posthospital surveys of patient satisfaction with their sleep while in the hospital and provide feedback for nursing staff (see http://www.hartfor- dign.org, Sleep topic).
B. Quality Outcomes
Improved quality and/or quantity of sleep during normal sleep intervals as reported by patients and staffs.
VII. FOLLOW-UP MONITORING
A. Depending on the diagnosis, follow-up may include long-term reinforcement of the original interventions along with support for adhering to treatments prescribed by a sleep specialist. For example, patient compliance with CPAP therapy for OSA is critical to its efficacy and should be assessed during the first week of treatment (Weaver et al., 1997a). All patients benefit from positive reinforcement while trying to acclimate to nightly use of a positive airway pres- sure device.
B. CPAP masks may require minor adjustments or refitting to find the most com- fortable fit. Most such changes are needed during the acclimation period, but patients should be encouraged to seek assistance if mask problems develop (Weaver et al., 1997a). In the acute care setting, respiratory care technicians are valuable in-house resources when staff from a sleep center are not readily available.
C. During the initial treatment phase of insomnia, sleep deprivation may cause rebound sleepiness, which should subside over time. Follow-up should include ongoing assessment of napping habits and sleepiness to track treatment effec- tiveness (Avidan, 2005).
(continued)
Protocol 5.1: Excessive Sleepiness (cont.)
ResOURces
American Academy of Sleep Medicine (AASM)
This organization for sleep professionals is also a great source of information for the public and for practice guidelines for professionals.
http://www.aasmnet.org/
Basics of Sleep Guide
This Sleep Research Society publication is designed for students, sleep researchers, and nonsleep professionals interested in studying sleep across the life cycle, sleep deprivation or restriction, and sleep physiology. Information about this publication and how to order it can be found on the Sleep Research Society website.
http://www.sleepresearchsociety.org/Products.aspx
National Institutes of Health, National Center on Sleep Disorders Research
This site includes brochures that may be downloaded or printed for distribution to patients or for the education of other health care providers.
For patients and the general public: http://www.nhlbi.nih.gov/health/public/sleep/index.htm For health care professionals: http://www.nhlbi.nih.gov/health/prof/sleep/index.htm
New Abstracts and Papers in Sleep
This free online subscription service is an excellent resource for professionals to find the most recent research on sleep disorders and their treatments on a regular basis. Services include weekly personalized e-mail alerts of new citations, author abstracts, a compilation of the current week’s literature in sleep, and an archive of the current year’s literature in sleep.
http://www.websciences.org/bibliosleep/naps/
Restless Leg Syndrome Foundation
This organization is dedicated to improving the lives of the men, women, and children who live with this often devastating disease. The organization’s goals are to increase awareness of RLS, to improve treatments, and, through research, to find a cure.
http://www.rls.org Sleep Research Society
This professional organization fosters scientific investigation, professional education, and career development in sleep research and academic sleep medicine. It is an excellent resource for nurses who are interested in studying issues of sleep and circadian processes.
http://www.sleepresearchsociety.org/
D. If obesity has been a complicating health factor, weight loss is a desirable long- term goal. With reduction in daytime sleepiness, the timing is ripe for increas- ing the activity level. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include regular exercise, which is also consis- tent with cardiovascular health and long-term diabetes control (Ancoli-Israel &
Ayalon, 2006).
Protocol 5.1: Excessive Sleepiness (cont.)
RefeRences
American Academy of Sleep Medicine. (2005). International classification of sleep disorders: Diagnostic and Coding Manual (2nd ed.). Westchester, MN: Author.
Ancoli-Israel, S. (2000). Insomnia in the elderly: A review for the primary care practitioner. Sleep, 23(Suppl. 1), S23–S30; discussion S36–S38. Evidence Level I.
Ancoli-Israel, S. (2005). Sleep and aging: Prevalence of disturbed sleep and treatment considerations in older adults. The Journal of Clinical Psychiatry, 66(Suppl. 9), 24–30; quiz 42–43. Evidence Level I.
Ancoli-Israel, S., & Ayalon, L. (2006). Diagnosis and treatment of sleep disorders in older adults. The American Journal of Geriatric Psychiatry, 14(2), 95–103. Evidence Level I.
Ancoli-Israel, S., Kripke, D. F., Klauber, M. R., Mason, W. J., Fell, R., & Kaplan, O. (1991). Sleep- disordered breathing in community-dwelling elderly. Sleep, 14(6), 486–495. Evidence Level IV.
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(6), 741–750. Evidence Level IV.
Ancoli-Israel, S., & Martin, J. L. (2006). Insomnia and daytime napping in older adults. Journal of Clinical Sleep Medicine, 2(3), 333–342. Evidence Level VI.
Avidan, A. Y. (2005). Sleep in the geriatric patient population. Seminars in Neurology, 25(1), 52–63.
Evidence Level I.
Bliwise, D. L., King, A. C., & Harris, R. B. (1994). Habitual sleep durations and health in a 50–65 year old population. Journal of Clinical Epidemiology, 47(1), 35–41.
Bloom, H. G., Ahmed, I., Alessi, C. A., Ancoli-Israel, S., Buysse, D. J., Kryger, M. H., . . . Zee, P. C.
(2009). Evidence-based recommendations for the assessment and management of sleep disorders in older persons. Journal of the American Geriatrics Society, 57(5), 761–789. Evidence Level I.
Brassington, G. S., King, A. C., & Bliwise, D. L. (2000). Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64–99 years. Journal of the American Geriatrics Society, 48(10), 1234–1240. Evidence Level III.
Buysse, D. J. (2004). Insomnia, depression and aging. Assessing sleep and mood interactions in older adults. Geriatrics, 59(2), 47–51. Evidence Level VI.
Buysse, D. J., Reynolds, C. F., III, Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pitts- burgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213.
Centers for Disease Control and Prevention. (2011a). Effect of short sleep duration on daily activi- ties—United States, 2005–2008. Morbidity and Mortality Weekly Report, 60(8), 239–242. Evi- dence Level IV.
Centers for Disease Control and Prevention (2011b). Unhealthy sleep-related behaviors—12 States, 2009. Morbidity and Mortality Weekly Report, 60(8), 233–238. Evidence Level IV.
Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., . . . Shapiro, C. M.
(2008). STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiol- ogy, 108(5), 812–821.
Cohen-Zion, M., Stepnowsky, C., Marler, Shochat, T., Kripke, D. F., & Ancoli-Israel, S. (2001).
Changes in cognitive function associated with sleep disordered breathing in older people. Jour- nal of the American Geriatrics Society, 49(12), 1622–1627. Evidence Level III.
Colten, H. R., & Altevogt, B. M. (Eds.). (2006). Sleep disorders and sleep deprivation: An unmet public health problem. Washington, DC: The National Academies Press. Evidence Level I.
Gamaldo, C. E., & Earley, C. J. (2006). Restless legs syndrome: A clinical update. Chest, 130(5), 1596–1604. Evidence Level I.
Johns, M. W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale.
Sleep, 14(6), 540–545.
Maislin, G., Pack, A. I., Kribbs, N. B., Smith, P. L., Schwartz, A. R., Kline, L. R., . . . Dinges, D. F.
(1995). A survey screen for prediction of apnea. Sleep, 18(3), 158–166.
Morgenthaler, T. I., Kapen, S., Lee-Chiong, T., Alessi, C., Boehlecke, B., Brown, T., . . . Swick, T.
(2006). Practice parameters for the medical therapy of obstructive sleep apnea. Sleep, 29(8), 1031–1035. Evidence Level I.
Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999).
Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep, 22(8), 1134–1156. Evidence Level I.
Netzer, N. C., Stoohs, R. A., Netzer, C. M., Clark, K., & Strohl, K. P. (1999). Using the Berlin Ques- tionnaire to identify patients at risk for the sleep apnea syndrome. Annals of Internal Medicine, 131(7), 485–491.
Newman, A. B., Spiekerman, C. F., Enright, P., Lefkowitz, D., Manolio, T., Reynolds, C. F., & Rob- bins, J. (2000). Daytime sleepiness predicts mortality and cardiovascular disease in older adults.
The Cardiovascular Health Study Research Group. Journal of the American Geriatrics Society, 48(2), 115–123. Evidence Level III.
Ohayon, M. M., & Vecchierini, M. F. (2002). Daytime sleepiness and cognitive impairment in the elderly population. Archives of Internal Medicine, 162(2), 201–208. Evidence Level IV.
Redeker, N. S. (2000). Sleep in acute care settings: An integrative review. Journal of Nursing Scholar- ship, 32(1), 31–38. Evidence Level I.
Rediehs, M. H., Reis, J. S., & Creason, N. S. (1990). Sleep in old age: Focus on gender differences.
Sleep, 13(5), 410–424. Evidence Level I.
Richardson, G. S., Carskadon, M. A., Orav, E. J., & Dement, W. C. (1982). Circadian variation of sleep tendency in elderly and young adult subjects. Sleep, 5(Suppl. 2), S82–S94.
Roehrs, T., Turner, L., & Roth, T. (2000). Effects of sleep loss on waking actigraphy. Sleep, 23(6), 793–797. Evidence Level IV.
Shen, J., Barbera, J., & Shapiro, C. M. (2006). Distinguishing sleepiness and fatigue: Focus on defi- nition and measurement. Sleep Medicine Reviews, 10(1), 63–76. Evidence Level VI.
Weaver, T. E., & Chasens, E. R. (2007). Continuous positive airway pressure treatment for sleep sleep apnea in older adults. Sleep Medicine Reviews, 11(2), 99–111. Evidence Level I.
Weaver, T. E., Kribbs, N. B., Pack, A. I., Kline, L. R., Chugh, D. K., Maislin, G., . . . Dinges, D. F.
(1997a). Night-to-night variability in CPAP use over the first three months of treatment. Sleep, 20(4), 278–283. Evidence Level II.
Weaver, T. E., Laizner, A. M., Evans, L. K., Maislin, G., Chugh, D. K., Lyon, K., . . . Dinges, D. F.
(1997b). An instrument to measure functional status outcomes for disorders of excessive sleepi- ness. Sleep, 20(10), 835–843.
Whitney, C. W., Enright, P. L., Newman, A. B., Bonekat, W., Foley, D., & Quan, S. F. (1998). Cor- relates of daytime sleepiness in 4578 elderly persons: The Cardiovascular Health Study. Sleep, 21(1), 27–36. Evidence Level III.
Young, J. S., Bourgeois, J. A., Hilty, D. M., & Hardin, K. A. (2008). Sleep in hospitalized medical patients, part 1: Factors affecting sleep. Journal of Hospital Medicine, 3(6), 473–482. Evidence Level VI.
Young, J. S., Bourgeois, J. A., Hilty, D. M., & Hardin, K. A. (2009). Sleep in hospitalized medical patients, part 2: Behavioral and pharmacological management of sleep disturbances. Journal of Hospital Medicine, 4(1), 50–59. Evidence Level VI.
89 eDUcATIOnAL OBjecTIVes
On completion of this chapter, the reader should be able to:
1. describe common components of standardized functional assessment instruments for acute care
2. identify unique challenges to gathering information from older adults regarding functional assessments
3. describe common nursing care strategies to restore, maintain, and promote func- tional health in older adults in acute care settings
OVeRVIeW
Physical functioning is a dynamic process of interaction between individuals and their environments. The process is influenced by motivation, physical capacity, illness, cognitive ability, and the external environment including social supports.
Management of these day-to-day activities (e.g., eating, bathing, ambulating, man- aging money) serves as the foundation for safe, independent functioning of all adults. Functional assessment instruments provide a common language of health for patients, family members, and health care providers across settings, especially for care of older adults.
The consequences of not assessing for change in status are significant. Acute changes in functional ability often signal an acute illness and an increased need for assistance to maintain safety. These changes have important implications for nursing care across settings, but especially during hospitalization. The ability to assess functional status is critical in accurately identifying normal aging changes, illness, and disability, and in developing an individualized plan for continuity of care across settings. The failure to assess function can lead to increased decline (e.g., malnutrition, falls), decreased quality of life, and the need for institutional care.