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Strategies to Improve Sleep Patterns in The Elderly at Palms Spring Hospital

Universidad del Turabo

NR502: Proposal

Session,

This paper is submitted in partial fulfillment of the requirements for the Master of Nursing Practice degree.

Running head: IMPROVING SLEEP PATTERNS OF THE ELDERLY 1

Strategies to Improve Sleep Patterns in the Elderly at Palms Spring Hospital

Normal aging brings about change in one's sleep patterns. As most people age, they start sleeping earlier than they used and sleep lighter than they used and do not get the quality of sleep they used. The elderly have reported to toss and turn their beds frequently and waking up earlier than usual. Several reasons have been attributed to changes in the sleep patterns of older people. The top five reasons are sleep problems due to underlying medical problems, sleep-related breathing disorders, restless leg syndrome, periodic limb movement of sleep and insomnia (della Monica et al., 2018). Due to the lack of proper sleep, the elderly often have compromised health, more so cognitive health. Therefore, it is critical for the elderly and all people, in general, to get quality sleep for better living. It is even more important for the elderly seeking medical assistance to access quality sleep as sleep helps heal and restore the body. To develop strategies that can help the elderly more so those hospitalized improve their sleep patterns, a study will be carried out. The study focuses on developing strategies to improve sleep patterns in the elderly at Palms Spring hospital.

Significance of the Practice Problem

Poor health in any generation or age group not only affects the sick people, but it affects society in general. If many people are sick and spend time seeking health assistance, the cost of health provision is bound to rise. In the case of the elderly, sickness that leads to hospital admission leads to a strain on their families' financial capabilities. Also, the elderly get to spend their hard-earned money taking care of ailments. Families that spend time taking care of the elderly are less productive, and the ripple effect of the unproductivity can be felt in the economy. Naturally, the human body has some mechanisms to help repair itself or cure itself in case it is sick. One of those mechanisms is sleep. According to Cao et al. (2020), sleep allows the body to repair damaged cells and nerves. It also helps boost one's immune system, strengthening the heart and preventing weight gain, amongst other things. Quality sleep helps in improving one’s quality of life (Ali et al., 2018).

When the elderly who are hospitalized do not get quality sleep, their health is greatly compromised. In most cases, hospitalized elderly who do not get quality sleep stay longer in hospitals than the elderly who do not have trouble getting quality sleep (Gulia & Kumar, 2018). Long stays in hospitals put people at a high risk of getting hospital-acquired infections, which further increases health risks and, at times, increases mortality. Furthermore, the nation's healthcare policy is also negatively affected if the elderly stay longer in hospitals (Abel-Smith, 2018). There is a higher chance of health funds being re-directed to cater to the elderly, and consequentially, other age groups suffer from the re-direction.

Patients, more so elderly patients who do not quality sleep, have a higher readmission rate than those who get quality sleep (Moye et al., 2018). Considering that sleep helps maintain and improve health outcomes, strategies that help the elderly get quality sleep must be formulated. The formulation of such strategies will be beneficial to all; it will benefit the general public.

PICOT Question

The question guides the research; In the elderly hospitalized population, what is the non-pharmacological intervention's effect on the improvement of sleep patterns compared to pharmacological interventions in the long run?

The PICOT question guides the study by forcing the researchers to consider which treatment methods effectively help hospitalized patients improve their sleep patterns. Two methods are identified to improve sleeping patterns, and they are sleep therapy and sleep mediation. The focus of the study is to identify the best solution between the two in the long run. The ultimate goal of improving the elderly's sleep patterns for the elderly is to reduce long stays and hospital readmissions and improve the health of the elderly generally.

Theoretical Framework

The nursing theory that serves as the study's foundation is the model of interpersonal relations by Peplau Hildegard. The theory is based on psychodynamic nursing, and it applies the principles of human relations (Suwandi & Yusuf, 2017). The theory focuses on the understanding of one's behavior in helping other people identify their difficulties. According to the theory, an individual is an organism that lives in unstable equilibrium and that tries to reduce anxiety caused by needs. The theory defines health as the forward movement of human processes toward creative, productive, constructive personal and community living. The theory also identifies nursing as a therapeutic process that cooperatively functions with other processes to make health possible. Furthermore, nursing involves problem-solving.

The theory focuses on not only offering medical assistance to those ailing or those in need. It instead focuses on helping people understand that one's behavior and external factors influence health. By helping people know the factors of proper health, nurses improve public health. In the elderly at Palm Springs Hospital, nurses have to make it clear to the elderly that there are factors that have played a role in the change of their sleep patterns. By doing so, the elderly can take measures to prevent further change and reverse the changes. The measures can involve either medical treatment or therapeutic treatments.

Synthesis of the Literature

Practical non-pharmacological intervention approaches for sleep problems among older adults

The first study under review in the literature review is published in 2018 by Stephanie Macleod and three other researchers. The article starts by noting that poor sleep is common amongst the elderly population, individuals who are 60 years above. According to Mcleod et al. (2018), poor sleep is associated with negative health outcomes such as higher mortality and morbidity.

The researchers were interested in exploring non-pharmacological intervention in the improvement of sleep quality among older adults. The researchers were guided by the view that many people were opting for non-pharmacological treatments to treat ailments. The researchers conducted a tailored literature review on improving sleep quality on the elderly. The researchers used online search engines to identify articles for their study.

From the literature review, Mcleod and her research team identified that several non-pharmacological interventions help with sleep disorders among the elderly. Of the interventions identified, two were found to be the most effective; cognitive behavioral therapy and mindfulness behavior therapy. Furthermore, the researchers also identified that integrating the therapies with chronic stress management effectively helped the elderly get quality sleep.

An analysis of the article reveals that therapeutic sleep treatment is an effective solution for the elderly. Unfortunately, the article was based on a literature review that did not focus on the sleep improvement of hospitalized elderly. s

Pilot test of a six-week group delivery caregiver training program to reduce sleep disturbances among older adults with dementia

In 2016, Sweta Tewary and three other researchers published their findings on a study that they had carried out. The four researchers had initiated a pilot program to test the feasibility of a modified sleep education program. The program was designed to reduce insomnia in community-dwelling older adults with dementia. The program was initiated after it was noted that insomnia was detrimental to the older population and their caregivers. Both the elderly and their caregivers were showing high levels of depression due to insomnia.

In implementing the program, a trained sleep educator taught caregivers on the impact of dementia, aging on sleeping (Sweta et al., 2016). The trained sleep educator also taught the caregivers how non-pharmacological interventions such as regular exercise, sleep hygiene strategies, and increasing light could help improve sleep in the elderly. As part of the program, the caregivers participated in goal setting.

The pilot program results revealed that the incorporation of the intervention helped reduce depression levels in both the caregivers and the elderly. The caregivers admitted the program provided them with valuable strategies that helped the elderly sleep better. The findings of the study were that non-pharmacological interventions were effective at helping the elderly sleep. Consequentially, the interventions helped improve the health outcomes of the elderly.

An analysis of the article revealed that non-pharmacological interventions effectively helped the elderly improve their sleep patterns. According to the article reviewed, the lack of quality sleep in the elderly not only affects the elderly, but it also affects caregivers to the extent it increases their depression rates. The article was appropriate as it touched on the elderly sick population. By going through the article, there is reliable evidence that improved sleep patterns contribute to improved health outcomes among the elderly.

Occupational Therapy Interventions Addressing Sleep for Community-Dwelling Older Adults: A Systematic Review

The third literature under review was published in 2018 by Smallfield and Molitor. The publication was about a study conducted to establish whether occupational therapy effectively addresses sleep challenges among the elderly population. The study was a systematic review based on three themes' group multicomponent interventions, one-to-one multicomponent interventions and one-to-single component interventions. The researchers wanted to identify the best intervention out of the three.

According to the systematic review findings, there was strong evidence that supported cognitive-behavioral interventions for sleep improvement in the elderly. The identified interventions included problem-solving, sleep hygiene education, relaxation, physical exercise, among others. The best delivery mode for the non-pharmacological interventions was one to one or in a group. Based on the findings, the researchers recommended that interventions be used on a routine basis.

An analysis of the article revealed two main things. The first thing is that age makes it harder for the elderly to sleep regardless of whether they are sick or not. The second thing is that non-pharmacological intervention is as effective as medical interventions. Furthermore, they are safer as they do not introduce foreign components to the body. Lastly, for the non- pharmacological interventions to work, they must be done routinely.

Insomnia in Elderly Patients: Recommendations for Pharmacological Management

In 2018. Abad and Guilleminault published their study's findings. Their study was interested in revealing which is the best treatment for insomnia in elderly patients. The knowledge drove the researchers that over 50% of the elderly in the United States suffered from chronic insomnia. As a result, the elderly were prone to impairments in normal daily functions, health, and life quality. According to Abad and Guilleminault (2018), chronic insomnia burdens the nation will spend billions of dollars in indirect and direct care costs.

At the time of the study, the main modalities of dealing with insomnia among the elderly were behavioral therapies, pharmacological treatment or a combination of both. According to the publication, specialty societies view behavioral therapies as the first treatment intervention for the elderly diagnosed with insomnia. On the other hand, pharmacological interventions are used when insomnia symptoms or if the cognitive-behavioral therapies are not effective.

The researchers identified insomnia drugs into five main classes; benzodiazepines, orexin agonists, antagonists, non-benzodiazepine gamma-aminobutyric acid receptor agonists histamine receptor. The drugs were found to be effective at improving the quality of sleep among the elderly. An analysis of the article provided evidence that pharmacological interventions for helping the elderly deal with sleep challenges were effective more so if the elderly struggled to get quality sleep for some time.

Practice Recommendations

Based on the synthesis of available literature on the elderly and sleep patterns, it is clear that the elderly are affected more by age regarding sleep patterns. The elderly are prone to anxiety, trauma and depression, making it harder for them to sleep as they were when they were younger (Blake, Trinder & Allen, 2018). Chronic ailments also make it harder for the elderly to get quality sleep. Consequentially their health is compromised.

The literature synthesis provides an answer to the research PICOT question of in the elderly hospitalized population, what is the effect of non-pharmacological interventions on improving sleep patterns compared to pharmacological interventions in the long run? The analysis of the article's providence that supports non-pharmacological interventions such as physical exercise and relaxation techniques effectively improves the sleeping patterns of the elderly. There is also evidence that pharmacological interventions are also effective in helping the elderly get quality sleep.

The analysis revealed that non-pharmacological interventions are effective when it is the first time that an elderly is having challenges with sleeping as expected. On the other hand, pharmacological interventions are effective and should only be used after insomnia, and other sleep disorders are persistent. Furthermore, pharmacological interventions should only be used if there are no other interventions used on the elderly. Clearly, from the synthesis, pharmacological interventions are recommended to treat persistent sleep disorders in the elderly.

Project Description

This project will be completed through a literature review. This will be carried out through Google Scholar, CINHAL, Ana G. Mendez Virtual Libraries, WorldCat, PubMed, Internet database. The research will be peer-reviewed. A minimum of 30 articles of no more than five years will be reviewed. I will use some keywords for my searches like insomnia, pharmacological treatment, non-pharmacological treatment, apnea and sleep-related disorders.

The results obtained from the study will contribute to determining if the use of non-pharmacological interventions to improve the sleep patterns of the elderly is much more effective than the use of pharmacological interventions.

All information collected in this review will be kept in a locked dresser in the principal investigator's office for five years. Both the principal investigator and the mentor will have access to this material. After this time (5 years), the data will be eliminated with a paper shredder and discarded.

Project Evaluation Results

Summarized tables with all citations will be presented in appendix A&B; appendix A will be used to summarize primary research evidence, and appendix B will be used for the summary of the systematic reviews.

Appendix A will include the citation, question or hypothesis, theoretical foundation, research designated and sample size, key findings, recommendations or implications, and level of evidence of each article. Appendix B will include citations, question, search strategy, inclusion/exclusion criteria, data, extraction and analysis, key finding, recommendation/implications, and level of evidence of each article.

Discussion and Implications for Nursing and Healthcare

The study has revealed that sleep disorder is not a lifestyle condition but is a condition that has many diverse risk factors. The study's findings are instrumental in the advancement of healthcare not only for the elderly population but for all generations considering that all ages are affected when the health of the elderly is compromised. Through the study, three key points have been identified to be of relevance to the health sector.

The first key point is the need to emphasize the importance of physical exercise. Nurses and the health sector, in general, have always claimed that participation in physical activity is important. However, with the new findings from the study, physical activity should be sold as a necessity for good health. Nurses need to enlighten masses on regular physical exercise that exceeds an hour every day (Fletcher-Brown et al., 2020). Physical exercises are therapeutic, and they help the elderly get some form of fatigue, which eases them to sleep (Hudson et al., 2020).

Plans for Dissemination

To achieve the purpose of making our research known, different types of media will be used. In the same way, interpersonal communication will be of vital importance to disseminate this project. Other forms of dissemination will also be used as a PowerPoint, and a poster will be presented at the University. The PowerPoint will have a duration of no more than 30 minutes and presented to the teacher and classmates. While the poster, which will include a summary of this research, will be shown in the University Room of the South Florida campus. In the library of this University, we will leave a copy of this literature review to be used by those interested in the subject.

Summary and Conclusion

The question guided the research; In the elderly hospitalized population, what are non-pharmacological interventions on improving sleep patterns compared to pharmacological interventions in the long run? The PICOT question guided the study by forcing the researchers to consider which treatment methods effectively help hospitalized elderly patients improve their sleep patterns. Two methods were identified to improve sleeping patterns, and they are sleep therapy and sleep mediation. The focus of the study was to identify the best solution between the two in the long run.

A literature synthesis was carried out and based on it. The elderly are affected more by age as regards sleep patterns. The elderly are prone to anxiety, trauma and depression, making it harder for them to sleep as they were when they were younger. Chronic ailments also make it harder for them to get quality sleep. Consequentially their health is compromised.

The literature synthesis provided answers to the research PICOT question of in the elderly hospitalized population, what is the effect of non-pharmacological interventions on improving sleep patterns compared to pharmacological interventions in the long run? The articles' analysis provided evidence that supports non-pharmacological interventions such as physical exercise and relaxation techniques to improve the sleeping patterns of the elderly. There is also evidence that pharmacological interventions are also effective in helping the elderly get quality sleep. Non-pharmacological interventions are effective when the first time an elderly is having challenges with sleeping as expected. On the other hand, pharmacological interventions are effective and should only be used after insomnia, and other sleep disorders are persistent. Furthermore, pharmacological interventions should only be used if there are no other interventions used on the elderly.

The first key point is the need to emphasize the importance of physical exercise. Nurses and the health sector, in general, have always claimed that participation in physical activity is important. However, with the new findings from the study, physical activity should be sold as a necessity for good health. Nurses need to enlighten masses on regular physical exercise that exceeds an hour every day. Physical exercises are therapeutic. They help the elderly get some form of fatigue, which eases them to sleep.

The third key point is that the nurses and the health sector have a reliable solution for sleep disorders in the elderly. The results have indicated that for the elderly not to suffer from sleep complications, they first have to participate in physical activities regularly and consistently. Secondly, they have to eat healthy foods and in moderation. They must refrain from alcohol consumption as alcohol consumption affects their ability to get quality sleep. Clearly, from the synthesis, pharmacological interventions are most recommended in treating persistent sleep disorders in the elderly. Pharmacological interventions can help improve sleep patterns in the elderly as Palms Spring Hospital.

References

Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management. Drugs & aging, 35(9), 791-817. Retrieved from https://link.springer.com/article/10.1007/s40266-018-0569-8

Abel-Smith, B. (2018). An introduction to health: policy, planning and financing. Routledge.

Ali, S., Birhane, M., Bekele, S., Kibru, G., Teshager, L., Yilma, Y., ... & Gudina, E. K. (2018). Healthcare-associated infection and its risk factors among patients admitted to a tertiary hospital in Ethiopia: a longitudinal study. Antimicrobial Resistance & Infection Control, 7(1), 2. Retrieved from https://link.springer.com/article/10.1186/s13756-017-0298-5

Blake, M. J., Trinder, J. A., & Allen, N. B. (2018). Mechanisms underlying the association between insomnia, anxiety, and depression in adolescence: implications for behavioral sleep interventions. Clinical psychology review, 63, 25-40. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0272735818300175

Cao, J., Herman, A. B., West, G. B., Poe, G., & Savage, V. M. (2020). Unraveling why we sleep: Quantitative analysis reveals abrupt transition from neural reorganization to repair in early development. Science advances, 6(38), eaba0398. Retrieved from https://advances.sciencemag.org/content/6/38/eaba0398?intcmp=trendmd-adv

della Monica, C., Johnsen, S., Atzori, G., Groeger, J. A., & Dijk, D. J. (2018). Rapid eye movement sleep, sleep continuity and slow-wave sleep as predictors of cognition, mood, and subjective sleep quality in healthy men and women, aged 20–84 years. Frontiers in psychiatry, 9, 255. Retrieved from https://www.frontiersin.org/articles/10.3389/fpsyt.2018.00255/full

Fletcher-Brown, J., Carter, D., Pereira, V., & Chandwani, R. (2020). Mobile technology to give a resource-based knowledge management advantage to community health nurses in an emerging economies context. Journal of Knowledge Management. Retrieved from https://www.emerald.com/insight/content/doi/10.1108/JKM-01-2020-0018/full/html

Gulia, K. K., & Kumar, V. M. (2018). Sleep disorders in the elderly: a growing challenge. Psychogeriatrics, 18(3), 155-165. Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/psyg.12319

Hudson, G. M., Hauff, C., Hayes, K., & Fruh, S. (2020). An NP's guide to current physical activity recommendations. The Nurse Practitioner, 45(9), 24-31. Retrieved from https://journals.lww.com/tnpj/fulltext/2020/09000/an_np_s_guide_to_current_physical_activity.6.aspx

MacLeod, S., Musich, S., Kraemer, S., & Wicker, E. (2018). Practical non-pharmacological intervention approaches for sleep problems among older adults. Geriatric Nursing, 39(5), 506-512. Retrieved from https://doi.org/10.1016/j.gerinurse.2018.02.002

Moye, P. M., Chu, P. S., Pounds, T., & Thurston, M. M. (2018). Impact of a pharmacy team–led intervention program on the readmission rate of elderly patients with heart failure. The Bulletin of the American Society of Hospital Pharmacists, 75(4), 183-190. Retrieved from https://academic.oup.com/ajhp/article-abstract/75/4/183/5102041

Peplau’s, H. E. Interpersonal Relations Theory. Nursing Inquiry, 2014, 21-4.

Smallfield, S., & Molitor, W. L. (2018). Occupational therapy interventions addressing sleep for community-dwelling older adults: A systematic review. American Journal of Occupational Therapy, 72(4), 7204190030p1-7204190030p9. Retrieved from https://doi.org/10.5014/ajot.2018.031211

Suwandi, T., & Yusuf, A. (2017). The Influence Of Nurse’s Interpersonal Relationship On Perioperative Patient’s Family Uncertainty Based On Hildegard Peplau’s Theory. Journal of Applied Science And Research, 4(2), 56-66. Retrieved from http://eprints.ners.unair.ac.id/482/

Tewary, S., Cook, N., Pandya, N., & McCurry, S. M. (2018). Pilot test of a six-week group delivery caregiver training program to reduce sleep disturbances among older adults with dementia (Innovative practice). Dementia, 17(2), 234-243.

Appendix A

Summary of Primary Research Evidence

Citation

Question or Hypothesis

Theoretical Foundation

Research Design (include tools) and Sample Size

Key Findings

Recommendations/

Implications

Level of Evidence

MacLeod, S., Musich, S., Kraemer, S., & Wicker, E. (2018). Practical non-pharmacological intervention approaches for sleep problems among older adults. Geriatric Nursing, 39(5), 506-512. Retrieved from https://doi.org/10.1016/j.gerinurse.2018.02.002

Is non-pharmacological intervention effective in the improvement of sleep quality among older adults

Evidence-based

tailored literature review

research team identified that several non-pharmacological interventions help with sleep disorders among the elderly. Of the interventions identified, two were found to be the most effective; cognitive behavioral therapy and mindfulness behavior therapy. Furthermore, the researchers also identified that integrating the therapies with chronic stress management effectively helped the elderly get quality sleep.

It is evident from the findings of the study that non-pharmacological interventions are effective at improving sleep quality and health outcomes in the elderly population. More research on the effectiveness needs to be done.

Level I

Tewary, S., Cook, N., Pandya, N., & McCurry, S. M. (2018). Pilot test of a six-week group delivery caregiver training program to reduce sleep disturbances among older adults with dementia (Innovative practice). Dementia, 17(2), 234-243.

How to reduce insomnia in community-dwelling older adults with dementia

Evidence-based

Pilot program study

The pilot program results revealed that the incorporation of the intervention helped reduce depression levels in both the caregivers and the elderly. The caregivers admitted the program provided them with valuable strategies that helped the elderly sleep better. The findings of the study were that non-pharmacological interventions were effective at helping the elderly sleep. Consequentially, the interventions helped improve the health outcomes of the elderly.

the lack of quality sleep in the elderly not only affects the elderly, but it also affects caregivers to the extent it increases their depression rates. There is a need to offer sleep therapy to both the caregivers and the patients

Level II

Legend:

Level I: systematic reviews or meta-analysis Level II: well-designed Randomized Controlled Trial (RCT) Level III: well-designed controlled trials without randomization, quasi-experimental Level IV: well-designed case-control and cohort studies Level V: systematic reviews of descriptive and qualitative studies Level VI: single descriptive or qualitative study Level VII: opinion of authorities and/or reports of expert committees

Appendix B

Summary of Systematic Reviews (SR) (this table may be single space)

Citation

Question

Search Strategy

Inclusion/ Exclusion Criteria

Data Extraction and Analysis

Key Findings

Recommendation/

Implications

Level of Evidence

Does occupational therapy effectively addresses sleep challenges among the elderly population

Google scholar, pubmed, ebscohost and science direct

The elderly with chronic conditions that can lead to insomnia

Thematic analysis

there was strong evidence that supported cognitive-behavioral interventions for sleep improvement in the elderly. The identified interventions included problem-solving, sleep hygiene education, relaxation, physical exercise, among others. The best delivery mode for the non-pharmacological interventions was one to one or in a group.

non-pharmacological intervention is as effective as medical interventions. Furthermore, they are safer as they do not introduce foreign components to the body. Lastly, for the non- pharmacological interventions to work, they must be done routinely.

Level I

What is the best way to deal with insomnia in the elderly?

Google scholar, pubmed, ebscohost and science direct

The elderly suffering from diseases that influence insomnia

Thematic analysis

According to the publication, specialty societies view behavioral therapies as the first treatment intervention for the elderly diagnosed with insomnia. On the other hand, pharmacological interventions are used when insomnia symptoms or if the cognitive-behavioral therapies are not effective.

Insomnia drugs should only be used after behavioral therapy has failed to yield any fruits

Level II

Legend:

IMPROVING SLEEP PATTERNS OF THE ELDERLY 23