Excessive Sleepiness As Health Care Issue Excessive Sleep: Causes, Contributing Factors, Health Consequences, Age as a Factor, Old Age Sleeplessness, and Interventions (Pharmacological and Non-pharmacological).
Learning Objectives
Upon completing this chapter, the reader should be able to:
- Identify the signs and symptoms of excessive sleepiness and quantify them using a standardized scale.
- Describe the signs, symptoms, and usual treatments for primary sleep disorders causing excessive sleepiness in older adults: obstructive sleep apnea, restless leg syndrome, insomnia, and short sleep duration.
- Discuss the implications of chronic illness, medications, and acute hospitalization on sleep.
- Provide nursing care that incorporates sleep hygiene measures and offer consistent ongoing treatment for existing sleep disorders.
- Educate patients and families about sleep disorders and sleep hygiene measures.
Introduction
Excessive sleepiness, sometimes called executive daytime sleepiness, is common in older adults. Fatigue manifests as difficulty in sustaining a high level of physical performance, while excessive sleepiness refers to the inability to maintain alertness or vigilance due to hypersomnolence.
Many factors can affect nighttime sleep and result in daytime sleepiness in older adults. These include psychological disorders, symptoms of chronic illnesses (e.g., pain), medication side effects, environmental factors, and lifestyle preferences. Increases in sleepiness can result from age-related changes in chronobiology and sleep disorders. In older adults, the most common primary sleep disorders are obstructive sleep apnea (OSA), restless leg syndrome, and insomnia.
The extent to which changes in sleep patterns experienced by older adults are caused by normal physiological alterations, pathological events, sleep disorders, or poor sleep hygiene remains unclear. Hospitalization and institutionalization can also interfere with sleep quality or quantity. There are many effective treatments for sleep disorders, but the first step is to identify the cause of excessive daytime sleepiness and then to quantify and aggressively treat this condition in the older adult.
This chapter outlines an overview of sleep disorders common in older adults, describes how to assess sleep, and provides interventions to improve sleep in older adults.
Background and Statement of Problem
The Institute of Medicine (Colten & Altevogt, 2006) reports that 50-70 million Americans are affected by chronic disorders of sleep and wakefulness. Recent data from the Behavioral Risk Factor Surveillance System (BRFSS) conducted by the Centers for Disease Control and Prevention (CDC) found that among community-dwelling persons older than age 65 years (23,167), nearly a quarter (24.5%) reported sleeping, on average, less than 7 hours in a 24-hour period, and more than half (50.5%) of these older adults reported snoring (CDC, 2011b).
Data from the 2005-2008 National Health and Nutrition Examination Survey (NHANES) show that 32% of persons older than age 60 years (n = 3,716) slept less than 7 hours per night on weekdays or workdays (CDC, 2011a). Likewise, the Cardiovascular Health Study documented excessive sleepiness in 20% among subjects older than age 65 years (n = 4,578; Whitney et al., 1998).
Further, some sleep disorders are more common in patients in acute and chronic care settings. Ancoli-Israel and colleagues (1991) and Ancoli-Israel, Kripke, and Mason (1987) studied only persons older than age 65 years and found undiagnosed sleep apnea in 24% of those living independently in the community, 33% of those in acute care settings, and 42% of older adults in nursing home settings.
Health Consequences of Excessive Sleepiness
The primary consequences of sleepiness are decreased alertness, delayed reaction time, and reduced cognitive performance (Ohayon & Vecchierini, 2002). The BRFSS found that nearly half (44%) of subjects in this telephone survey reported that they unintentionally fell asleep during the day at least once in the preceding month, and one out of 50 older adults had fallen asleep while driving in the preceding month (CDC, 2011a).
The 2005-2008 NHANES data also show that older adults reported difficulty concentrating (18%) and remembering (14.7%) because of sleep-related problems (CDC, 2011a). Recent studies show that daytime sleepiness is significantly associated with declining cognitive function (Cohen-Zion et al., 2001), falls (Brassington, King, & Bliwise, 2000), and cardiovascular events (Whitney et al., 1998).
In the Cardiovascular Health Study, daytime sleepiness was 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., 2000). This linkage between sleep and medical conditions is consistent with the 2005-2008 NHANES results that demonstrated a greater rate of sleep-related problems with concentration, memory, and activities of daily living among women (CDC, 2011a).
Physiological Changes in Sleep That Accompany Aging
Normal changes in sleep that occur as part of human development and lifestyle choices must be differentiated from pathological sleep conditions that are common among older adults.
Although older adults require as much sleep as younger adults, older adults may divide their sleep between nighttime slumber and daytime naps, rather than a single consolidated period. The endogenous circadian pacemaker, located in the suprachiasmatic nucleus, along with exogenous environmental cues and a homeostatic need for sleep, mediate the normal wake and sleep pattern.
With aging, the circadian pattern for sleep-wake decreases in amplitude, possibly in association with less robust changes in core body temperature (Richardson, Carskadon, Orav, & Dement, 1982). Compared with younger adults, healthy older adults have a more pronounced biphasic pattern of sleepiness during the afternoon hours (about 2-6 pm) and a phase advancement of nighttime sleepiness earlier in the evening (Rochrs, Turner, & Roth, 2000).
Changes in sleep architecture associated with normal aging include increased difficulty in falling asleep, poorer sleep quality with decreased sleep efficiency, more time awake after sleep onset, increased “light” sleep (Stages 1 and 2 sleep), and decreased quantity and amplitude of restorative “deep” slow-wave sleep (Stages 3 and 4). Although older women report more sleep disturbances than older men, studies indicate that their sleep is less disturbed than that of men (Redichs, Reis, & Creason, 1990).
Primary Causes of Excessive Daytime Sleepiness
Obstructive Sleep Apnea
OSA is a condition in which intermittent pharyngeal obstruction causes cessation of respiratory airflow (apneas) or reductions of airflow (hypopneas) that last for at least 10 seconds. This results in a microarousal that restores upper airway patency, permitting breathing and airflow to resume.
According to the American Academy of Sleep Medicine (AASM, 2005) Task Force, OSA is diagnosed when these events occur at a rate of greater than five per hour of sleep and are accompanied by daytime sleepiness and impaired daytime functioning. It is common for patients with severe symptoms to experience multiple arousals during the night. These multiple arousals severely fragment sleep, preventing the deep sleep (Stages 3 and 4) and rapid eye movement (REM) sleep necessary for healthy mental and physical functioning.
OSA is both an age-related and an age-dependent condition, with an overlap in both distributions in the 60- to 70-year-old age range (Bliwise, King, & Harris, 1994). Age-related risk factors for OSA in older adults include an increased prevalence of overweight and obesity. Conversely, age-dependent risk factors include increased collapsibility of the upper airway, decreased lung capacity, altered ventilatory control, decreased muscular endurance, and altered sleep architecture (Brassington et al., 2000).
Treatments for OSA depend on the contributing pathology and patient preference and include nocturnal positive airway pressure, surgical procedures designed to increase the posterior pharyngeal area, oral appliances, and weight reduction when obesity is a contributing factor. Nasal continuous positive airway pressure (CPAP) therapy, which is highly effective when individually titrated to eliminate apneas and hypopneas, is currently the gold standard for treating OSA (Morgenthaler et al., 2006). Older adults tolerate CPAP therapy with patterns of compliance similar to that of middle-aged adults (Weaver & Chasens, 2007).
Although oral appliances offer a low-tech treatment option, they require a stable dentition that may be problematic for persons with extensive tooth loss or dentures.
Insomnia
Insomnia can be defined as delayed sleep onset, difficulty in maintaining sleep, premature waking, and/or very early arousal that result in insufficient sleep (Ancoli-Israel & Martin, 2006). Insomnia can be transient or chronic, and the perception of sleep loss may not correspond to objective assessment.
The frequent awakenings suggestive of insomnia may be a conditioned arousal response because of environmental (e.g., noise or extremes of temperature) or behavioral cues. Anxiety associated with emotional conflict, stress, recent loss, feeling insecure at night, or significant changes in living arrangements can also produce insomnia (Ancoli-Israel & Martin, 2006).
Chronic insomnia can result in a conditioned response of anxiety and arousal at bedtime in anticipation of difficulty falling asleep; this may prompt use of hypnotic medications, over-the-counter (OTC) drugs, or alcohol. Although the use of hypnotics may produce short-term relief, they also affect sleep architecture and consequently lead to deterioration of sleep quality. The cycle of dependency and substance abuse is a potential problem in this age group (see Chapter 17, Reducing Adverse Drug Events).
At this time, the general recommendation is that when hypnotics are indicated, the most short-acting drug should be selected and, optimally, used in conjunction with an appropriate behavioral intervention (Ancoli-Israel, 2000).
Causes and Duration
Both the cause and duration of insomnia should inform the choice of treatment. For example, insomnia associated with a psychological origin, such as depression or anxiety, is best treated from that perspective. If pain is affecting sleep, pain management should be addressed first, and strategies to promote sleep onset should be added secondarily.
Short-term pharmacotherapy may be appropriate if insomnia is situational and of recent onset. When insomnia has been “learned” and the behavior becomes chronic, behavioral interventions are most appropriate. Behavioral treatments for insomnia include stimulus control, progressive muscle relaxation, paradoxical intention, sleep restriction, biofeedback, and multifaceted cognitive behavior therapy (Morin et al., 1999).
Data show that 70%-80% of patients benefit from behavioral therapies and that improvement in sleep is often sustained for a minimum of 6 months after treatment.
Restless Legs Syndrome
Restless legs syndrome (RLS) is a neurological condition characterized by the irresistible urge to move the legs. It is usually associated with disagreeable leg sensations that become worse during inactivity and often interfere with initiating and maintaining sleep.
As a secondary condition, this movement disorder can be caused by iron deficiency anemia, uremia, neurological lesions, diabetes, Parkinson’s disease, rheumatoid arthritis, or it can be a side effect of certain drugs (e.g., tricyclic antidepressants, serotonin reuptake inhibitors, lithium, dopamine blockers, xanthines). Periodic leg movement disorder (PLMD) is a similar condition also known as nocturnal myoclonus.
However, PLMD is characterized by involuntary flexion of the leg and foot that produces micro arousals or full arousals from sleep, interfering with achieving and maintaining restorative slow-wave sleep (Stages 3 and 4). Although the etiology and associated mechanism of this specific movement disorder are not well defined, this condition has been linked to metabolic, vascular, and neurologic causes.
Dopaminergic drugs are the most effective agents for treating RLS and PLMD, as well as opioids, benzodiazepines, anticonvulsants, adrenergic drugs, and iron supplements. However, their efficacy for long-term treatment in older adults has not been sufficiently evaluated (Ancoli-Israel & Martin, 2006; Gamaldo & Earley, 2006).
Secondary Causes of Excessive Daytime Sleepiness
Medical and psychiatric illness can interfere with sleep quality and disturb sleep. For example, depression or anxiety appears to have a bidirectional relationship with insomnia (Buysse, 2004). Painful chronic conditions, such as arthritis, reduce sleep efficiency, or simply changing body position may be painful enough to cause awakenings.
Because older adults frequently have multiple medical conditions, they are also more likely to take OTC and prescription medications for symptom relief. However, many medications and nonprescription drugs (e.g., pseudoephedrine, alcohol, caffeine, and nicotine) interfere with sleep. Thus, health care providers must be acutely aware of which OTC medications and beverages can cause sleep problems.
Symptom management must be balanced against preventing polypharmacy in older adults to maintain sleep quality (Ancoli-Israel, 2005).
Sleep Disturbance During Hospitalization
Studies have shown that as many as 22%-61% of hospitalized patients experience impaired sleep (Redeker, 2000). Many older adults have primary sleep disorders (OSA, insomnia, restless leg syndrome), and these conditions can become more pronounced or acute during acute illness and hospitalization.
Sleep disorders may go unrecognized in acute care settings; thus, patients may experience acute sleep deprivation concurrently with a medical crisis or surgical intervention. Protecting sleep and monitoring sleep quality should be routine elements of care in hospital settings (Young, Bourgeois, Hilty, & Hardin, 2008).
There are three common causes of sleep disruption in hospitals that are often overlooked by nursing staff: noise, light, and patient-care activities (Redeker, 2000). Further, anesthesia, cardiopulmonary disorders, and pain medications can reduce the respiratory drive and lead to hypopnea and apnea.
Medications typically administered postoperatively can affect alertness by causing excessive sedation, changes in sleep architecture, decreased REM sleep, nightmares, or insomnia. Pain and anxiety may also cause older patients to have insomnia. Inadequate sleep impedes healing and recovery and may be associated with acute mental confusion in older adults (Young, Bourgeois, Hilty, & Hardin, 2009).
In summary, older adults in acute care settings are exposed to many conditions that can negatively affect sleep and result in excessive daytime sleepiness.
The sleep environment and the quality of patients’ sleep can be improved in hospital settings if caregivers recognize the essential importance of sleep in illness and health. As a standard practice, nurses should include a thorough sleep history during admission to determine usual sleep patterns and/or symptoms of sleep disorders.
Patients with OSA who use CPAP at home should be instructed to bring their machines with them to the hospital. Sleep hygiene measures should be incorporated into nursing care routines during evening and night hours and also incorporated into care plans on every nursing unit.
This includes simple practices such as reducing light intensity, maintaining a quiet environment, and efficiently delivering patient care to minimize sleep disruption among patients. Anticipatory and preventive pain management is also an important element of care to promote adequate sleep in the hospital setting (Young et al., 2009).
Assessment of the Problem
There are several valid and reliable measures to screen for sleepiness. One of the most commonly used instruments is the Epworth Sleepiness Scale (ESS; Johns, 1991). Although OSA can only be diagnosed with a sleep study, the risk of OSA can be determined using the Multivariable Apnea Prediction Index (Maislin et al., 1995), the Berlin Questionnaire (Netzer, Stoohs, Netzer, Clark, & Strohl, 1999), or the STOP-Bang Questionnaire (Chung et al., 2008).
The STOP-Bang questionnaire (Table 5.2), first developed to screen for OSA in persons scheduled for anesthesia, consists of eight questions and has sensitivity from 76% to 96%. The Functional Outcomes of Sleep Questionnaire (Weaver et al., 1997b) is used to evaluate the impact of sleepiness on functional status; the Pittsburgh Sleep Quality Index (PSQI) (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) quantifies sleep quality over the past month (see Sleep topic at http://www.hartfordign.org).
Many sleep clinicians use the ESS to screen for sleepiness and track symptoms over the previous week during common activities such as sitting and reading, watching TV, or riding in a car. It is easy to administer and includes a scoring parameter to indicate the need for a medical evaluation. A brief sleep history can be obtained by using the questionnaire in Table 5.1.
In a sleep laboratory setting, a complete evaluation of sleep is conducted using polysomnography that includes electroencephalography (EEG), electromyogram (EMG), electro-oculogram (EOG), respiratory effort, airflow, and oxygen saturation. This comprehensive assessment helps to diagnose sleep disorders and plan appropriate treatment interventions.