Sleep and Rest
The nurse is caring for an older patient who has REM sleep behavior disorder. What is the priority concern? 1. Ensuring safety 2. Teaching sleep hygiene practices 3. Ensuring adequate rest 4. Monitoring respirations
Answer 1: When a person experiences REM sleep behavior disorder, muscle activity is not inhibited during REM, and older individuals may thrash around in bed, jump or fall out of bed, or sustain an injury (or injure their partner) as they attempt to protect themselves from vivid or violent dreams.
An older person tells the nurse that he will lie in bed feeling very anxious for several hours before falling asleep. What advice will the nurse give? 1. Lie in bed and try to think about being relaxed and calm 2. If 20-30 minutes passes without sleep, get up and read until tired 3. Don't worry about falling asleep and eventually sleep will come 4. If you can't sleep, get up and pace around or do light exercise
Answer 2: If the person is unable to sleep after 20-30 minutes, encourage the person to get up and quietly watch television, read, or listen to music.
Which modification of lighting will best help the older patient to maintain a normal circadian rhythm? 1. Leave lights on 24 hours a day to ensure safety 2. Provide bright lighting during the daytime winter hours 3. Turn the lights off and on at the same hours every day 4. Provide bright lights in the summer to mimic seasonal hours
Answer 2: Provide bright lighting during the daytime, particularly during winter months. Dark rooms are best for sleep, but this may not be feasible in institutional settings. Provide lighting that allows for safety but does not interfere with sleep. Position curtains and doors to block light. Some individuals can sleep only if there is a night-light; others are disturbed by any light.
An older patient who has dementia has experienced a problem with a disrupted sleep pattern. . Which nursing action is the nurse most likely to perform for this patient? 1. Check on the patient in the early morning hours 2. Observe for hypersomnia during the daytime hours 3. Monitor for waking and wandering during the night 4. Observe for loud snoring and apnea during sleep
Answer 3: People with dementia often experience abnormal sleep cycles and are prone to waking and wandering during the night. Depression is most likely to be associated with early awakening but may also be related to hypersomnia (excessive sleepiness at a time of normal wakefulness). Snoring and periods of apnea are seen in sleep apnea.
The older patient is being treated with cognitive behavioral therapy (CBTI) for insomnia. Which nursing action would be included in this approach? 1. Administering a benzodiazepine medication as ordered 2. Encouraging the patient to sleep in a side-lying position 3. Suggesting that the patient take a warm bath before bedtime 4. Assessing the frequency of nightmares or vivid dreams
Answer 3: The "behavioral" part of CBP includes teaching behaviors promoting sleep, such as sleep hygiene practices; breaking the mental association between the bedroom and being awake, for example, using the bed only for sleep; and getting rid of thoughts that hinder sleep.
Which class of medication is most likely to cause insomnia because of muscle pain? 1. Alpha blockers 2. Corticosteroids 3. Cholinesterase inhibitors 4. Statins
Answer 4: For statins, muscle pain is a common side effect that contributes to insomnia.
An older patient requests an evening snack. Which food is most appropriate to facilitate sleep? 1. Graham cracker with banana and milk 2. Cheese, toast, and hot chocolate 3. Slice of cake and hot tea 4. Fruit, cheese, and a glass of wine
Correct answer: 1 A light snack or beverage before bed is commonly requested. Caffeinated beverages such as coffee should be discouraged because caffeine can interfere with sleep. Decaffeinated coffee, herbal tea, and milk are good choices. Milk is often suggested because it contains tryptophan, which has sleep-inducing properties. Heavy meals put extra stress on the body and should be avoided near bedtime. Alcoholic beverages should also be discouraged because they may interfere with normal sleep cycles and may lead to awakening because of diuresis.
A patient, who lost his wife six months ago, has been diagnosed with clinical depression. He plans to ask his primary care provider for a prescription for sleep medication. He asks for advice about what else he can do. The lack of sleep is interfering with his daytime activities, making him feel like he's "in a fog," and he states that his chronic obstructive pulmonary disease (COPD) is getting worse. What should the nurse keep in mind when providing an answer? 1. Most of the newer sleep medications are safe choices for people with depression. 2. Benzodiazepines carry a low risk of dependence. 3. Cognitive behavioral therapy has been shown to be more effective than medications in treating insomnia. 4. The newer medication, Ramelteon, is the best choice for someone with COPD.
Correct answer: 3 CBT has been shown to be the most effective therapy for insomnia. The "cognitive" part of CBT deals with retraining one's expectations about sleep, such as an absolute number of hours of sleep needed. The "behavioral" part of CBP includes teaching behaviors promoting sleep, such as sleep hygiene practices and breaking the mental association between the bedroom and being awake. Pharmacologic approaches are usually prescribed temporarily while the person is learning CBT techniques. Sleep-inducing medications are likely to have deleterious effects on older adults, such as urinary retention, drowsiness, fatigue, confusion, and disturbed coordination, which increase fall risk.
The wife of an overweight older adult reports that her husband snores very loudly, then stops breathing several times each night. In addition to recommending a visit to the primary care provider, what should the nurse suggest? 1. The husband should have a glass of wine at bedtime to promote relaxation. 2. The husband should use an OTC decongestant to open the respiratory passages. 3. The husband should sleep in the supine position with two pillows to open the airway. 4. The husband should try to lose weight and sleep in a side-lying position.
Correct answer: 4 Signs of sleep apnea include excessively loud snoring interspersed with periods of apnea lasting 10-30 seconds. People experiencing sleep apnea should try to lose weight and avoid alcohol, sedatives, and muscle relaxants, which can worsen the condition. Sleeping in the supine position may also make the condition worse, so a side-lying position is recommended.
Which of the following are true statements regarding insomnia and its treatment? (Select all that apply.) 1. Sleep medications can be useful in short-term management of insomnia. 2. Cognitive behavioral therapy may be indicated when sleep medications fail. 3. Valerian root is the most effective herb for the treatment of insomnia. 4. Tai chi at bedtime has been shown to be effective in preventing insomnia. 5. Taking the medication cortisone, especially late in the day, can contribute to insomnia.
Correct answers: 1, 5 Sleep medications can be helpful in treating insomnia but are usually prescribed temporarily while the person is learning CBT techniques. CBT has been shown to be the most effective therapy for insomnia. The effectiveness of valerian root has not been proven. Tai chi can be helpful in enhancing sleep quality, as long as not done late in the day. Corticosteroids can give the individual a boost of energy and therefore should be administered early in the day to not interfere with sleep.
In promoting sleep hygiene practices for her older adult patient, what should the nurse suggest? (Select all that apply.) 1. Implement a routine of bedtime cocoa. 2. Make the bedroom warm for a comfortable sleep. 3. Eat a light snack before bedtime. 4. Develop a daily exercise program, preferably outdoors. 5. If the older adult cannot fall asleep, lay there until it eventually happens.
Correct answers: 3, 4 Good sleep hygiene practices include: establish a regular bedtime and wake-up time, and follow this schedule as closely as possible; exercise daily, preferably early in the day and outdoors; increase overall light exposure, avoid naps or limit to no more than 30 minutes and no later than early afternoon; avoid caffeinated beverages after lunchtime; avoid alcohol and tobacco, particularly in the evening; eat a light snack before bed; avoid eating large meals late at night; take a warm bath or shower before going to bed; use relaxation breathing or meditation techniques; listen to relaxing music; establish a restful sleep environment with a comfortable bed, good pillow and covers, shades or curtains to block out light, and a slightly cool temperature, etc.; if you cannot fall asleep after 30 minutes, get up, read, watch TV, or do something relaxing until you feel tired, and then return to bed.
List factors that are likely to cause sleep problems in older adults.
Medical condition (arthritis, bursitis, chronic pain, diabetes, gastroesophageal reflux, chronic obstructive pulmonary disease, congestive heart failure, sleep apnea, prostatic problems, cystitis, and others); some medications; psychologic (anxiety, depression, dementia); behavioral (physical inactivity, poor sleep routines, late-night eating or exercise, the use of tobacco, and consumption of alcohol or caffeine); or environmental (excessive noise, light, activity, or other distracting stimuli) factors may exist.
