Chapter 20: Sleep and Rest

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Welcome to the Deep Dive.

We take complex source material, break it down, and we'll give you that essential clinical knowledge you need.

Today, we're tackling something really vital, but often overlooked in geriatric care.

The sleep rest health pattern.

I mean, the numbers are pretty stark.

Our sources say more than half of older adults have significant sleep issues.

And if they're in a facility, that number just jumps way up.

We know poor sleep isn't trivial.

It links to pain, fatigue, falls,

even appetite and thinking problems.

Absolutely.

And that thinking connection, the cognitive part, that's, well, that's crucial.

We're really moving beyond just saying, oh, sleep changes when you get older.

That's not enough.

So our goal today, our mission is to give you that structured, kind of rigorous clinical approach from the basic geriatric nursing text.

We need to get into the why the actual physiological changes, you know, and then how we as clinicians step in effectively.

Okay.

So to guide us, we'll use maybe three core ideas.

We'll talk about this age -related shift called phase advance.

That sounds important.

It is.

And then the range of disorders, things like insomnia and apnea.

And finally, that gold standard intervention you hear about cognitive behavioral therapy for insomnia or CVTI.

Exactly.

And look, it's really important to grasp the stakes right away.

Chronic sleep loss in older adults.

It's not just about feeling tired the next day.

There's some alarming research linking it to the buildup of beta amyloid and tau proteins, you know, the stuff associated with Alzheimer's disease.

So when we talk about fixing sleep problems in geriatrics, we're actually talking about maybe protecting the brain, neuroprotection.

It's that significant.

Okay.

That sets the stage.

Let's start with the basics then.

The normal cycle, the rhythm, our bodies run on this roughly 24 -hour clock, right?

Tied to light and dark.

That's the one, the circadian rhythm.

And it's this incredibly complex timekeeping system managed mainly by the central nervous system and hormones.

How does that work exactly?

What controls being awake versus asleep?

Well, wakefulness.

That's largely driven by norepinephrine, which explains why caffeine perks you up so much.

And then sleep is more regulated by serotonin release happening down in the brain stem.

And melatonin fits in there somewhere, the sleep hormone.

Precisely.

Melatonin comes from the pineal gland and its production ramps up when light levels drop.

It basically signals, okay, time to wind down.

And this is a key clinical point.

Older adults, maybe especially those in nursing homes or hospitals, often don't get enough bright light during the day.

And that directly messes with the pineal gland's ability to keep that sleep -wake cycle strong and distinct.

Got it.

So sleep itself,

it's not just one big block of unconsciousness, is it?

It has structure, cycles.

Oh, absolutely.

Very structured.

We typically go through about four to six full cycles a night, and each one lasts maybe 60 to 120 minutes.

And these have stages within them.

Yes.

You start with NREM that's non -rapid eye movement sleep.

Stage one NREM is super light.

If you nudge someone awake, then they might say, I wasn't even asleep.

Then you go deeper through stage two until you hit NREM stages three and four.

That's your slow wave sleep, deep physically restorative stuff.

That's where the body does a lot of repair work.

And then comes REM sleep, rapid eye movement.

Right.

About 90 minutes into the cycle, you hit REM.

And this stage is, well, it's pretty wild.

How so?

You get vivid dreaming, often in full color.

Your autonomic system goes a bit haywire.

Heart rate, breathing, they fluctuate.

And critically, your skeletal muscles lose tone.

They become temporarily paralyzed.

Which is a good thing, presumably, so you don't act out your dreams.

Exactly.

It's protective.

Stops you from leaping out of bed, chasing dream monsters.

Okay.

So that's the ideal setup.

What breaks down as we age?

What's this phase advance thing you mentioned?

Right.

Phase advance.

That's the key physiological change.

Basically, as we get older, levels of certain hormones, particularly melatonin and growth hormone, tend to decrease.

And the result is that the internal body clock actually shifts forward.

Meaning?

Meaning they start to feel sleepy earlier in the evening, maybe 7 or 8 p .m.

instead of 10 or 11.

And consequently, they wake up much earlier in the morning, like 3 or 4 a .m.

Oh, okay.

That explains why my grandpa is always up before the sun.

But what about the quality of the sleep they do get?

Is it as good?

Well, unfortunately, no.

That's the other part of the equation.

Sleep efficiency,

the percentage of time in bed actually spent asleep, goes down quite a bit.

They spend more time in that very light, easily broken stage one sleep, and less time in those deep restorative stages three and four.

So lighter sleep overall.

Yes.

And they're much more easily woken up by noise or light or needing the bathroom, more interruptions, less consolidation, just less restful, even if the hours in bed seem okay.

So when this normal cycle gets really disrupted, that's when we start talking about actual sleep disorders.

The big one is insomnia.

Absolutely.

They're most common.

Insomnia isn't just not sleeping.

It's the difficulty falling asleep or difficulty staying asleep, or even just the feeling that the sleep you got wasn't refreshing or adequate.

It can be short -term, acute, or chronic.

And there are different types based on when the problem happens.

Yeah, we tend to categorize it.

There's sleep -onset insomnia, trouble getting to sleep in the first place, then sleep -maintenance insomnia, waking up frequently during the night.

And finally, terminal insomnia, waking up way too early and not being able to get back to sleep.

And our source text specifically notes this type is often linked with depression.

Interesting.

And often there's an underlying medical reason, isn't there?

Box 20 .2 in the text lists quite a few.

What are the main physical culprits?

Oh yeah, absolutely.

Pain is probably number one.

Chronic arthritis pain, back pain, acute pain from surgery.

It's hard to sleep when you hurt.

Makes sense.

Then you have respiratory issues.

Like COPD patients might get orthopnea that's trouble breathing when they lie flat.

So they wake up gasping, anxious.

Okay.

Cardiovascular problems too.

Angina pain can actually flare up during REM sleep.

Same with acid reflux from ulcers.

Summit gas production increases during REM, waking people up.

And just needing to use the restroom, that's huge too, right?

Nocturia.

Yep.

Nocturia -frequent nighttime urination is a really common sleep disruptor for older adults.

Bladder changes, prostate issues, sometimes medication effects.

And don't forget movement disorders.

Things like restless leg syndrome.

That awful creepy -crawly feeling and urge to move your legs.

Or nocturnal myoclonus sudden leg jerks that wake you or your partner.

Okay, let's switch gears slightly to sleep apnea.

Especially obstructive sleep apnea, OSA.

Seems like we hear more about that now.

We do.

And it's often underdiagnosed.

OSA is basically where the airway collapses or gets blocked repeatedly during sleep.

It's strongly linked to things like excess weight, high blood pressure, and smoking.

And the signs are pretty obvious if you know what to look for.

Usually.

Really loud snoring is classic.

But it's snoring interspersed with periods where breathing just stops.

That's the apnea.

Can last 10, 20, 30 seconds or more.

That sounds dangerous.

It is.

The body isn't getting enough oxygen over and over all night.

Leads to terrible daytime sleepiness, poor concentration, irritability, and importantly, it puts a huge strain on the cardiovascular system.

Increases risk for hypertension,

stroke, heart rhythm problems.

So how do we manage it?

Well, lifestyle change is our first line.

Weight loss if needed.

Avoiding alcohol and sedatives, especially before bed, because they relax the throat muscles more.

Sleeping on your side can help.

But often the most effective treatment is a CPAP machine.

Continuous Positive Airway Pressure.

It keeps the airway open with gentle air pressure.

Yeah, the mask device.

Before we move to interventions, we absolutely have to talk about medications messing things up.

Oh, the medication minefield.

Yes.

This is critical in geriatrics.

If an older patient suddenly starts having sleep problems, you must review their medication list.

What are some common offenders?

Lots.

Beta blockers.

Used for heart conditions.

They can inhibit melatonin release.

Corticosteroids.

They stimulate cortisol.

The wake -up hormone.

ACE inhibitors for blood pressure.

They can cause this persistent dry hacking cough that keeps people up.

Okay.

Even some meds for Alzheimer's, the cholinesterase inhibitors, can cause problems.

They boost acetylcholine, which can lead to really vivid, sometimes disturbing dreams or nightmares.

Wow.

So many potential culprits just on the prescription list.

Exactly.

Always check the meds.

All right, so we've covered the what and the why of sleep disruption.

Let's talk about how we actually assess and intervene using that nursing process or clinical judgment model.

Okay.

Assessment.

It's not just looking, right?

It's listening to.

Absolutely.

You need both.

Objective data.

Are they obviously tired, yawning, dark circles, maybe less engaged in activities?

But the subjective stuff is key.

You have to ask them, how do you feel when you wake up?

Rested.

What kinds of questions should we be asking?

You need to map out their pattern.

Usual bedtime.

Wake time.

How long to fall asleep do they wake up during the night?

If so, why?

Pain.

Noise.

Bathroom.

Get collateral info if you can.

Ask caregivers if they notice loud snoring, pauses in breathing, or any unusual movements during sleep.

That helps screen for things like apnea or REM sleep behavior disorder.

Okay, so once we've identified, say, a disrupted sleep pattern, what are the goals for the patient?

Pretty straightforward, really.

We want the patient to, one, understand why their sleep might be changing, two, be able to talk about and try the interventions we suggest, and three, the ultimate term, report feeling more rested and refreshed.

Makes sense.

Now, implementation.

Let's focus on non -drug approaches first, especially in a hospital or care facility.

What can nurses do?

Right, non -pharmacologic first, always.

Okay, number one, covered in pain management.

If they're in pain, treat it aggressively.

Be aware of conditions like that orthopnea.

Maybe they need extra pillows or to sleep in a recliner.

Good point.

What else?

Scheduling.

Think about when you're doing things.

Can that diuretic be given earlier in the day to reduce nighttime tricks to the bathroom?

Yeah.

And noise.

Huge issue in institutions.

The QSEN focus in the text highlights minimizing noise, especially around shift change or near the nurse's station.

It takes teamwork.

Older adults wake up so easily.

And respecting their personal routines.

Crucial.

Don't just impose the facility's schedule.

Ask about their lifelong sleep rituals.

What helps them wind down?

Can we incorporate that?

And the 20 -30 minute rule.

If they're just lying there awake and getting frustrated after half an hour, encourage them to get up.

Do something quiet, like read a bit under low light, then try again later.

Break that bed equals frustration cycle.

What about the room itself?

Environment.

Keep it conducive to sleep.

Clean linens, comfortable temperature, non -restrictive mejays.

Use minimal light.

Just enough for safety if they need to get up.

And remember the daytime light we talked about?

Ensure they get good bright light exposure during the day to help set that circadian rhythm.

Nutrition.

Any magic bedtime snacks?

No magic, but maybe some help.

A late snack can be good.

Something with tryptophan like warm milk, maybe some graham crackers or a banana.

But definitely avoid heavy meals, caffeine or alcohol close to bedtime.

Those are sleepwreckers.

And just being present.

Emotional comfort.

Hugely important.

Sometimes just sitting and listening to their worries for a few minutes can ease anxiety.

Maybe gentle back rub.

Relaxation techniques.

That human connection matters.

So all these practical steps kind of build towards the big one.

The gold standard.

CVTI.

Exactly.

Cognitive behavioral therapy for insomnia.

It's the evidence -based preferred non -drug approach.

It's really effective long term.

How does it work in simple terms?

It has two main parts.

The cognitive part helps people identify and change unrealistic thoughts or worries about sleep.

Like catastrophizing about not getting enough sleep.

Reducing that anxiety.

And the behavioral part involves reinforcing good sleep habits.

What we call sleep hygiene.

Things like sticking to a regular schedule.

Avoiding naps.

And, critically, using the bed only for sleep and intimacy.

No watching TV.

No working.

No worrying in bed.

That sounds great, but I have to ask.

CVTI seems like it takes time and consistency.

In a really busy nursing setting, is it practical?

Can nurses really deliver that?

That's a really important practical question.

Look, the full multi -session CVTI program usually needs a trained therapist.

But nurses are constantly implementing the behavioral pieces.

Every time you manage the environment, reinforce the get out of bed if not sleeping rule.

Teach good sleep hygiene.

You are doing parts of CVTI.

It's about consistently applying those behavioral principles.

That builds the foundation.

Okay, that makes sense.

Now sometimes, despite everything, non -drug methods aren't enough.

So we have to consider medications.

Reluctantly, yes.

And when we do, that geriatric mantra is key.

Start low, go slow.

Use the lowest possible dose and increase it very gradually if needed.

Why such caution with sleeping pills in older adults?

Because the risks are really significant.

Sedatives, hypnotics.

They often cause this lingering hangover effect the next day.

Confusion, grogginess, poor coordination.

Which leads to falls.

It's exactly.

Big risk of falls.

Partly from dizziness or orthostatic hypotension blood pressure dropping when they stand up.

Plus, these drugs can actually worsen the quality of sleep, reducing restorative stages.

So if we absolutely must use one, we aim for the lowest dose of a drug with a short half -life to minimize those next day effects.

Got it.

What about complementary things?

People always ask about melatonin, herbs.

What does the evidence say, according to our source?

Yeah, approach with caution is the main message.

Valerian root.

Maybe some help, but the evidence isn't super strong and it can interact with other meds.

Chamomile tea is popular, seems safe for most, but there's a potential bleeding risk if someone's on anticoagulants and people with ragweed allergies might react.

And melatonin itself, the supplement everyone takes.

Well, it can definitely help regulate the sleep -wake cycle, especially with things like jet lag or shift work issues, but it's not risk -free.

The text notes it can sometimes cause paradoxical alertness, wake people up more.

And there's a documented concern about potential coronary vasoconstriction narrowing blood vessels in the heart.

So, not entirely benign.

What about non -pill things?

Things like acupuncture, relaxation or meditation techniques,

gentle exercise like Tai Chi.

Those are generally considered safe and potentially beneficial, but they often take time and consistent practice to work.

And vigorous exercise should be done earlier in the day, not right before bed.

Okay, this has been incredibly comprehensive.

Let's zoom out.

If you had to boil it down, what are the three biggest takeaways for our listener?

Right.

Okay, first,

sleep problems in older adults are a major health issue, not just a normal part of aging.

Don't dismiss them.

Second, good care starts with good assessment.

Really dig into their whole sleep pattern, objectively and subjectively.

Find the why.

And third, interventions should always prioritize non -pharmacologic strategies, especially those CBTI principles.

Use medications only as a last resort, very carefully.

Start low, go slow.

And maybe one final thought, kind of provocative to leave you with.

Remember we talked about chronic sleep deprivation being linked to beta amyloid and Tau buildup.

Yeah, the Alzheimer's connection.

Exactly.

So think about this.

When you, as a clinician,

really focus on improving an older person's sleep, managing their pain, keeping the noise down, promoting good sleep hygiene, you're not just helping them feel rested.

You might actually be playing a role in protecting their brain health long term, delaying those neurodegenerative processes.

That's how powerful good geriatric sleep care can potentially be.

That's, yeah, that's a really powerful way to think about it.

Puts it all in perspective.

Thank you so much for walking us through all of that today.

We really appreciate you taking this deep dive with us.

Hopefully you can take these insights, apply them, share them, keep learning.

And thank you for being part of our little last minute lecture family.