Chapter 11: Sleep & Activity in Older Adults

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Hello and welcome back to the Deep Dive.

Today, we have a very specific and I think incredibly important mission.

I think so too.

We're taking a comprehensive educational walkthrough of chapter 11 titled Sleep and Activity from the textbook Gerontologic Nursing.

This is the 5th edition by Sue E.

Minor.

It's a pleasure to be here.

And you're right, this conversation is really tailored for college nursing students, you know, those of you who might be seeing these gerontologic concepts for the first time.

Right.

We know how dense these textbooks can be.

I mean, they're full of tables, lots of physiology.

So our real goal here is to translate that material into something you can actually digest, remember, and then, you know, apply on the floor.

Exactly.

And to that point, we're going to stick strictly to the text provided.

No fluff, no outside theories, just what you need to know from chapter 11 to, well, to ace that exam or maybe more importantly, take better care of your patients.

And here's the hook for today, which I found really compelling right off the bat.

We're talking about sleep and activity.

They seem like total opposites, don't they?

Like heads and tails on a coin.

In many ways, they are dichotomous functions.

I mean, one is rest, the other is motion.

They're opposites.

Yeah, but biologically, as the text points out, they're completely interdependent.

If you don't have one, the other one just falls apart.

It's this whole rhythm of life that, as we're going to find out, gets a little shaky as we age.

It does.

And the nurse's role, your role as a student, is to help that older adult adapt to those changes.

So we have a lot of ground to cover today.

Where are we starting?

We're going to start with the biology of sleep and the specific age related changes.

Basically, you know, why does grandpa wake up at 4 a .m.?

Then we'll move into sleep disorders, environmental factors in hospitals, pharmacology, and we'll finish up with the activity side of things.

And that includes a deep look at dementia care and ADLs.

Yeah, absolutely.

We promise to decode the tables, the studies, the nursing care plans found in the chapter, and we will definitely get to all of that.

Okay, let's dive right in.

Section one, the biology of sleep and age related changes.

Where is the control center for all of this?

Well, it all starts in the hypothalamus.

The text identifies the small region of the brain as the primary regulation center for sleep and wakefulness.

The primary one.

Yes, it actually contains both a sleep center and a wakefulness center, kind of like a light switch.

So the hypothalamus is the CEO.

It is the boss, yeah, but it has a board of directors, you could say, or supporting players.

You've got the thalamus, the limbic system, and something called the reticular activating system, or RAS.

Ah, the RAS.

They're all interconnected, but the hypothalamus is really pulling the strings.

And physiologically, when minor defines sleep, we're not just talking about closing your eyes.

There's more than that.

Oh, much more.

It's a specific state of consciousness where we see reduced blood pressure, a reduced pulse rate, and a slowed respiratory rate.

And a decreased response to external stimuli, which is why you hopefully don't wake up every time the wind blows outside.

Now, the text breaks sleep down into specific architectures or stages, and I know students get grilled on this constantly.

There's a table in the chapter, table 11 to 1.

Can we walk through that in detail?

We absolutely must.

This is really foundational knowledge.

Normal sleep is divided into two big categories, REM, which is rapid eye movement, and NREM, or non -rapid eye movement.

Which one dominates the night?

NREM does by a lot.

It accounts for about 75 % to 80 % of sleep.

It's really the heavy lifter in terms of time.

And NREM isn't just one thing.

It's further divided into four specific stages.

Okay.

Let's unpack those stages then.

What happens in stage one?

Stage one is the lightest level.

You're just drifting off.

You know that feeling.

You're easily awakened.

If someone whispers your name or a door creaks, you're up.

I know well.

Then what?

Then you move into stages two and three, which are just progressively deeper levels of sleep.

And finally, stage four.

Stage four is the basement.

This is the deepest level.

This is where your muscle tone drops significantly

and your vitals, your pulse, BP, respirations, they're all at their lowest basal levels.

And the text calls stage four restorative sleep.

It does.

So that's where the body is physically repairing itself, like a maintenance crew coming in.

Exactly.

That is where the maintenance crews come out and fix the tissues.

Now contrast that with REM sleep.

Okay.

REM makes up the remaining 20 % to 25%.

In REM, your vitals actually increase or fluctuate.

Blood pressure can jump around a bit.

And of course, this is where dreaming happens.

And there's a specific clinical note in the text about what happens if you don't get enough REM sleep specifically.

Yes.

And this is so important for nurses to spot during an assessment.

If a patient has reduced REM sleep, they might be irritable, anxious, or have difficulty concentrating the next day.

So it's not just about feeling tired.

It really messes with your emotional regulation.

It really does.

In these cycles, it's not like you do all your NREM and then all your, right?

It's not linear like that.

No, not at all.

It cycles throughout the night.

A full cycle lasts about 70 to 120 minutes.

And we repeat that four to six times a night.

Okay.

So that's the baseline biology for a healthy adult, but this is a gerontology text.

So what changes when we get older?

I feel like everyone just assumes older people sleep less, but is that actually true?

Well, it's more nuanced than that.

The text refers to box 11 to one, which lists age related changes in sleep.

Now these are considered normal changes, but that doesn't mean they aren't frustrating for the patient.

Of course.

First up, we have sleep latency.

Sleep latency.

That's the delay in falling asleep, right?

The time it takes from head on pillow to actually being asleep.

Correct.

And the statistics here are pretty telling.

Over 30 % of older women report taking more than 30 minutes to fall asleep.

Wow.

That is a long time to be scaring at the ceiling.

It is.

And because they spend more time in bed trying to sleep, their sleep efficiency drops.

What's sleep efficiency?

It's the percentage of time in bed you're actually spent sleeping.

In young adults, it's about 90%.

Okay.

That sounds pretty good.

It is.

But in older adults, it drops to 75%.

So they are in bed, but a quarter of that time, they're not actually sleeping.

Precisely.

They're just lying there awake.

And the architecture of the sleep stages changes too.

REM decreases.

Stage one, that light fragile sleep that actually increases.

But they're easier to wake up.

Much easier.

And those deep restorative stages three and four, they become less deep.

In the very old, especially men, deep sleep can be greatly reduced or even absent.

So if they aren't getting that stage four, they aren't getting that physical restoration.

Right.

They're missing that deep repair cycle.

And then there's the circadian rhythm shift.

You know, why do older adults wake up so early?

Is that the hypothalamus again?

It is.

There's a shift in the body's internal clock that leads to earlier bedtimes and consequently, very early morning awakenings.

And this often leads to increased daytime napping.

The nap.

Yeah.

This is where it gets really interesting for the nurse because we often think napping is bad.

We tell patients, don't let them nap.

They won't sleep at night.

We do.

But the text mentions a study by Floyd regarding napping that kind of turns that idea on its head.

Yes.

The Floyd study.

This is a crucial aha moment for evidence -based practice.

We have this ingrained belief that napping is bad because it ruins nighttime sleep.

It steals from the night's sleep bank.

Right.

But Floyd found that there was no difference in the length of nighttime sleep between nappers and non -nappers.

Really?

So the naps weren't actually stealing from the night?

No.

Floyd concluded that the napping actually supplemented the total sleep time.

So unless the napping is a symptom of an underlying disease or it's causing confusion, it's not necessarily a problem to be fixed.

It might just be how they get their total hours in for the day.

It might be.

That is a great takeaway for any nursing student.

Don't pathologize the nap unless you have a good reason to.

Okay.

That's a perfect transition.

Let's move to section two.

Factors influencing sleep quality.

We know the biology changes, but the environment plays a huge role, especially in a hospital.

A massive role.

The text contrasts the home environment with the institutional environment.

Home is familiar, comfortable.

Right.

Familiar bedding, familiar noises, but the hospital, it's a sensory assault.

The text cites a study by Misseldeen that is, frankly, shocking.

They monitored patients in acute care settings.

Okay.

Lay the numbers on us.

How much did they actually sleep?

Patients slept very little.

The mean sleep time was only 224 minutes.

Wait, 224 minutes?

That is less than four hours.

You cannot heal on four hours of sleep.

It is severely, severely deficient.

And why?

The study found light and sound levels in the hospital room were comparable to an urban residence like living downtown in a busy city.

And the sources of noise listed in box 11 to 2 aren't exactly rock concerts.

It's everyday hospital stuff, right?

Lending carts, staff talking in the hallway, alarms.

It's the constant low -level disruption.

So for the nursing student listening, here's your intervention list.

This is practical stuff.

Close the patient's door, use headphones for the TV.

Small things.

Tiny things that make a huge difference.

And there is a very practical tip in the text regarding equipment.

Let me guess.

Ask maintenance to lubricate the wheels on the utility carts.

Yes.

Lubricate the wheels.

It makes a difference.

Also practice cluster care.

What's cluster care?

Don't go in at 2 a .m.

for vitals, then back at 3 a .m.

for meds, then again at 4 a .m.

to turn them.

Do it all at once so they can get a solid block of uninterrupted sleep.

Makes sense.

What about temperature?

My grandmother's always cold.

A very common complaint.

The text is specific here.

Keep the ambient temperature no lower than 65 degrees Fahrenheit.

Older adults have a reduced metabolic rate and less muscle activity at night, so their core temp drops more easily.

So pile on the blankets.

Well, flannel sheets and light thermal blankets are recommended.

Also bed socks.

But, and here is a major safety flag, if they wear socks to bed, they need to put on slippers with grips before they step onto a linoleum floor.

Right, because socks on tile is a recipe for a fall, a major fall risk.

Exactly.

And the text warns to avoid heating pads if possible.

Their skin is so fragile and the risk of burns is just too high.

Let's talk about pain and comfort.

The text makes a strong point that pain really interferes with sleep onset.

It absolutely does.

And sometimes, structurally, the bed itself might be the enemy.

If a patient has COPD or heart failure, laying flat might be impossible because of orthopnea.

That shortness of breath when lying down.

Correct.

The text suggests using a reclining chair or even a rocking chair.

A rocking chair for sleep.

Yes, the rhythmic motion can be very soothing and actually promote sleep onset.

It's an old school remedy, but you know what?

It works.

I want to touch on the lifestyle shifts mentioned in the chapter because they're so profound.

Specifically, widowhood.

The statistic was that 40 % of women over 65 are widows.

It's a massive, massive lifestyle shift.

Sleeping alone after decades of partnership isn't just an emotional loss.

It disrupts the physical routine of sleep.

The text says it just feels strange to be in the bed alone.

And that strangeness causes insomnia.

It does.

And on the flip side, if they do have a partner or more likely a roommate in a nursing home, that can cause a whole other set of issues.

Oh, absolutely.

Snoring, different TV habits, different schedules.

It's a huge problem.

The text suggests matching roommates by interest or lifestyle whenever possible.

This is all part of what's called relocation stress when moving to assisted living.

And sleep is often the first casualty.

Okay, let's move on to section three.

Dietary and pharmacologic influences.

This is huge.

We all know coffee keeps you up.

But what does the text specifically say about caffeine?

Well, it acts as a stimulant.

Obviously, it can cause restlessness, tremors.

But the key for nurses is to note the hidden sources.

It's not just coffee, right?

Like tea, chocolate and some over the counter or OTC pain meds.

The nurse needs to check the label on everything.

And what about alcohol?

I feel like a lot of people use a nightcap to help them sleep.

The text calls alcohol's position equivocal, which I think is a great word for it.

Meaning it's a mixed bag, a very mixed bag.

A small amount might relax you, but larger amounts act as a diuretic.

It inhibits ADHD.

So you have to get up and pee all night.

And it specifically reduces REM and deep sleep.

So you might pass out faster, but the quality of sleep is garbage.

Total garbage.

You wake up feeling unrested.

And what about that classic bedtime snack?

Warm is better than cold.

The text suggests warm milk, custard, capioca.

A protein -based warm snack provides some calories in that comforting warmth.

Custard.

Haven't had custard in years.

Sounds nice.

Okay, let's get into the weeds on meds.

This is a huge area for nurses.

It is.

And the text is very, very cautious about hypnotics.

They should be used short -term only.

We're talking less than three weeks.

Why so short?

Because tolerance builds up incredibly fast and then you get rebound insomnia when you stop.

The problem actually gets worse.

And benzobizepines.

I feel like those get a particularly bad rap in gerontology.

They do.

For good reason.

High risk.

The text explicitly warns about them for older adults because of the long half -life.

Meaning the drug stays in their system longer.

Way longer than in a younger person.

This leads to daytime drowsiness, confusion, and a significantly increased risk of falls.

It's a major safety issue.

There's also Table 11 -2, which lists drugs that can mess up sleep.

Some of these were surprising to me.

It's a great table for students to review.

For example, beta blockers, like propranolol, are listed as a potential cause of nightmares.

Nightmares from a blood pressure med.

Yes.

And antihistamines, which people often take to sleep, can cause daytime sleepiness or paradoxically agitation and confusion in older adults.

That's wild.

It seems like natural remedies aren't always safe either.

Box 11 -3 warns about herbal remedies.

Right.

And this is a key teaching point for patients.

Natural does not mean safe.

The risk of drug interactions is real and many of these herbal compounds haven't been fully tested for safety in this population.

So you always have to ask what supplements they're taking.

Always.

Every single time.

Let's get into the heavy hitters.

Section 4.

Sleep disorders.

We have insomnia, sleep apnea, and PLMS.

Insomnia is categorized by duration.

So transient is just a few nights of stress.

Short term is less than a month, maybe due to an acute illness or grief.

And chronic is anything lasting more than a month.

But sleep apnea seems to be the one with the most severe physiological consequences.

Absolutely.

The text distinguishes between three main types.

First, you have central sleep apnea, or CSA.

This is where the brainstem literally stops sending the signal to breathe.

That's a brain issue, not a blockage.

Exactly.

It's often linked to serious conditions like heart failure or stroke.

Then you have the more common obstructive sleep apnea, or OSA.

That's the blockage one.

Right.

Risk factors are obesity, a short thick neck, jaw deformities, the airway physically collapses during sleep.

Then there's a third type mentioned that's fascinating.

Complex sleep apnea, or COMFESS.

I'm not familiar with that one.

What is it?

It's so interesting.

It emerges when you treat OSA with a CPAP machine.

You fix the obstruction, but then the patient starts developing central apnea characteristics.

So the brain sort of forgets to breathe once the airway is open.

It's like that, yes.

It's a very complex issue.

Wow.

Now there is a nursing care plan case study in the text about Mr.

V.

I love these case studies because they make it all real.

Tell us about Mr.

V.

So Mr.

V is 79.

He has a tough combination of diagnoses.

OSA, COPD, obesity, and depression.

He's in a facility recovering from a recent tracheotomy.

And he's not a happy camper.

No.

The text says he refuses to go to the dining room.

He wants a fridge in his room.

He just plays solitaire and watches TV all day.

He's very isolated.

So what does the nurse do?

What's the plan?

The interventions focus on breaking that cycle of inactivity and isolation.

They encourage weight loss using the MyPlate guide.

They want him keeping a food diary.

What about activity?

Physically, they want him walking to tolerance.

To tolerance.

That's a key nursing phrase, isn't it?

It is.

It means don't push him until he collapses, but you have to push him a little bit.

And crucially for his OSA, they want him in a sideline position for sleep to help keep his airway open.

And the social part seems huge, too.

It's probably the most important part.

Engaging him in activities to reduce that daytime napping, which in turn might help him sleep better at night.

It really shows how holistic the care has to be.

You can't just treat the apnea.

You have to treat the isolation and the diet and everything else.

There's a call connected.

Before we leave disorders, can you quickly clarify PLMS for me?

How is that different from restless leg syndrome?

Good question.

Periodic limb movements and sleep, or PLMS, involves repetitive kicking like every five to 90 seconds throughout the night.

The patient might not even know they're doing it, but their bed partner certainly does.

Right.

RLS, on the other hand, is more of a sensation when you're awake.

It's that irresistible urge to move your legs.

PLMS is the actual movement during sleep.

And the text warns against using antidepressants for PLMS.

It does.

Certain antidepressants can actually make it worse.

The treatment of choice is usually a dopamine agonist.

Yes, yeah, that makes sense.

Let's move to section five, assessment.

Now we're playing detective.

We need to take a good sleep history.

We do.

Box 11 for 4 outlines the components.

And a key thing here is to distinguish between quality and quantity.

What's the difference?

Quality is subjective.

It's the patient saying, I feel terrible.

Quantity is objective.

It's the patient saying, I slept for four hours.

You need both pieces of the puzzle.

And what are the tools available to us?

Well, the sleep diary is the gold standard for getting a 24 -hour view of their patterns.

But there are also two specific scales mentioned.

The Stanford Sleepiness Scale, or SSS.

And the Epworth Sleepiness Scale, or ESS.

OK, what's the difference between those two?

The Stanford Scale measures how sleepy you feel right now at this very moment.

The Epworth Scale measures something called sleep propensity.

Sleep propensity.

Yeah, it's about how likely you are to doze off in a specific situation, like sitting in traffic or watching TV after dinner.

It's more about your general level of D times sleepiness.

That's a really useful distinction.

And finally, sleep hygiene.

We hear this term a lot.

What does the text say?

It's all the behavioral stuff.

You know, stable schedules, a quiet environment.

But the text mentions two specific therapies that are really interesting.

Stimulus control and sleep restriction.

Stimulus control is the bed is for sleep and sex only rule.

Correct.

No TV, no eating in bed, no arguing in bed.

If you can't sleep after about 20 minutes, you get up and leave the room.

You have to reassociate the bed with sleep.

And sleep restriction.

That sounds counterintuitive, restricting sleep.

It does, doesn't it?

But it's very effective.

You limit the time in bed to the actual estimated sleep time plus 15 minutes.

So if they only sleep five hours a night, they are only allowed in bed for five hours and 15 minutes.

And what's the logic there?

It forces the body to consolidate sleep, making it deeper and more efficient.

It's tough love, but it often works to break the cycle of chronic insomnia.

Wow, that is tough love.

All right, we are rounding the corner into the second half of our mission.

Activity, section six.

Here we go.

And first, we need to define some acronyms that will be on every nursing exam forever.

ADLs and IADLs.

Break them down for us.

ADLs are activities of daily living.

This is the basic survival stuff.

Bathing, dressing, eating, toileting, moving from bed to chair.

And IADLs.

Instrumental activities of daily living.

These are the more complex tasks you need for independent living in a community.

Things like driving, shopping, cooking a meal, handling your finances.

So if I can't balance my checkbook, that's an IADL deficit.

If I can't pull up my pants, that's an ADL deficit.

That's a perfect way to put it.

And the nursing role here is to identify assistive devices to preserve independence for as long as possible.

Like what?

Oh, simple things.

Velcro clothing instead of buttons.

Built -up handles on utensils so arthritic hands can grip them better.

Raised toilet seats to make standing up easier.

Small things that make a huge difference in dignity.

A world of difference.

It's all about maintaining function.

Now what about physical exercise?

What are the guidelines for older adults?

The text cites the World Health Organization, the WHO.

The recommendation is 150 minutes of moderate intensity aerobic exercise per week.

Plus some strength training.

Yes, plus muscle strengthening two days a week.

150 minutes might sound like a lot to an 80 -year -old who's been sedentary.

It might.

That's why the text suggests the talk test.

It's a great, simple tool.

You should be able to talk while you're exercising, but not sing.

If you can sing, you aren't working hard enough.

Exactly.

And if you can't talk at all, you're working too hard and need to back off.

And for someone who is completely sedentary, how do they start?

Start low and go slow.

The text says start with just five minutes a day.

That's it.

Just five minutes.

And safety is absolutely key.

Like what?

Hydration, proper shoes, avoiding extreme weather.

And the text actually recommends mall walking.

Mall walking.

It's a classic for a reason, I guess.

It is.

It's climate controlled.

The surfaces are flat.

There are benches to rest on.

And it's safe.

It's a perfect environment.

Section seven is really special.

It's about activity in the context of dementia.

This requires a whole different mindset, doesn't it?

It really does.

The philosophy here is asset -based.

You have to focus on what they can do, not on what they can't.

The ultimate goal is preserving dignity and their remaining abilities.

The text uses the phrase meaningful activities.

What defines meaningful for someone with advanced dementia?

It must be voluntary and it must have a purpose.

But purpose can just be fun or enjoyment.

It shouldn't be childish and it must not feel like a test or a scolding.

Can you give us some examples from Box 11 to 5?

Absolutely.

Simple, repetitive tasks are great.

Things like folding towels or dusting.

It makes them feel productive and part of the household.

That's familiar.

Very familiar.

And for agitation, a physical activity like sitting in a rocking chair or going for a slow walk can help redirect that restless energy.

And reminiscence is listed as an activity.

I find that so interesting.

Yes.

And music is so powerful here.

Song lyrics are often preserved in memory long after other things are lost.

Singing old songs isn't just noise.

It's connecting them back to their identity.

The text also mentions how to handle personal care, like bathing as an activity.

Right.

And the key is to break it down.

Don't say, go take a bath.

That's too many steps.

What do you say instead?

You say, let's walk to the bathroom.

Then sit down on the bench.

Then let's put your feet in the water.

Simple, single steps.

Use visual cues.

And critically, never use don't commands.

Why no don't commands?

Because it's too negative and too abstract.

Instead of saying, don't go in there, you say, come over here with me.

You always want to redirect, not scold.

That's a powerful shift in communication.

Finally, section eight covers lifestyle transitions.

Retirement, relocation, loss of a spouse.

These are the big social determinants of activity.

Retirement removes structure.

If you don't replace work with volunteering or a hobby, it's very easy to become sedentary.

And relocation?

Relocation, like moving to a new home or an assisted living facility disrupts all your routines.

Maybe you lost your safe neighborhood walking route.

You have to start all over.

And loss of a spouse is probably the biggest one.

It is.

Grief just kills motivation.

But practically, the surviving spouse might suddenly need to learn a whole new set of skills.

If the husband always drove and he passes away, the wife's entire activity radius shrinks, unless she learns to drive or navigate public transit.

So the nurse's role is to support that new skill acquisition.

Exactly.

It's about helping them rebuild their life and their activity patterns.

So we've covered the biology, the environment, the drugs, the disorders, the assessment, and now activity.

It's a huge chapter.

It is.

But as you can see, it all connects.

Let's wrap this up with a recap, then.

What is the big picture for the listener, for that nursing student?

The big picture is that sleep and activity are two halves of the whole day.

As a nurse, you are a detective.

If your patient isn't sleeping, you have to ask why.

Is it just their age?

Is it the noisy hospital?

Is it that coffee they had at 6 p .m.?

Or is it the benzodiazepine causing confusion?

Is it undiagnosed sleep apnea?

Exactly.

You have to investigate all the possibilities.

And on the activity side, what's the takeaway there?

The goal is always quality of life.

Whether that's helping someone hit their 150 minutes of mall walking or simply preserving the dignity of folding towels in a memory care unit.

It all matters.

Here's a final provocative thought to leave you with.

We talked about the cycle of sleep and activity.

So consider this.

If we don't treat the activity deficit during the day, if we let the patient just sit in a chair for 12 hours straight, we cannot possibly fix the sleep deficit at night.

That's it right there.

You can't sedate your way out of a sedentary lifestyle.

They are not separate problems.

They are one continuous rhythm of life that the nurse helps to orchestrate.

I love that.

You can't sedate your way out of a sedentary lifestyle.

That is going on a t -shirt.

I wear it.

Thank you so much for breaking all of this down with us.

And to our nursing students listening, good luck with chapter 11.

You've got this.

You certainly do.

Keep learning.

Thanks for listening to this deep dive.

A warm thank you from the last minute lecture team.

We'll catch you on the next one.