Note from the National Guideline Clearinghouse (NGC): In this update of the guideline, the process previously used to develop the geriatric nursing protocols has been enhanced.
Levels of evidence (I – VI) are defined at the end of the "Major Recommendations" field.
Parameters of Assessment
- A sleep history (see Table 20.2 in the original guideline document) should include information from both the patient and family members. People who share living and sleeping spaces can provide important information about sleep behavior that the patient may not be able to convey.
- The Epworth Sleepiness Scale (Johns, 1991 [Level IV]; Avidan, 2005 [Level I]; National Center on Sleep Disorders Work Group, 1999 [Level VI]) (see Table 20.1 in the original guideline document) is a brief instrument to screen for severity of daytime sleepiness in the community setting. See Resources section Try this at www.ConsultGeriRN.org.
- Table 20.3 the original guideline document outlines key points in obtaining salient information from older patients and their family members as well as gauging severity of symptoms. (American Academy of Sleep Medicine Task Force, 1999 [Level I]).
- The Pittsburgh Sleep Quality Index (Buysse et al., 1989 [Level IV]) is useful to screen for sleep problems in the home environment and to monitor changes in sleep quality. See Resources section Try this at www.ConsultGeriRN.org.
Nursing Care Strategies
- Vigilance by nursing staff in observing patients for snoring, apneas during sleep, excessive leg movements during sleep, and difficulty staying awake during normal daytime activities (Ancoli-Israel & Ayalon, 2006 [Level I]; Avidan, 2005 [Level I]).
- Management of medical conditions, psychological disorders and symptoms that interfere with sleep such as: depression, pain, hot flashes, anemia, or uremia (Ancoli-Israel & Ayalon, 2006 [Level I]; Avidan, 2005 [Level I]).
- For patients with a current diagnosis of a sleep disorder, ongoing treatments such as continuous positive airway pressure (CPAP) should be documented, maintained, and reinforced through patient and family education (Avidan, 2005 [Level I]). Nursing staff should reinforce patient instruction in cleaning and maintaining positive airway pressure equipment and masks.
- Instruction for patients and families regarding sleep-hygiene techniques to protect and promote sleep among all family members (see Table 20.4 in original guideline document) (Avidan, 2005 [Level I]).
- Review and, if necessary, adjustment of medications that interact with one another or whose side effects include drowsiness or sleep impairment (Ancoli-Israel & Ayalon, 2006 [Level I]).
- Referral to a sleep specialist for moderate and severe sleepiness or a clinical profile consistent with major sleep disorders, such as obstructive sleep apnea or restless legs syndrome (Avidan, 2005 [Level I]).
- Aggressive planning, monitoring and management of patients with obstructive sleep apnea when sedative medications or anesthesia are given (Avidan, 2005 [Level I]).
- Ongoing assessment of adherence to prescriptions for sleep hygiene, medications and devices to support respiration during sleep (Avidan, 2005 [Level I]).
Follow-up Monitoring
- Depending upon diagnosis, follow-up may include long-term reinforcement of the original interventions along with support for adhering to treatments prescribed by a sleep specialist. For example, patient compliance with CPAP therapy for obstructive sleep apnea is critical to its efficacy and should be assessed during the first week of treatment (Weaver et al., 1997 [Level IV]). All patients benefit from positive reinforcement while trying to acclimate to nightly use of a positive airway pressure device.
- CPAP masks may require minor adjustments or refitting to find the most comfortable fit. Most such changes are needed during the acclimation period, but patients should be encouraged to seek assistance if mask problems develop (Weaver et al., 1997 [Level IV]). In the acute-care setting, respiratory-care technicians are valuable in-house resources when staff from a sleep center is not readily available.
- During the initial treatment phase of insomnia, sleep deprivation may cause rebound sleepiness, which should subside over time. Follow-up should include ongoing assessment of napping habits and sleepiness to track treatment effectiveness (Avidan, 2005 [Level I]).
- If obesity has been a complicating health factor, weight loss is a desirable long-term goal. With reduction in daytime sleepiness, the timing is ripe for increasing the activity level. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include regular exercise, which is also consistent with cardiovascular health and long-term diabetes control (Ancoli-Israel & Ayalon, 2006 [Level I]; Avidan, 2005 [Level I]).
Definitions:
Level I: Systematic reviews (integrative/meta-analyses/clinical practice guidelines based on systematic reviews)
Level II: Single experimental study (randomized controlled trials [RCTs])
Level III: Quasi-experimental studies
Level IV: Non-experimental studies
Level V: Care report/program evaluation/narrative literature reviews
Level VI: Opinions of respected authorities/Consensus panels
Reprinted with permission from Springer Publishing Company: Capezuti, E., Zwicker, D., Mezey, M. & Fulmer, T. (Eds). (2008) Evidence Based Geriatric Nursing Protocols for Best Practice, (3rd ed). New York: Springer Publishing Company.
