E NVIRONMENTAL S OLUTIONS T O SLEEP IMPAIRMENT FOR OLDER ADULTS Presenters: Brenda Frie, EdD, OTR/L, CHT; Siri Dusek, OTS; Alissa Hynes, OTS
Learning objectives • Participants will identify three environmental modifications that are effective in long term care settings. • Participants will discuss how to customize sleep interventions to the specific needs of the population. • Participants will analyze a case study and determine three appropriate sleep interventions for the population. 2
Sleep patterns in America • Sleep Duration: Decreased from 9 hours to 7 hours • Lack of Sleep: Reduced work productivity and attendance Increased accidents Increased medical costs and error rates Rand, 2017 3
How Much? Recommended Hours of Sleep Per Age Group Day 1,2 Infant 4-12 months 12-16 hours per 24 hours (including naps) Toddler 1-2 years 11-14 hours per 24 hours (including naps) Pre-school 3-5 years 10-13 hours per 24 hours (including naps) School Age 6-12 years 9-12 hours per 24 hours Teen 13-18 years 8-10 hours per 24 hours Adult 18-60 years 7 or more hours per night Paruthi S, Brooks LJ, D’Ambrosio C, Hall WA, Kotagal S, Lloyd RM, et al., 2016, Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM, Buysse D, et al.,2015 4
Stages of Sleep (90 min cycles) Stage 1: Shallow Sleep (5 min or so) Stage 2: Light Sleep. Increased brain activity , then slows down (power nap, 20-50 min) Stage 3-4: Deep restorative sleep. Brain slows down, no eye or muscle movement. Body repairs muscles and tissues, boosts immune system, produces growth hormone and prepares for the next day. (30 min or so) Stage 5: Rapid Eye Movement (REM). Sleep stage of dreaming, paralysis of motor function, learning and long term memory. Heart, Blood pressure, and respiration increase (5-20 min) 5
Circadian Rhythms Finkel,M. (2018). Master Clock . Image retrieved from https://www.nationalgeographic.com/magazine/2018/08/science-of-sleep/ 6
Age-Related Sleep Change ● Sleep Latency: Awake more frequently Takes longer to fall asleep Increased time in bed ● Sleep Duration: More fragmented sleep Return to sleep takes longer ● Circadian Rhythm: Shift in sleep/wake cycle, lighter sleep Roepke & Ancoli, 2010; Espiritu et al, 2008; Duffy, Zitting, & Chinoy, 2015 7
Health Conditions Related to Poor Sleep Physica l Cognitive ● Increased: ● Increased: Anxiety Stress response Depressive disorders Heart, respiratory disease Confusion/irritability ● Decreased: ● Decreased: Pain tolerance Tissue repair Learning ability Immune function Memory Response time = fall risk Excitability Finkel, 2018, Stone et al. 2014; Ancoli et al. 2008 8
Environmental Influences on Sleep (Light, Sound, Diet, Routine) 9
Light: Evidence Based Practice Decrease Bright and Blue Light: ● Nighttime light: Increased daytime sleepiness and out of sync circadian rhythms Blue Light: Caused delay in sleep cycles Increase Natural Light: ● Reduced natural light disrupted rhythms result in depression, sleeping during the day, trouble falling asleep at night, unclear sleep/wake patterns, hunger at odd times, and loss of cognitive ability Promotes Circadian rhythm sleep cycles Brainard et al., 2001; Chapperon, et al., 2007; Duffy, Zitting, & Chinoy, 2015; Figueiro et al., 2014; Kerr, 2011; Royer et al., 2012; Riemersma-Van der Lek et al., Steaphen, Olson, & Stutzman, 2017; 2008; Thappan, Arendt, & Skene, 2001; White, et al., 2013 10
Blue Light Delay in Sleep Cycles Finkel,M. (2018). Master Clock . Image retrieved from https://www.nationalgeographic.com/magazine/2018/08/science-of-sleep/ 11
Brainstorming Light Interventions 12
Sound: Evidence Based Practice Reduce Sleep Disruption : ● Noises from staff and staff-patient interaction at night disrupt patient sleeping. Roommate, cleaning equipment, slamming doors, bed alarms, TVs, etc. Increase Relaxing Sounds: ● Soft relaxing music promotes sleep. Alessi, Yoon, Schnelle, Al-Samarrai, and Cruz 1999; Hume, Brink, & Basner, 2012; Schnelle et al., 1998; Steaphen et al., 2017; MIssildine, 2008; Ellmers, Arber, Luff, Eyers, & Young, 2013; Gilsenan, 2012; Kerr 2011: Wang et al., 2016; Jenson & Padilla, 2017; Bressler, Redfern, & Brown, 2011; Middelkoop et al., 1994 13
Brainstorming Sound Interventions 14
Diet :Evidence Based Practice • Snooze Foods? No single cure but overall helpful trends. Minimal evidence chamomile tea, cherry juice • Sleep Promoting: Healthy diets increased sleep duration Melatonin promoted sleepiness L tryptophan decreased sleep latency High protein diets decreased waking episodes • Sleep Disrupting Poor diet reduced sleep duration Refined sugar linked to reduced sleep quality Afternoon/evening caffeine consumption reduced sleep quality St-Onge and Anja Mikic 2016; Lloret ‐ Linares et al., 2012; Valtonen et al., 2005; Yurcheshen et al 2015 15
Brainstorming Diet Interventions 16
Routine: Evidence-Based Practice • Standardize Care Routines (consistent daily timing): Consistent bedtime/wake time Regular short nap (stage 2) Set work/rest schedule consistent with circadian rhythm Increase Physical Activity and Socialization: • Longer sleep durations, more efficient sleep habits, and less depressive symptoms Bartick, Thai, Schmidt, Altaye, & Solet, 2010; Chen, Li, Huang, & Cheng, 2016; Cohen-Mansfield & Jensen, 2005; Espiritu, 2008; Harris & Grando, 2014; Lareau et al., 2008; Lorenz et al., 2012; Richards et al., 2011; Schnelle et al., 1999; Smallfield & Molitor, 2018; Steaphen et al.., 2017; Zisberg, Gur-Yaish, & Shochat, 2010 17
Brainstorming Routine Interventions • Night-time care check lists • Staff lanyards with routine • Provide education on the importance of routine to staff and residents • Increase social and daytime activity • Darkening shades at night/ natural light day (or outside time) • Unit Cue Cards: Double voiding and position for comfort • Reduce nighttime noise 18
Case: Minnesota Veterans Home Staff Identified Sleep as a quality improvement project Environment: Newly opened unit 19
Case Setting ● Minnesota Veterans Home ● 24 bed Unit ● Average Age 76 ● Poor Sleep Quality ● PSQI above 5 (Personal Photo, 2018) ● 8 out of 16 residents Diagnoses: cerebrovascular disease (n=3), cerebral infarction (n=2), dementia or Alzheimer’s disease (n=2), Parkinson’s disease (n=2), weakness or age-related physical disability (n=2), bipolar disorder (n=1), Type 2 diabetes (n=1), major depressive disorder (n=1), multiple sclerosis (n=1), quadriplegia (n=1). 20
Group Case-Based Intervention Planning ➢ Sound ➢ Diet ➢ Light ➢ Routine Implementation of Change 21
Quality Improvement Project: Environmental Sleep Toolkit for Elderly Veterans 22
St. Catherine University Clinical Scholar Program • MAOT/DPT Program Capstone • Clinical Scholar Program • Research Education • Community Partnerships • GHR Innovative Scholarship Grant • SCU IRB Approval 23
Rapid Cycle Change The first cycle: Needs Assessment Staff Qualitative Feedback, Resident PSQI The second cycle: Staff Education Education on the evidence surrounding older adult sleep changes, influence on health status, conditions associated with poor sleep, and environmental interventions. The third cycle: Environmental Toolkit 26-day implementation, compliance (checklist, random checks) Fourth cycle: Pre-post assessment of the results . “ Plan, Do, Study, Act ” Loop (Johnson, K., Gustafson, D., Ewigman, B., Provost, L., & Roper, R., 2015). 24
Cycle 3: Environmental Toolkit • Light Interventions Pull shades at night, natural daylight day • Amber night light • Hug lights • Turn off room lights, dim hall • (Personal Photo, 2018) • Sound Interventions • Silicone door stoppers • Close doors • Cue to reduce room TV volume, Turn off Unit TV • Move Staff rounds away from resident care • Play soft relaxing music 30 min prior to bed https://images-na.ssl-ima ges-amazon.com/image s/I/81p%2BZXnSY7L._S X425_.jpg (Personal Photo, 2018) ● Implementation of Sleep Hygiene Routine 25 compliance checks ○ checklists, reminder cards ○ sleep champion on each wing ○
Cycle 3: Environmental Toolkit • Diet Interventions High protein snacks sustainable at site • https://images-na.ssl-images-amazon.c Offering nightly non-caffeinated beverages • om/images/I/A1LLpJDVV9L._SX522_.jp g Cue cards to limit caffeine intake after 3:00 • • Routine Interventions • Set quiet time (sound and light reduction) • Double voiding • Position for comfort • Option new pillows • Evening relaxation cart (reading, music CD, sleepytime tea, snacks, lavender) (Personal Photo, 2018) 26
R ESULTS 27
Overall Conclusions and Recommendations Conclusions ● Environmental toolkit improved quality of sleep on the unit. ○ The staff also felt that the toolkit was feasible and effective. ● Behavior change is difficult ○ Having a champion on the unit appeared to help compliance with implementation of the tool kit on each unit. ○ Random Student Observations ○ Checklist improved compliance 28
D ISCUSSION Significance to OT • Sleep is an occupation! 29
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