ENVIRONMENTAL SOLUTIONS TO 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.

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Sleep patterns in America• Sleep Duration:

Decreased from 9 hours to 7 hours

• Lack of Sleep:Reduced work productivity and attendanceIncreased accidentsIncreased medical costs and error rates

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Rand, 2017

How Much?

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Age GroupRecommended Hours of Sleep Per Day1,2

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

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)

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Circadian Rhythms Finkel,M. (2018). Master Clock. Image retrieved from

https://www.nationalgeographic.com/magazine/2018/08/science-of-sleep/

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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, 20157

Health Conditions Related to Poor SleepPhysical● Increased:

Stress responseHeart, respiratory disease

● Decreased:Pain toleranceTissue repairImmune functionResponse time = fall risk

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Cognitive● Increased:

AnxietyDepressive disordersConfusion/irritability

● Decreased:

Learning abilityMemory Excitability

Finkel, 2018, Stone et al. 2014; Ancoli et al. 2008

Environmental Influences on Sleep (Light, Sound, Diet, Routine)

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Light: Evidence Based Practice

● Decrease Bright and Blue Light:Nighttime light: Increased daytime sleepiness and out of sync circadian rhythmsBlue 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

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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

Blue Light Delay in Sleep CyclesFinkel,M. (2018). Master Clock. Image retrieved from https://www.nationalgeographic.com/magazine/2018/08/science-of-sleep/

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Brainstorming Light Interventions

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Sound: Evidence Based Practice

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● 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

Brainstorming Sound Interventions

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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 durationMelatonin promoted sleepinessL tryptophan decreased sleep latency High protein diets decreased waking episodes

• Sleep Disrupting Poor diet reduced sleep durationRefined sugar linked to reduced sleep qualityAfternoon/evening caffeine consumption reduced sleep quality

St-Onge and Anja Mikic 2016; Lloret‐Linares et al., 2012; Valtonen et al., 2005; Yurcheshen et al 201515

Brainstorming Diet Interventions

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Routine: Evidence-Based Practice

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

• Standardize Care Routines (consistent daily timing):Consistent bedtime/wake timeRegular 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

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Brainstorming Routine Interventions

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• 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

Case: Minnesota Veterans Home Staff Identified Sleep as a quality improvement project

Environment: Newly opened unit

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Case Setting● Minnesota Veterans Home

● 24 bed Unit

● Average Age 76

● Poor Sleep Quality

● PSQI above 5

● 8 out of 16 residents

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(Personal Photo, 2018)

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).

Group Case-Based Intervention Planning➢ Sound

➢ Diet

➢ Light

➢ Routine

Implementation of Change

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Quality Improvement Project: Environmental Sleep Toolkit for

Elderly Veterans

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St. Catherine University Clinical Scholar Program

• MAOT/DPT Program Capstone• Clinical Scholar Program• Research Education• Community Partnerships• GHR Innovative Scholarship

Grant • SCU IRB Approval

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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).

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Cycle 3: Environmental Toolkit• Light Interventions

• Pull shades at night, natural daylight day• Amber night light• Hug lights• Turn off room lights, dim hall

• 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

● Implementation of Sleep Hygiene Routine○ compliance checks○ checklists, reminder cards○ sleep champion on each wing

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(Personal Photo, 2018)

(Personal Photo, 2018)

https://images-na.ssl-images-amazon.com/images/I/81p%2BZXnSY7L._SX425_.jpg

Cycle 3: Environmental Toolkit• Diet Interventions

• High protein snacks sustainable at site• Offering nightly non-caffeinated beverages • 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)

26(Personal Photo, 2018)

https://images-na.ssl-images-amazon.com/images/I/A1LLpJDVV9L._SX522_.jpg

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RESULTS

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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

DISCUSSION

Significance to OT• Sleep is an occupation!

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