Page 73 Complete Your CE Test Online - Click Here Nursing consideration: Multiple factors may prevent an older adult from discussing the topics of STDs and/or HIV/AIDS. Older adults may not even perceive themselves as being at risk for contracting STDs or HIV/AIDS. They may believe these diseases only affect young people. On the other hand, there are misconceptions and lack of awareness among providers which may contribute to the underestimation and misdiagnosis of STDs and HIV/AIDS [26,27]. Resources specific to older adults that may be helpful to nurses include the following websites. The information offered pertains to sexuality as well as many other issues that impact nursing practice. ● ● The website for the Hartford Institute for Geriatric Nursing provides information about best practices and geriatric assessment tools and models. The site may be accessed at: ● ● Lippincott’s Nursing Center’s older adults section provides articles, tools and links to sites that specialize in information regarding older adult care. This site may be accessed at: https://www.nursingcenter. com/articles-publications/nursing-care-of-older-adults. Assessing sleep patterns Mrs. Burns is 74 years old and in good health. During her annual physical she tells her physician that she is “not getting enough rest.” When questioned further she explains that when she falls asleep, “it never feels like I really sleep. I just feel like I’m half awake and half asleep and if the clock so much as ticks I’m wide awake. It’s really making me tired and feeling like I have no energy.” Sleep stages A good night’s sleep is important for healthy daily function, alertness, and overall well-being. We must remember that sleep occurs in multiple stages including: periods of light and deep sleep (which usually are dreamless); and occasional periods of active dreaming (i.e., REM sleep during which respirations, heart rate, and blood pressure increase and there is increased brain activity and dreaming). These cycles are repeated several times during the night with the total sleep time remaining constant, but with more time being spent in the lighter stages of sleep than in deep sleep. Aging does not mean older adults should encounter sleep disorders; it merely increases the possibility that older adults will seek help to manage the problem [27]. “Age-related insomnia has been linked to changes in the strength of the circadian regulation of sleep, which leads to increased fragmentation of the sleep-wake cycle” [29]. These changes in circadian rhythm can lead to fatigue, cognitive difficulties, and mental/physical changes. Nursing consideration: Mrs. Burns seems to be lacking in the deeper stages of sleep. Her descriptions of feeling as though she never slept and being easily aroused (by the ticking of a clock) indicate Stage-1 and Stage-2 sleep. She may not be entering the deeper stages of sleep necessary for proper rest and body healing. Sleep assessment in the older adult A common mistaken belief is that the need for sleep decreases with age. In fact, older adults need about the same amount of sleep as they did when they were young or middle aged [9]. The majority of older adults need between six and ten hours of sleep each night. Research shows that less than four, or more than eight hours of sleep is associated with higher mortality rates than those of persons sleeping eight hours [9]. The Epworth Sleepiness Scale (ESS) is a reliable, well-known sleep scale and is considered to be a best practice method in assessing sleepiness in older adults. It distinguishes the average amount of sleep, and identifies problems arising from sleep deprivation that may require intervention [29]. When asking an older adult about his or her sleep patterns, try to avoid “yes” and “no” questions because these usually do not elicit enough helpful information. Ask instead about sleep behaviors and bedtime rituals [29]. Here are some suggestions for phrasing questions when assessing sleep patterns [9,27]: ● ● “What time do you usually go to bed?” and “What time do you usually get up?” A regular bedtime and awakening time is associated with better sleep patterns. ● ● “How many times do you wake up during the night?” and “What causes you to wake up?” This is better than asking the patient whether s/he sleeps through the night and requires older adults to think about their answers. They may assume that it is normal to wake up frequently during the night. If they do wake frequently, this may indicate a health problem. ● ● “How many times do you wake up to go to the bathroom during the night?” The answer to this question can indicate various problems, such as incontinence, or enlarged prostate in men, or anxiety. ● ● “What kinds of things help you to sleep at night?” and “What kinds of things prevent you from sleeping at night?” The answers to these questions may provide you with clues to specific physical or mental health problems. For example, a patient may tell you that some nights s/he wakes up gasping for air or coughing, indicating a possible cardiovascular or nervous system problem. ● ● “How many naps do you take during the day?” and “How long do you nap?” Frequent naps or lengthy naps can disrupt a person’s nighttime sleep patterns. It is estimated that about five million older adults in the U.S. have a serious sleep disorder [9]. When identifying and treating insomnia, you must determine some of the potential causes, such as sleep apnea, uncontrolled pain, restless leg syndrome, or other periodic limb movement disorders associated with neurological disease. Some of the more common problems that adversely affect sleep include the following issues [9,17,27]: ● ● Anxiety and depression: These issues can interfere with a person’s ability to fall asleep and/or stay asleep. ● ● Substance abuse: Abuse of alcohol, prescription drugs and/or illegal drugs can profoundly disrupt a person’s sleep patterns. ● ● Excessive intake of caffeine: Excessive intake of caffeine, especially in the evening, can prevent a person from falling asleep or staying asleep. ● ● Pain: Older adults may deal with chronic pain issues. Pain may be due to arthritis, cancer, nervous system disorders, and so on. Older adult patients who are in physical discomfort take longer to fall asleep, stay asleep, or find a comfortable sleeping position. ● ● Cardiovascular disease and respiratory disease: These types of diseases may cause orthopnea and shortness of breath. Asking patients “How many pillows do you sleep on at night” gives you an indication that they may need to sit up or be propped up to sleep without difficulty breathing. ● ● Dementia: Older persons with dementia experience more sleep problems than other older persons. Sleep is often fragmented, and nighttime wandering may occur. ● ● Urinary issues: Frequency, nocturia and urgency commonly occur in older adults and these increase with age. Older men may experience benign prostatic hypertrophy, which prevents the bladder from emptying completely and often causes the sensation of constantly feeling the urge to void. These issues are compounded by the decreased bladder capacity of the older adult. ● ● Sleep apnea: This is an intermittent, temporary pause in breathing during sleep. This can occur many times throughout the night and lasts about ten seconds each time it occurs. These interruptions in breathing can lead to hypoxia. Research shows that older adults who suffer from these kinds of hypoxic episodes are more likely to experience sudden death, stroke, angina and/or exacerbating hypertension. Patients and their sleeping partners should be questioned about the occurrence of the signs and symptoms of sleep apnea, which include: heavy, loud snoring; choking, coughing or struggling to breathe while sleeping; extreme sleepiness during the day; headaches in the morning; and trouble concentrating. ● ● Medications: A number of medications can interfere with sleep patterns. When providing pharmacology patient education as well as assessing sleep and rest, be sure to familiarize yourself with medications that may disturb a patient’s sleep. Some drugs commonly associated with sleep interference include decongestants, antihistamines, beta-blockers and beta-agonists. Nursing consideration: Some antidepressants, such as Elavil and Sinequan, can have sedating effects and should be taken in the evening. Antidepressants such as Zoloft and Paxil may have stimulating effects and should be taken in the morning [9].