Artigo Acesso aberto

Let Sleeping Elders Sleep

2017; Elsevier BV; Volume: 18; Issue: 9 Linguagem: Inglês

10.1016/j.carage.2017.08.004

ISSN

2377-066X

Autores

Karl Steinberg,

Tópico(s)

Sleep and related disorders

Resumo

One thing all of us share — whether we are practitioners or patients, presidents or prisoners — is the need for sleep. A good night’s sleep is a blessing, and a bad night’s sleep is a curse. Although the term “la petite mort” (the little death) is more commonly applied to a different physiological phenomenon, it could easily pertain to sleep. Our bodies, and more importantly our brains, slow down. We may have vivid dream activity, but for most of the night it is as if we were near death — unconscious, relaxed, restoring our energy and recharging our batteries — and feeling no pain. When we don’t sleep well, the lack of rest can bleed over into the next day, resulting in irritability, poor concentration, and other unfortunate (to us and those around us) consequences. Luckily, I’ve always been a good sleeper, and I can usually fall back asleep without much trouble if I get a late-night nursing home call. But I do remember some serious sleep deprivation, especially during residency. We had some 36-hour or even 40-hour shifts on the infamous “labor deck” (labor and delivery), and sometimes we would not even get the 45-minute equivalent of a disco nap throughout the whole shift. I remember being almost delirious at times, forgetting that I had met a postpartum mom a day earlier, or nodding off during a cesarean delivery and almost collapsing into the operative field. Although this outrageously excessive work requirement created some good war stories for today, it did not create a very efficient or safe clinician then. More than half of the elder population have insomnia, and it’s one of the top five most frequent complaints in outpatient medical practices. Roughly one of six elders has sufficiently severe insomnia to seek medical attention for it, and women are almost three times as likely to have moderate to severe insomnia as men (35% vs. 13% in a large study). In elders who reside in long-term care facilities, almost two-thirds have some form of sleep disturbance. Among age-related changes in sleep are an increased sleep latency time (time from going to bed to actually falling asleep), less time spent in deep sleep, and more of a propensity to awaken spontaneously or in response to external stimuli. Numerous conditions more common in older patients can contribute to disturbed or nonrestorative sleep, including pain symptoms (related to arthritis or other problems), respiratory issues such as chronic obstructive pulmonary disease and central or obstructive sleep apnea, cardiac conditions such as systolic heart failure with associated orthopnea or paroxysmal dyspnea, skin conditions such as pressure ulcers or pruritus, and gastrointestinal issues including constipation and gastroesophageal reflux disease. Polypharmacy is another contributor, and many individual medications have deleterious effects on sleep. In the nursing home, opportunities for further sleep disruption are rampant. Our facilities are not quiet places. Most residents have roommates, even if it’s a spouse. Certified nursing assistants (CNAs) may communicate loudly in the halls on night shifts. When patients are on “alert charting” when newly admitted, or while on antibiotics, or after a change of condition, their vitals may be assessed once every shift, and it may not be right at the beginning or end of the shift (usually 11 p.m. to 7 a.m. for a night shift). A common peeve of mine: Some residents come from the hospital with medication ordered every 6 hours around the clock, including inhalers. (“Wake up, it’s midnight, it’s time for your inhaler.” Then, “Wake up, it’s 6 a.m., it’s time for your inhaler.”) Blood sugar tests ordered for before breakfast are often done before 7 a.m., which may be fine for some people but would not be agreeable to me (I’m not a morning person). Most facilities still have policies requiring CNAs to turn and reposition all residents who can’t do it themselves every 2 hours, any time they are in bed, even those who may not be at high risk for pressure ulcers. Incontinent residents get checked to see if they are wet or soiled multiple times overnight. Imagine how difficult all the multiple awakenings would be for a person who has a hard time getting back to sleep — or falling asleep in the first place! Add to that the fact that many residents are encouraged to nap during the day, and you have quite a recipe for rotten sleep. So with that background we get to the point of the column: In nursing homes, helping our residents get their best possible night’s sleep can be exceptionally challenging for many of the reasons I’ve discussed. Recently my colleague Mike Wasserman, MD, CMD, mentioned another: In many nursing homes, routine lab work is drawn in the pre-dawn hours. Not surprisingly, many residents report that they have trouble getting back to sleep after being rousted and poked by a phlebotomist. The reasoning behind this practice probably includes the high likelihood that the resident can be located easily (i.e., they’re not in therapy or the activities room), and the idea that the results will be ready by close of business so the doctor can receive them at a reasonable hour. These ideas make sense from a practical standpoint but not so much from the perspective of resident-centered care. As a fellow nursing home corporation chief medical officer, Dr. Wasserman suggested that we, along with our state Society chapter (the California Association of Long-Term Care Medicine), take action to eradicate this seemingly unnecessary and inhumane practice within our organizations and beyond, if possible. I took the idea to the Quality Subcommittee of our state affiliate of the American Health Care Association (California Association of Health Facilities) and found overwhelming support there. The legendary (and just now retired) Jocelyn Montgomery, RN, PHN, felt that merely changing the routine phlebotomy times didn’t go far enough — we should also try to eradicate night-shift vitals, unnecessary turning and repositioning, and all the other culturally ingrained indignities that disturb nursing home residents’ sleep. What a great idea! Our organizations are working on a broader coalition with the mission of improving the nocturnal quality of life for our residents. We are hoping to raise awareness of these common practices that disturb our residents’ sleep and encourage facilities (and physicians, nurses, administrators, nursing home chains, contracted reference laboratories, and others) to reduce their routine use. We are starting by trying to get our largest laboratory provider to agree to afternoon draws for routine blood work — with non-panic-value results reported the following morning. There may be concerns about this change, including risk management issues, workforce issues for phlebotomists and laboratory technicians, and traffic-related or transportation factors — but also just general inertia. The prevailing culture in nursing homes is not the most amenable to change, yet we have seen huge changes in the not-so-distant past, including major reductions in the use of physical restraints and unnecessary antipsychotic medications. With a little effort, it should not be that hard to reduce these assaults on our residents’ sleep as well. Let’s do our best to put a stop to unnecessary nighttime awakenings for routine interventions that either don’t need to be done at all or can wait until a time when the resident is awake. I’m hoping to follow up on this column next year with news of how our tentatively named “Protect Sleep” initiative is faring. Other routine sleep hygiene measures should be care-planned and implemented whenever possible, especially for our residents with insomnia. These include: •Avoiding daytime naps.•Exercising in the morning or early afternoon.•Reducing polypharmacy.•Avoiding caffeine late in the day.•Using the bed only to sleep or for sexual activity.•Getting a lot of early morning light.•Going to the bathroom right before going to bed.•Using a white noise machine to mask hallway sounds and other ambient noise.•Aiming for a regular bedtime and wake-time routine.•Having a snack or some milk before bedtime.•Trying to cohort roommates with similar sleep habits. Melatonin can help regulate the sleep-wake cycle. In general, routine use of traditional hypnotics such as zolpidem — which still seem to be handed out like candy in many hospitals — should be discouraged. Antihistamines, with their heavy anticholinergic burden, should be avoided as insomnia treatment in our elders. Ruling out more serious sleep disorders, especially sleep apnea and restless legs syndrome — or diagnosing and treating them — also are important interventions. If any of our readers have had experience with initiatives like the one I have described here, we would love to hear about your successes as well as any barriers to implementation. We know that poor sleep has significant adverse health effects. Please consider knocking off the routine checks and turnings, vitals checks, and medication administration for patients who do not need them in the middle of the night. If I were living in a nursing home, I would certainly not want someone messing with me every couple of hours. Let’s try to do unto others as we would have them do unto us! Dr. Steinberg is chief medical officer for Mariner Health Central in California, and a longtime nursing home and hospice medical director. He is editor in chief of Caring for the Ages and chairs the Public Policy Committee for the Society. The views he expresses are his own and not necessarily those of the Society or any other entity. He may be reached at [email protected] and he can be followed on Twitter @karlsteinberg.

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