Sleep: The New Vital Sign

February 27, 2018
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The nurse began her morning like any other day, walking from one resident room to the next. She checked vital signs, passed meds, and shared the usual conversation with both residents and staff. It was not until she entered Thelma’s room and asked, “How did you sleep last night?” that she realized the importance of the assessment data she could gather from that one question. She learned Thelma had knee pain and was unable to sleep. From Bob she learned in detail about how noisy the staff had been during the night, something that had awakened him several times. Barbara said she had slept well all night for the first time in two weeks.

Assessing sleep reveals essential data about a resident’s health. The nurse learned that Thelma had knee pain needing treatment. She discovered that new staff needed education on the importance of sleep, and she learned that Barbara’s new medication for her infection was working and reducing her pain. Asking about nighttime sleep is as important to quality care as taking vital signs. Sleep is essential to good health and critical for improved quality outcomes in nursing home residents.

Contrary to popular belief, sleep problems are not a normal part of aging. When a resident does not sleep well at night, the cause must be investigated. Sleep deprivation can lead to serious consequences such as falls, anxiety, and sundowning. Nursing home residents need an average of 8 hours of sleep per night, two 4-hour phases of uninterrupted sleep. Daytime napping of more than 30 minutes per day can interfere with nighttime sleep, so, as a resident’s clinical status allows, encourage him or her to avoid longer naps to improve nighttime sleep. Uninterrupted sleep during the night is crucial for health and healing.

The body regenerates itself during sleep. During the night the body cycles through five stages of sleep, Stages I through 4 plus REM (rapid eye movement). Each of these phases is important to the sleep cycle, but Stages 4 and 5 are vital. Stage 4 is known as pre-REM sleep. During Stage 4 the body recharges itself physically, much like a rechargeable battery. This stage allows the body to physically regenerate. Stage 5 sleep, known as REM, is when the brain is the busiest. Many recognize this stage, as it is when dreams occur. REM sleep allows the brain to reconcile the stress and the emotions of the day, cementing memories and achieving psychological homeostasis.

Education on sleep is an essential first step in improving sleep. Many staff are not aware of the importance of sleep and believe that sleep deprivation is a common problem of aging. Staff may believe that resident napping during the day is adequate for quality sleep. Daytime sleep actually interferes with nighttime sleep and inhibits a person from cycling through all five stages of sleep. A common sign of sleep deprivation in a nursing home is residents’ dozing at the breakfast table or between meals. When residents get adequate sleep at night they are well rested, more alert, and able to participate in conversation during the day.

Promoting quality sleep during the night is essential for health and healing. Sleep assessment should be a priority nursing intervention. Sleep-deprived residents can exhibit symptoms such as decline in ADLs, increased confusion, behaviors, falls, depression, and anxiety. Research suggests that quality nighttime sleep reduces sundowning for residents with dementia.

Sleep deprivation in nursing home residents is a multifaceted problem that is not easily resolved. Barriers to quality sleep include environmental noise such as alarms, conversations, shutting doors, and call lights. Shift change is often a time when sleeping residents are awakened by noise. Pain can be another barrier to sleep. Pain is often unreported and undertreated in long-term care. Turning, repositioning, and toileting can also interfere with resident sleep. For many years it was believed that waking residents every two hours for care demonstrated good nursing. The latest research on sleep is causing providers to rethink traditional practices in the nursing home setting.

The MDS can be an assessment tool for sleep. Although the MDS does not have a specific measure for sleep, there are questions that measure poor outcomes associated with sleep deprivation. Pain, increasing antipsychotic use, decline in ADLS, falls, depression, and increasing behavioral issues indicate the need for further investigation into sleep patterns.

Sleep deprivation in nursing home elders is a problem not just for nurses but for the whole interdisciplinary team. Interventions to improve nighttime sleep include (1) reducing napping in the day, (2) increasing physical activity, (3) increasing exposure to bright sunlight in the morning and late afternoon, (4) limiting fluids before bedtime, (5) using snooze foods as bedtime snacks, and (6) reviewing medications for diuretic and sleep-altering effects.

Assessing for sleep deprivation is as important as taking residents’ vital signs. All staff should be taught the importance of sleep and how it impacts the health and wellness of residents. Once staff understands how important sleep is to residents, their first question will be, “How did you sleep last night?”

Dr. Linda Shell, MA. RN |

Dr. Linda Shell MA, RN, principal and co-owner of LindaShell.Com and Legacy Market Services, Inc, has over twenty-five years of experience providing education, leadership development and consultation to non-profit and for-profit senior care organizations.

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