Effectively Managing Inpatient InsomniaTaylor Brazelton RN, MSN, AGCNS-BC
ObjectivesThe learner will be able to describe the impact of insomnia on older adults
The learner will be able to explain sleep challenges in the inpatient setting for older adults
The learner will be able to apply pharmacologic and nonpharmacologic interventions to promote sleep in the hospitalized older adult
Case StudyIt’s 2am and you get a call from a nurse on the cardiac telemetry unit requesting sleep medication for your patient Ms. Jones. Ms. Jones is an 82 year old female admitted for chest pain. She has a history of COPD. BMI is 35.
SleepNormal age related changes
Earlier bedtime, earlier wake time
Changes in circadian rhythm
Decrease production and quality of melatonin, decrease in vasoactive intestinal polypeptide, and vasopressin-expressing neurons
Shorter
less time in slow wave sleep (NREM2 stage) and REM
Fragmented
Daytime sleepiness
InsomniaDifficulty falling asleep or maintaining sleep
Severity is determined by frequency, duration, and intensity
3 nights per week or more
Greater than one month
Impacts day time functioning
Amount of time awake during normal sleep time
ImpactHigher health care costs
$100 billion USD per year Depression and mood disorders, HTN, MI, DM
Cognitive impairment
Stress on relationships
Automobile accidents
Increased mortality
31.93% of medication for treatment of insomnia is used outside of doctor’s recommendation
Insomnia in Older Adults
40%-50% of insomnia is chronic sleep onset or maintenance insomnia
Women > men
Poorer quality of life
Decrease in function/ability to complete ADLS
Hospitalization, nursing home, home care
Risk and Aggravating factors
CONDITIONS
Psychiatric conditionsadjustment disorders, anxiety, bereavement, depression
Respiratorycough, dyspnea, sleep apnea
GI/GUnocturia, GERD
Neuroparasthesias, parkinsons, stroke, dementia
Pain
MEDICATIONS
Alcohol/caffeine
Psychi.e antidepressants
Cardiacdiuretics
Respiratorybronchodilators
Inpatient challengesTime of admission
Bed availability
Acute illness requiring care/treatment
Nursing protocols/assessments
Scheduling of procedures
Lack of private rooms
Inpatient Management
Inpatient interventionsBe mindful when putting in orders
Work with pharmacists to limit dosages and/or frequencies of high risk medications/sedative hypnotics
(Adeola, 2018)
Hospital Elder Life Program© 1999
Educate patients/families about their sleep medications
Consider deprescribing
Pharmacological TreatmentPoints to consider:
Short term use
Use in combination with behavioral therapies
Added risk for fall
Is it sleep maintenance or sleep onset issue?
Half life of medications
Choosing Wisely®“Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary.”
Patient education resources on Choosing Wisely® regarding “Sleeping Pills for Insomnia”
“Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.”
Pharmacological Treatment
CAUTION
Beer’s List- sleep medications potentially inappropriate
Benzodiazepines
Anticholinergic
Z drugs
zolpidem, zaleplon, eszopiclone
Antipsychotics
CONSIDER
Melatonin
Mirtazapine (Remeron)-insomnia, anorexia, nervousness
Trazadone (Desyrel)-antidepressant, sedating
Case Study
You are rounding when a day shift nurse on a med-surg unit asks you about one of your patients who is requesting a sleeping pill. Mr. Robertson is an 80 year old male with a BMI 18. He was admitted for abdominal pain and has a history of depression, CAD, HTN, cataracts. Mr. Robertson informs you that he just “can’t turn off his brain at night.”
Nonpharmacological TreatmentPoints to consider:
Cognitive behavioral therapy first line treatment
If request for sleep medication, ask more questions-
History of sleep apnea?
How long/when does it occur?
Review discharge medications
i.e. Are sedative-hypnotics discontinued prior to discharge?
Nonpharmacological Treatment
Day
Encourage day light, open blinds
Minimize day time naps
Encourage mobility- reduce time in bed
Monitor caffeine intake
Night
Do not wake patients at night
Encourage family to bring own pillow/blanket
Close blinds at night, adjust temperature
Toileting schedule
Quiet- Offer ear plugs, nurses phones on vibrate
Individualize care to patients schedule
Hospital Elder Life Program©1999Sleep Protocol
Volunteers:Relaxation- guided imageryMusic/Care TVMilk/TeaWarm blanketClose blindsDim lightsBack rub/hand massages
Interdisciplinary:Reschedule labs, medications, vital signs other procedures Evaluate timing of caffeine and diuretics
Case StudyMs. Brooks is an 86 year old female patient recently admitted to the neurology unit. from the ER. You check in with the nursing staff before seeing the patient, and the staff report that the patient has been napping for most of the day. Her family is concerned she will be up all night as she is also a light sleeper at home. She has a history of mild cognitive impairment, high cholesterol, hysterectomy. The family is asking to speak with the physician regarding how they can help her sleep.
Thank you!
ReferencesAdeola, M., Azad, R., Kassie, G. M., Shirkey, B., Taffet, G., Liebl, M., & Agarwal, K. (2018). Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults. Journal of the American Geriatrics Society. doi:10.1111/jgs.15438
ABIM. (2018). Choosing Wisely®. Retrieved August 16, 2018, from http://www.choosingwisely.org/
Cohen-Zion, M., & Ancoli-Israel, S. (2009). Sleep Disorders. In Hazzard's Geriatric Medicine and Gerontology (6th ed., pp. 677-681). McGraw Hill.
Hadden, L. (2013). Insomnia. In Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse (Vol. 1, pp. 117-129). Pittsburgh, PA: Hospice and Palliative Nurses Association.
Hospital Elder Life Program. (2018). Retrieved August 16, 2018, from https://www.hospitalelderlifeprogram.org/
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