Chapter

13
Clinical Judgment to
Promote Healthy
Rest, Sleep, and
Activity
Objectives

• Identify factors that affect rest, sleep, and

activity as we age.
• Discuss the importance of sleep and activity
to the health and well-being of older adults.
• Describe the beneficial effects of exercise
and appropriate exercise regimens for older
adults.
• Utilize clinical judgment to identify and
evaluate nursing actions for rest, sleep, and
promotion of activity.
Sleep and Rest
• Sleep and rest help the body to
• Conserve energy
• Prevent______________
• Provid __________________ respite
• Relieve tension
• Sleep is a _____________ need, and
rest occurs with sleep. Both are
physiologically and mentally
necessary for survival!
 FYI What is Healthy People initiative
• IN the 1980s the U.S. Department of Health and Human
Services(HHS) along with other Government agencies started an
initiative to improve prevention of illness.
• Mission is to nationwide: improve health, increase public awareness,
provide measurable goals, engage multiples sectors to take action to
strengthen policies driven by best available evidence and knowledge,
identify critical research and date collection, promote health equity
and eliminate health disparities.
• Started in 1980 put out new every 10 years
• 1980 to1990
• 1990 to 2000
• 2000 to 2010
• 2010 to 2020
• 2020 to 2030
 BOX 13.1
Healthy People 2020 Sleep Health Goals
• Increase public knowledge of how ________________sleep
and treatment of sleep _____________________ improve;
health,
productivity,
wellness,
quality of life, and
safety on roads and in the workplace.
• Increase the proportion of persons with symptoms of
obstructive sleep apnea who ___________ medical
evaluation.
• Increase the proportion of adults who get sufficient
sleep.
Circadian Rhythm
• Awake and sleep biorhythm of the body
• Biorhythms vary from individual to
individual and with age.
• With aging, the natural circadian rhythm
may become
____________________responsive to external
stimuli such as light.
• The amplitude of all circadian endogenous
responses—such as body temperature,
pulse, blood pressure, and hormonal levels
—reduces.
• This effects the sleep cycles as we age.
• https://www.youtube.com/watc
h?v=c__xcePkUcM
 Sleep and Aging
• Between 40 to 60 age related changes in sleep
architecture (sleep cycle) occurs.
• Less N3 sleep more time spent in N1
• This leads to fragmented sleep and
________________ awakening
• As an individual ages, the time spent in rapid
eye movement (REM) sleep
_______________________.
• This stage is important for replenishing
neurotransmitters and the decreased REM
effects learning, remembering and problem
solving
• In adults over 90 N3 sleep may may disappear
 BOX 13.2
Changes in Sleep With Age
• ___________ time spent in bed ______________________ before
falling asleep
• Total sleep time and sleep efficiency are __________________
• Periods awake are frequent, increasing after age 50
• Daytime _________________________
• Changes in circadian rhythm (early to bed, early to rise)
• Sleep is subjectively and objectively lighter (more stage 1,
little stage 4, more disruptions)
• Rapid eye movement (REM) sleep is short, less intense, and
more evenly distributed
• Frequency of abnormal ___________________ events is
increased
• Frequency of leg movements during sleep is
Older adults sleep better when they

• are in general good health.

• have a positive mood.
• are engaged in an _______________
lifestyle.
• perform ___________________ activities.
Sleep Disorders
• Poor sleep is not an inevitable
consequences of aging but should be an
indicator of health status and assessed
• Insomnia
• Sleep apnea
• Restless leg syndrome
• REM sleep behavior disorder
• Circadian rhythm sleep disorder
 Insomnia
• Condition that interferes with sleep quality
and quantity and is associated with
subjective complaints of sleep disturbance
that are
• difficulty _______________________sleep,
• difficulty ___________________________
sleep,
• premature morning awakening, or
• nonrestorative sleep
• Requires that a person has difficulty falling
asleep for at least 1 month and that
impairment in daytime functioning results
Sleep
hygiene
ideas
Insomnia and Alzheimer’s Disease
• Occurs in about half of those with dementia
• Associated with agitation, wandering, comorbid
illnesses, primary sleep disorders, or the
medications used to treat dementia
• Caregivers of individuals with dementia also
experience poor sleep quality.
• Behavioral techniques to enhance sleep for
individuals with Alzheimer’s disease include
• sleep hygiene education,
• daily walking, and
• increased light exposure.
 Tips for reducing sundowning
• Sometimes what seems like ‘sundowning’ could be the
person trying to communicate a need. This could be
needing the toilet, feeling hungry or being in pain.
• Uneven indoor lighting and reflective surfaces can
sometimes cause confusion by creating disturbing
shadows or mirrors. Close the curtains or blinds once
it starts to get dark and cover the television with a
dust cover, if it’s not being used.
• Think whether something that’s happened during the
day has affected them. If they seem agitated, try to
calm them by distracting them, perhaps talking about
a Favorite memory or event they enjoy thinking about.
 How to assess sleep and Recognizing
and analyzing cues
• Review of sleep patterns
• Presence of contributing factors such as pain,
chronic illness, medications, alcohol use,
depression, and anxiety
• Sleep _____________________or logs
• Self-rating scales
• Pittsburgh Sleep Quality Index
• Epworth Sleepiness Scale
• Polysomnography conducted in sleep laboratories
• https://www.youtube.com/watch?v=FpN_GaOaq
 Nursing Actions: Sleep
Promotion
• Nonpharmacologic treatment
• __________________treatment
• Cognitive behavioral therapy
• Pharmacologic treatment
• Used _____________________ with older
adults
• May be used with behavioral
interventions
• Avoid sedative-hypnotics
Question 1
A resident in the long-term care setting complains of
not being able to sleep. What action would be a
priority for the nurse to implement?

A. Administer a sleeping medication at the same

time each evening.
B. Decrease noise around the resident at bedtime
and during the night.
C. Have the resident participate in light exercise 2
hours before bedtime.
D. Do not allow the resident to watch TV or listen to
music after dinner.
Answer to Question 1
ANS: B

Noise is a major factor contributing to sleep

deprivation in long-term and acute care
settings.
 Sleep Apnea
• A condition in which people ____________ breathing
while sleeping
• Episodes are terminated by arousal.
• Fragmented sleep and daytime sleepiness are the
results.
• Symptoms include loud periodic snoring, gasping and
_______________upon wakening, unusual nighttime
activities such as sitting upright or falling out of bed,
morning headaches, poor _________________, irritability,
and personality changes.
Treatment of Sleep Apnea
• Depends on the type
• Losing weight
• Avoiding alcohol and sedatives
• Stopping smoking
• Avoiding supine sleeping
• Wearing a continuous positive
airway pressure (CPAP) device
at bedtime
Restless Leg Syndrome (1 of 2)
• A sensorimotor neurologic disorder
characterized by unpleasant leg
sensations that disrupts sleep
• Symptoms include paresthesia,
_______________________sensations,
crawling sensations, tingling,
cramping, burning _______________,
pain, or indescribable sensations.
• Can be temporary and relieved by
movement
• Disrupted sleep is the reason
Restless Leg Syndrome (2 of 2)
• Antidepressants and neuroleptic
medications can relieve the
symptoms.
• Nonpharmacologic therapies
include stretching the lower
extremities, taking hot baths,
performing relaxation techniques,
and avoiding alcohol.
 Rapid Eye Movement Sleep
Behavior Disorder
• Is __________________ in older adults
• Characteristics include the loss of voluntary
muscle atonia during REM sleep and
__________________ behaviors while dreaming
(punching or kicking) with potential injury to
the partner.
• May be observed in _______________________
such as Parkinson’s disease, diffuse Lewy
body disease, Alzheimer’s disease, or
progressive supranuclear palsy.
 Circadian Rhythm Sleep Disorders
• Normal sleep occurs at abnormal times.
• Types include
• Advanced sleep phase disorder (ASPD)
• Irregular sleep–wake disorder (ISWD)
• Treatments for ASPD include hygiene
practices and methods to delay the timing of
sleep and wake; bright light therapy for 1 to 2
hours daily.
• Treatments for ISWD include increasing the
duration and intensity of light exposure
Question 2
A patient has been referred for
polysomnography to confirm a diagnosis of
sleep. What symptoms would the nurse
expect the patient to report?

A. Inability to fall asleep with medications

B. Kicking and hitting his partner while
sleeping
C. Consistently falling asleep during the
evening meal
D. Loud periodic snoring with choking on
wakening
Answer to Question 2
ANS: D

Symptoms of sleep apnea include loud

periodic snoring, gasping and choking upon
wakening, unusual nighttime activities such
as sitting upright or falling out of bed,
morning headaches, poor memory,
irritability, and personality changes.
Activity
• Any bodily movement produced by
skeletal muscle that requires energy
expenditure
• Regular physical activity throughout
life is essential for healthy aging.
• Most older adults do not achieve
recommended activity levels.
• ______________ hours per week
(brisk walk, swimming, bicycling
• 30 minutes a day several days a
week improves health of even
chronically ill in frail health
• Improve brain health
 Using Clinical Judgment to Promote
Healthy Aging
• Recognizing and analyzing cues
• Function and mobility
• Determine if adaptations are necessary.
• Nursing actions
• Provide exercise counseling.
• Initiate an appropriate intensity exercise
program.
• Educate individuals about the importance
of exercise and physical activity.
• Provide suggestions on ways to