We have all heard that the average person needs eight hours of sleep per night, which improves mood, eating, and almost everything else during the light of day. This eight-hour rule includes elders, stresses Linda Shell, DNP, RN, MA, principal of LindaShell.com in Lakeville, Minnesota. Sleep is key to promoting residents’ wellness and best function, especially for residents with behavioral dementia.
The Skinny on Sleep
It takes a full four hours to cycle through all four the stages of sleep, which include stages 1–3 and REM sleep. “During stage 3, our muscles and organs regenerate themselves,” says Shell. “Elders have aging hearts, eyes, and other muscles, and they need this deep rest. Not only will it help muscles to regenerate, it helps medications to work better because muscles and organs are regenerating.” The last stage of sleep, REM (rapid eye movement) sleep, is the busiest time of day for our brains. During REM sleep, our brains consolidate all of our emotions and experiences from thoughout the day, says Shell. “Imagine cleaning up the files on a computer desktop. REM sleep does something similar for the brain. This process is essential for elders, especially those with dementia.” Once our bodies have cycled through the four stages of sleep, which takes about four hours, we may naturally wake up—to use the restroom, for example—before going back to sleep and moving through the cycles again. Here are some tips that you can use to get your residents their best rest.
Reposition at the right time. Typically, when people sleep well, they naturally reposition themselves throughout the night, except during REM sleep, when the body is immobile. “Because our bodies are wired to move through the first 3 cycles of sleep before waking up, if you do have to wake residents up to take them to the bathroom, reposition them, etc., it’s best to try to wake them up after four hours of sleep,” stresses Shell.
Encourage residents to wake up naturally in the morning. During REM sleep, your body is immobile and temporarily paralyzed. When woken up during this stage of sleep, by an alarm, for example, you feel jolted and you start your day feeling groggy. “All residents have their own cycles of sleep,” says Shell. “Letting them go through those cycles of sleep and wake up naturally in the morning will improve how they feel and function in the morning and throughout the day.”
Encourage a bedtime. “It’s best to identify what residents’ sleep patterns are upon admission. If a bedtime hasn’t been identified, nurses should encourage residents to establish a bedtime by first asking what time they like to go to bed and wake up,” says Shell. Many residents like to stay up late, watching the nightly news before going to bed. Encouraging a consistent bedtime will help residents to establish healthy sleep patterns.
Treat sleep like a vital sign. Caregivers should treat the level of good-quality sleep like a vital sign, says Shell. “Every nursing assistant should be asking the resident how he or she slept the night before,” she suggests. Often, residents will reveal important information, sharing that they were too hot or too cold, that there was too much light, or that they have pain. Asking how a resident slept and really listening to the answer also supports effective person-centered care.
Reduce light and noise levels. “As nurses, we need to do everything we can to reduce noise and light so that residents get good-quality sleep,” says Shell. “We want sleep to be in sync with circadian cycles. If there is a light on in the nurses’ station, for example, it will keep the resident’s serotonin levels elevated, preventing the resident from achieving all of the stages of sleep.”
Use a hug light. “If you need to enter a resident’s room at night, to reposition, for example, using a hug light (a stethoscope of light) is best,” says Shell. It provides enough light to reposition, but not enough to abruptly wake the resident up.
Use amber night lights. Most resident rooms have night-lights. “If a night-light emits amber light instead of white light, it does not interfere with circadian rhythm,” says Shell.
Increase activity and reduce napping during the day. Our bodies are designed to exert energy. “For residents who are 80 and 90 years old, it doesn’t take a lot of physical movement to exert energy. For example, encourage walking to the dining hall if possible,” says Shell. She also suggests finding ways for residents in wheelchairs to exert energy. “For example, if playing bingo, have residents put their hands up throughout the game. There was one facility that designed a paint-by-numbers mural on the wall for residents, which necessitated that residents in wheelchairs use their arms.” Shell also suggests reducing daytime napping to less than one hour, if possible, to help ensure residents are tired enough to sleep well when night comes.
Encourage water early in the day. It’s best to encourage lots of fluid intake in the morning and afternoon. “Don’t encourage elderly residents to drink a lot after dinner. Without good cardiovascular pressure, they don’t have good fluid circulation. When they lie down, the fluids are pulled up, forcing them to have to use the restroom very frequently. You want residents to be able to make it through four hours of sleep before waking up to use the restroom,” says Shell.
Encourage snacks before bed. “Certain foods before bed will help residents sleep, which is especially true for diabetics and other residents who need help managing blood sugar.” Shell suggests bananas, plain vanilla ice cream, warm milk, apples, cherries, and peanut butter.
Honor residents’ choices if they prefer to sleep in a chair. Many residents choose to sleep in chairs. If the resident feels more rested, perhaps because that is the accustomed manner of sleeping, that is okay, according to Shell. “The important thing to remember is to support their getting good-quality sleep. Residents who sleep in chairs tend to leave the television on, which emits blue light that interferes with quality sleep. Be sure that the television is turned off overnight and that these residents have quiet and darkness.”
Time resident medication right. “If a resident takes cardiac medication that has a diuretic component, such as Lasix, be sure to administer it in the morning or afternoon, rather than late in the day,” says Shell. This will prevent the resident’s having to wake up to use the restroom throughout the night, which will also prevent falls.
Minimize the use of alarms. “Alarms interfere with sleep, cause delirium, and cause depression. If your facility is still using alarms to prevent falls, they are also interfering with sleep,” stresses Shell.
Match compatible neighbors. “We should do everything we can to match residents appropriately,” says Shell. If residents have different sleep patterns, it’s important to make sure a divider is being used and to encourage the roommate who would like to watch TV to use headphones at night.
Honor bathing preferences. Asking residents about bathing preferences in terms of what works best for their sleep as part of their assessment is very helpful. Shell advises, “Ask the resident upon admission, When do you prefer to shower or bathe, and what helps you sleep best at night?”
Get with resident routine. After a while, staff members become very good at knowing what time each resident naturally starts to wake up. By identifying the normal patterns of residents’ sleep, the staff can have a kind of schedule and provide care when residents naturally wake up. “People with dementia especially love routine, which helps them to feel safety and security,” stresses Shell.
Distinguish between dementia and sleep deprivation. Sleep deprivation, which is linked to delirium, is very common for elders who have spent three to five nights in the hospital. At the hospital, the lights are left on, patients are checked throughout the night, and monitoring is always going on. “Many times, when someone comes into a post-acute setting after experiencing sleep deprivation in the hospital, it is thought that they have dementia,” says Shell. “Instead, what they really need is good-quality sleep, and then they do much better.”
Linda Shell works with facility leaders who want to improve their facilities’ sleep programs. She can be reached at firstname.lastname@example.org.
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