Med Surg 2-Depression in Older Adults

Article Review

In their article, Suzuki, Miyamoto, and Hirata (2017) explore sleep disturbances in older adults, common symptoms/diagnosis, potential causes, and management. According to the article, older people exhibit age-associated sleep changes such as advanced sleep phases and decelerated slow-way sleep, resulting in distorted sleep patterns and early awakening. Sleep disorders in adults are caused by several factors, primarily comorbid diseases and medications, tobacco, caffeine, alcohol, and the individual’s sleep patterns. It is imperative to screen for sleep behavior disorder (RBD), psychiatric diseases including anxiety and depression, sleep apnea syndrome (SAS), and rapid eye movement (REM) when a person presents with sleep disturbances.

Besides, Suzuki, Miyamoto, and Hirata (2017) also attribute sleep disturbances to modern lifestyle, occasioned by reduced sleep time and deteriorated sleep quality because of the changes in contemporary life, characterized by working late hours alongside excessive consumption of internet and TV, which extends to late hours in the night. An epidemiological study in Japan indicated that more than 50% of the adult population had insomnia, and such people are often undertreated. The authors defined insomnia as a subjective sleep difficulty often characterized by trouble with sleep initiation, duration, and quality occurring despite the availability of opportunities and conditions for sleep. Insomnia disorder is a disease or syndrome occasioned by insomnia complaints described by the International Classification of Sleep Disorders (ICSD), editions 2 and 3. In ICSD-2, primary insomnia incorporates different subtypes, including psychological insomnia, insufficient sleep hygiene, and paradoxical insomnia. Psychological insomnia is the most common primary symptom and is associated with hyperarousal. Secondary insomnia occurs due to medication conditions and mental disorders, including anxiety and depression. However, the symptoms of both primary and secondary insomnia can overlap.

Again owing that it is challenging to determine whether insomnia is due to co-occurring comorbid disorders or medical conditions, the ICSD-3^rd edition classifies subtypes of insomnia, both primary and secondary occurring three nights or more weekly for at least three months, like chronic insomnia. Diagnosis of chronic insomnia according to ISCD‐3 occurs when insomnia symptoms develop independently from co-occurring sleep disorders such as RBD and SAS, psychiatric or medical conditions and persist despite sufficient treatment for the co-occurring psychiatric or sleep disorders. There is no diagnosis of chronic insomnia if the treatment of co-occurring psychiatric, sleep or medical condition equally resolves the insomnia symptoms.

Older adults complain of sleep maintenance insomnia alongside early awakening than sleep-onset insomnia. The authors attribute this phenomenon to age-associated shifts in sleep architecture and circadian rhythm. The circadian master clock controls the 24-hour sleep cycle in the hypothalamus’ suprachiasmatic nuclei. The clock is synchronized by external trainers, including food and light. The pattern is that the urge follows a sleep loss for more sleep for compensation, a phenomenon described as homeostatic sleep pressure. As such, circadian systems optimize best sleep timing while homeostatic systems promote sleep. The article shows that both men and women older adults experience distorted circadian and homeostatic rhythms and exhibit shorter sleep time, decreased sleep efficiency, and accelerated arousal. Management of primary insomnia includes: a) regular exercise; b) maintaining conducive bedroom hygiene, including keeping the bedroom dark and quiet; c) keeping regular meal patterns; d) limiting fluid intake before bedtime; and e) avoiding alcohol, smoking, and caffeine before bedtime. Pharmacological insomnia treatments include benzodiazepine medications such as triazolam, melatonin receptor agonists (ramelteon), and dual orexin receptor antagonists (suvorexant).

Strengths and Weaknesses

The article comprehensively discussed the diagnosis of insomnia, both clinical and differential, and management of insomnia in older adults. The evidence is perceptive and convincing, backed by peer-reviewed studies on the same issue. The study purpose and target are also clearly identified from the onset, and the paper is logically structured from the introduction, the body, and conclusion, clearly demarcated. However, the article also has some weaknesses, including a very short conclusion that does not adequately summarize all the main points of the study. The research procedure or methodology is also not clearly stated and ethical consideration while surveying the human population. A research procedure is vital in a science paper because it provides an overview of how the researcher reached the conclusions.

Significance and the Nurse’s Role

Nurses report burden related to sleep disturbances as a common challenge. This article helps nurses understand the causes of sleep disturbances and management approaches. This is essential for developing effective interventions for insomnia and other sleep problems and even training nurses on how to manage residents’ sleep disorders.

Research Needed

            Even though the article provides compressive insights into the diagnosis, causes, and management of sleep disturbances in older adults, more study is needed on non-drug therapy to treat insomnia, particularly on cognitive behavioral therapy and the role of caregivers and care environment in promoting effective management of insomnia in older people, and the benefits of adequate sleep in older people.

Part 2

Care Environments

While studying sleep and aging, Lavoie, Zeidler, and Martin (2018) noted that insomnia and other sleep disorders are common in older people and lead to greater occurrences of poor sleep with older age. The researchers observed that most health care settings recommend non-pharmacologic as the first treatment choice for chronic insomnia. Cognitive Behavioral Therapy (CBT) is considered an evidence-based therapy for insomnia in older people. The treatment incorporates stimulus control, sleep restrictions, and sleep hygiene, among other cognitive and behavioral methods. The sleep restriction method decreases bedtime to escalate sleep motivation, reducing sleep inactivity while raising sleep maintenance. The time spent in bed is slowly increased once sleep improves. Bennett (2020) argues that some caregivers recommend sleep compression as an alternative approach for older people who may be vulnerable to the impacts of daylight sleepiness, such as individuals with heightened risk of falls. Sleep compression progressively, instead of directly, decelerates sleep time in bed to nearly entire sleep time. The goal is to strengthen the bed and sleep relationship while weakening the link between bed and activities discordant with sleep, such as worry.

Stimulus control as part of the CBT is entrenched in the notion that a patient must only retire to bed when exhausted and that staying awake on the bed can be harmful to quality night rest. If an individual lies roused in bed for more than 20 minutes minus falling asleep, they should get something to keep them busy in another room until they feel exhausted again (Sandlund, Kane, Ekstedt, & Westman, 2018). Besides, therapists also train their patients to commit to waking up at the same time every day and avoid sleeping during the day. Sleep pattern is also impacted by the environment, the hospital surroundings where lighting, noise, and regular monitoring and treatment occur. The harm resulting from inadequate sleep can be immediate; hence nursing care is critical. In the hospital setting, nurses are trained on being aware of insomnia and help their patients get adequate sleep. Nurses educate their patients on the proper management of insomnia and approaches to avoid such conditions (Sandlund, Hetta, Nilsson, Ekstedt, & Westman, 2017). Medication is recommended if the symptoms persist after exploiting CBT and other non-pharmaceutical approaches.

Benefits to the Older Adult

Study shows that regular sleep patterns of about 8 hours a night is vital to help older people function to their best. Providing neurological, sensory and sleep needs help older people to restore their energy levels and heal both cognitive and physical damages (Bisson, Robinson, & Lachman, 2019). While studying the impacts of sleep disruption, Medic, Wille, and Hemels (2017) argues that sleep is essential in older people’s emotional and physical health, just it was when they were younger. Adequate night sleep can improve memory formation and concentration, allowing the body to restore cell injured during the day and revive the immune systems, consequently preventing diseases. Rani, Singh, and Kumari (2019) argue that older people who do not get adequate sleep are likely to suffer from memory and attention problems, depression, more daytime sleep and nighttime falls. Inadequate sleep can also result in serious health complications such as increased risks of cardiovascular diseases, weight problems, diabetes, and breast cancer. Caregivers need to understand the primary causes of sleep disorders to help the patients overcome age-associated sleep challenges.

Innovation

Several innovations are emerging to manage insomnia in older adults most cost-effectively and conveniently as possible. For instance, in recognition of financial constraints and inadequate psychological resources required for cognitive behavioral therapy for insomnia, researchers have invented a short form of treatment called brief behavioral therapy to help in insomnia management. The technique incorporates core approaches from CBT-I (cognitive behavioral therapy for insomnia) to enhance circadian control of sleep in a two-session therapy. The method has proven effective in older people with insomnia, with the benefits continuing for six months or more (Bennett, 2020). Internet-based behavioral therapy (ICBT) has also been established to manage insomnia in older people effectively. ICBT is a form of therapy offered through mobile devices or computers for insomnia patients. With the advances in technology and integration in healthcare systems, ICBT is becoming a fast-growing and effective intervention channel for its cost-effectiveness and convenience, and even more, patients prefer it to conventional psychotherapy. Multi-component cognitive behavioral therapy (MCBT) for older adults, integrating sleep hygiene mechanisms, relaxation approaches, stimulus control and sleep restriction (Patel, Steinberg, & Patel, 2018). Researchers are still developing more innovations, less costly and more convenient for insomnia management in the elderly population.

Conclusion

This study has reviewed the article by Suzuki, Miyamoto, and Hirata (2017) on sleep disorders in older adults, alongside utilizing additional journal articles to examine how healthcare facilities can improve the care for older adults by providing for their sleep needs. The peer-reviewed article noted that older people are prone to sleep disturbances caused by several factors, including comorbid diseases and medications, tobacco, caffeine, alcohol, and the individual’s sleep patterns. Further study shows that CBT, alongside medication, can remedy sleep problems in older adults.