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6/01 cJCIRC/DateDuepBS-p. 15

 

 

INSOMNIA IN THE ELDERLY PRESENTING IN A

PRIMARY HEALTH CARE SETTING

By

Moiiy McCrum Lawrence

A NON-THESIS

Submitted to
Michigan State University
in partiai fuifiiiment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

COTTege of Nursing

1984

 

 

LIBRARY
Michigan State
University

 

 

ABSTRACT

INSOMNIA IN THE ELDERLY PRESENTING TO A
PRIMARY HEALTH CARE SETTING

By

Molly McCrum Lawrence

Elderly are believed to have an increased incidence of insomnia.
The problem investigated is: Do elderly clients presenting to a pri-
mary health care system identify insomnia as a problem; if they do, how
is it manifested; is it viewed as a health problem to be treated by the
primary health care provider, or do the elderly institute self-care?

Using Nightingale's theory, it is conceptualized that nurses can
assess insomnia of the elderly holistically to preserve and promote
health.

A pilot study was done using a self-rating questionnaire survey.
Forty elderly 65-85 presenting to a primary health care setting par-
ticipated. Descriptive analysis of the data was done.

Nursing implications are that the primary health care nurse should
assess insomnia when working with the elderly. A thorough history and
physical assessment are necessary when the elderly complain of insom-

nia.

450mm IN THE ELDERLY PRESENTING IN A
PRIMARY HEALTH CARE SETTING/

By

Molly McCrum Lawrence
/(

A NON-THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING
College of Nursing

1984

LIST OF
LIST OF

Chapter
I.

II.

III.

TABLE OF CONTENTS

TABLES O O O O O

FIGURES . . . . . .

WE mOBLEM O O O O O .........

Introduction . . . . . . . .
Background of the Problem .
Purpose

Description of Study . ........

Definitions of Concepts . .
Importance of Study
Assumptions and Limitations

CONCEPTUAL FRAMEWORK . . . . .

overv16w O O O O O O O O O O I O

Elderly
Primary Health Care System .
Identify . . . . . . . . . .
Insomnia . . . . . . . . . .
Primary Health Care Provider
Self-Care
Strategy . . . . . . . . . .

Relationship of Model to Nursn

REVIEW OF LITERATURE . . . . .

OVGNIGW O O O O O I O O O 0
Normal Sleep . . . . . . . .
Sleep Changes With Aging . .

Differential Diagnosis of Insomnia
Assessment of Insomnia . . . . . .

Strategies to Promote Sleep

IV. METHODOLOGY AND PROCEDURES

Introduction . . . . . .

Research Design . . . .
Hypotheses . . . . . . .
Operational Definitions
Pretest . . . . . . . .
Sample . . . . . . . . .
Instrumentation . . . .
Field Procedures . . . .
Data . . . . . . . . . .

V. SUMMARY AND CONCLUSIONS

Introduction . . . . .
Results
Recommendations
Conclusions
Implications for Nursing.

Relationship to Conceptual

Research .

Conclusions and Recommendations

APENDICES O C C O C O O O O O O
A. SLEEP QUESTIONNAIRE . . .

8. DATA ANALYSIS . . . . . .

REFERENCES 0 O O O O O O O O O O O

Frameuor

o o r. o o o o

and

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58

58
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59
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84
85

88
90

97
98
105

112

LIST OF TABLES

Sociodemographic Data . . . . . . . . . . . . . . . .

Time Factors Related to Insomnia . . . . . . . . . .

Health Care Provider Variables . . . . . . . . . . .

Factors and Frequency of Factors That Inferfere With
5169p O O O O O O O O O O O O O O O O O C O O O O 0

Health and Life Style Variables. Medical Reported
Illness and Medications . . . . . . . . . . . . . .

Types and Numbers of Strategies Used by Respondents

to Help Them Sleep

Page
68
7O
73

75

76

80

LIST OF FIGURES

Figure Page
1. Conceptual Model . . . . . . . . . . . . . . . . . . . . 21

2. An Adaptation of Nightingale's Ladder Model of
Nursing . . . . . . . . . . . . . . . . . . . . . . . . 26
3. Adaptation of Nightingale's Concept of Nursing . . . . . 28

CHAPTER I

THE PRCBLEM

Ininnduciinn

Sleep has been defined as a natural temporary period of almost
complete unconsciousness. normally at night. in which the body rests
(Webster‘s. 1981). Yet for many persons. feeling rested after sleep is
a bodily condition that eludes them. These persons suffer from insom-
nia. Insomnia is a type of sleep disturbance that seems to be an
especially common and frequent complaint of the elderly (Collings.
1983; Hayter. 1893L

Old age is a difficult and trying time. Old age is a portion of
our lifespan that is filled with many significant life changes.
Retirement. financial strain. role change. and death of important loved
ones are but a few of the stresses faced by the elderly population.
Along with the many life changes that are occurring. an elderly per-
son's sleep pattern may be disrupted. leading to insomnia.

Empirical evidence suggests that the elderly population experience
more frequent qualitative and quantitative changes in their sleep
pattern than that of any other age group (Collings. 1983). Since most
people spend one-third of their life sleeping and good sleep is seen as

a measure of health (Bahr. 1983). the symptom of insomnia to the

elderly becomes an important element that may appear to threaten the
well-being of this population.

Intensive sleep research using sophisticated techniques and
instrumentation has been conducted for little more than 20 years
(Collings. 1983). The use of elderly subjects rather than young adults
in sleep research is an area of even newer investigation. Most of the
research with elderly subjects previous to the 19805 compared older and
younger subjects and was limited to research conducted in sleep labora-
tories (Hayter. 1983). No reliable information was available regarding
the sleep problems or patterns of older persons of various ages or how
they reported a sleep problem.

From research done in the 19605 and 19705. it is known that the
elderly have more frequent awakenings during the night (Tune. 1968;
Webb. 1975) and they take more naps (Tune. 1968; Webb. 1975). It is
also believed the total sleep time of the elderly gradually declines to
about 6.5 hours (Kupfer 8. Reynol d5. 1983). Early morning awakenings
are also a more frequent complaint of the elderly population (Dement.

Miles. & Carskadonn. 1983).

W

Since the research studies that have been done previous to the
19805 did not make the results generalizable only to the elderly popu-
lation but mostly compared them to another more youthful population.
the information does not help us to better understand the sleep dis-
turbances of the elderly. It appears that with the number of elderly

persons increasing in our society. there is an increased need to under-

stand and be able to care for their health care needs. especially at
the primary health care level. Elderly persons are having a signifi-
cant impact on our society as their number increases. 'The elderly are
often seen in the primary health care setting for chronic health prob-
lems or acute episodes of illness. Since research shows that the
elderly are generally dissatisfied with their sleep (Dement et alu
1983). the complaints of sleep disturbances are likely to be brought
frequently to the practicing clinicians in primary care settings. In
order to be better prepared and more knowledgeable. it is important to
have accurate information about the sleep habits. sleep disturbances.
and sleep changes that are occurring in this essentially healthy
elderly population that presents to the primary health care setting.

Because the client presenting to a primary health care setting is
elderly. the health care provider may view the complaint of insomnia as
part of the aging process and totally ignore the complaint of the
client. changing his attention to other areas of concern. In this
case. inaction may be a response of the primary health care provider.
On the other hand. the provider may act on the complaint presented by
the client and recommend some strategies to be used.

The action taken by the primary health care provider is a response
to the identified complaint of insomnia leading to a prescribed
treatment. Hopefully. the treatment will be undertaken after a careful
history and physical exam have been completed and there has been some
evaluation of the findings related to insomnia. The recommendation of

the provider should take into consideration such factors as the effect

of the aging process on sleep. the client's knowledge of this. the
client's sleeping environment. life's stresses. activity level. normal
sleeping pattern. current medication. and any existing chronic illness
rather than quickly prescribing some medication. as the desired
strategy. to relieve the complaint.

Through acquiring strategies to utilize. the elderly client is
able to work at resolving a symptom that might lead to disability.

The client is showing self-responsibility by seeking advice for a
symptom that could lead to further disability if not addressed early.
The client is attempting to achieve a higher level of wellness
(Ebersole 8. Hess. 1981). Wellness indicates a balance in one's own
physical. spiritual. emotional. and social relation and with the natu-
ral environment (McClure. 1982). ‘The elderly are often viewed as
"feeble" and already in a state of degenerating health. These clients
do suffer from some degenerative changes. but wellness is a state of
being and feeling that one strives to achieve (Ebersole & Hess. 1981);
thus achieving a higher level of wellness is within the reach of the
elderly person.

Whatever the strategies advised by the primary health care provider
for the elderly client with insomnia. it should be health promoting.
helping the elderly to achieve a high level of wellness. The client.
at this point. is not suffering from a disease but is essentially a
healthy individual. Using Florence Nightingale's theory. it is with
healthy human beings that nurses can intervene and put the individual

in a state for nature to act upon to preserve health and prevent

disease. This leads to health promotion by helping this human being
achieve a high level of wellness (George. 1980).

It is interesting that elderly clients may not identify insomnia
as a problem or choose to seek the care of the primary health care
provider regarding this complaint. Elderly clients may have developed
their own strategies or solutions that they feel have aided in provid-
ing relief for their insomnia. They are instituting methods of self-
care that they find to aid in promoting their wellness. Since insomnia
is not a disease entity. the elderly may not view it as a health
problem that should be taken care of by the primary health care pro-
vider. Again. in this instance. strategies of self-care may be

employed by the elderly who are seeking to promote their own health.

The problem investigated in this study is: .Dg_e1den1y_911ents

Eumse

Current knowledge of elderly persons' sleep habits and assessment
and treatment of insomnia are mostly limited to research conducted in
sleep laboratories. Little is known about the elderly populationus
identification and perception of insomnia in relation to the primary
health care setting. The literature is lacking in reports of studies

of the elderly population's identification of insomnia as a health

problem. particularly receiving care in a primary health care setting.
The purpose of this study is to conduct a survey to determine if
elderly presenting in a primary health care setting identify insomnia
as a problem. If insomnia is a problem. (1) how is it manifested? (2)
is it seen as a health problem? (3) do the elderly view this sleep
problem as a relevant problem to be taken care of by the primary health
care provider? (4) or do the elderly choose to use self-care approaches
in treating insomnia? and (5) what strategies for self-care do they

use?

Wad!
This study could bring out areas of knowledge that are lacking in

literature about sleep in the elderly client who presents to the pri-
mary health care system. This study has the potential of helping us.
as advanced practice nurses and primary health care providers. to
better understand whether or not the elderly truly have an increased
incidence of insomnia. Also. this study will aid in understanding if
the elderly view insomnia as a health problem. or if it is an issue
that providers need to raise with the elderly client to promote well-
ness. Through this study. knowledge regarding self-care techniques and
strategies used to treat insomnia should become evident. 'This knowl-
edge perhaps will help the advanced practice nurse develop strategies
that can be used with each individual client in dealing with a com-
plaint of insomnia. This study should help nurses in advanced practice
to better assess sleep problems and develop strategies to intervene to

help the elderly achieve a higher level of wellness.

A pilot study. using the tool that was developed to assess the
el derly's perception of insomnia. was conducted using 40 elderly
clients presenting to a primary care setting for health care. The
analysis of the pilot study is descriptive only. since the population
used was small. This study will look at how insomnia is manifested.
how it is viewed by the elderly client. what strategies--medical. self-
care. or both--are used. if the client is satisfied with medical man-
agement. whether other chronic illnesses are present. what medications
the client is taking at the present time. and sociodemographic data
about the clients. This pilot study will. it is hoped. demonstrate
that a sleep questionnaire can be used in the primary care setting to

help address areas of concern to the elderly client.

MW
For the purposes of this study. the elderly are defined as those

persons between the ages of 65 and 85. Theories concerning aging have
changed since 1970 (Ebersole & Hess. 1981). It is difficult to define
or measure when one becomes old because of the way the world is chang-
ing around us. The ages specified are used. first of all. because an
individual is aware of the aging process and most likely involved in
certain aspects of the changing lifestyle and. second. because the
population of the primary health care system used for study purposes
had more individuals in this age group who seek health care services.
Primary health care has been defined by the Department of Health.

Education. and Welfare (1972) as comprising two dimensions:

responsibility for a person's first contact in any given episode of
illness with the health care system leading to a decision of what must
be done to resolve his/her problem; and coordination of the continuum
of care. that is. maintenance of health. evaluation and management of
symptoms. and initiation and follow-up of appropriate referrals. A
man: W is a setting that combines these dimensions
and makes these services available to clients.

The term mm is defined by Webster's (1981) as "recognizing
to be the very thing described." In other words. it is a cognitive
mechanism whereby an individual either positively attributes the char-
acteristic to be true of himself or it is not. or it is not identified.

1052mm. the condition studied. is not a disease but rather a
symptom indicating that there is an'abnormality of one's sleep pattern.
Insomnia signifies want of sleep and is used to indicate any interfer-
ence with the duration or depth of sleep (Harrison. 1980). Insomnia is
an interruption in one's sleep pattern that is a restorative physio-
logical factor important to health and well-being. These interrup-
tions. for the purposes of this study. are frequent awakenings.
difficulty falling asleep. longer periods in bed. and early morning
awakenings.

A problem has been defined in Webster's (1981) as a difficult
matter requiring a solution. A health problem. then. would be a matter
requiring a solution pertaining to one's health. Health has been
defined as the subjective presence of well being along with data that

measure normal function (American Academy of Nursing. 1977). From

these definitions. a health_pngh1em is defined as a matter requiring a
solution that pertains to the subjective presence of well-being that
measures normal function.

The pL1m3Ly_health_gane_pngxiden is viewed as part of the primary
health care system. The provider is seen as being able to identify the
health status of an individual; assume the responsibility of the
management of the health problem. ongoing health maintenance. and
clinical management; and identify the need for continuity of care by
coordinating. collaborating. consulting. and referral of services as
needed (Yedidia. 1981).

[Seli;gane. according to Norris (1982) consists of those processes
that permit people and families to take initiative. to take responsi-
bility. and to function effectively in developing their own potential
for health. Self-care encompasses preventive self-care. self-
treatment. and deciding whether to call a health care provider for
assistance.

.Strategy is a term used frequently throughout nursing literature
as a means of developing a plan of assistance for a client. Websterks
(1981) defines strategy as just that--a careful plan or method. The
strategy that is developed is to be used as a method toward the solu-
tion of the problem or an end goal of relief from the problem.

In summary. sleep has a restorative and recuperative function
necessary for the preservation of life. When a person becomes older.
there seems to be more difficulty in achieving quality sleep; thus

insomnia is seen as a common complaint. To be able to understand

l0

elderly clients'lnanifestation of insomnia and perception of whether
insomnia is a health problem will assist the health care provider in

instituting a plan of care to promote their current health status.

W

The findings of this research project should provide new
information on the problem of insomnia as perceived by the elderly
client. These findings should have a significant effect on increasing
the health care providerhs awareness of whether insomnia is a signifi-
cant problem in the elderly population. The literature is lacking in
studies of sleep problems. their prevalence and significance as related
to a primary health care setting. This author has developed a tool to
be used for sleep assessment of the elderly client. By using this
tool. perhaps the relationship between the elderly client. the sleep
problem of insomnia. and its relationship to the primary health care
provider can be studied in more detail. As the elderly population of
our nation steadily increases and if insomnia is a prevalent complaint
of this population. than the primary health care provider will need to
realize this complaint. With this realization. the primary health care
provider can gain knowledge of effective strategies and treatment to

help the elderly client in dealing with insomnia.

Won:

It is assumed that insomnia is. indeed. a problem that occurs more
frequently in the elderly. Although this does appear to be true of

studies done with hospitalized or institutionalized elderly. it cannot

be generalized to the healthy elderly. since there is only one that
deals with a healthy elderly population (Hayter. 1983). Thus the
assumption of a problem being true with one segment of the elderly has
been believed to be true of all elderly.

The fact that only one sleep study was found that was concerned
with healthy elderly is a limitation of this study. There is not a
great source of literature to review regarding the elderlyfis sleep
habits. Specifically. the sleep complaints of the healthy elderly. not
hospitalized or institutionalized. are limited. Sleep literature con-
cerning the elderly has increased since the 19805. but these sources of
information are not often concerned with the healthy elderly who would
' be presenting to a primary health care setting. ‘The number of sleep
studies involving healthy elderly and the small amount of literature in
this area of sleep are viewed as limitations of this study.

It is hypothesized that the elderly client obtaining health care
at a primary health care setting would identify insomnia as a problem
and that these elderly persons would implement self-care strategies
before seeking the advice of a primary health care provider.

The remainder of this written project covers various portions of
the research. First. the concepts as applied according to Florence
Nightingale's theory. a review of the literature regarding insomnia and
the elderly. the methodology and procedures used to implement the
assessment tool and. finally. a summary of the conclusions obtained from
the study and their implications for nursing practice are discussed in

the remaining chapters.

GMRERII

CONCEPTUAL FRAMEWORK

01mm

The elderly are having a more significant impact on our society as
their number increases. 'They are becoming involved in community
activities. varied group organizations. and many are involved in poli-
tics at the community. state. and national levels. With the number of
elderly increasing in our society. there is an increased need to under-
stand and be able to care for their health problems at the primary care
level. 'The elderly may be seen often by a primary care provider for
chronic health problems or acute episodes of illness.

Insomnia has been identified in the literature as a common
complaint of the elderly. Along with the many life stressors and
changes the elderly face. they may also be experiencing a disruption of
their sleep--or insomnia. The question arises. would the elderly
identify a change in their sleeping pattern. namely insomnia. as a
health care problem that they would be likely to bring to a primary
health care provider to assist them in overcoming? Since sleep is
viewed as a normal body function. perhaps the elderly would not iden-
tify this as a health problem. and self-care for insomnia would not be

instituted as they may suffer needlessly.

12

13

Whether a primary health care provider is sought for the identi-
fied problem of insomnia or self-care is used. specific strategies for
the relief of insomnia are the end result. These strategies may or may
not be effectivet This may result in using many strategies to attempt
to achieve the relief of insomnia. By using strategies used to relieve
insomnia in the elderly. the primary health care provider of the
elderly should be capable of maintaining the present health status and
quality of life of the elderly.

In summary. the elderly population is increasing in size. There-
fore. the number of elderly seen by primary health care providers will
also be increasing. Insomnia is a common complaint of the elderly. As
primary health care providers. it is important for us to understand
whether the elderly do identify insomnia as a problem and how it is
manifested. It is also important to know whether insomnia is identi-
fied as a health problem if it is managed by using self-care. In
either instance. specific strategies. believed to be useful in reliev-
ing the complaint of insomnia. should come forth.

In the remaining portion of this chapter. the concepts of this
research are defined; also included is a schematic presentation of the
conceptual framework. A discussion of Florence Nightingale's theory of
nursing and its relationship to the research conceptual framework
follows. Finally. a summary of how these concepts relate to the

research problem under study is presented.

l4

Elderly
Elderly as defined by Webster's (1981) is "rather old." being past

middle age. This is a poor measure of age since everyone's perception
would be different. Theories concerning aging have changed since 1970
(Ebersole & Hess. 1981). It is difficult to define or measure when one
becomes old because of the way the world is changing around us. ‘The
chronological age using 65 as the dividing line for "old age" was begun
by Bismark in the 18805 in legislation dealing with retirement pensions
(NIH. 1980). At this age in life one is able to retire. collect Social
Security benefits. and often no longer remains a "working"rnember of
society. This arbitrary choice of age 65 was appropriate in the
nineteenth century. when this age was the life expectancy for males in
most Western countries. The National Institute of Health and World
Health Organization have defined "e1 derly." "aged." and "old" to mean
age 65 and over (NIH. 1980). Since this is the traditional view of
when old age or elderly begins. I defined elderly. for the purpose of
this study. to be ages 65 to 85. This age span is used because it will
give some depth to the variety of responses to be returned. The indi-
vidual will be aware of the aging process and most likely involved in
certain aspects of the changing lifestyle. Also. the particular set-
ting used for this study has a high volume of clients between the ages
of 65 and 85. Thus elderly is defined as those persons 65 to 85 years

of age.

15

W

The system that delivers ongoing longitudinal care for an indi-
vidual is a characteristic of a primary health care system. The system
serves as a point of entry to a setting delivering health care. and
also a point of screening and referral if necessary. Basic services
are provided that deal with preserving health. health maintenance. or
health promotion. Being capable of offering human support to its
clients concerning health-related issues is a quality of the primary
care system that aids in helping individuals through difficult circum-
stances (College of Nursing. 1981).

The care given in a primary care system is client centered and
holistic. The care given helps the clients define their involvement
with professional services and how to continue with the care. Thus the
primary health care system is seen as the coordinating. collaborating.
and integrating system when other health care services are needed
(College of Nursing. 1981).

The primary health care system is. then. one's first encounter
with a system that treats the client holistically concerned with
preserving health. health maintenance. and health promotion. It is an
autonomous system of health care that refers when necessary. collabo-
rates and integrates the system with other services that are needed.
The primary health care system provides continuity of care to the
client over time. 'The system keeps the client as its central focus
(College of Nursing. 1981). The primary care system is defined. then.

as the entry point of an individual to the health care system.

16

Identity
Identify implies a recognition of a particular state as being
present. according to hfifiufizufis_fligtignany (1981). Thus to not

identify would be not recognizing a particular state to be present.
Recognition of such a state would mean that some»sort of mental process
has occurred in which a person would either attribute or not attribute
known characteristics of a state to be true of one's self. The answers
on the sleep questionnaire. to be used in this study. will indicate
whether insomnia is a sleep disturbance that he/she has encountered.

By this process. then. the elderly will identify or not identify insom-
nia as a problem that they face. ‘They will do this identifying by

completing a sleep questionnaire.

Insomnia

Insomnia is the symptom to be studied. Insomnia is not a disease
but rather a symptom that is an abnormality of one's sleep pattern.
Insomnia signifies want of sleep and is used. popularly. to indicate
any impairment in its duration. depth. or restorative properties
(Harrison et al.. 1980). Insomnia is. then. an interruption in one's
normal sleep pattern which is a restorative physiological factor
important to health and well being. The fact that this symptom
signifies a threat to the individual's health and well being is true of
those who would present themselves to a primary health care setting.

Insomnia of the elderly is the specific category of clients to be

studied. Little is known about the elderly population's identification

17

and perception of insomnia in relation to the primary care setting.
Research has been done on the subjective characteristics of sleep in
the elderly population using sleep laboratories. electrocepholograms.
and electroculograms (Feinberg. 1967; Gerard. 1978; Herbert. 1978;
Karacan & Williams. 1978L The elderly clients presenting to a primary
care setting are chosen because they are at a stage in their lives when
health has great importance. Insomnia is a symptom that may arise
causing a disturbance in their lifestyle. The elderly's perception of
whether insomnia is truly a health problem to be taken care of in a
primary care setting will be evaluated. As noted earlier. studies
regarding the elderly"s perception of whether insomnia is a significant
problem and its prevalence as a complaint in a primary health care
setting are not abundant. Thus the study will help to give an indica-
tion of the prevalence of insomnia as a problem of the elderly that
would be encountered by the primary health care provider.

According to the literature. insomnia will be defined as a want of
sleep due to (1) increased number of nighttime awakenings or difficulty
remaining asleep (Bradner. 1976; Cohen. 1978; Hayter. 1980; Johns.
1975). (2) sleep latency or difficulty in falling asleep (Cohen. 1976;
Hayter. 1983; Johns. 1975). and (3) early morning awakening (Cohen.
1976; DeLOughery. 1982; Hayter. 1980). 'The elderly who identify
insomnia are likely to be describing one or more of these sleep
problems. .Age has been shown to be a factor in the reporting of sleep
disturbances. The elderly reports a problem to a greater degree than

does a younger person (Weiss. 1974).

18

In summary. insomnia will be viewed as an interruption in one's
sleep pattern which is a restorative physiological factor important to
health. The population to be studied will be the elderly client
classified earlier. The presence of insomnia will be determined by
administering a self-rating sleep questionnaire. The questionnaire
will determine if the elderly identifies insomnia as a problem. and

also how insomnia is manifested and managed.

WW
Primary health care has been defined as including the initial

contact of the client with the health care system and encompasses a
full range of basic health services (Silvers & McAttee. 1979). Primary
health care involves taking care of those who are well and ill. The
care should be accessible. individualized. client-oriented. of high
quality. comprehensive. and based on a firm background of knowledge
that integrates the medical. biological. physiological. psychological.
social. and behavioral sciences.

The provider of this primary health care can be one of a variety
of health professionals. For the purpose of this study. the primary
health care setting whose elderly are to be studied are given care by
two physician primary care providers. Thus. these are the health
professionals whose care the elderly would be seeking if insomnia is
identified as a problem for which they would seek care. The primary
health care provider. then. is the person who assumes the responsi-

bility and accountability for the coordination. integration. and

19

continuing management of the client's total health care and services
(Silvers & McAtee. 1979L

In summary. a primary health care provider will be the health
professional whose care is sought in a clientfls initial contact with

the health care system offering a full range of basic health services.

Mane

Individuals have been taking care of their own health needs for
years. Norris (1979) defined self-care as encompassing those processes
that permit people to take initiative. to take responsibility. and to
function effectively in developing their own potential for health.

This definition implies that self-care encompasses preventative self-
care. self-treatment. and deciding whether to call health care pro-
viders for assistance. For the purposes of this study. this perception
of self-care will be utilized in relation to the elderly.

Self-care. according to the definition. includes those acts of
everyday living that maintain the well-being of older adults. Self-
care is caring for one's self. Elderly persons have been caring for
their own needs for many years. Although the current health care
system fosters the dependence of the elderly. self-care is a process
that is often chosen over seeking the advice of the health care pro-
vider. The elderly have the knowledge. experience. and ability to make
effective decisions regarding their own health status that maintain
life. health. and well-being.

In summary. sel f-care is the process that permits people to take

initiative. responsibility. and to function effectively in developing

20

their own potential for health. The elderly have experienced and
learned much about self-care throughout their lives. 'This puts them in

a unique situation to implement self-care.

Strategy

A strategy according to Webster's (1981) is a careful plan or
method. This plan or method that is implemented by the elderly is
either a recommendation of the health care provider or of self-care. ll
strategy is an attempt to devise and employ certain methods that will
result in relief of the problem. in this study being insomnia. A
strategy. then. is the careful plan or method that has been developed
to attempt to reach the goal of easing the problem of insomnia.

In summary. the elderly may either identify or not identify
insomnia as a problem. In the instances where insomnia is viewed as a
problem. the elderly may choose to address the problem with a health
care provider or institute self-care in order to obtain relief. Spe-
cific and a variety of strategies may be employed in order to provide
relief for the elderly suffering from insomnia.

The concepts that have been defined are connected. The conceptual
framework depicted in Figure 1 illustrates the connectedness of these
concepts. The elderly is the individual who either will identify
insomnia or will not identify insomnia as a problem. If insomnia is
identified. the options of whether to present this problem to a primary
health care provider or to institute self-care exist. Whichever

approach is taken to relieve the problem of insomnia. strategies should

21

be the end result. This conceptual framework goes back to the original
research problem of: Whether the elderly presenting to a primary

health care setting identify insomnia to be a problem; if they do. how
is it manifested and is it viewed as a health problem to be taken care

of by the primary health care provider or is self-care instituted.

 

 

 

elderly

I

primary health care system

 

 

 

 

 

 

 

 

 

¢' ¢r
insomnia insomnia
not identified identified

 

 

 

 

 

 

J,
l l

self-care primary health
- care provider

 

 

 

 

 

 

 

 

 

 

strategies

 

 

 

Figure l.--Conceptual model.

22

WW

Florence Nightingale was born into a society characterized by
widely disparate social structures. At one end of society the care-
free. complacent upper class lived in a state of isolated affluence; at
the other end was the victimized. oppressed lower stratum (Palmer.
1977). Born in 1820 of well-to-do parents. Florence Nightingale pos-
sessed energy and determination that would make her eminent in any age.
Nightingale's character was influenced by a love of the arts; dissent
from religious orthodoxy; a meticulous education. equal to that of most
men of her day; extensive travel; and her belief that she had received
a call from God to do His will. The status of nursing. her mission in
life. was so low that her ultra-conservative family was startled and
ashamed by her intentions. Nightingale was a strong individual. and
the tenacity with which she clung to this sense of vocation enabled her
to succeed where a less resourceful character would most certainly have
failed (Bcflster. 1964). Few persons of the nineteenth century have
been surrounded by so much glamour and public adoration as has Florence
Nightingale. Nightingale did much to establish nursing as a profes-
sion. Her theory of what nursing is and is not is still applicable to
the profession today.

Nighti ngale's general focus of nursing comprises the units of
person. environment. health. and disease. The person is viewed as
comprising physical. emotional. social. and spiritual components. or a
holistic being. A person is believed to be able and responsible to

alter his situation to relieve suffering. The environment is those

23

physical elements. external to the person. that affect the healing
process and health. Health is. then. a result of environmental.
physical. and psychological factors. Health is being able to use well
every power we have to use. Nightingale believed these units act
together and were units that nursing could influence to prevent
disease. which was seen as the reparative process of the body to
correct some problem.

The central focus of Florence Nightingale's theoretical framework
is nursing and its relationship to health. Her primary focus for
nursing to aid in promoting health is by influencing the environment. '
She has conceptualized nursing as a science of health and has described
it as primarily directed toward improving and managing theienvironment
so that nature can heal patients (Ellis. 1982). Nightingale viewed
nursing as having an assistive function in helping the client return to
or maintain health. Nightingale viewed the nurse as primary care agent
and as the first defense in health maintenance. promotion of wellness.
and prevention of disease (Palmer. 1983). Today. this conceptualiza-
tion of nursing is again receiving a great deal of attention with
health maintenance and health promotion being areas where nursing is
putting emphasis. especially in the case of the nurse in primary care.

Nightingale. in the 18005. realized the importance of nursing the
well. She had the wisdom to know the best way to promote the health
and welfare of the British soldier was to improve the health of the
British population. which was the source of the army (Palmer. 1977).

Nightingale perceived the nurse as the key to establishing a healthy.

24

disease-free citizenry; further. she perceived that nursing extended
from the active care setting to the broadest concept of the community.
or primary care nursing. She believed the laws of health are of
nursing. for they are in reality the same and apply among the well as
among the sick (Nightingale. 1860). Nightingale was a leader in
recommending preserving health as well as curing the 11L. Thus. using
Nightingale's ladder concept of what nursing is and following it down
the side of health. one can see that putting the healthy elderly in a
condition to preserve their present health would be a prime role for
nursing.

In her book. Notes_on_NuLsing (1860). Nightingale viewed sleep as
an important aspect of life. She addressed the fact that the first
cycle of sleep is most restorative and if a patient is roused out of
this sleep he is almost certain to have no more sleep. Nightingale
stated. "never to allow a patient to be wakened. intentionally or
accidentally. is a sine qua non of all good nursing" (p. 25). Thus.
Nightingale would have been concerned by the elderlyNS frequent
awakenings at night and would have believed nursing could impact this
restorative function. Nightingale also wrote of the healthy person
who allows himself to sleep during the day will lose his sleep at
' night. Napping during the day is often a habit of the elderly and
perhaps is a reason for the complaint of insomnia. Nightingale also
believed the environment should be conducive to sleep. She addressed
the fact that sleep should not be disrupted by noise. that bedding

should be clean and light. light in the room and fresh air essential

25

for providing a proper environment. Thus. Nightingale's concern for
sleep as a necessary. restorative function that is affected by oneus
habits and environment gives credence to the el derly's need for sleep
and support for some strategies to promote sleep for them. Another
strategy to promote sleep. as addressed by Nightingale. was reading.
Although her works do not say a great deal about spirituality. one can
infer from her upbringing that this is an aspect of the total indi-
vidual she did not mean to neglect. Therefore. when reading is said to
be relaxing. one can infer it is the Bible being read. which was comnmni
practice in the era in which she lived. One can derive that Nightin-
gale approaches the client in a holistic sense and interprets sleep as
an important process which nursing can impact.

Nightingale did not ever write about the client being involved
in self-care. She assumed the client to be almost passively affected
by the nurse and the environment. She did see the person as having
the ability and responsibility to alter his situation to relieve suf-
fering. Thus it is felt that she did. in a sense. believe in self-
care. Nightingale was a progressive individual for the nineteenth
century. She most likely would have been a proponent of self-care and
have seen this as the clientfls choice to affect his environment.
relieving insomnia and promoting and preserving his health.

Following Nightingale's ladder conceptualization of nursing
addressing the healthy client. the concepts of this study are appli-
cable to what Nightingale believed nursing to be Figure 2% A.primary

health care nurse can put the healthy client in condition for nature to

26

 

Nursing
is

 

 

 

 

 

 

 

 

to help to put

 

 

 

 

 

 

I I

healthy

 

 

 

 

 

patients suffering
from disease

 

 

 

 

 

I I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

children human beingsJ
elderly
in condition for nature
to act on
N?
to live restore health preserve health
cure disease prevent disease
and injury

 

 

 

Figure 2.--An adaptation of Nightingale's ladder model of nursing.
(From George, J. (1980). Nursingfltheories: The base for
professional nursing practice. Englewood Cliffs, N.J.:
Prentice-Hall.)

 

 

27

act upon to preserve health and to present disease and injury. Thus.
if the healthy elderly client brings the problem of insomnia to the
primary care provider. the provider should be able to maintain the
health and prevent disease in the elderly by using strategies that act
on the environment to effect change and relieving insomnia.

This study will illustrate that the environment affects the
elderly by using Georgeus(l980) triangle representation dividing the
environment into the segments of physical. psychological. and social
environment (Figure 3). Dealing with insomnia as the patient's condi-
tion. the physical environment can promote sleep by being conscious of
the air. light. noise. temperature. pain. humidity. cleanliness. and
other variables. The psychological environment relates to promoting
sleep by being aware of stressors. anxieties. fear. depression. allow-
ing communication so that the elderly gain knowledge of the condition.
The social environment affects the elderly by the daily routine that
they have established affecting circadian rhythms and by allowing for
prevention of disease and health promotion. Using these factors and
fitting them into the triangle conceptualization of nursing. one is
able to see that insomnia is a health problem that nursing is capable
of managing holistically for the elderly. Nightingale treats the
client holistically and discusses sleep in her writings with the
desired outcome being to have an environment that enhances sleep. which
is necessary for a healthy individual.

In summary. Nightingale's theory of nursing in dealing with the

healthy is in the same focus as this study. 'The primary health care

28

Physical
Environment

     

cleanli-
ness
ventilation
pain
temperature
exercise
naps
caffeine
alcohol
medications
snack
fatigue
humidity

  
   
     
     
   
   
   
   
     

 

     

pt. condition
' in nature

  
 
 
 
  
  
 

 

 

  
  

depression

   
  
 

 

guilt I
stress I
anxiety I
fear : daily routine
communication ' prevention of disease
knowledge 2 promotion of health
Psychological Social
Environment Environment

Figure 3.--Adaptation of Nightingale's concept of nursing.
(From George, J.(l980). Nursing theories: The base
for professional nursing practice. Englewood Cliffs,
N.J.: Prentice-Hall.)

29

provider. today. is working with healthy clients. and many of these
clients are elderly. The primary health care provider is in a position
to aid the elderly in preserving their health and promoting health.
Today. self-care is also seen as an option to primary health care that
the healthy has to maintain or preserve his health. Nightingale
believed sleep to be a restorative function necessary for health that
can be enhanced by environmental factors. Again. this conviction is
maintained throughout this study. Nightingale's theory of nursing and
statements regarding sleep give support to the conceptual framework of

this study.

CHAPTER III

REVIEW OF LITERATURE

91612119.!

How many thousand of my poor subjects

Are at this hour asleep! 0' sleep. 0' gentle sleep.
Nature's soft nurse. how have I frightened thee.
That thou no more wilt weigh my eyelids down

And steep my senses in forgetfulness?

Shakespeare...fibnry_1¥

How did you sleep last night? This commonplace question has taken
on new significance for health and longevity in recent years as
investigators have begun a detailed exploration of sleep and wakefulness
in older people. Sleep research began in the 19605; then momentum and
monies for sleep research increased in the 19705. We are now in the
19805. The focus of much sleep research is studying the sleep pattern
of the elderly (Dement et al.. 1981).

The elderly are becoming a dominant force in our society as the
life span increases (Gelein. 1982L Society appears to be aware of
the impact the increased number of elderly have in affecting change in
political candidates. organizations. schools. and the health care
system. As their number increases. the elderly are having an increased
contact with the health care system. Age has been shown to be a factor

in the reporting of sleep disturbances. The elderly person reports a

30

31

problem with sleep to a greater degree than does a younger person
(Collings. 1983; Weiss. 1974).

Since we spend approximately one-third of life in sleep (deBrun.
1981; Ebersole & Hess. 1981; Fenton. 1976). it is an important body
function to understand. In response to the question of the nature of
sleep. many definitions of sleep are found. Sidney Cohen (1976)
defined sleep as a condition of reduced consciousness. Oswald (1976)
expanded on this definition. defining normal sleep as a recurrent
healthy condition of inertia and unresponsiveness which is associated
with various physiological changes. Although one generally accepted
definition of sleep does not exist. most researchers have defined it in
basically similar terms. The major components included are: (1) sleep
suspends the complex sensory motor activity which brings one into
relation with the environment (Fenton. 1976); (2) sleep and wakefulness
comprise alternate phases in the cycle of existence (Hayter. 1980); and
(3) sleep is a normal body function which is required to maintain

physical and mental health (Hartman et al.. 1972).

mum

The sleep process can be divided into two neurologically distinct
states. These are NREM (non-rapid eye movement) and REM (rapid eye
movement) (Gambert & Duthie. 1981; Karacan & Williams. 1988). 'These
states cycle through a sequence of four stages of NREM followed by REM.
This cycle usually lasts approximately 90 minutes and is repeated four
or five times in the course of a night (deBrun. 1981; Hayter. 1980;

Karacan & Williams. 1983).

32

In Stage I of NREM sleep. the first stage of normal sleep. a
person is somewhat aware of his surroundings. very relaxed and dreamy
at this time. In this stage of sleep a person is frequently awakened
by involuntary body jerks. Stage I of sleep only lasts approximately
5% of the total sleep time (Hayter. 1980; Kinzie & Markoff. 1974).
Low-voltage sleep waves with mixed frequencies appear on EEG during
this stage (Kinzie & Markoff. 1974).

Stage II NREM follows and is the first well-defined stage of
sleep. It has been estimated to fill between 40 and 55% of our total
sleep time (Kinzie & Markoff. 1974; Walsleben. 1982L. There is
moderately easy awakening during this stage of sleep. One remains
somewhat aware of his surroundings. Sleep spindles and K complexes are
recorded on EEG at this time (Walsleben. 1982).

Stage III NREM sleep is the next phase of sleep that a person
enters. This phase encompasses approximately 10% of one's total sleep
time. High-voltage sleep waves with generalized slowing are recorded
on EEG during this stage of sleep. Sleep is becoming deeper. thus
making awakening more difficult. Physiological changes noted are a
slower pulse. respiratory rate and blood pressure are lowered (Kinzie &
Markoff. 1974).

The next stage of sleep one enters is Stage IV NREM. This stage
usually appears approximately 40 minutes after the start of Stage I
(Hayter. 1980). This is a phase of profound sleep during which there
is the greatest difficulty in awakening. Confusion. for a brief time.

may appear upon being aroused from Stage IV NREM. Physiological

33

changes that occur are again a slow pulse. lowered blood pressure. slow
respiration. and body temperature falls (Kinzie & Markoff. 1974;
Martin. 1975; Walsleben. 1982). This stage of sleep takes up
approximately 10 to 15% of the total sleep time. Stage IV sleep is
said to restore. relax. and rest the body physically (Hartmann. 1976;
Hayter. 1980L This stage of sleep is what most people think of when
they think of sleep. when they are in total oblivion to their surround-
ings. An EEG tracing during Stage IV NREM shows a high-voltage wave
with slowing.

Often Stages III and IV NREM are referred to together as slow-wave
sleep or Delta Sleep (deBrun. 1981). The human growth hormone is
believed to be sleep dependent and requires the precursor of slow-wave
sleep (Martin. 1975). The bulk of Stages III and IV sleep is believed
to occur in the early portion of the night (Fenton. 1976). being
prevalent in the first third of the night.

By the end of about 90 minutes total sleep time. one gradually
returns up through the lighter stages of sleep to Stage I (Hayter.
1980). Instead of reentering Stage I or awakening. one enters REM
sleep. REM sleep on EEG tracing is low-voltage. high-frequency.
similar to Stage I of NREM. Approximately 20% of one's total sleep
time is spent in the REM phase (Gambert & Duthie. 1981; Kinzie &
Markoff. 1974; Walsleben. 1982). REM sleep has many unique features.
The one for which it is named is the frequent bursts of rapid eye
movement. which often can be observed through closed eyelids (Fenton.

1976; Hayter. 1980). Other unique physiologic characteristics of REM

34

sleep include profound muscular twitching. muscular relaxation with
complete relaxation of the lower jaw and neck. the pulse and breathing
become irregular. the blood pressure variable. body temperature becomes
uncontrolled. and a marked paroxysmal increase in nerve cell activity.
Males have penile erections. and gastric secretion is increased in both
sexes. the highest level of oxygen consumption occurs. and increased
cerebral blood flow (Hayter. 1980; Karacan. 1971; Kinzie & Markoff.
1976; Martin. 1975; Oswald. 1976; Walsleben. 1982L. The need for REM
sleep is said to be psychologically and mentally restorative (Hartmann.
1971; Hayter. 1980). REM sleep is believed to have a particular role
of restoring and maintaining the function of catecholamine mechanisms
within the brain. A high proportion of REM sleep is associated with
periods of most rapid brain growth (Oswald. 1976L Periods of REM
sleep increase during each cycle of sleep throughout the night (deBrun.
1981; Fenton. 1976; Hayter. 1980). So as Stages III and IV NREM
decrease as the night progresses. REM sleep is increasing.

The dreams associated with REM sleep are believed to be essential
to the process of mental restoration. Studies of sleep behavior reveal
that everyone dreams during REM sleep. although these dreams may not be
remembered upon awakening (Hayter. 1980). When one is awakened from REM
sleep. he is likely to report vivid dreams with much visual imagery.
This REM mentation slips rapidly from the memory unless rehearsed upon
reawakening (Fenton. 19760. Because of this fact. many deny having

dreams.

35

The psychological and mental restoration that are said to
accompany REM make it important for learning. memory. and psychological
adaptation. It is during REM sleep that the day's events are reviewed.
This perhaps is why problems sometimes are solved when one "sleeps on"
a troublesome issue or. at least. a new perspective may be gained
(Hayter. 1980). The requirement for REM sleep has been said to be
increased if one is facing psychological stresses. This increase in
REM sleep may give one a feeling of not having slept soundly due to the
fact that REM sleep is a lighter sleep (Hartmann. 1971).

The cycle of sleep from Stage I NREM to REM sleep is said to occur
four to five times per night. with a complete sleep cycle about every
90 minutes. The distribution of these sleep stages has been shown to
be relatively consistent across the population (Karacan & Williams.
1971). That is. most REM sleep occurs in the later one-third of the
night. and Stages III and IV NREM sleep are more prevalent during the
first third of the night. People are generally aware that they sleep
more lightly and dream more during the hours just before awakening
(Fenton. 1976; Hayter. 1980; Karacan. 1971). Some research exists that
states these 90-minute cycles are part of the body's rhythm. circadian
rhythm. It is believed these 90-minute cycles occur throughout the 24
hours of the day and are part of the biological rhythms of man
(Brandner. 1976; Collings. 1983; Hayter. 1980). In normal humans of
all ages. the regular alteration of sleep and wakefulness in a 24-hour

period is a fundamental biological rhythm.

36

In summary. normal sleep has been described according to different
stages. with the various physiological changes that occur. the approxi-
mate amount of time spent in each stage. the EEG tracing characteris-
tics of each. and the functions that each stage of sleep is said to
serve. ‘These descriptions of what takes place during normal sleep give
the primary health care provider a foundation to help assess sleep-

related complaints.

was

As one ages. the distribution of time spent in each stage of sleep
changes. This. in turn. affects the quality of sleep in the elderly.
There is a need to have a working knowledge of the fundamental
principles of the changes that occur in sleep throughout the life
cycle. By understanding the basic changes of sleep that occur with
aging. one may gain valuable insight for assessment and management of
elderly clients (Lerner. 1982). Various characteristics of NREM sleep
change dramatically with aging.

Stage I NREM is altered for the elderly. In this instance. there
is said to be an increased total duration of Stage I and an increase in
the number of shifts into Stage I sleep (Dement. 1981; Karacan. 1983).
Since more Stage I sleep predominates elderly persons' sleep pattern.
then it would be understandable to think that their sleep would be
lighter.

Stage II of NREM sleep is apparently unchanged as one ages (Bahr.

1983; Dement. 1981; Hayter. 1980L Dement did mention that the

37

characteristic EEG tracing of Stage II may show an alteration in the
sleep spindles.

Karacan (1983) stated that slow-wave sleep or Stages III and IV
sleep gradually decrease with age until it is nearly absent by age 60.
Brandner (1976) in his research agreed with this statement. These are
the sleep stages that are physically restorative. Other research has
indicated that Stage IV NREM sleep decreases steadily throughout life.
estimating a 30 to 55% decrease by age 70 (Cohen. 1976; Gambert &
Duthie. 1981; Kinzie & Markoff. 1974). Dement (1981) stated that in
Stage IV NREM there is an absolute and relative reduction in time spent
in this stage. with little or none by age 60. His research findings
indicated that there tends to be normal or even an increase of Stage II
in elderly women and normal or reduced in men.

Rapid eye movement (REM) sleep also undergoes some changes with
the aging process. One study said that there is a decrease of REM
sleep to about 20% of the total sleep time (Brandner. 1976). Hayter
(1983) said that REM sleep remains unchanged with aging. Karacan
(1971. 1981) and Dement (1981) believed that REM sleep remains fairly
stable until extreme old age. Dement went on to express his view that
this decrease in REM sleep of the elderly may show a trend of reduced
intellectual function related to organic brain syndrome with changes in
cerebral blood flow. When the period of REM sleep decreases. there is
also a decrease in the physiological change that accompanies it. The
length of REM sleep remains fairly uniform throughout each sleep cycle.

So the majority of REM sleep for the elderly does not occur in the last

38

one-third of sleep. Stage II NREM is believed to frequently interrupt
REM sleep for the elderly (Dement. 1981; Karacan & Williams. 1983;
Kellerman. 1981L

In summary. research has shown that the stages of sleep are
altered by the aging process. Stage I NREM increases in amount. Stage
II NREM is unchanged except by EEG tracing. Stages III and IV NREM
have the most dramatic change as one ages. 'They are greatly decreased
as one ages. Some researchers believe they are absent. There are
varied opinions about the changes in REM sleep. Some research has
stated there is a decrease of REM in extreme old age. 'The period of
REM sleep remains uniform throughout the sleep cycles and is frequently
interrupted by Stage II NREM sleep.

Another change that accompanies aging is in the total sleep time.
There are varying beliefs about the total sleep time of the elderly as
compared to that of the average person. Hayter (1983) believed that
the total sleep time of the elderly does not change with age; the older
person does not require more or less sleep but does require longer to
go to sleep. On the other hand. Fenton (1976) and Brandner (1976)
believed that with age there is a decrease in the total sleep time.
They stated that the elderly function well on 5 to 6 hours of sleep
compared to 7 or 8 for the young adult. Gerard (1978). Lerner (1982).
and Johnson (1975) believed that it takes the elderly more time in bed
to achieve the same amount of sleep as a younger person. Dement (1981)
commented that there are studies indicating the total sleep time to be

reduced and those that show it unchanged. A consideration that needs

39

to be taken into account along with total sleep time in an elderly
person is whether napping is part of their lifestyle. 'The number of
daily naps averages 1.8 for men and 1.4 for women (Dement. 1981).

One further alteration of the sleep pattern that occurs with aging
is an increase in the number of awakenings per night. Lerner (1982)
stated that scarcely an hour goes by without the elderly person
awakening. Other researchers have shown that there is a definite
increase in the number of awakenings after sleep onset until the final
awakening (Brandner. 1976; Dement. 1981; Gambert & Duthie. 1981).

As has been discussed here. aging involves changes at all levels:
cellular. physiological. and functional. By these changes. the
delicate mechanism of sleep is altered. 'The elderly person experiences
quantitative as well as qualitative changes in sleep patterns. Thus.
the picture of sleep for the elderly that emerges from research is one
of marked fragmentation. The stages of sleep are altered. The elderly
can be expected to take longer to go to sleep. to wake up more fre-
quently and for longer periods (Herbert. 1978). The more time spent in
bed presumably correlates with the frequency of complaints of insomnia
in the elderly (Gambert & Duthie. 1981).

About 50% of all persons over the age of 60 report insomnia-
related symptoms (Karacan. 1983L. Insomnia is a symptom of sleepless-
ness. It is a complaint. not a disease (Brandner. 1976). There are
three types of insomnia that have been identified: (1) sleep latency
or difficulty in falling asleep after retiring; (2) broken sleep or the

multiple awakenings during the night with difficulty in falling asleep

40

again; and (3) early morning awakening (Cohen. 1976; DeLoughery. 1982;
Dement. 1981; Karacan. 1983).

As was noted earlier. multiple awakenings are part of the aging
process. These frequent awakenings may leave one with the feeling that
he has had a poor nightfls sleep. Early morning awakenings are also a
common complaint of the elderly (DeLoughery. 1982L This type of
insomnia is often equated with an early sign of depression (Cohen.
1976; DeLoughery. 1982; Frankel et al.. 1976). Difficulty in falling
asleep may be due to the fact that the elderly person has had a nap
after dinner and is not able to sleep again when it is bedtime (Hayter.
1980). If there is a preoccupation about getting to sleep. the anxiety
that results can lead to sleep latency. The frustration of wanting to
fall asleep can become a repetitive cycle. Cohen (1976) noted that
elderly persons seem obsessed with their insomnia and persistently
brood about it during their waking hours.

The normal body rhythm. circadian rhythm. appears to undergo
change in the elderly. beginning at about age 60 (Karacan. 1983).
Collings (1983) stated that there is a tendency toward disassociation
and asynchrony of some circadian rhythms in elderly peoplet 'This is
due to central nervous system deterioration. sensory impairment. and
changes from biphasic to polyphasic sleep patterns that may occur as a
normal part of the aging process. ‘Thus the sleep and wakefulness
pattern of the elderly may not follow a pattern of circadian

rhythmicity.

41

In summary. changes in the el derly's sleep occur not only in the
sleep stages. but the sleep patterns are also affected. The total
sleep time of the elderly. number of nighttime awakenings. early
morning awakening. and changes in the circadian rhythm alter the
quality of sleep for the elderly. Insomnia is a common complaint of
the elderly. often due to the reporting of a change in one of these

sleep patterns.

WW
Other factors affect the reasons why the elderly frequently have

the complaint of insomnia. Kramer (1982) stated that insomnia is often
treated as if it were different from other symptoms--that is. one that
does not call for the same differential diagnosis as would chest pain
or dyspnea. Insomnia can be a symptom of some illnesses that are
progressive or that can be exacerbated by the use of sedatives (Dement.
1981).

An accurate diagnosis is necessary. then. to be sure that insomnia
is truly the chief complaint needing treatment. The first step in
diagnosis is taking a thorough history based on an appreciation of the
possible relevant diagnosis (Kramer. 1982). Subjective measures such
as sleep questionnaires can be used to help differentiate if the
elderly person presenting with a complaint of insomnia truly has a
sleep disturbance (Johns. 1971). A normal sleep pattern for the
elderly individual should be established as compared to the causes that
have brought on the complaint of insomnia (Gambert & Duthie. 1981;

Mathis. 1978).

42

There are underlying conditions that may alter the normal sleep
pattern and cause an elderly person to complain of insomnia. 'These
pathological conditions should be considered in attempting to
accurately differentiate a diagnosis of insomnia. Effects of stress.
emotional conflict. or changes often precipitate a disturbance of
sleep. With the elderly. these might include hospitalization. change
of residence. or death of spouse or close friend. Usually these stress
factors are temporary. and the sleep disturbance will last less than 3
to 4 weeks (Karacan. 1983).

Sleep loss that occurs due to a chronic tension-anxiety can become
a vicious cycle. In this situation. the bedroom becomes associated
with frustration and arousal. This. in turn. perpetuates the sleep
loss (Cohen. 1976). Elderly persons with stress disturbances tend to
complain of insomnia and multiple awakenings throughout the night
rather than daytime sleeplessness and of difficulty falling asleep
(Karacan. 1983).

Depression. as a cause of insomnia. has already been alluded to.
The clinical symptoms of depression are frequent awakenings. early
morning wakefulness. and reduced Stage IV NREM. ‘The severity of these
symptoms increases with age. However. decreased Stage IV NREM and
frequent awakenings are common in the normal sleep pattern of the
elderly (Karacan. 1983; Kramer. 1982). A health care provider should
be cautious in attributing sleep disturbance to depression without

careful evaluation.

43

Cardiovascular disease is another pathological condition to be
considered. Deaths from cardiac disorders occur more often during
sleep than waking hours. with the greatest number between S and 6 a.m.
This is an interval abundant with REM sleep. when more irregular
autonomic activity occurs (Karacan. 1983). The slight fall in blood
pressure that normally accompanies sleep may contribute to stroke in a
person with cerebrovascular disease (Hayter. 1980; Karacan. 1983).

The incidence of duodenal ulcer increases sharply after age 60
(Karacan. 1983). As noted earlier. gastric secretion increases during
REM sleep. Duodenal ulcer patients will secrete 3 to 20 times more
gastric acid than normal during sleep. With this increase in gastric
acid. pain may be prevalent during the night (Lerner. 1982).

Arthritis. a comnmuiailment of the elderly. may cause awakening
during the night. This awakening is due to the pain and joint stiff—
ness because of the extended period of inactivity. Conditions that
produce discomfort will preclude the normal sleep pattern (Lerner.
1982; Mathis. 1978L

Chronic obstructive lung disease will produce an abnormal increase
in alveolar tension and decrease in oxygen saturation. Lying in a
prone position often causes dyspnea and stasis of mucous (Lerner.
1982). Breathing is already irregular during Stages III and IV NREM
and REM sleep. Thus. frequent awakenings during the night may occur
during the critical physically and mentally restorative phases of
sleep. cuasing the COLD client to have an increased fragmentation of

sleep.

44

It has been recognized that patients with Parkinson syndrome have
problems during sleep. Their tremors and rigidity stop. yet sleep is
altered severely. There is a total wake time increase and a decrease
in REM sleep. Drug therapy may improve this sleep pattern. but most
often the complaint of insomnia persists (Lerner. 1982).

Hyperthyroidism can produce a sleep disturbance that may persist
for 1 year even after appropriate treatment has been started (Kramer.
1982A Hypothyroidism is associated with a decrease in Stage III NREM
sleep (Hayter. 1980). Thus endocrine causes of insomnia need to be
considered when evaluating the complaint of insomnia.

Alcohol use and abuse need to be considered when assessing a
client who has the complaint of insomnia. Every phase of chronic
alcoholism is associated with some sleep disturbance. Alcoholics suf-
fer from long sleep latency. frequent awakenings. and disordered sleep
patterns (Kramer. 1982). Alcohol use. although it seems to speed the
onset of sleep. has more deleterious than beneficial effects on sleep
because it affects REM sleep. 'The hangover that frequently follows
alcohol consumption may be partially due to REM deprivation (Hayter.
1980).

A thorough history of the drugs a client uses may uncover the
cause of insomnia and alleviate the need for further treatment. CNS
stimulants. including caffeine. cause increased stability of wakeful-
ness. Drugs. including thyroid preparations. anticonvulsants. mono-
amine oxidase inhibitors. ACTH. and propanolol may interfere with sleep

(Kramer. 1982). The major tranquilizers. hypnotics. opiates.

45

sedating tricyclics. and even aspirin may cause disturbance in the
stages of sleep with chronic use or upon withdrawal (Mendelson. 1980).
In summary. pathological conditions that need to be assessed when
a complaint of insomnia is presented to a health care provider are
stress. depression. ulcer disease. cardiovascular disease. chronic
pulmonary obstructive lung disease. Parkinson syndrome. thyroid
disease. and alcohol and drug use. If these or some other pathological
condition is not the cause of insomnia. then an indepth history
assessing the elderly person's sleep pattern needs to be conducted

(Johns. 1971).

AssessmentJLInstnia

A normal sleep pattern for the individual should be established as
compared to the causes of insomnia that have brought the client to the
health care system (Gambert & Duthie. 1981; Mathis. 1978L This
history should be amplified in the following areas of difficulty
falling asleep: erratic or broken sleep. early morning awakenings.
daytime naps. dreams. nightmares. feelings upon awakening. habits
directly before retiring. and the total number of hours of sleep
desired (Kramer. 1982; Mathis. 1978L. This information will provide a
description of the sleep pattern that is causing the complaint of
insomnia.

An investigation of the onset of the complaint should be conducted
next. The investigation should ascertain when the symptom of insomnia
began. if it is cyclical or continuous. what was going on in the

environment at the time. have there been worries. changes in life

46

patterns. or previous episodes of insomnia before (Kinzie & Markoff.
1974; Mathis. 1978L

Substance intake is another area that needs to be considered when
inquiring about sleep disturbances (Brandner. 1976). Questioning
should include the consumption of coffee and other caffeine-containing
beverages. of medications. sleeping pills. alcohol. and diet (Gambert &
Duthie. 1981; Mathis. 1978).

Environmental conditions also need evaluation. The questioning
process should cover what the sleeping arrangements are. the external
noises. disquieting stimuli. too much exercise before bedtime. too
little exercise during the day. snoring by person bringing complaint or
spouse. is bed comfortable. sleep partner. restless. climate too warm
or too cold. or variation in lighting (deBrun. 1981; Kinzie & Markoff.
1974; Mathis. 1978).

To accurately assess an elderly person's sleep disturbance once
any other existing pathological condition has been ruled out. a history
evaluating a normal sleep pattern. sleep pattern causing the disturb-
ance. onset of the complaint. substance intake. and environmental
conditions needs to be conducted. Most of the sleep disturbances can
be diagnosed on the basis of the history. which may also include an
interview with the person's bed partner (Kramer. 1982).

Assessment tools to be used for the complaint of insomnia that
would assess patterns of sleep. naps. habits before retiring. substance
intake. environmental conditions. present medical illness. and social

status are lacking in all the literature reviewed. Most of the tools

47

that were reviewed did not pertain to the elderly (Dement. 1976; Lamb.
1980; Webb. 1976). Lerner (1982) did develop a self-assessment test
for the elderly. but this is a short questionnaire and does not address
many of the areas mentioned. Hayter (1983) did a study of healthy
elderlyAS typical sleep behaviors. She used a preliminary sleep
questionnaire that addresses age. sex. and daily activities that might
affect sleep. This questionnaire was followed by 2-week recording
sleep chart. Although the healthy elderly Hayter studied could have
been seen in a primary health care setting. the areas of present
illness. medications. and self-care were not assessed.

In summary. the literature is lacking in sleep questionnaires that
could be used to assess patterns of sleep. naps. habits before retir-
ing. substance intake. environmental conditions. present illness. social
status. and self-care for the healthy elderly. This area of assessment
could aid a clinical nurse specialist who is working with the healthy
elderly in a primary health care setting or similar setting. The
assessment would provide the clinical nurse specialist with an examina-
tion of the basic sleep changes that have occurred with the elderly.
Also. an assessment of the habits. environmental factors. medications.
medical illness. and what self-care the elderly use would aid the
clinical nurse specialist in developing strategies that might help
promote a healthier sleep.

Once the sleep disorder causing insomnia has been accurately
evaluated to be present. then some strategies need to be developed to

aid the elderly in achieving a higher quality of sleep. Understanding

48

that insomnia is rarely a medical emergency. there is time to investi-
gate thoroughly by having the elderly person keep a sleep log or diary
for at least a week (DeLoughery. 1982). One should record such things
as the time they retire and arise. if they take naps. how often they
awaken at night. and any sleep events (Mathis. 1978). Often a person
will overestimate the amount of time spent awake (Cohen. 1976). so this
diary work-up may be curative for the person (Mathis. 1978).

A fair amount of geriatric insomnia is related to ignorance about
the fact that advancing years are accompanied by a normal reduction of
one's sleep requirement (Cohen. 1976). The most helpful therapy for
many elderly persons is education about the normal sleep pattern
(Karacan. 1983). Sleep efficiency declines after middle age; that is.
elderly people spend more time in bed. yet spend less of that time
sleeping. However. they get as much sleep as younger adults because
they make up fer nocturnal sleep loss by napping (Dement et al.. 1981;
Johns. 1975; Karacan. 1983). The changes within the stages of sleep of
the elderly have already been reviewed. By sharing the changes of the
sleep pattern that accompany the aging process with the elderly. one can
increase the understanding of why their sleep is not what it was when
they were younger (Brandner. 19760. By education. a new perspective
can be gained that may ease anxiety and help the elderly adapt to

change.

49

WW

One approach to help the elderly achieve a more restful sleep is
to maintain conditions that are conducive to sleep (Ebersole & Hess.
1981). This includes a maintenance of a bedtime ritual. such as a
regular time to retire and awaken. These bedtime patterns often help
to induce sleep (Cohen. 1976; DeBrun. 1981; DeLoughery. 1982; Mathis.
1978). The elderly may need help in establishing a new routine.
Family members or close friends should be enlisted to help maintain
this new routine (Karacan. 1983).

Suggesting that the elderly person limit his nap to less than
1 hour per day should aid in promoting a longer period of sleep at
night (Brandner. 1976). Ebersole and Hess (1981) said naps are useful
and provide relaxation and compensation for less sleep at night. Day-
time naps do not have the same rhythm as night sleep. REM sleep
predominates during morning sleep and Stage IV NREM predominates in
late afternoon or evening naps (Hayter. 1980). This information can be
used to decide if one would benefit more from a nap that would be
mentally or physically restorative. Boredom is a factor in at least
some napping (Hayter. 1980; Yura. 1978). 'ho alleviate this boredom.
the best advice is to set up stimulating. demanding schedules involving
other people. Daytime stimulation tends to lessen napping and thus
consolidate restful sleeping at night (Brandner. 1976).

A common cause of insomnia is lack of exercise (Bower. 1978L If
not already established. an elderly person should begin a routine of

daily exercise. This should not be done close to bedtime. at least not

50

in the 2 hours before retiring. but earlier in the day (Hayter. 1980).
The exercise program may need to be done gradually for the elderly
person who is not used to it (DeLoughery. 1982; Hayter. 1980; Mathis.
1978). Physical exercise can promote sleep (DeBrun. 1981).

Eliminating the intake of caffeine-containing beverages at least
8 hours before bedtime can help alleviate the problem of insomnia for
the elderly (DeLoughery. 1982; Mathis. 1978). Stimulants such as these
can produce an exhilaration that retards the onset of sleep and
increases one's anxiety (deBrun. 1981). This simple action can help
reduce the el derly's problem.

Alcoholic beverages before bedtime should be discouraged. Even a
"nightcap" may create nighttime wakefulness (deBrun. 1981). The
effects alcohol has on REM sleep have been discussed previously.

A warm glass of milk or a snack before bedtime can be sleep-
promoting techniques. Most protein foods. including milk and some
vegetables. contain the amino acid L-tryptophan. L-tryptophan is a
precursor of the neurotransmitter serotonin. which is believed to
induce and maintain sleep (Ebersole & Hess. 1981; Hayter. 1980A
Research shows that 1 gram of L-tryptophan in food changes the length
of time needed to produce sleep from 23 minutes to 12 minutes (Ebersole
& Hess. 1981). L-tryptophan has thus been found to speed the onset of
sleep and prolong the period of sleep without altering REM sleep in any
way (Hayter. 1980; Karacan. 1983). This natural substance has not yet
been approved as a drug by the Food and Drug Administration. L-trypto-

phan has little possibility of toxicity or abuse and does not alter

51

sleep stages. lhfifil it becomes marketable. warm milk. cocoa. and other
ordinary food preparations that contain serotonin can aid the elderly
in falling asleep (Ebersole & Hess. 1981).

Relaxation techniques have been used by researchers to enhance
sleep and help eliminate sleep problems. In a study done at Stanford
University. men from age 30 to 71 years were given either sleep hygiene
information. training in nighttime relaxation techniques. or instruc-
tion in daytime stress reduction. ‘These subjects were successfully
withdrawn from sleeping medication. and 75% reported that they now were
sleeping better (Mediga1_uews. 1983). Relaxation techniques have fre-
quently been quite effective in the treatment of insomnia. Progressive
relaxation. self-hypnosis. and biofeedback are treatment approaches
that can be used for relief of insomnia (DeLoughery. 1982; Mathis.
1978).

By attending to environmental factors. sleep quality can be
enhanced. We may overlook the influence that various environmental
irritants may have on sleep (Brandner. 1976). The types of environmen-
tal factors that need to be attended to were mentioned earlier.

Some strategies that can be employed to aid in producing a higher
quality of sleep in the elderly are. first of all. education about the
normal aging changes. maintaining a sleep diary. bedtime rituals.
limiting naps. regular exercise routine. eliminating caffeine and
alcoholic beverages before bedtime. a warm glass of milk or snack.

using relaxation techniques. and maintaining environmental conditions

52

conducive to sleep. These strategies are all nonchemical interventions
that can aid in promoting sleep.

The focus of modern medicine and its support system provide the
elderly with a network of pharmacological sophistication and interven-
tion to aid in sleep promotion. This is the chemical intervention for
the solution to the complaint of insomnia. With all of our resources
we have a paradox since drug-dependent sleep produces an antithesis of
treatment and makes regulation increasingly difficult; Due to the
prolonged half life of medications in the elderly. the effects of
sedatives may continue into the daytime and result in confusion and
sluggishness (Dement et al.. 1981; Lerner. 1982).

Drugs. especially hypnotics. may profoundly affect sleep patterns
in a manner having considerable clinical significance. Hypnotics are
drugs given to produce sleep. but have been found to suppress REM sleep
(Kinzie & Markoff. 1974). Although promoting drowsiness does not
insure alleviation of insomnia. it is widely assumed the amount and/or
quality of sleep is improved when a hypnotic drug is ingested at
bedtime. It is further assumed that this improved sleep will also
improve daytime alertness and overall sense of well-being. These
untested assumptions have led to widespread use of hypnotics in medical
practice (Dement et al.. 1981; Lerner. 1982). One-third of medically
prescribed hypnotics are used by people over 60. who constitute 15% of
the population (Karacan. 1983).

Use of hypnotic drugs in the elderly leads to a danger of drug-

related mortality. Old age is one of the several contraindications to

53

the use of these drugs; the others are snoring. psychosis. drug abuse.
concurrent use of other drugs. and concomitant medical illness
(Karacan. 1983). In 1981. there was one single sleep laboratory that
was done evaluating the use of hypnotics in the elderly population.
This seems to be a neglect in view of the disproportionate use of
sleeping pills by older persons (Dement et al.. 1981).

The potential hazards of hypnotics are that they are easily
abused. leading to habituation dependency. overdose toxicity. additive
toxicity. adverse interactions with other drugs. hangover effect on
daytime activities. difficulty in awakening to respond to emergencies.
an increase in the number and duration of sleep apnea episodes. and a
disruption of normal sleep stages. that are already disturbed in
advanced age (Karacan. 1983; Lerner. 1982).

The commonly used hypnotic drugs are amytal. seconal. nebutal.
luminal. chloral hydrate. paraldhyde. nitrazepam. methalqualone.
glutethimide. and alcohol (Kellerman. 1981; Kinzie & Markoff. 1974;
Lerner. 1982). A hypnotic drug should be given only for transient or
intermittent insomnia for a few days of occasional use. and at the
lowest efficacious dose (DeLoughery. 1982). This dosage is probably
lower than that recommended by the manufacturer (Karacan. 1983).

The suppression of REM sleep that is caused by the hypnotics is
often followed by an increase in REM. REM rebound. when the drug is
withdrawn (Karacan & Williams. 1971). REM rebound can be accompanied
by unpleasantly vivid and detailed dreams. which in turn may lead the

elderly to again ask for sleeping medication (Lerner. 1982). There may

54

be a return to the use of hypnotic drugs. The broken sleep. unsatis-
fying dreams. and frequent nightmares caused by REM rebound may lead to
a pattern of continued drug use to prevent the symptoms that are actu-
ally being caused by the prescribed medication. 'This vicious cycle may
lead to habituation (Mathis. 1978L

Recently there has been a swing to the less-dangerous benzodiaze-
pines. These minor tranquilizers are often used for anxiety and sleep
disturbances (DeLoughery. 1982; Lerner. 1982). The benzodiazepines
include chloridiazepoxide. diazepam. flurazepam. clorazepate dipotas-
sium. and oxazepam (DeLoughery. 1982; Kellerman. 1981). These drugs
are generally nonlethal unless used by those prone to use alcohol.
There is a long duration of action. Side effects are more frequent and
severe with nightly use. A particular disadvantage of this group of
drugs with the elderly is that they further decrease Stages III and IV
NREM. Normal. age-related changes are thus exaggerated (Karacan. 1983;
Kellerman. 1981). DeLoughery (1982) noted that these antianxiety drugs
do not effectively induce sleep but can have a long-lasting hangover
effect. and users develop tolerance levels in 2 weeks"time. Fre-
quently this leads to an increase in the dosage of the drug. only to
have the amount become equally ineffective in a short period of time
(Mathis. 1978).

A sedating antidepressant before bedtime is preferable to other
drugs for the depressed elderly person with disturbed sleep. These
drugs include amitriptyline. doxepin. and imipramine (Karacan. 1983;

Mathis. 1978). These drugs can be dangerous if taken in overdose and

55

are particularly dangerous to cardiac patients (Kellerman. 1981).
These antidepressants may totally suppress REM sleep at ordinary doses.
but this effect lessens during a month of drug administration. Never-
theless. REM rebound is a potential side effect after the drug is
discontinued (Kinzie & Markoff. 1974). When these drugs are used with
elderly persons. they may require a dosage only one-half to two-thirds
of the usual adult dose (Mathis. 1978L

Antihistamines such as diphenhydramine also are used to help
promote sleep with some individuals. ‘They seem to be extremely safe.
but their effectiveness is questionable (Gambert & Duthie. 1981).

Over-the-counter sleeping medications may be used to help attain
sleep. The limited effectiveness of these drugs is thought to be the
side effect of drowsiness and/or the placebo effect (DeLoughery. 1982L
The elderly should be advised against the use of over-the-counter
medication in other than the recommended dosage and especially against
using in combination with any other sleep-inducing medication
(Brandner. 1976).

Drug treatment for insomnia has its place. but very often is not
necessary and frequently is an underlying cause of the problem
(DeLoughery. 1982). The hypnotic. benzodiazepams. antidepressants.
antihistamines. and over-the-counter medication have been presented.
along with the effects they may have on an individual's sleep pattern.

This chapter of literature review has presented information on the
normal sleep pattern. the aging sleep pattern. pathological conditions

causing sleep disturbance. methods used for investigation of complaint

56

of insomnia once an underlying disease has been ruled out. strategies
used to address sleep problems. and finally the medications used in
treating insomnia. There are large gaps in the literature regarding
knowledge about sleep in the elderly. Much of the research done in
sleep laboratories and pharmacologic treatment has been performed in
young or middle-aged adults (Karacan & Williams. 1983). Since there is
a change in the e1derly‘s sleep pattern. the accepted classification of
diagnosis may not be able to be generalized to the elderly population
(Dement et al.. 1981). Much of the recent literature concerning sleep
seems to be concerned with the elderly. If this increase in research
continues. perhaps a better understanding of the elderlyhs sleep pat-
tern. disturbances. and treatment will result.

As Weiss (1962) noted. there clearly appears to be a greater
incidence of sleep disturbance with increased age. By understanding
the elderly. having a working knowledge of the fundamental principles
of the changes in sleep. assessing the basic changes that occur in the
elderly person. and knowing what strategies are most efficacious for
the elderly. perhaps we. as clinical nurse specialists. will gain
valuable insight for future assessment and management of the elderly
person complaining of insomnia. thus helping them in promoting a higher
quality of sleep.

This literature review clearly indicates that assessment of the
complaint of insomnia in the elderly has not been addressed. Nurses
should capitalize on the lack of study in the area of sleep in the

elderly by research. developing tools for assessment. and strategies

57

for management to promote a healthier life. By doing this. nurses
would display expertise in the area of health promotion. Health promo-
tion is an area of the health care system in which nurses have been
able to demonstrate more advanced skills than the other health profes-
sions. Being able to attend to the complaint of insomnia in the
elderly could demonstrate that nursing is a link between health and
adaptation to aging. Nursing research. assessment tools. and strate-
gies could bring nursing into a key role in assisting elderly clients

in developing health-promoting skills.

CHAPTER IV
METHODOLOGY AND PROCEDURES

.InILQduQIIQn
The description of the methodology and procedures used to opera-
tionalize this study follows. This chapter will give a description of
the research design. the hypotheses. pretest. sample and population.
instrumentation. field procedures. the process of data scoring. data
collection and. finally. the analysis of the data. The information
that is received will be used to aid in understanding the symptom of

insomnia in the elderly presenting to a primary health care setting.

Reseancnfisjgn

The research design used for this study was a survey. This survey
was done as a preliminary work to aid in understanding the nature of
the problem of insomnia in primary health care.

A survey design. using a self-rating sleep questionnaire. was used
for the implementation of this study. This design was chosen because
it would:

--provide information about sleep patterns of the elderly in a

setting familiar to them.

--allow the study of insomnia in the elderly to be from their

own perspective.

58

59

-—facilitate the formulation of various strategies used by the
elderly that have been effective in dealing with the problem of
insomnia.

--provide guidance for the development of further strategies that
nurses can utilize in working with the elderly in primary care.

Data obtained through a survey design are always limited to what

the respondent believes to be the case (Mendenhall. 1971. p. 6). This
may be a limitation in many studies. but it is a strength in this
investigation. 'The survey will seek subjective information concerning
the elderly‘s sleep patterns and habits. If the elderly identify
insomnia as a problem. and if insomnia is a health problem or self-care
strategies are used. will be other variables examined in the survey.
The elderly individualhs identification of insomnia is an important
factor in his selection of ways to deal with the problem and important
to a basic understanding of the extent of the problem in primary care.
This preliminary work in the study of insomnia will also aid in further

research in this area.

131291119555
The hypotheses of this study are derived from the study questions.

These hypotheses were arrived at by the researcher because of previous

research. literature review. and familiarity of working with the

elderly in a primary care setting. The hypotheses of this study are:
--That the elderly obtaining health care at a primary care

setting would identify insomnia as a problem

60

--These elderly would implement self-care strategies before

seeking the advice of a primary care provider

Qaenatinnal_fle£1n1t19ns

To implement the concepts of this study. the concepts were defined
in the following terms:

.Eldenly was defined as those persons 65 to 85 years of age.

.Enimazy_gane_setting was defined as a private general practice
health care setting in Howell. Michigan. It is the practice of two
osteopathic physicians.

Insgmnja was defined as difficulty with falling asleep. frequent
awakenings. and early morning awakenings. This concept was operation-
alized using Questions 5. 6. 7. 8. 9.10.14. and 15. (See question-
naire. Appendix A.)

Identify was operationalized by the subjective responses obtained
using the self-rating sleep questionnaire. (See Appendix A.)

Seljzcane means were defined as processes the elderly had taken
responsibility for in developing their own health potential and were
operationalized according to answers to Questions 22. 23. 25. 26. 12.
and 13. (See questionnaire. Appendix A.)

use_9I_ths_nE1manx_health_cats_ntgxider was defined as seeking the
help of a health provider who identifies and assumes responsibility for
management of care. and was operationalized according to the answers on
the self-rating sleep questionnaire to Questions 17. 18. 19. 20. 21.

and 24. (See questionnaire. Appendix A.)

61

Strategies used by the elderly and ones used by the health care
provider were defined according to the answers to Question 23. (See
questionnaire. Appendix A.)

Background and sociodemographic variables were operationalized
according to Questions 30. 31. 32. 33. 34. 35. and 36. (See question-
naire. Appendix A.)

Other variables that may affect one's sleep were operationalized
by the answers to Questions 11. 16. 27. 28. and 29. (See question-

nai re. Appendix A.)

ELQIQSI

A pilot study of the survey instrument was conducted. A pilot
study was used for several reasons. First of all. it would help to
verify if a survey design would be applicable in dealing with the
problem of insomnia in the elderly. The instrument used was a self-
rating sleep questionnaire that was developed to assess the complaint
of insomnia in the elderly. It was also felt that this pilot study
would be a useful way to assess whether the instrument would be an
effective way to receive the subjective information needed. Forty
elderly persons were identified and completed the instrument. The
results received were used to describe the symptom of insomnia and the

approach the elderly used to resolve or deal with the symptom.

Sample

The population for this sample were those elderly persons 65 to 85

who present to a primary care setting. The population included

62

presented to the setting with other health care problems between the
week of July 14 and the week of August 10. 1983. .A sample size of.N =
40 elderly individuals was selected for participation in this study.
The only exclusionary factors for the sample of 40 elderly were for
those who were mentally incapable or those who were too ill to complete
the questionnaire. No person refused to complete the questionnaire.

A nonprobability. convenience sampling technique was used to
obtain the sample of elderly. These subjects were chosen from the
population of elderly 65 to 85 years old who presented to a primary
health care setting. The particular setting used for purposes of this
study is one in which the researcher previously worked. Due to the
fact that the researcher wished to be present on the days the survey
was taken in order to answer any questions. the sample was drawn from
the elderly 65 to 85 presenting to a primary care setting on the days
when the researcher was present. (See Field Procedures for format
followed.)

In summary. a sample of 40 elderly individuals 65 to 85 years of
age was obtained from a population of clients presenting to a primary

health care setting in Howell. Michigan.

Instnumentatinn

No valid or reliable instrument that measures overall subjective
sleep habits and sleep patterns was found in the literature. The self-
rating sleep questionnaire was developed by the researcher for the

purpose of this study. This self-rating sleep questionnaire was

63

developed to be a preliminary tool designed to elicit information in
seven categories of variables. including:

1. demographic data

2. subjective feelings about sleep patterns

3. subjective report of sleep habits

4. subjective feeling of sleep and its relationship to health

5. subjective feelings of physical health and current medications

6. subjective feelings about self-care used for sleep promotion

7. subjective data of lifestyle habits that impact sleep

Data were obtained on all these categories using the self-rating
sleep questionnaire. The pilot study was conducted to test this
instrument to determine if the information desired according to the
categories could be collected. Thus. the only instrument utilized in

this research study was that of the self-rating sleep questionnaire.

EJeJdiEchduLes

To implement the self-rating sleep questionnaire. it was necessary
that it be completed by 40 elderly individuals 65 to 85 years of age in
a primary care setting. 'These elderly individuals were presenting for
some other health problem. At the time this questionnaire was com-
pleted. the researcher was present at the setting. The 40 elderly were
first told the purpose of the questionnaire and then asked if they
would be willing to participate in the study. The time required to
complete this questionnaire varied from 15 to 25 minutes. None of the
participants approached refused to complete the self-rating sleep ques-

tionnaire. Next. the participants were presented the questionnaire and

64

instructed how to complete ft. The questionnaires were completed in
the office waiting room or examining rooms. If questions arose. the
researcher was available to clarify and answer these problems. Very
few questions arose throughout the data-collection period. Most of the
questions that did arise were regarding the names of medications the
elderly individuals were taking. Once these questionnaires were com-
pleted. they were collected from the participants with an expression of
appreciation for participating in the study. The elderly person was
then seen by the physician for further health care. Over a period of 3
weeks. the needed number of self-rating sleep questionnaires were
completed.

In summary. a procedure of informing the participants of the
purpose. time involved. manner in which to complete the questionnaire.
being available for questions. and collecting the completed question-

naires was used in the field procedures of this study.

.Dnta
Once all 40 of the self-rating sleep questionnaires were
completed. the data received were coded onto the necessary forms.
After this coding was completed. the keypunch was done. in order for
the information to be put into the computer. The data were processed
by the computer. following which a sample descriptive analysis of the
results was done. The age. time to go to bed. fall asleep. and time to

wake up are variables for which a mean was used. A range was used in

6S

examining the time to go to bed. fall asleep. and wake up. All of the
other variables were analyzed by descriptive percentages.

The process of implementing the scientific method throughout this
study of insomnia in the elderly presenting to a primary care setting
has been outlined here. The research design. hypotheses. pilot study.
sample. operational definitions. instrumentation. field procedures. and
data processing were described. Results of the data analysis. recom-
mendations. conclusions. implications for nursing. and the relationship
of this study to Nightingale's conceptual framework and to previous

research are presented in Chapter V.

CHAPTER V

SUMMARY AND CONCLUSIONS

Introduction

The purpose of this chapter is to review the results received from
the pilot study that was conducted. Implications for nursing practice.
service. and education are presented. along with recommendations for
how these suggestions can be implemented in these areas of nursing.

The relationship these results have to Nightingale's conceptual frame-
work is presented. as well as to previous research done in the area of
insomnia in the elderly. Finally. the conclusions and recommendations

that have been derived from this study are outlined.

.Boanltfi

A survey study of 40 elderly individuals was done. Since the
sample size was nonprobabilistic. small. and only a pilot study was
done. the results of this study cannot be generalized to all elderly
individuals (Pollit & Hungler. 1983). A survey was used to gather data
from a portion of the population for the purpose of examining the
characteristics. opinions. and habits of the elderly in relation to
sleep. The central focus of the survey was to describe the el derly's
sleep habits. life-style variables. existing chronic diseases. medica-

tion use. and perception of insomnia in relation to health. The

66

67

information received in this sleep questionnaire survey was descriptive
in nature. and this survey allowed for the beginning examination of the
problem of insomnia in the elderly. From this preliminary work. an
assessment tool can be developed for more in-depth testing.

A descriptive analysis of the data received from the 40 elderly
who completed the sleep questionnaire was done. Summary data are
presented in percentages. except that mean age. time subjects go to
bed. time subjects fall asleep. and time subjects wake up are in a
range analysis. Thus. the results of this study were all computed
using descriptive statistics.

The results received from the data (see Table 1) showed that the
sex ratio of the sample was two-thirds females and one-third males.
with a mean age of 73.4 years (N = 40). All of the respondents were
Caucasian.

The sociodemographic data (see Table 1) show that the majority
(52.5%. N = 21) of those participating in the study were married. The
remainder were either widow/widower or single. The majority of the
elderly were retired (see Table 1). with 35% (N = 14) being homemakers
and 2% (N = 1) employed full ti me. Sixty-three percent (N = 25) of
those elderly owned their own homes. with the remainder (N = 15) living
in apartments. senior citizen housing. condominiums. and with family
other than spouse (see Table l). The majority of the elderly (52%. N =
21) who participated lived with someone. whereas 48% (N = 19) lived

alone. Most of those persons (61%. N = 24) had received at least a

68

Table 1.--Sociodemographic data (N_= 40)

 

 

Number Percent
Age of Participants
Range: 65-85 years
Mean: 73.4 years
Sex of Participants
Male 13 33.0
Female 27 67.0
Total 40 100.0
Marital Status
Married 21 52.5
Widow/widower 16 40.0
Single 3 7.5
Total 40 100.0
Yearly Income
< $5.000/year 11 27.0
$5.00l-$10.000/year 12 30.0
$10.001-320.000/year 13 32.0
$20.001-$30.000/year 1 2.0
> $30.000/year 2 5.0
No answer 1 2.0
Total 40 98.0
Type of Home
Own home 25 63.0
Condominium 1 2.0
Apartment 6 15.0
Senior citizen housing 4 10.0
With family other than spouse 3 7.0
Other 1 2.0
Total 40 99.0
Number of People Live With
None 19 48.0
One 16 40.0
Three to four 4 10.0
More than four 1 2.0
Total 40 100.0

69

Table 1.--Continued.

 

Number Percent

 

Type of Education Completed

College 5 13.0
High school 19 48.0
Grammar school _ 12 30.0

Did not complete grammar school 4 10.0
Total 40 101.0

Occupational Status

Retired 25 63.0
Homemaker 14 35.0
Working full time 1 2.0

0.0

Total 40 10

 

high school education (see Table l). The yearly income of those par-
ticipating in this study was $l0.000/year for 57% (N = 23). Other
subjects (N = 13) had an income of $l0.000-$30.000 (see Table 1). One
individual had an income of greater than 330.000. and two chose not to
answer this question. This information gives a background under-
standing of the types of elderly who participated in this study.

The variables to be analyzed are whether the elderly identify
insomnia to be a problem; if they do. how it is manifested; is insomnia
viewed as a health problem to be treated by the primary health care
provider. or is self-care instituted. The researched questions indi-
cating whether the client identifies insomnia to be a problem show that
62.5% (N = 25) believed that they had no difficulty sleeping (see Table

2). The remaining 37.5% (N = 15) of the elderly did identify

70

Table 2.--Time factors related to insomnia (N = 40).

 

 

 

Category __fll!izi__ Sometimes Never
.N % .N % .N %
Difficulty falling asleep 4 10 32 80 4 10
Difficulty falling asleep if awakened 2 5 3O 75 8 20
Feel rested when awaken in a.m. 14 35 26 65 O 0
Number Percent

Frequency of nighttime awakenings

One to two 20 50

Three to four 14 35

Four 5 13

Never 1 2
Length of time to fall asleep
if awakened

0-15 min. 11 28

16-30 min. 15 38

31-60 min. 10 26

> 1 hr. 4 8
How often/week awaken too early

Zero to one times 15 38

Two to three times 17 42

Four or more times 8 20
How long have you experienced
difficulty sleeping?

No difficulty 25 62.5

Experienced difficulty for 6 months 2 5.0

Experienced for 1 year 1 2.5

Experienced > 1 year 12 30.5

 

71

sleep as a problem. For all (N = 15) who identified insomnia as a
problem. it had been a problem over 6 months; 80% (N = 12) had had the
problem longer than 1 year (see Table 2). These results are consistent
with the estimate of 20 to 40% of the U.S. population having sleep
problems (Kruper & Reynolds. 1983). Walsben (1982) estimated that 20
to 25% of people have occasional bouts of insomnia. According to
Dement et a1. (1983). insomnia appears to be more frequent in the
elderly than in other age groups. The results of this study. which
showed that 37.5% (N = 15) of those who identified insomnia as a sleep
problem is within the normal estimate of 20 to 40% of the population
who have sleep problems; yet it is greater than the estimate of 20 to
25% who suffer from insomnia. Thus. the elderly studied do identify
insomnia to be a problem.

Although only 37.5% (N = 15) of the 40 elderly identified insomnia
as a problem. 80% (N = 32) of the elderly reported having trouble
falling asleep sometimes. and another 10% (N = 4) reported this trouble
always occurred (see Table 2). This is a total of 90% (N = 36) of the
elderly who at least sometimes have difficulty falling asleep..
Frequency of nighttime awakenings was reported to be more than three
ti mes a night by 48% (N = 19) of the elderly (see Table 2). If
awakened during the night. 75% (N = 30) of the elderly subjects
reported difficulty falling asleep sometimes. and 5% (N = 2) reported
always (see Table 2). Thirty-four percent of the elderly individuals
(N = 13) reported it took 30 minutes or more to fall asleep if

awakened. Eight percent (N = 3) of these individuals took more than

72

1 hour to fall asleep again (see Table 2). Frequency of being awakened
too early was reported to be two or more times per week by 62% (N = 25)
of the elderly. Twenty percent (N = 8) of these reported early morning
awakenings more than four times per week (see Table 2%

Thus. what has been defined as insomnia. difficulty falling
asleep. frequent nighttime awakenings. and early morning awakenings are
actually reported by 95% (N = 38) of the elderly individuals. This is
a much greater percentage than the 37.5% (N = 15) who identify insomnia
as a problem. The striking aspect of this finding is that the elderly
have in some way compensated for what research would define as manifes-
tations of insomnia. Either the elderly believe these manifestations
to be normal for their age or just do not perceive these factors as a
problem.

Of the 37.5% (N = 15) who identified insomnia as a problem. only
16% (N = 3) believed insomnia was a health problem (see Table 3).
Eighty-four percent (N = 16) of these elderly who identified insomnia
did not believe it was a health problem (see Table 3). Yet 72% (N =
13) of the elderly felt a doctor was able to help with a sleep problem
(see Table 3). Sixty-nine percent (N = 11) of those who identified
insomnia said they would discuss it with their doctor. but only 34% (N
= 6) had done so (see Table 3). Of those who did discuss insomnia with
a health care provider. 83% (N = 5) were satisfied (see Table 3).
Thirty-nine percent (N = 7) of the elderly individuals who identified

insomnia had tried something themselves for sleep (see Table 3).

73

Table 3.--Health care provider variables.

 

 

Number Percent
If trouble falling asleep. is it a
health problem? (N_= 19)
Yes 3 16
No 16 84
Would you discuss sleep with your
doctor? (N_= 16)
Yes 11 69
No 5 31
Is doctor able to help with sleep
problem? (N_= 18)
Yes 13 72
No 5 28
Have you discussed sleep with your
doctor? (N_= 18)
Yes 6 34
No 12 66
If yes. were you satisfied? (N = 6)
Yes 5 83
No I I7
Tried something yourself for sleep? (N_= 18)
Yes 7 39
No 11 61

 

Thus. insomnia is not usually viewed as a health problem by those
who identify insomnia. even though a majority feel a doctor is able to
help with a sleep problem. Less than a majority had discussed a sleep
problem with their doctor. A few elderly had tried to treat their
sleep problems themselves. It would seem that sleep is not viewed as a

health problem but an issue that could be discussed with the health

74

care provider. This would seem to indicate that sleep perhaps was not
discussed unless the issue arose or was brought out by the health care
provider. If the sleep issue was discussed with a health care pro-
vider. a greater percentage of the elderly were satisfied with the help
received. This seems to indicate that health care providers can be of
assistance in providing some relief for insomnia.

Of the 40 elderly subjects. 90% (N = 36) identified at least one
factor; 67.5% (N = 27) identified at least two factors; 45% (N = 18)
identified at least three factors; and 25% (N = 10) identified four
factors that interfered with their sleep (see Table 4). Fifty-eight
percent (N = 23) of the elderly believed humidity interfered. and 50%
(N = 20) identified temperature as a factor (see Table 4). Other
factors commonly cited as interfering with the sleep of these elderly
subjects were restlessness for 38% (N = 15) and anxiety for 33% (N =
13) (see Table 4). Noise was reported by 17.5% (N = 7). pain by 20% (N
= 8). and light by 11% (N = 5) of the elderly subjects.

Even though insomnia is not identified as a problem by most of the
elderly. there are factors that interfere with the sleep of almost all
the elderly subjects. Perhaps the reason for humidity and temperature
being reported so frequently as factors that interfere with sleep is
because the data were collected in July and August. during a hot sum-
mer. ‘The psychological factors. guilt and anxiety. were a problem for
many of the elderly. ‘The environmental factors. pain. noise. and
light. are reported to a greater extent as interfering with sleep.

These findings would seem to indicate that we. as health care

75

providers. can help the elderly holistically in providing strategies
that provide relief for these factors that are believed to interfere

with the sleep of the elderly.

Table 4.--Factors and frequency of factors that interfere with sleep.

 

 

Factor Number Percent
Restlessness 15 38.0
Anxiety 13 33.0
Depression 2 5.5
Guilt 0 O
Spouse 2 5.5
Noise 7 17.5
Light 5 11.0
Temperature 20 50.0
Humidity 23 58.3
Pain 8 20.0
Fatigue 3 8.3
Other 2 5.5

W
0 factors 4 10.0
1 factor 36 90.0
2 factors 27 67.5
3 factors 18 45.0
4 factors 10 25.0

 

The elderly subjects who participated in this study reported 50%
(N = 20) that their health was good to excellent (see Table 5). Fifty
percent (N = 20) reported their health as fair or poor (see Table 5).
Some factors that may affect insomnia are naps. exercise. caffeine use.

disease. and medicines. Nap taking three or more times a week was

76

Table 5.--Hea1th and life style variables. medical reported illness
and medications.

 

Number Percent

 

Health and Life Style Variables

 

Rate your health

 

 

Excellent 2 5
Very good 5 13
Good 13 32
Fair 19 48
Poor 1 2
Number of naps/week
Never 12 30
One to two times 8 20
Three to four times 7 18
Five to six times 7 18
Seven or more times 6 14
Frequency of regular exercise
Regular 9 21
Walk. but not regular 17 44
< 5 days/week 1 3
< 3 days/week 13 33
Amount of coffee. tea. soda/day
One to two cups 18 45
Three to four cups 19 47
Five to six cups 3 8
Medical Reported Illness and Medications
Number of chronic diseases
One 17 42
Two 16 40
three 4 10
Four 3 7
Types of chronic diseases
Hypertension 16 4O
Diabetes 5 15
Ulcer 2 5
Arthritis 18 45

Cancer 2 5

77

Table 5.--Continued.

 

Number

Percent

 

Types of chronic diseases (cont'd)
Gout
Obesity
Kidney disease
Alcoholic
Emphysema
Heart disease
Other

Number of medications used

No medications

One medication

Two medications

Three medications

Four medications

Five medications

Six medications

Seven medications

Over-the-counter medications currently used
Vitamins
Laxative
Analgesic
Sleeping medicine

Number of over-the-counter medications used
No medications
One medication
Two medications
Three medications

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reported by 50% (N = 20) of the elderly. with 5% (N = 6) napping seven
or more times a week (see Table 5). Only 21% (N = 9) reported getting
regular exercise (see Table 5). Thirty-three percent (N = 13) reported
an exercise amount of less than 3 days per week (see Table 5). The

amount of coffee. tea. and soda intake was reported to be three to six

78

cups by 55% (N = 22) of the elderly subjects. All subjects (N = 40)
reported at least one chronic disease. Arthritis was reported by 45%
(N = 18) of the elderly and hypertension by 40% (N = 16) (see Table 5).
Medication use was reported by 85% (N = 34) of the elderly individuals;
15% (N = 6) used no medication; 20% ON = 8) used only one medication;
18% (N = 7) used two medications; 18% (N = 7) used three medications;
20% (N = 8) used four medications; and 9% (N = 4) used five to seven
medications (see Table 5). Hypertensive medications were used by 50%
(N = 20); digital is preparations by 17.5% (N = 7); diuretics by 15% (N
= 6); and vasodilators. benzodiazepines. bronchodilators by 12.5% (N =
5) of the elderly subjects (see Table 5). Over-the-counter medication
use was reported by 35% (N = 14) of the elderly. with vitamins being
most frequently used (see Table 5). It seems that factors other than
those reported could interfere with the sleep of these elderly sub-
jects. Naps are frequently reported by half of the elderly. There is
a lack of exercise for at least one-third of the elderly subjects.
Chronic disease is a comnmnlvariable among all participants. Medica-
tion use is a factor that is common to a majority of the elderly
subjects. This seems to indicate that other than the psychological.
physical. and social factors reported by the elderly need to be exam-
ined by the health care provider in order to accurately assess insomnia
of the elderly.

A limitation of this study is the manner in which the analysis
was done. The confounding variables of chronic illness and medication

may not give a true indication of the percentage of elderly who have a

79

problem with insomnia. This limitation needs to be recognized when
examining the results of this pilot study.

Of the 37.5% (N = 15) of the elderly subjects who identified
insomnia as a problem. 59% (N = 9) of the elderly reported symptoms
occurred the next day (see Appendix B. Item 16). Fatigue was the most
commonly reported symptom to occur. Forty-one percent (N = 4) reported
this. Forgetfulness and uncoordination were symptoms reported to occur
the next day by 12% (N = 2) of the elderly individuals. Thus. by a
majority of the elderly who identified insomnia some type of symptom
resulted the next day after having experienced insomnia. This indi-
cated that for those elderly persons who suffer from insomnia. their
daily ability to function may also be affected.

When those who identified insomnia as a problem were questioned as
to whether they had tried something themselves to relieve insomnia. 39%
(N = 7) replied yes and 61% (N =11) stated no (see Table 3). When all

40 elderly were asked to check items used to help them sleep. 100% (N =

40) checked at least one item (see Table 6). Thirty-two percent (N

13) used one sel f-care strategy; 2% (N = 9) used two sel f-care

strategies; 20% (N = 8) used three self-care strategies; and 25% (N 10)
used four self-care strategies (see Table 6).

Reading was used by 40.5% (N = 16) of the elderly subjects to help
them sleep. Thirty-five percent (N = 14) of the elderly reported
sleeping alone was used to help them sleep. Taking a shower/bath was a

self-care strategy used by 17.5% (N = 7) of the elderly. Drinking

milk. having a snack. and watching television were reported equally by

8O

15% (N = 6) of the elderly as an approach to help one sleep. Thus.
even though the elderly did not identify that they had the problem of
insomnia. all elderly subjects used at least one self-care strategy to
promote their sleep. Of those who identified insomnia as a problem.
many did not feel they had actually done something themselves to help
with their sleep problem but did actually check at least one self-care
strategy. These would seem to indicate that the elderly are institut-
ing approaches that will promote a better quality of sleep even though

they do not perceive they are in fact doing this.

Table 6.--Types and numbers of strategies used by respondents to help
them sleep.

 

 

Strategy Number Percent
Shower/bath 7 17.5
Night light 2 5.0
Sleep alone 14 35.0
Snack 6 15.0
Beverage (nonalcoholic) 5 12.5
Beverage (alcoholic) 3 7.5
Exercise 3 7.5
Music 5 12.5
Television 6 15.0
Reading 16 40.5
Milk before retiring 6 15.0
Prescription sleeping medicine 3 7.5
OTC sleeping medicine 2 5.0
NumboLoLStEatooJoLIIsod
At least 1 self-care strategy 40 100.0
Only 1 self-care strategy 13 32.5
Two self-care strategies 9 22.5
Three self-care strategies 8 20.0

Four self-care strategies 10 25.0

 

81

In summary. the results of this study showed that the elderly do
identify insomnia as a problem to a greater extent than the normal
population. ‘The elderly reported manifestation of insomnia to a
greater extent than insomnia was reported as a problem. Only a small
percentage of those who identified insomnia as a problem believed it to
be a health problem. ‘Those who did seek the advice of their health
care provider were mostly satisfied with the results. The results
indicate that a majority of the elderly reported factors that interfere
with or affect their sleep. Even though all did not feel they had done
something to help themselves. all participants in the study had insti-

tuted at least one self-care strategy to promote their sleep.

Booomsnoatjons

These findings support the limited research presently available
in the area of insomnia. Insomnia is a problem in the elderly popula-
tion. The results seem to indicate that even though the elderly do
have manifestations of insomnia. these changes are not perceived by
them as a problem to present to the health care profession. A major
recommendation of this study is that nurses in primary health care do
an accurate assessment of whether the elderly individual is exhibiting
symptoms of insomnia. Since the elderly indicate difficulty falling
asleep. frequent nighttime awakenings. and early morning awakenings to
a greater extent than they identify insomnia. a thorough assessment of
these areas is indicated to determine if insomnia is present. Nurses
need to help the elderly become aware that difficulty falling asleep.

frequent nighttime awakenings. and early morning awakenings are really

82

sleeping problems and maybe something can be done about them. If
insomnia is a problem for an elderly individual. then a further assess-
ment of lifestyle factors. chronic disease state. and medication use

is needed to determine if these factors may be affecting the elderlyus
sleep. It has been noted that lifestyle factors. chronic disease. and
various medicines can all impact the quality and quantity of sleep. An
assessment of whether the symptom of insomnia exists and what life-
style. chronic disease. and medication factors exist that may affect
sleep can aid in developing strategies to promote health.

The nurse working with the elderly also needs to assess environ-
mental factors that could be causing difficulty sleeping. These fac-
tors include such areas as light. temperature. odor. noise. and
humidity. which have been identified in research to affect the sleep
pattern. Other factors such as guilt. restlessness. spouse's disturb-
ance. and pain are areas that need assessment in regard to sleep. By
assessing these various areas. the nurse in primary health care could
help the elderly client see that one or more of these environmental
factors may be eliminated and thus produce a higher quality of sleep.

For each elderly person. baseline data about their sleep behaviors
should be obtained. It is recommended that the nurse in primary health
care be the one to raise the question of sleep with the elderly. since
the elderly is not apt to address the issue. This would help to not
only address sleep patterns. but also promote education and health.

The elderly may not perceive sleep problems to be a health problem.

83

Another area that the primary health care nurse needs to assess is
what the elderly do use to promote sleep. This study showed that 100%
of the elderly used some method to promote sleep even though all of the
elderly did not feel they had a problem with insomnia. Once the nurse
helps the elderly assess what promotes successful sleep for them. then
strategies can be developed that may be useful in helping other elderly
clients with the problem of insomnia.

It is recommended that this study be replicated in an urban set-
ting to see if results would be consistent. A test of the reliability
and validity of this survey instrument should occur before the tool is
used for further research. It is suggested that the study be repli-
cated with a larger. more heterogeneous sample. A more detailed analy-
sis of the results of this study or any similar study might look at
factors such as use of medications that interfere with sleep. disease
processes that interfere with sleep. and lifestyle factors that would
interfere with sleep.

In summary. it is recommended that the nurse in primary health
care assess whether insomnia is a problem for the elderly. A further
assessment of lifestyle factors. chronic disease. and medication use
will aid in determining if these may affect the el derly's sleep. The
issue of sleep needs to be brought out with the clients by the primary
health care provider. or it may not be addressed when necessary. The
nurse can assess if the elderly are using any sleep-promoting strate-
gies and if these are successful. Also. it is recommended that further

research of insomnia in the elderly presenting to a primary health care

84

setting be done. More in-depth analysis of data related to sleep

patterns among the elderly is a recommendation for further study.

Conclusions

The findings of this study indicate that insomnia is indeed a
problem experienced by the elderly. Since this is true and findings
indicate that insomnia is not believed to be a health problem. primary
health care providers need to be made aware of these facts. A concl u-
sion of this study is that the elderly do indicate difficulty with
their sleep. even though it is not identified as a health problem. Also.
factors that interfere with the el derly's sleep are reported to a
greater extent than insomnia is identified as a problem. Knowing these
findings. the problem of insomnia should be addressed by the primary
health care provider. and further assessment to facilitate education of
the elderly regarding sleep and sleep patterns should become a routine
part of the care of the elderly.

The findings of this study show that the elderly use self-care
strategies to promote a better quality of sleep even though insomnia
may not be identified as a problem. The elderly may be using self-care
strategies to promote sleep. It can be concluded that the strategies
used by the elderly may not be effective. since insomnia is still
identified even though various strategies are used. Since this is
true. primary health care providers need to assess which strategies
work and educate the elderly to various strategies that can provide

relief for insomnia and promote a better sleep.

85

Since insomnia is not usually seen as a health problem. at least
this is indicated from the results of this study. nurses in primary
health care can help to promote the health of the elderly by addressing
the issue of insomnia. The area of health promotion is an area of
health in which the elderly are apt to be receptive to the information
received. Nurses working in primary health care can then promote the
elderlyhs health while at the same time promoting the nursing profes-
sion's expertise in the area of health promotion.

In conclusion. it is felt that the findings of this study show
that nurses working in primary health care settings should be sensitive
to the increased possibility of insomnia being a problem of the
elderly. Because of this possibility. nurses should be able to assess
and prepare the elderly for the sleep changes that will be occurring and
factors that interfere with sleep. Also. primary health care providers
should first address insomnia with the elderly through anticipatory
guidance. ‘Dhe elderly would not be overly concerned then when sleep
changes occur and offer the opportunity to develop strategies to

relieve insomnia.

IanJoationLtoLNuEang

The major implication for nursing from this study. especially
related to nurses working in primary health care settings. is to
address and assess whether insomnia is a symptom that is a problem for
the elderly. This study showed that symptoms of insomnia may be pres-
ent more often than the elderly define it as a problem. ‘This study

also indicated that the elderly are using various strategies to help

86

them sleep. These findings would seem to indicate that a thorough
assessment of insomnia is warranted to help the elderly to better
describe sleep patterns and achieve a better quality and quantity of
sleep.

If the complaint of insomnia arises from the client or has been
identified as a problem. the nursing implications differ. An
assessment of other variables that affect sleep is needed. Nurses in
primary care need to do a complete physical exam to rule out an under-
lying cause for sleep disturbance. Along with the physical exam. the
nurse working in a primary health care setting should take a careful
sleep history. The sleep history should assess the following: the
number of hours spent trying to sleep. number of naps. number of times
the elderly awakens per night. time of awakening. the number of hours
of sleep desired each night. current medication--prescription and over-
the-counter. a 24-hour sleep/wakefulness pattern. timing of naps that
are taken. additional information from the sleep partner. a drug
history--caffeine. soda. alcohol. chocolate. and a family history. A
physical assessment and sleep history will give insights into this. If
the elderly client initiates the complaint of insomnia or it is identi-
fied as a problem. a thorough physical exam and detailed health and
sleep history are areas a primary health care nurse should assess.

The implication for nurses. especially those working in primary
health care. is to assess if insomnia is a problem for the elderly.

If insomnia is a problem. then a further assessment of lifestyle

factors. physical disease. and medication use is indicated. This

87

information can be obtained by doing a physical assessment and sleep
history assessment. Strategies that are shown to be effective should be
implemented to promote sleep. Also. the sleep information could
increase the understanding of the sleep stages and changes that
practicing nurses may not be aware of. ‘This study illustrated that
insomnia is a problem in the elderly. that it is not often viewed as a
health problem. and that self-care is almost always used by the

elderly. Nurses in practice can help to provide a healthier sleep for
the elderly by accurately assessing if insomnia is a problem and

further assessing variables that can result in sleep disturbance.

Nursing education. especially at the graduate level and in
gerontology areas. should include textbook information regarding
assessment and strategies that can be utilized by students. The nurse
educator needs to include the areas of physical exam. sleep pattern
and sleep history. environmental factors. chronic disease. medications.
lifestyle variables. and what is being done to promote sleep when
instructing others how to assess insomnia in the elderly. By including
these areas of assessment in nursing education. nurses will be prepared
to accurately assess the problem of insomnia for the elderly.

More research on the sleep habits of healthy elderly to increase
nursing's data base should be encouraged by nurse educators. The
results of nursing research and nursing practice can be used in nursing
service areas. The implications for the nursing profession are great
in helping to better assess the problem of insomnia so that strategies

can be developed to promote sleep for the elderly.

88

WW
anLEEstiouLBosoarob

The results from this study of insomnia of the elderly in a pri-
mary care setting provide clarity to Nightingale's pyramid and ladder
conceptual frameworks of nursing. Using the ladder conceptual frame-
work (Figure 1). nurses put healthy elderly in condition for "nature to
act on" to preserve health. prevent disease and injury. Nurses can
intervene with or put the healthy elderly presenting in a primary
health care setting in condition for nature to act on by initiating or
pursuing an accurate assessment of the problem of insomnia which this
study shows is a problem for the elderly. Once a nurse has put the
healthy elderly in condition for nature to act on. then the nurse is
able to institute strategies to preserve the health of the elderly
individual. Also. this action can prevent further disease and injury
to the healthy elderly. Thus. Nightingale's ladder concept of nursing
is reinforced by the results of this study.

Nightingale's pyramid concept of nursing (Figure 2) illustrates
how the patient's condition is impacted by the physical environment.
social environment. and psychological environment. This conceptual
framework is congruent appropriately with the results of this study.
The areas mentioned under each of these environments are areas that
need to be addressed when assessing the complaint of insomnia. It is
often by using strategies that affect the physical. social. or psycho-
logical environment that a nurse is able to provide some relief and

promote health in the elderly. The elderly in this study did not

'89

identify insomnia as a problem to bring to the primary health care
provider. Nurses can impact the health of the elderly by addressing
insomnia and assessing the areas of the physical. social. and psycho-
logical environment. ‘The results also indicate that insomnia is a
greater problem for the elderly and that they may have been using self-
care even though insomnia was not identified as a problem. Using the
pyramid concept. the professional nurse may be capable of providing
other strategies that will aid in promoting a higher quality of sleep
for the elderly. In these ways. it can be seen that Nightingale's
pyramid concept is related to the results of this study of insomnia in
the elderly in a primary health care setting.

Previous research in the area of insomnia in the elderly is
related to the findings of this study-~primarily. that insomnia is a
problem to a greater extent for the elderly. ‘The findings from this
study disagree with previous research. except Hayter's 1983 study. that
insomnia is manifested by either difficulty falling asleep. frequent
nighttime awakenings. or early morning awakening using one or any
combination of factors. This study disagrees because a greater per-
centage of elderly had difficulties in one or more of these factors
than the percentage who identified insomnia as a problem. Thus. even
though the elderly may have one of these factors. it does not imply
that it is a manifestation of the problem of insomnia for that elderly
individual. There is no research that was found that discussed how the
elderly managed insomnia or what self-care strategies were used. There

is one study done with healthy elderly in a community setting (Hayter.

90

1983) that studied manifestations of insomnia and sleep pattern changes
with aging. No research was found that addressed insomnia of the
elderly presenting in a primary health care setting. Although some of
the findings of this study reinforce previous research. the findings
dispute some research and add new information to the data base of
nursing research in the area of insomnia of the elderly.

In summary. the results of this study of insomnia of the elderly
presenting in a primary health care setting do integrate Nightingaleus
conceptualization of nursing. ‘The finding that insomnia is a problem
for the elderly relates to previous research. disputes some research
on how insomnia is manifested. and adds to what research has been

completed in studying strategies to relieve insomnia of the elderly.

Condosjonsmojsoomonoatjons

The major recommendation for nursing from this study. especially
related to nurses working in primary health care settings. is to
determine what changes in sleep patterns accompany the aging process.
This study also showed that the elderly may not perceive that their
sleep changes are a problem or are a normal part of the aging process.
Even those who don’t label the problem have indicated difficulty in
various areas. For these reasons. a better assessment of sleep
patterns will help to insure a higher quality of sleep for the elderly.
Nurses need to incorporate this education into their practice when
seeing the elderly because although sleep pattern changes may be
occurring. the elderly are not apt to raise the issue with the primary

health care provider. Also. that we. as health care providers. are

91

aware that these changes may be causing difficulties in their daily
lifestyle. and would like to help the elderly develop habits to improve
their quality of sleep. Thus. education of what factors interfere with
sleep and can affect a change in the quality of sleep need to be
included when caring for the elderly. Increasing the el derly's
awareness of the effect diseases. medicines. naps. exercise. environ-
mental. psychological. and social factors have on sleep is part of the
education in which nursing practice needs to partake. Therefore.
education of the elderly in sleep pattern changes and factors that
interfere with and affect sleep is an area that nurses can address and
implement into their practice once more detailed research has been
completed. ‘This education will help to assure the elderly that chang-
ing sleep patterns are normal.

Nursing practice is seen as an area where the results of this
study can be effectively used. Nurses in practice can use the knowledge
gained from the results of this study to promote a better quality of
sleep for the elderly. By assessing whether insomnia is a problem and
assessing lifestyle factors. disease processes. and medication use
through a sleep history. nurses are able to help the elderly assess a
cause for the problem. Nurses can investigate the elderlyWS motive for
asking for sleeping medication. which may disturb their sleep. Thus.
nurses can promote a better quality of sleep by addressing it with the
elderly. by a physical assessment and a thorough sleep history assess-

ment.

92

Stimulating further research of insomnia of the elderly is one
area where nursing education can use the findings of this study.
Because some of the findings do not substantiate all of the research
done in the area of insomnia of the elderly and some of the findings
are new information. then further research is needed to substantiate
and validate the findings of this study.

A recommendation drawn from this study is that more research in
the area of insomnia of the elderly is needed. .All of the elderly who
participated in this study identified something that they used to help
them sleep. Further research in the area of insomnia of the elderly
could be done using experimental studies to help to identify if the
strategies the elderly use are beneficial in promoting sleep. Various
intervention studies could be done testing the strategies that the
elderly have indicated they use to help them sleep. If the elderly has
complained of insomnia or has given an indication that his/her sleep is
troublesome. then it is nursing's responsibility to assess with the
elderly in identifying what strategies they use to promote a healthier
sleep. Effective strategies should be identified and tested using
experimental research.

This pilot study illustrates that the elderly may have symptoms of
insomnia more often than it is reported as a problem. This implicates
that developing good sleep hygiene habits is an action that can be
taken with all elderly. Sleep hygiene covers many different strategies
that can be used to help promote a better quality of sleep and could be

tested through research. One of the more important strategies is to

93

help the elderly keep to a rigid sleep schedule. This schedule
involves retiring at the same time each night and getting out of bed at
the same time each morning. This regularity of sleep schedule and
eating meals at the same time each day should help to stabilize body
rhythms. Nurses could help the elderly learn that a comfortable envi-
ronment is important to promote one's sleep. The bedroom should have
clean linens. a firm mattress and pillow. be odor-free. have a level of
lighting that is comfortable and will make the room remain dark in the
mornings. the temperature should be comfortable. and the noise level
should be decreased since the elderly have a decreased arousal
threshold. Nurses can develop and test other sleep strategies that can
be implemented when working with the elderly. Rituals used by the
elderly may entail a nighttime bath. brushing teeth. and checking the
doors and lights. The routineness of these activities may become a cue
to the body and promote sleep onset. It may be important to help the
elderly eliminate daytime naps or resting in bed and increase activity
and decrease boredom. This may help to associate the bed with night-
time sleeping.

Other implications for nurses in working with the elderly may be to
develop good sleep hygiene habits. Nurses should assess the elderly's
caffeine and alcohol consumption before bedtime and whether a light
bedtime snack may help to reduce sleep latency. .A routine of daily
exercise might be sleep promoting. ‘The elderly need to begin this
exercise gradually. Nurses can help the elderly to develop an exercise

plan. Nurses can also help the elderly to realize that exercise should

94

probably be done at least 3 hours before retiring or it will be
stimulating instead of sleep promoting. .Another sleep hygiene habit
which nurses can test by intervention with groups is to test if allow-
ing a transition period of a lower activity level about 1 hour before
retiring is sleep promoting. If the elderly cannot get to sleep. a
strategy that may be helpful is to get out of bed and do something
relaxing until they become sleepy. If the elderly awaken during the
night. nurses can help them to realize that it is important to remain
drowsy rather than become aroused by some activity. Finally. a sleep
hygiene habit of using a nightlight in the bedroom or bathroom can aid
in eliminating disorientation when awakened and promote safety for the
elderly.

By implementing some of these strategies into the care of the
elderly. primary health care nurses can treat manifestations of insom-
nia. which are the early morning awakenings. difficulty falling asleep.
and frequent nighttime awakenings. ‘This study illustrates that the
elderly do have an increased number of manifestations even though it
may not be perceived as a problem. Nurses can be of great assistance
to the elderly in using any of the various strategies to develop good
sleep hygiene habits that will promote a better quality of sleep.

Relaxation exercises may be indicated and tested to assess if
they help reduce daytime stresses that the elderly experience.
Stresses that the elderly are experiencing would cause the body to

release chemicals that inhibit sleep. So. nurses can promote sleep for

95

the elderly by educating the elderly in relaxation techniques and
stimulus control that together relieve somatic tension and anxiety.

As this study shows. the elderly do identify insomnia. and by
testing of strategies through experimental and intervention research.
nurses may develop effective treatment plans for the problem of insom-
nia. Perhaps the elderly want a "pill" to solve their insomnia. Nurses
working in primary health care can recommend L-tryptophan to the
elderly client. L-tryptophan is a normal dietary amino acid. available
at most health food stores. that is believed to be a precursor of
serotonin. which induces sleep. Another strategy for nursing is to use
in practice with the elderly is a sleep diary. Although the client may
have manifestations of insomnia. as this study shows that many elderly
do. the elderly client may sleep more than he/she realizes.

Older persons are often still sexually active. Sexual activity
before retiring may have been relaxing at one time. Sexual activity at
bedtime may now interfere with getting to sleep. so the elderly may
need to consider having sex earlier in the day. If insomnia has been a
long-standing problem. as this study shows that many have had symptoms
longer than a year. then behavioral therapy may be indicated. Elderly
persons may need assistance in changing accumulated sleep habit prob-
lems. Nurses can help to involve family. friends. and/or the elderlyhs
support system in instituting behavioral changes. In summary. the
conclusions drawn from this pilot study are for nursing research to

further test strategies used by the elderly. By doing this. nurses can

96

add to their data base strategies that are effective in managing the
problem of insomnia for the elderly.

In conclusion. this study of insomnia of the elderly presenting in
a primary health care setting has a great significance for nursing
practice. It is recommended that all the results can be employed by
the primary health care nurse provider. Nurses in practice can truly
impact the health of the elderly by making use of the findings of this
study. Also. nursing education can directly benefit from the results
of this study. It is recommended that they assess the el derly's sleep
and sleep patterns. that the curriculum areas include sleep assessment.
and that research be done to test strategies to promote sleep. reliev-
ing insomnia for many elderly. ‘Thus. this study of insomnia of the
elderly presenting in a primary health care setting adds to the data

base for all areas of the nursing profession.

APPENDICES

97

APPENDIX A

SLEEP QUESTIONNAIRE

98

APPENDIX A

SLEEP QUESTIONNAIRE

DIRECTIONS: This form contains questions concerning your sleeping
habits. Your response to these questions should reflect your normal
sleeping habits over the past year. It is not necessary to spend a
great deal of time on any one question. If you have difficulty with
any part of the form. leave it blank and your question will be
clarified when the form is collected. Do not put your name on the
form. All information gained from this questionnaire will remain
confidential. Thank you very much.

Please check appropriate box: Male Female Your age

 

 

1. Do you have a scheduled time for retiring each night?

 

 

Yes

No
2. At what time do you usually go to bed? _______ a.m.
p.m.
4. At what time do you usually wake up? ________ a.m.

5. Do you have trouble falling asleep?

Always
Sometimes
Never

 

6. How many times during the night do you wake up?

____,1 or 2
____.3 or 4
More than 4

 

7. Do you ever have difficulty falling asleep if you are awakened?

____,Always
Sometimes
Never

 

8. How long does it take to fall asleep if you are awakened?

.____ O-15 minutes

_____16-30 minutes
31-60 minutes
Longer than 1 hour

99

10.

11.

12.

13.

14.

15.

lOO

How often per week do you awaken too early?

____ 0-1 times
____ 2-3 times
____ 4 or more times

Do you feel rested when you awaken in the morning?
____,Always

____ Sometimes
Never

 

How do you rate your overall health?

Excellent
Very good
Good

n” .
Fair .“ lulj_/
‘1 .1 'JJ ." 0‘ a V 7'7 .—
Poor ;F ;?_.

 

 

 

 

 

How many times per week do you nap?

0 times g~ CO

1 to 2 times 4,0 “U—
3 to 4 times w° ‘,e
5 to 6 times 40"

7 or more times

When do take your nap?

Morning
Mid-afternoon
_ Evening

Please check any and all factors which interfere with your sleep.

___ Restlessness .___ Spouse ___ Temperature
___ Anxiety ___ Noise ___,Humidity
_ Guilt _ Light __ Pain

___ Depression ___,Odors ___ Fatigue

___ Other (write in)

 

If you do not have a sleeping problem. skip to Question 23. If
you do have a sleep problem. please continue.

If you have difficulty sleeping. how long have you experienced this
difficulty? (Please check)

___ One week .___ One month ___ Six months ___ More
____Tho weeks ___ Two months ___ One year

16.

17.

18.

19.

20.

21.

22.

23.

101

If you have trouble sleeping. what symptoms occur the next day?
(Please check any and all that are included.)

___ Fatigue ___ Forgetfulness Other (write in)
___ Confusion ___ Uncoordination ,___ No symptoms occur

If you have trouble sleeping. do you see this as a health problem?

.____ Yes
____,No

Do you feel your doctor is able to help with your sleep problem?

Yes
No

 

 

Is this sleep problem something you would discuss with your doctor?

Yes
No

 

 

If no. why not?

 

 

Have you discussed your sleep problem with your doctor?

_____Yes
No

 

If yes. were you satisfied with the assistance you received from
your doctor?

Yes
No

Have you tried something yourself to help your sleep problem?

Yes
No

Please check any and all of the following items used to help you
sleep.

____,Shower/bath ____,Beverage (alcoholic)
_____Night light .____ Exercise

____ Sleep in room alone _____Music

_____ Snack _____ T.V.

____ Beverage (non-alcoholic) .____ Reading

Continued on next page . . .

23.

24.

25.

26.

27.

28.

102

(Continued)

_____Sleeping medication:
Name:
How often do you use per week?

 

 

____ Over-the-counter medication:
Name:
How often do you use per week?

 

 

Do you feel your doctor is able to help with problems related to
sleep?

Yes
No

 

 

Do you ever drink warm milk before retiring?

____ Always
Sometimes
Never

 

How frequently do you get some physical exercise?

Regular daily program of exercise

Walking. but not regularly

Exercise fewer than 5 days a week

Occasional exercise--less than 3 days a week

How much coffee. tea or soft drink (pop) do you drink per day?

_____1 to 2 cups
_ 3 to 4 cups
___..5 to 6 cups
More than 6 cups

 

Please check any and all of the following chronic illnesses you
have.

 

____ High blood pressure ____ Obesity
____,Diabetes (high blood sugar) .____ Kidney disease
_____U1cer ____ Alcoholism
_ Arthritis __ Emphysema
Cancer ____ Other (write in)
Gout

 

 

Heart disease

 

29.

30.

31.

32.

33.

34.

103

Please list any prescribed and over-the-counter medications you
are currently using:

 

 

 

 

How frequently do you leave your home?

Every day
_____2 to 5 days/week
On the average less than 2 days/week

 

 

What type of home do you live in?

Own home

Condominium

Apartment

Senior citizen housing

With family member other than spouse
Other (write in)

 

 

How many other people live with you?

None

One

Two

3 or 4

More than 4

 

 

 

What type of education have you completed?

College

High school

Grammar school

Did not complete grammar school

How much is your yearly income?

____ Less than 35.000 a year
____ 35.000 to 310.000 a year
____ 310.001 to 320.000 a year
____,320.001 to 330.000 a year
____ More than 330.000 a year

35.

 

36.

Thank you for taking the time to complete this questionnaire.

Copy
Moll
Mich
1984

IOA

Are you .....

Retired

Working full time
Working part time
Homemaker

 

 

Are you .....

Married
Widow/widower
Divorced
Single

 

right
y Lawrence
igan State University

APPENDIX B

DATA ANALYSIS

105

APPENDIX B
DATA ANALYSIS

Sex: 32% male (#13) Age: Mean 73.A
67% female (#27)

Regular time for retiring

60% Yes (#ZA)
AO% No (#16)

What time do you usually go to bed?
Range: 8:00 p.m. to 12 midnight
Mean: 10:50 p.m.

What time do you usually fall asleep?
Range: 10:00 p.m. to 3:00 a.m.
Mean: 10:3“ p.m.

What time do you usually wake up?
Range: 2:00 a.m. to 9:00 a.m.
Mean: 6.h2 a.m.

Trouble falling asleep:

10% always
80% sometimes
10% never

How many times do you wake up?

50% l or 2
35% 3 or A
13% more than A
2% never

Difficulty falling asleep if awakened:

5% always
75% sometimes
20% never

How long does it take to fall asleep if awakened?

28% 0-15 min.
38% l6-30 min.
26% 31-60 min.
8% more than 1 hr.

106

107

9. How often/week do you awaken too early:

38%
42%
20%

10. Do you

35%
65%
0%

11. How do

5%
13%
32%
h8%

2%

0-1 times
2-3 times
A or more

feel rested when you awaken in the a.m.?

always
sometimes
never

you rate your health?

excellent
very good
good
fair
poor

12. How many times/week do you nap?

30%
20%
18%
18%
15%

13. When do

A%
71%
18%

2%

14. Factors

36%
33%
5.5%
5.5%
17.5%
11%
50%
58.3%
l9.h%
8.3%
5.5%

15. If you

62.5%
37.5%
5%
2.5%
30%

never
1-2 times
3-h times
5-6 times
7 or more

you nap?

morning
mid-afternoon
evening

noon

that interfere with sleep:

factors
factor

factors
factors
factors

restlessness 10%
anxiety 90%
depression 67.5%
spouse A5%
noise 25%
light

temperature

humidity

pain

fatigue

other

L‘WN-‘O

have difficulty sleeping, how long have you experienced:

no difficulty sleeping
responded

6 mos.

1 yr.

more than I yr.

l6.

I7.

18.

I9.

20.

2l.

22.

23.

108

What symptoms occur the next day?

AI% fatigue
6% forgetfulness
6% uncoordination
6% other
hl% no symptoms

If you have trouble falling asleep, do you see this as a

health problem?

16% yes
84% no
Do you feel a doctor is able to help with a sleep problem?
72% yes
28% no

ls sleep something you would discuss with your doctor?

69% yes
31% no

Have you discussed your sleep problem with your doctor?

33.3% Yes ( 6)
66.7% no (12)

If yes, were you satisfied with help?

83% Yes (5)
17% no (I)
Have you tried something yourself?
39% yes (7)
61% no (11)

Please check any and all the items used to help you sleep:

17.5% shower/bath
5% night light
35% sleep alone
15% snack
12.5% beverage (non-alcoholic)
7.5% beverage (alcoholic)
7.5% exercise

12.5% music
15% T.V.
“0% reading

7.5% sleeping medication
5% OTC sleeping medication

32%
22%
20%
25%

l
2
3
i.

100% used items

self-help
self-help
self-help
self-help

109

2A. 00 you feel your doctor is able to help with problems related

to sleep?
76% yes
24% no

25. Do you drink warm milk before retiring?

15% sometimes
85% never
26. How frequently do you get regular exercise?
21% regular
h4% walk, but not regular
3% less than 5 days/wk.
33% less than 3 days/wk.
27. How much coffee, tea, soda per day? {4
45% 1-2 cups
h7% 3-A cups
8% 5-6 cups
28. Chronic diseases:
42% l C.D. 50% HTN
40% 2 C.D. 15% 0M
10% 3 C.D. 5% ulcer .&*j
7% ti c.0. 45% arthritis W"
5% Ca
15% gout
12.5% obesity ‘ _rA
7.5% kidney disease P“
0% alcoholic
12.5% emphysema -’
12.5% heart disease (1*
12.5% other
29. Current medications:
2.5% anticonvulsant 0% tranquilizer
17.5% digitalis prep. 0% narcotic
5% antiarrhymetic 0% sedatives
10% antidiabetic 15% diuretic
2.5% antidepressant 7.5% hypnotic
7.5% antiarthritic 12.5% benzodiazepine
7.5% antiasthmatic 7.5% antispasmodic-
50% antihypertensives anticholinergics
12.5% vasodilators 7.5% histamine H2 receptor
7.5% electrolyte blocker
7.5% vitamins 12.5% bronchodilator
5% hormone 7.5% analgesic
7.5% thyroid 2.5% xanthine oxidase inhibitor

29.

30.

31.

32.

33.

110

Current medications (cont'd):

15% antianginal 85% on meds
2.5% antilipidemic

2.5% psychotherapeutic 15% O meds
2.5% quinine prep. 20% l med

5% uricosuric blocking agent 18% 2 meds

2.5% Ca drug 18% 3 meds
20% A meds

5% 5 meds

OTC meds currently using: 2% 6 meds
2% 7 meds

35% vitamins
2.5% laxative

20% analgesic

0% sleeping med

65% 0 OTC meds
18% l OTC med

13% 2 OTC meds
5% 3 OTC meds

How frequently do you leave your home?

32% every day
A5% 2-5 days/week
22% less than 2 days/week

What type of home do you live in?

63% own home

2% condominium

15% apartment

10% senior citizen housing

7% with family member other than spouse
2% other

How many people do you live with?

A8% none
AO% one
10% 3-A

2% more than A

What type of education have you completed?

13% college

A8% high school

35% grammar school

10% did not complete grammar school

111

3A. What is your yearly income?

27% less than $5,000/yr.
3oz $5.001-10,000/yr.
32% $10,001-20,000/yr.
2% $20,001-30,000/yr.
5% more than $30,000/yr.

35. Are you .

63% retired
35% homemaker
2% working full time

36. Are you .

52.5% married
A0% widow/widower
7.5% single

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112

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