DEVELOPMENT 0!: A SCREENING TOOL "

FOR ASSESSING ADULT INSOMNIA IN PRIMARY CARE. '_ _' .

Schoéarly Project fer the Degree om. 3. ~ "
MICHIGANSTATE UNIVERSITY
CAROLVN a. BAKER
1997 ’

 

 

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ABSTRACT

DEVELOPMENT OF A SCREENING TOOL
FOR ASSESSING ADULT INSOMNIA IN PRIMARY CARE

BY

Carolyn D. Baker

Insomnia is a prevalent problem in the United States.
To determine its causes and subsequent treatment requires a
thorough and occasionally time-consuming assessment of the
patient. In this project, a protocol for gauging insomnia
in adults was developed to facilitate the assessment
process. The product was an assessment tool for primary
care providers to use in collecting data from adults having
complaints of insomnia. Data from the tool should enable
the Advanced Practice Nurse to formulate a plan of care and
potential treatment options for the client.

The tool has many nursing implications relating to

primary care, education, and research.

DEVELOPMENT OF A SCREENING TOOL

FOR ASSESSING ADULT INSOMNIA IN PRIMARY CARE

BY

Carolyn D. Baker

A SCHOLARLY PROJECT
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE
College of Nursing

1997

ABSTRACT

DEVELOPMENT OF A SCREENING TOOL
FOR ASSESSING ADULT INSOMNIA IN PRIMARY CARE

BY

Carolyn D. Baker

Insomnia is a prevalent problem in the United States.
To determine its causes and subsequent treatment requires a
thorough and occasionally time-consuming assessment of the
patient. In this project, a protocol for gauging insomnia
in adults was developed to facilitate the assessment
process. The product was an assessment tool for primary
care providers to use in collecting data from adults having
complaints of insomnia. Data from the tool should enable
the Advanced Practice Nurse to formulate a plan of care and
potential treatment options for the client.

The tool has many nursing implications relating to

primary care, education, and research.

Copyright by
Carolyn D. Baker
1997

ACKNOWLEDGMENTS

I want to take this opportunity to formally thank the
committee members of this project: Chairperson Louise
Selanders, Linda Keilman, and Patty Peek. With their support
and guidance, this project finally came to fruition.

Thanks to my family, friends, and peers for their input
and patience. Thanks also to Jean Terrell for her technical
support. And many thanks to all who were helpful and

supportive throughout this project.

iv

TABLE OF CONTENTS

LIST OF FIGURES ....................................... Vii
Introduction .......................................... 1
Role of the Advanced Practice Nurse ................... 2
Intended Project Outcome .............................. 3
Conceptual Definitions ................................ 4
Circadian Rhythm ................................. 4
Sleep ............................................ 5
Sleep Stages ..................................... 5
Sleep Disturbances ............................... 7
Insomnia ......................................... 8
Literature Review ..................................... 10
Prevalence ....................................... lO
Causes of Insomnia ............................... ll
Psychological Disorders ..................... 13

Chemicals ................................... 14

Behaviors ................................... 16

Medical Conditions .......................... 17

Treatment of Insomnia ............................ 18
Sleep Hygiene ............................... 18

Stimulus Control ............................ 20
Pharmacological Interventions ............... 23
Theoretical Framework ................................. 24
Person ........................................... 25
Environment ...................................... 26

The Environment and Holism ....................... 26
Health ........................................... 28
Health and Dys—ease .............................. 28
Nursing .......................................... 29
Conceptual Model ...................................... 29

Project Development ...................................
Procedure for Using the Protocol .................
Evaluation of the Protocol .......................
Implications for the APN ..............................
Primary Care .....................................
Education ........................................
Research .........................................
Summary ............................................
APPENDICES
A DIAGNOSTIC CLASSIFICATIONS OF DISORDERS OF
INITIATING AND MAINTAINING SLEEP (DIMS) .....
B COMMON STRESSORS CAUSING INSOMNIA ...........
C DISORDERS CAUSING CHRONIC INSOMNIA ..........
D SLEEP HYGIENE ...............................

E ASSESSMENT TOOL FOR ENVIRONMENTALLY-INDUCED
INSOMNIA ....................................
References ............................................

vi

32
33
34

35
35
35
36

37

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4O
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42

43

47

LIST OF FIGURES

FIGURE 1. HOLISTIC PERSON AS CONCEIVED BY NIGHTINGALE 27
FIGURE 2. NIGHTINGALE'S MODEL FOR NURSING PRACTICE ... 30

FIGURE 3. NIGHTINGALE'S MODEL FOR NURSING PRACTICE
WITH THE INSOMNIA ASSESSMENT TOOL .......... 31

vii

Introduction

Sleep is a basic human need and is a naturally
occurring state, consuming nearly one-third of life (Anch,
Browman, Mitler, & Walsh, 1988). Disturbed sleep presents
disorders which may be categorized into hypersomnolence or
insomnia. Hypersomnolence is excessive sleepiness during the
daytime, perhaps leading to sleep at inappropriate times
(i.e., while driving). Insomnia, on the other hand, is a
perception of not getting enough restful sleep (Gillin,
1990; Hauri & Esther, 1990; Rakel, 1993). Only insomnia will
be addressed in this project.

Insomnia is a prevalent problem in the United States.
The prevalence of insomnia complaints within the previous
year of their respective study is estimated between 30% and
35% (Coleman & Roffwarg, 1982; Ford & Kamerow, 1989; Kales,
Kales, Bixler, Soldatos, Cadieux, Dashurba & Bueno, 1984).
Each year 10 million Americans consult health care providers
with the complaint of difficulty in sleeping (Anch et a1.,
1988). Daytime habits and activities (smoking, medications,
exercise, alcohol use, etc.) influence one's quality of
sleep, while sleep habits and sleep patterns influence

daytime performance. Insomnia affects the whole individual

and his or her sense of well being. The consequences of lack
of sleep or poor quality sleep are clear: Insomnia can
adversely affect quality of life by impairing concentration
and the ability to cope with minor irritations. A person may
also not feel well, decreasing the ability to enjoy
interpersonal relationships (Anch et al., 1988; Fillingim,
1992; Hauri & Esther, 1990; Rakel, 1993). Long-term insomnia
may cause fatigue and increased daytime sleepiness, which,
in turn, may increase an individual’s risk for accidents
(Mendelson, 1993).

Role of the Advanced Practice Nurse

A principle role of the Advanced Practice Nurse (APN)
is to promote health maintenance and wellness. The APN has
the skills of assessment, client education, support, and
counseling, all of which help to provide a holistic approach
to managing problems such as sleep difficulties and are well
within the scope of practice. APNs frequently collect a more
complete history from clients than physicians, which may
lead to more specific and appropriate interventions for
their clients (Everitt, Baker, & Avorn, 1990).

Insomnia, like pain, is a symptom that is just a piece
of the whole, and the APN must determine an overall
“picture” to make appropriate treatment recommendations.
This is accomplished by assessing the characteristics of the

disorder (Rakel, 1993). But management of insomnia is

sometimes challenging for the primary care provider, as it
may have obvious causes or may subtly develop over a long
period. To properly assess and treat the client may,
therefore, become more time consuming. Because APNs are
trained to take a holistic approach to wellness, clients
benefit from the APN’s ability to develop a complete
strategy to promote optimum and restful sleep. Indeed, the
APN is less likely to use pharmacological interventions and
more likely to address the causes of the disorder, employing
sound behavioral and natural interventions (Everitt et al.,
1990).

Intended Project Outcome

This project explored research from nursing and other
disciplines regarding insomnia, its prevalence, causes, and
treatment. Based on the literature, the product of this
project was an insomnia assessment tool for adults (18-65
years of age) for the primary care provider to use in the
primary care setting. While primary care providers can
manage insomnia in children and older adults, these age
groups did not fall within the scope of this project.

The theoretical framework was based on Florence
Nightingale's concepts. Nightingale asserted that the
environment affected the health of individuals. She stressed
the importance of holism; that is, that all parts of the

individual are connected and that what affects one part of

the individual is felt throughout. She wrote that through
environmental adjustments, health is promoted for the
individual. Thus, when APNs use this theory in practice,
they will be able to use the tool to assess potential causes
of insomnia and make internal and external environmental
adjustment recommendations as the primary nursing
intervention.
Conceptual Definitions

To understand what insomnia is, one must have an
understanding of normal and disturbed sleep. The following
are conceptual definitions of key concepts relating to
insomnia.

Circadian Rhythm

 

Circadian rhythm is an inherent cycle of biological
rhythms including body temperature, sleep, wakefulness, and
a variety of hormonal changes. Sunlight and other time cues,
called Zietgeber, help to set circadian cycle consistency
from day to day. For most individuals the circadian rhythm
is 24-25 hours long, but length of the cycle normally
changes in adolescents and the elderly (American Sleep
Disorder Association (ASDA), 1992).

Circadian rhythms are coordinated by small nuclei
centered at the base of the brain called the suprachiasmatic
nuclei (SCN). The SCN have connections with other parts of

the brain to control the body’s temperature, hormone

release, and many other functions. A neural pathway runs
from the eye to the SCN, and light seems to have the
greatest impact on setting the circadian clock. Other
factors that many influence SCN and the circadian cycle
include changes in body temperature and use of certain types
of medications such as alcohol and central nervous system
(CNS) stimulants (American Sleep Disorder Association, 1992;
Hauri & Esther, 1990).
222

Sleep is part of two alternating states that influence
each other: An individual is either awake or asleep. For a
healthy adult, the average amount of sleep is 7 or 8 hours
per night, though activities during the day influence the
quality and quantity of that night’s sleep. Short sleepers
are described as those who sleep less than 6 hours while
long sleepers are those who sleep more than 9 hours per
night (Anch et al., 1988). Sleep needs remain relatively
constant from week to week (Hauri & Esther, 1990). A person
may sleep 5 hours one night and 9 hours the next, but it
averages to about the same total hours each week throughout
one's adult life. The pattern or structure, however, may
change with age (Hauri & Esther, 1990).

Sleep Stages

 

Sleep is not a constant state; rather, it occurs under

two categories: nonrapid eye movement (non-REM) and rapid

eye movement (REM). There are four non-REM stages of sleep,
the first two (1-2) referred to as light sleep and the
second two (3-4) as deep or slow-wave sleep. A normal
progression through these stages, also termed sleep
architecture, occurs during the night (Berry, 1995; Hauri &
Esther, 1990).

Going to sleep is like going up and down stairs. There
are typically 2 to 4 cycles with the following pattern: 1-2-
3-4-3-2-REM. Cycles usually occur the first part of the
night in 90—120 minute intervals. The remainder is then
spent in stages 1, 2, or REM sleep (Anch et al., 1988;
Berry, 1995; Ford & Kamerow, 1989). REM sleep is thought to
be essential because it is during this period that
restoration of the mind and body occurs. Hormones are
excreted and healing of tissues and mental rejuvenation
takes place.

The function of the REM stage has been studied by
depriving individuals of sleep. The first definite finding
was that REM deprivation can lead to a marked increase in
the drive for sleep (Anch et al., 1988). The longer the
deprivation, the stronger the drive/need for sleep. On the
night of recovery sleep, it has been noted that there is a
rebound in REM sleep and REM periods are longer. Some of the
manifestations of REM deprivation are irritability, anxiety,

difficulty in concentrating, and possibly paranoid thinking

(Anch et al., 1988). REM deprivation also seems to result in
musculoskeletal symptoms and increased sensitivity to pain
(Ford & Kamerow, 1989).

Sleep Disturbances

 

A sleep disturbance is anything that interferes with
sleep. Individuals who experience sleep that is nonrestful,
inefficient, or ineffective experience a sleep disturbance.
Sleep disturbances can be caused from environmental,
behavioral, or medical stimuli (ASDA, 1992).

To uniformly name sleep and arousal disturbances and
operationalize criteria to aid in diagnosis, the Association
of Sleep Disorder Centers developed a standardized and
internationally recognized classification system called
Difficulty Initiating & Maintaining Sleep (DIMS) (see
Appendix A)(Erman, 1987). DIMS has formalized the naming of
sleep and arousal disturbances and operationalized criteria
to aid in diagnosis under two primary categories:
hypersomnolence (disorders of excessive somnolence) and
insomnia (disorders of initiation and maintaining sleep)
(Coleman & Roffwarg, 1982; Erman, 1987). Under DIMS, causes
of insomnia are delineated as use of drugs, underlying
medical or psychological conditions, and environmental or

behavioral problems (Hauri, 1982).

Insomnia

The characteristics of insomnia are the duration and
severity of the symptoms, underlying medical or
psychological conditions, or any identifiable stressful life
event which must have an accompanying complaint of daytime
difficulty (Roth, Roehrs, Stepanske, & Rosenthal, 1990).
Daytime difficulty may be reported as problems in completing
tasks or concentrating, falls or clumsiness, and/or other
complaints.

Duration of insomnia symptoms can be generalized into
three categories: transient, short-term, and chronic.
Transient insomnia typically lasts from a few days up to two
weeks and is generally triggered by situational stress, such
as an impending business meeting or jet lag (Anch et al.,
1988; Hauri & Esther, 1990, Rakel, 1993). It usually
resolves itself once the stressful event has passed. Short-
term insomnia may last 3 to 4 weeks and is often associated
with an identifiable (often self-limiting) situational
stress, such as death of a family member, pending divorce,
or change at work or home (Anch et al., 1988; Gillin &
Byerley, 1990; Rakel, 1993; Appendix B). Both transient and
short-term insomnia account for approximately 15% of
insomnia cases (Coleman & Roffwarg, 1982; Fillingim, 1992).

Chronic insomnia, however, is the persistent inability

to initiate or maintain sleep, often defined as lasting more

than 3 weeks (Gillin & Byerley, 1990; Rakel, 1993) and by
others as a month and longer (Coleman & Roffwarg, 1982;
Walsh & Mahowald, 1991). Chronic insomnia is generally
complex and caused by multiple factors (Lahmeyer, 1994).
Coleman and Roffwarg (1982) cite that the most common type
of chronic insomnia is insomnia with an underlying
psychological problem. Their study cites the second most
common cause of insomnia as psychophysiological.
Psychophysiological insomnia is a sleep disorder unrelated
to psychiatric illness, specific organic diagnosis, or drug
intake (Guilleminault, 1995). In this condition, a
maladaptive condition process has occurred (generally
unknown to the person), whereby the bedroom environment, or
simply the anticipation of bedtime, results in arousal
rather than relaxation. The individual’s frustration and
vigorous attempts to sleep are met with further arousal and
performance anxiety. Rampant mental activity or the
inability to “turn off the mind” is often characteristic of
psychophysiological insomnia. Paradoxically, when in
nonsleep-related sedentary situations, the person may
unintentionally fall asleep (Walsh & Fillingim, 1990).
Individuals with psychophysiologic insomnia report being
anxious or “stressed” about not being able to sleep and feel

that sleep would alleviate this anxiety (Bonnet & Arand,

10

1996). These individuals are different from those with an
underlying anxiety disorder.
Literature Review

A review of nursing literature revealed little
regarding insomnia. However, a number of studies have been
conducted by medicine and other disciplines. These studies
provide a foundation of pathophysiological research on sleep
and sleep disturbances, including prevalence, causes, and
treatments of insomnia. While most of the literature offers
treatment options in the medical modes, behavioral
psychology literature supplies greater information on
behaviors associated with insomnia and behaviorally-based
solutions.

Prevalence

 

Over 4% of all Americans seek medical assistance to
alleviate their complaints of insomnia each year (Anch et
al., 1988). Various studies have found 30-35% of subjects
had experienced insomnia within the last year (Coleman &
Roffwarg, 1982; Ford & Kamerow, 1989; Kales, Kales, Bixler,
Soldatos, Cadieux, Dashurba, & Vela Bueno, 1984). Radecki
and Brunton (1993) found incidences of insomnia for
individuals over age 18 recorded in 2.6 million patient
charts (78.8%) out of 3.3 million reviewed; the remainder
was individuals under 18. Sixty-five percent of the

individuals with insomnia complaints were treated by primary

11

care providers. Higher complaints of insomnia have also
appeared among lesser-educated and lower-income individuals
(Bixler, Kales, Soldatos, Kales, & Healey, 1979; Ford &
Kamerow, 1989).

Bixler et al. (1979) conducted a study in Los Angeles,
collecting data from 1,006 individuals 18 years and older
who responded to a 1973 metro area survey (Bixler et al.,
1979). The multistratified, 100-question survey included six
questions related to sleep patterns. The data showed 32%
experienced insomnia with an increase to 42% when a past
history was included. Data also revealed that those with
insomnia had a higher incidence of mental health problems
(33%), compared to those without such problems (23%). While
only 16% of insomnia sufferers reported symptoms lasting for
one year or less, 80% indicated symptoms for over a year and
40% for 5 or more years, implying that insomnia can be a
persistent problem throughout the life cycle.

Causes of Insomnia

 

Generally, clients suffering from insomnia do not
describe outright their troubles of sleeping; rather, they
complain of fatigue, “something’s not right,” or state other
vague complaints. Many consider insomnia a “fact of life”
and a problem not worth help. This compounds assessment
difficulties for the APN, and a more thorough assessment may

reveal less obvious conditions contributing to the problem.

12

The APN must be particularly aware of individuals
complaining specifically of chronic insomnia, as this may
suggest a psychological disorder, underlying medical
condition, maladaptive behavior, or severe emotional or
environmental stress (Hauri & Esther, 1990; Rakel, 1993;
Appendices B and C).

Zorick, Roth, Hartze, Piccione, and Stepanski (1981)
conducted a descriptive study to delineate causes of
insomnia. Of 84 participants (46 men, 38 women), 20 were
control subjects (9 men, 11 women). Ages ranged from 36 to
65 years. Complaints of insomnia spanned from 6 months to 40
years. All subjects were tested by one—night
polysomnolography, a sleep diary, the Cornell Medical Index,
the Minnesota Multiphasic Personality Inventory (MMPI), and
a history and physical. The control group individuals were
defined as having no history of sleep disturbances or
history of serious physical or mental health problems. Data
revealed that of insomnia complaints approximately 29%
experienced a primary sleep disorder, 20% psychological
problems, 12% used drugs and/or alcohol, 8% had circadian
rhythm changes, 7% had an underlying medical condition, and
19% had subjective complaints of insomnia that proved to
have no findings (Zorick et al., 1981).

Coleman and Roffwarg (1982) evaluated approximately

5,000 individuals from 11 sleep centers across the United

13

States with chronic or established sleep complaints. The
overall prevalence of insomnia was 31%, with the most common
underlying cause related to psychological disorders. Of
those in the sample with psychological disorders, 35% had
affective disorders. Another 15% had psychophysiological
disorders; that is, environmental or cognitive stimuli led
to conditioned arousals (anxiety) but without a known
psychological disturbance. The study also documented that
12.4% related their insomnia to drug and alcohol use, and
another 9-10% to medication use (Coleman & Roffwarg, 1982).

Psychological Disorders.

 

Psychological disorders contributing to insomnia
include stress, anxiety, depression, and the like. Pagel
(1994) reported that 60% of those patients with chronic
insomnia related symptoms to an underlying psychological
illness, versus Ford and Kamerow (1989) who found 40%
suffered from psychological difficulties. Weyerer and
Dilling (1991) also found a high correlation between
individuals with a depressive or anxiety disorder and
moderate to severe insomnia when they conducted their study
of 1,536 individuals over 15 years old, of which 28.5% had
insomnia complaints.

Ford and Kamerow (1989) specifically investigated the
relationship between insomnia and psychological disorders.

The study involved 7,954 individuals who responded to the

14

National Institute of Mental Health Epidemiologic Catchment
Area Study and who had experienced insomnia lasting more
than two weeks. A follow-up interview was conducted one year
later. On the initial questionnaire, 10% of the individuals
complained of insomnia during the prior 6 months. On
reinterview, 31% of those who had originally complained
continued to have insomnia while 69% did not. Forty percent
of those suffering chronic insomnia had an underlying
psychological disorder (Ford & Kamerow, 1989).

Kales et a1. (1984) studied 100 insomniacs having
symptoms for greater than one year. They found 75% of
reported symptoms were triggered by a stressful life event
and began before age 40, and 80% frequently went to bed with
things on their minds. Disturbed sleep was found to be
caused from (a) psychological issues, dreams, or nightmares;
(b) pain or the need to void; and (c) environmental stimuli
(light, noise temperature) (Kales et al., 1984).

Chemicals.

 

Chemical intake also plays a significant role in
sleeplessness. Many chemicals--whether alcohol, drugs,
caffeine, or medication--interfere with the architecture,
patterning, and/or the amount of sleep during its various
stages.

Ten percent of those suffering from insomnia can relate

it directly to alcohol consumption or drug use. Alcohol

15

initially induces sleep; however, it disturbs sleep 3—4
hours after ingestion. The primary effect of alcohol is it
changes sleep structure by decreasing sleep latency,
suppressing REM, and decreasing the number of eye movements
during the first half of the night, all of which lead to
disturbed sleep (Anch et al., 1989; Lahmeyer, 1995).

Mellinger, Balter, and Uhlenhuth (1985) evaluated data
from the 1979 National Survey of Psychotherapeutic Drug Use
involving individuals from 18 to 79 years old to determine
the prevalence of insomnia and drug-use patterns. The
researchers found that 35% of the population had experienced
DIMS within the last year, of which 17% stated that it
“bothered them seriously.” The study also found insomnia
increased with age, was more prevalent in women, and had a
higher association with anxiety (Mellinger et al., 1985).

Other common chemicals that disturb sleep are caffeine
and nicotine, both stimulants that interrupt sleep for many
individuals. Eliminating or changing the consumption pattern
of these chemicals can affect the quantity and quality of
sleep. Caffeine's stimulant effect can last up to 12 hours
in some individuals (Nakra, Grossberg, & Peck, 1991) and
taken before bedtime increases the body’s metabolic rate and
reduces sleep efficiency (Bonnet & Arand, 1992).

Some over-the-counter (OTC) medications that interfere

with sleep and potentially cause insomnia are cold and

16

allergy medications and cough syrups containing
decongestants that act as a CNS stimulant. Many other
prescription and OTC medications also interfere with sleep
because they often contain alcohol, caffeine, or other
stimulants. Thus, it is important for the APN to know the
patient’s medication usage including prescription and OTC
medications, herbs, vitamins, caffeine, nicotine, and use of
any illicit drugs (Lahmeyer, 1995).

Behaviors.

 

Approximately 10% of individuals suffer insomnia from
circadian rhythm disturbances, while another 20% experience
insomnia as a conditioned or learned behavior (Lahmeyer,
1995). Most commonly, circadian rhythm disturbances are
found in individuals who work off shifts (Hauri, 1982;
Lahmeyer, 1995).

Conditioned or learned behaviors causing insomnia are
those that lead to the association of the bedroom with
anything other than sleep. Watching TV, reading, and eating
in bed may develop an association between the bedroom and
the activity. Others may lie down to sleep and find
themselves going through problems and events of the day and
are unable to go to sleep. The association of
bed/worry/can’t sleep on a repeated basis eventually leads
to “I go to bed and I can't sleep” or “I hate to go to bed”

(Bootzin, 1984).

17

Behaviors between bed partners can also affect sleep.
For example, Pankhurst and Horne (1994) investigated 46 bed
partners for three consecutive nights in a sleep lab. The
pairs were monitored for movements and subjective data. High
movement between partners was related to restlessness,
snoring, or the other partner was taking up too much bed
space. Men were less affected by movements than women.
However, both men and women reported “better” sleep with
their partner present than alone (Pankhurst & Horne, 1994).

Medical Conditions.

 

Approximately 10% of insomnia is caused by an
underlying physical condition (Coleman & Roffwarg, 1982). An
acute illness or recovery from surgery may cause insomnia
but is generally short term. Ford and Kamerow (1989)
suggested that 15-20% of chronic insomnia is related to
chronic pain, allergies, metabolic diseases, and other
medical conditions such as gastroesophageal reflux disease
(GERD) and headaches. GERD is a sensation of heartburn,
which disturbs sleep by causing partial or full arousal of
the individual during the night (Ford & Kamerow, 1989).
Migraine headaches, though usually relieved by sleep, are at
times triggered by sleep. In contrast, cluster headaches and
chronic paroxysmal hemicrania occur predominantly at night
and are frequently triggered by sleep (Hauri & Esther,

1990).

18

Treatment of Insomnia

 

Most of the research offers treatment options in the
medical model. However, there are many ways to treat
insomnia, and the majority of insomnia can be managed on an
outpatient basis (Pagel, 1984). Sleep experts generally
agree that a single modality approach is only partially
beneficial. As with other medical problems, for the best
results a holistic approach is necessary for long-term
improvement of insomnia. This holistic approach includes
sleep hygiene (a group of sleep activities and habits),
stimulus control (behavior modification specifically for
insomnia), and possible pharmacological therapy.

Sleep Hygiene.

 

Sleep hygiene is a group of behaviors and health
practices that affect an individual’s quality of sleep.
Jamieson and Becker (1992) found that up to 20% of insomnia
was directly related to inadequate sleep hygiene, involving
irregular or poor sleep habits and sleep-incompatible
behaviors. Regularly violating these habits impacts the
quality of sleep (see Appendix D). However, optimizing sleep
habits and behaviors should improve the quality of sleep and
decrease insomnia.

Though cited by many authors for its importance, the
beneficial or detrimental effects of sleep hygiene on sleep

quality are difficult to determine. The many routine

19

activities which affect the ability to obtain restful sleep
include amount and degree of strenuous exercise, what and
when individuals eat, where they sleep; and a host of
environmental factors (Jamieson & Becker, 1992; Morin,
Culbert, & Schwartz, 1994); Walsh & Fillingim, 1990).
Environmental factors are comprised of noise, room
temperature, light, and foreign surroundings, etc. (see
Appendix B).

Sleep is influenced by drop in body temperature and
decrease in basal metabolic rate (BMR). When core body
temperature is increased by passive heating or exercise, it
falls back to normal and below. It is this drop in body
temperature that helps induce sleep. Passive heating with
heating pads or hot baths can accomplish this goal, but the
compensatory drop in core temperature occurs earlier with
passive heating than with exercise. Hot pads and baths are
most effective 2-3 hours before going to bed if exercise 4-6
hours before cannot occur (Hauri, 1993; Morin et al., 1994).

Exercise is perhaps one of the most important aspects
of sleep hygiene behaviors in that it aids in ease and
deepening of sleep. Exercise influences both body
temperature and metabolism (Morin et al., 1994). In contrast
to the good sleeper, Morin et al. (1994) have shown that the
metabolism rates do not slow down during the night in the

poor sleeper. Exercise increases metabolism and the core

20

body temperature, with a compensatory drop about 4 to 6
hours later, thus leading to sounder sleep (Bonnet & Arand,
1995; Morin et al., 1994). Vigorous aerobic exercise has
been demonstrated to increase slow-wave sleep, the phase of
sleep considered the most restful and restorative.

The time of day for regular exercise can determine the
amount of benefit it has for management of sleep
disturbances. Morning exercise, for example, is not as
advantageous as exercise later in the day because the
compensatory drop in core temperature and metabolism occurs
long before bedtime. Conversely, late evening exercise
should be avoided because of its arousing effect (Hauri,
1993). To optimize sleep induction, exercise would be best
4-6 hours before bedtime.

Stimulus Control.

 

Stimulus control is most appropriate for the individual
who has psychophysiologic insomnia. Bootzin (1984) defines
stimulus control as a technique that promotes the
association of the bedroom environment with sleep instead of
wakefulness. This association is formed between various
bedtime rituals and experiencing an inability to sleep. The
individual who associates or anticipates going to bed with
poor sleep is unable to relax and sleep. Repeatedly pairing

the act of going to bed with being restless and frustrated,

21

while waiting for sleep, may lead to insomnia (Hauri, 1982;
Jamieson & Becker, 1992).

The goal of stimulus control is to help the insomniac
acquire a consistent sleep rhythm, strengthen the
bed/bedroom as a cue for sleep, and weaken the bed/bedroom
as a cue for activities interfering with sleep. The
assumption underlying the teaching is that falling asleep is
an instrumental act promoting the conditioned reinforcement
of sleep or nonsleep. Stimuli that become associated with
sleep or falling asleep become discriminative stimuli for
promoting sleep (Hauri, 1982; Jamieson & Becker, 1992).

Difficulty in falling asleep reflects established
stimuli for activities not compatible with sleep. For
example, in an experiment applying a stimulus at various
times during sleep, Arkin and Antrobus (1991) found that
individuals who knew about the stimulus seemed to anticipate
it and reported “seeing” it in their dreams. With
repetition, the researchers suggested sleep would be
interrupted. Individuals who retire with daily concerns and
anxieties may have interrupted sleep with either partial or
full arousals (Arkin & Antrobus, 1991). And those who use
the bed/bedroom for virtually all of life’s activities
(reading, eating, watching TV) reinforce wakefulness,
causing an inability to sleep (Bootzin, 1982; Harsh & Badia,

1990; Orr & Altshuler, 1982).

22

It is important for those experiencing insomnia to
associate the bed/bedroom with no activities other than
sleep and sexual relations (Bootzin, 1984; Pagel, 1994;
Spielman, Caruso, & Glovinsky, 1987; Walsh & Mahowald,
1991). To help control stimuli affecting sleep, the
individual should follow the rules listed below:

1” Go to bed only when you are sleepy.

2. Use bed/bedroom only for sleep and sexual relations.

3. If unable to sleep after 20 minutes, get up, go to

another room, and engage in nonstressful activities.
4.Repeat #1-3 as many times as needed.

5.Set an alarm clock and get up at that time.

6.Do not nap during the day.

For those with chronic insomnia, combinations of both sleep
hygiene and stimulus control may prove beneficial
(Guilleminault, 1995; Walsh & Fillingim, 1990).

A comparison study of nonpharmacological interventions
by Morin, Culbert and Schwartz (1994) showed a decrease in
sleep latency after using various nonpharmocological
interventions by 25-30%, compared to the control group which
did not receive any intervention. When nonpharmocological
interventions were used, chronic insomniacs demonstrated a
more reliable and durable change in sleep patterns. The
study demonstrated that stimulus control and sleep

restriction were the most beneficial interventions.

23

Pharmacological Interventions.

 

Walsh and Fillingim (1990) and Gillin and Byerley
(1990) recommend hypnotic medication for short-term,
transient, or psychophysiologic insomnia which, given early
enough in the psychophysiologic cycle, may abort the cycle.
In cases of chronic insomnia, Silva, Chase, Sartorius, and
Roth (1996) recommend the use of hypnotics in most cases for
approximately two weeks, while the National Consensus
Conference (NCC) recommends use for 30 days, but in
conjunction with sleep hygiene and behavior modification
(National Institute of Mental Health, 1996). For long-term
therapy of chronic insomnia, Regestien (1987) suggests
therapy be evaluated on an individual basis.

The major groups of medications used for insomnia are
the hypnotic and sedatives, and more specifically, the
benzodiazepines. The keys to choosing hypnotic therapy are
dose, half-life, and therapeutic index of the medication.
Dose determines the safety of the drug. Half-life helps
predict the length of action and residual effects of the
drug (i.e., daytime sleepiness). And the therapeutic index
describes interactions with other medications that may bind
or potentiate the hypnotic (Silva et al., 1996; Walsh &
Fillingim, 1990).

Benzodiazepines are a group of medications whose

primary mode of action is not clearly defined. They are

24

thought to act on the limbic, thalamic, and hypothalamic
areas in the central nervous system. These drugs produce
sedative, hypnotic, anxiolytic, relaxive, and anticonvulsant
effects. Benzodiazepines are widely distributed throughout
the body and cross the blood/brain barrier, and depending on
the route of administration, the onset of drug action occurs
typically after 15-45 minutes with a peak action in 7-8
hours. The benzodiazepine group has a varied half-live, and
the long half-life of some of these drugs can produce
daytime sleepiness (McEvoy, 1995).

Another group of medications sometimes prescribed is
the tricyclic antidepressants. Tricyclics are used as
effective treatment for insomnia because of the sedating
properties (McEvoy, 1995; Pagel, 1994). These drugs work
particularly well with those individuals with insomnia who
have an underlying depressive component, but may also be
used for chronic pain or anxiety. Though not a drug
prescribed as a first order of treatment for insomnia, a
major side effect of tricyclics is sleepiness; hence it
should be employed at low dosage levels (Pagel, 1994).

Theoretical Framework

A theoretical framework is useful to assist in
describing a set of events within a given context. Many
theories, although rooted in a specific academic base, such

as sociology or psychology, have broad applicability. In

25

particular, nursing theories have-been developed to explain
the phenomenon of nursing. They also have broad
applicability in a wide range of practice settings.

The concepts first put forth by Florence Nightingale in
the nineteenth century addressed environmental alteration as
a means of implementing nursing care (Selanders, 1993).
Nightingale’s theory identified the relationship of the
person with the internal and external environments and the
importance of how they influence each other. When an
individual experiences illness or disequilibrium,
Nightingale asserted that making changes in the environment
improves well being, placing the patient in the best
possible condition for Nature to heal (Nightingale,
1946/1996).

Nightingale’s concepts have great utility in the
diagnosis and management of insomnia. The nurse is the one
recommending the environmental changes. Today, the APN
assesses and identifies the environment for imbalances and
provides strategies for clients to change, returning them to
equilibrium, and thus, to health.

Person

Nightingale defines the person as the individual who is
affected by the environment (Selanders, 1993). The person is
the “object" of care, not the disease or symptom.

Nightingale viewed the person from a holistic perspective: a

26

multidimensional being of biological, social, and spiritual
elements (De Graaf, Marriner—Tomey, Mossman, & Slebodnik,
1989; Selanders, 1993).

Environment

 

The external environment is composed of physical
surroundings, daily activities, habits, and exposures. The
internal environment is within the person and includes
emotional, spiritual, and biological dimensions of the
person. The psycho—spiritual dimension can affect the
individual by causing feelings of anxiety, fear, worry, or
other emotions and concerns that can be intense enough to
interfere with sleep. All of the internal processes can be
affected by intake from or exposure to the external
environment. Therefore, Nightingale’s emphasis on
ventilation, pure food and water, light and noise control
attempts to improve both the internal and external
environments. Nightingale asserts that making changes in the
environment will improve the health of the person
(Nightingale, 1946/1996). In the instance of insomnia, the
patient experiencing it requires environmental adaptation,
thereby allowing Nature to heal.

The Environment and Holism

 

The focus of Nightingale’s Theory is the environment.
Both internal and external dimensions affect the individual,

causing health or dys-ease (see Figure 1).

27

 

 

\ l
‘_ ’
~——“’

Figure 1. Holistic Person as Conceived by Nightingale (Selanders, 1996).

28

Bio-psycho—social-spiritual dimensions of an individual’s
environment overlap each other, and to omit a dimension
would be missing a piece of the whole. This model
demonstrates the interconnectedness of each dimension. Thus,
when assessing or treating a client, a holistic approach is
the most beneficial; all dimensions must be considered. The
American Holistic Nurses’ Association (1995) states that
holism involves understanding the individual as an
integrated whole, interacting with and being acted upon by
both internal and external environments (Dossey & Guzzetta,
1995).
Health

Nightingale describes health as a relative state
determined by both factual and perceived factors. The
perception of health is according to how one feels and is
heavily dependent on the psychological, spiritual, and
social spheres. Nightingale also viewed health as the
perfection of health and that persons should use every power
to move toward wellness or the best that one can be at any
given point in time (Nightingale, 1946/1996; Selanders,
1993).

Health and Dys-ease

 

Insomnia is a perception by the person that he or she
is experiencing nonrestful sleep and consequently

experiencing dys-ease. Nightingale describes dys-ease as

29

lacking comfort and being alerted to a lack of health
(Selanders, 1993). This feeling of dys-ease suggests to the
nurse that environmental adaptation is required as part of a
planned nursing intervention. The theory asserts that making
alterations in the environment will lead to relief of the
dys-ease (Nightingale, 1946/1996; Selanders, 1993).
Nursing

Nursing is a way of facilitating nature’s reparative
processes by placing the person in the condition for Nature
to act upon them. The nurse is, directly or indirectly, the
manipulator of the environment (De Graaf et al., 1989).

Conceptual Model

A nurse in advanced practice uses the nursing process
to observe, assess, and document findings, identify
disequilibrium, and make recommendations and/or alterations
to the person’s environment. The goal is to improve the
health status of patients and return them to health. After
intervention, the nurse again assesses, observes, and
documents progress, and, depending on the progress, may
recommend new interventions. This process is recurring and
is, in essence, a feedback loop. It can be visually depicted
in a model to symbolize representations of phenomena and
show relations of the metaparadigm components as described
by Nightingale (see Figure 2). The model of nursing practice

is linear, starting with action initiated by the nurse.

30

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This model can be easily adapted for specific care-
giving experiences, such as for those who experience dys-
ease because of insomnia. In the case of the nurse treating
a patient with insomnia, the assessment tool is specifically
inserted into the observation portion of Nightingale’s
nursing practice model (see Figure 3).

Project Development

The purpose of this project was to develop a protocol
and assessment tool for clients with complaints of insomnia.
This tool will act as a guideline for the APN in appraising
and determining treatment for the insomnia patient in the
primary care setting. Because a complete analysis of an
individual's insomnia requires time, and may require several
visits, the tool should facilitate that process. The APN can
focus on key assessment points, including medical/surgical,
psychological, and sleep histories. The goal of the tool is
to gather enough data to determine whether an individual has
transient, short-term or chronic insomnia, probable
causitory factors, and from the assessment, form a treatment
plan. Many health care providers currently document in the
SOAP format, into which this tool should be easily
incorporated.

The tool focuses on such elements as the person's

insomnia, history, symptoms, possible causes, and previous

33

treatments. The information collected from the tool aids the
APN in determining problems, directing the plan, and
recommending interventions to change the environment. Such
recommendations frequently include sleep hygiene, stimulus
control, and/or pharmacological interventions. A return
visit is necessary to establish movement toward identified
goals. This represents the feedback loop.

Using the Protocol

 

This tool is for use in the primary-care setting to
evaluate insomnia in adults and is divided into three
sections: Sleep Inventory, Sleep Environment, and Sleep
Assessment (see Appendix E). Sleep Inventory (sleep habits)
and Sleep Environment list questions to be answered by the
client, which include information on how long the individual
has experienced insomnia, sleep patterns, presleep habits,
bedroom environmental conditions, and the like. Most
questions need only short answers, but for those questions
requiring further explanation, extra space has been
provided. To reduce time constraints and aid the health care
provider in determining what is causing insomnia, clients
should ideally complete their sections in advance of their
appointments, allowing the provider to review client answers
and focus on areas needing further attention.

The Sleep Assessment portion is for use by the health

care provider and reviews past medical history of probable

34

relevance to insomnia, medical symptoms that may disturb
sleep (e.g., cough, pain), medications/social habits, and
psycho-social history. It is presumed a more complete
history (e.g., previous diseases, surgeries, and their
sequela) was taken at a client’s initial visit to the
provider and prior to the complaint of insomnia. This
history can be check-marked for “yes” responses, but because
the patient may not be familiar with medical terminology and
diagnoses, it is important the provider or a member of the
health care team, such as a nurse practitioner, nurse, or
medical technician take the history. However, yes answers
may require a more in-depth assessment by the primary
provider. Space is provided to describe the condition(s).

The patient history covers medical problems that are
particularly relevant to determining probable causes of
insomnia. It is presumed that a more complete medical
history (i.e., previous diseases and surgeries and their
sequela) would occur at the patient’s first visit. It is
also presumed that the patient has complained of suffering
from insomnia.

Evaluation of the Protocol

 

Evaluation of the tool should include its content,
applicability, and ease of use by primary care givers. There
are a variety of groups that could test this tool (family

members, groups of patients, medical or graduate students)

35

in a variety of settings (internal medicine, family

practice). Through feedback and re-evaluation, adjustments

can be tailored to both professional and lay groups to

ensure clarity and usability and appropriateness.
Implications for the APN

Primary Care

 

There are many goals for primary care, among which are
promoting wellness and healthy lifestyle behaviors and
identifying and treating health problems. Insomnia is a
symptom with many potential causes, and because of its
widespread occurrence, it becomes a primary care issue. In
family or primary care practices, the APN is qualified to
use the tool to facilitate identification and treatment of
individuals with insomnia. Portions may be incorporated into
the routine physical to identify potential sleep problems,
especially since many clients vaguely describe their
symptoms (Hauri & Esther, 1990; Rakel, 1993).

Education

 

APNs' use of the tool should familiarize them more with
sleep problems and their frequency. Because of the APN’s
expertise and knowledge, educational services about insomnia
can subsequently be tailored to peers and clients. For
example, information on insomnia could be presented in
seminar format with a general background (“Improving Your

Sleep”) or more targeted content (“How to Maximize Sleep

36

Using Sleep Hygiene”). The APN could also author reference
materials geared to the professional or the client, either
generalized or specific. Such educational services may
further demonstrate the importance of client assessment and
use of the assessment tool.
Research

This project can serve as a starting point to further
development of potential research. The APN is qualified to
design and implement research projects based on the
assessment tool. Data collected from the tool may provide
generalizations about clients with insomnia and generate a
variety of research questions. Potential research projects
might include (a) comparing specific treatment modalities to
determine which ones best improve sleep, (b) comparing
nonpharmacological and pharmacological treatments, (c)
evaluating treatments individually and in combination, or
(d) comparing treatment modalities described in this project
with options not presented herein. A researcher could also
act as a clinical investigator to gather data for area
and/or national studies relating to insomnia. Thus, research
opportunities in which the APN can participate are many,
from both design and implementation aspects.

Summary
Insomnia is a primary health care problem that can be

acute or chronic, simple, or complex. Insomnia affects all

37

aspects of individuals' lives. It affects how they feel and
how they perform. Florence Nightingale asserted that the
environment affected individuals and how they felt; thus,
she promoted adjusting the environment to improve health.
Adapting sleep hygiene, stimulus control, and
pharmacological agents to the client's situation adjusts the
client's environment toward improved sleep, hence reduced
insomnia.

The literature indeed established insomnia as a
frequent complaint, arising from the individual’s internal
or external environments. Most authors agreed that thorough
assessment of the client's history, routines, and sleep
patterns were necessary to identify and treat the problem.
However, the literature did not reveal a tool for the health
care provider to use to facilitate the assessment process.

This project sought to develop an assessment tool for
insomnia based on Nightingale’s premise that dys-ease is a
person’s lack of comfort, thus lack of health (Selanders,
1993). The tool focused on the elements of insomnia:
history, symptoms, and internal/external causes. In the
primary care setting, the information gathered should assist
the APN in evaluating the problem, then develop a plan and
direct interventions to move the client away from dys-ease

and toward wellness. This tool can serve as a springboard

38

for the APN for future nursing research, education, and

practice.

APPENDICES

APPENDIX A

DIAGNOSTIC CLASSIFICATIONS OF

DISORDERS OF INITIATING AND MAINTAINING SLEEP (DIMS)

DIMS
1.

\1

(Insomnia)

Psychophysiological

a. transient and situational

b. persistent

Associated with psychiatric disorders

a. symptom and personality disorders

b. affective disorders

c. other functional psychoses

Associated with use of drugs and alcohol

a. tolerance to or withdrawal from CNS depressants

b. sustained use of CNS stimulants

c. chronic alcoholism

Associated with sleep-induced respiratory impairment

a. sleep apnea DIMS syndrome

b. alveolar hypoventilation DIMS syndrome

Associated with sleep-related (nocturnal) myoclonus

and restless legs

a. sleep-related (nocturnal) myoclonus DIMS syndrome

b. restless legs DIMS syndrome

Associated with other medical, toxic, environmental

condition

Childhood-onset DIMS

Associated with other DIMS conditions

a. repeated REM sleep interruptions

b. atypical polysomnographic features

c not otherwise specified

No DIMS abnormality

a. short sleeper

b subjective DIMS complaint without objective
findings

c. not otherwise specified

Disorders of the sleep—wake schedule

1.

Transient

a. rapid time zone change (jet lag) syndrome

b. work shift change in conventional sleep/wake
schedule

Persistent

frequently changing sleep/wake schedule

delayed sleep phase syndrome

advanced sleep phase syndrome

non—24-hour sleep-wake syndrome

irregular sleep-wake pattern

not otherwise specified

i'thQOC‘DJ

39

40

APPENDIX B

COMMON STRESSORS CAUSING INSOMNIA

MAJOR LIFE CHANGES
Death of a loved one
marriage
divorce
birth of a child
severe illness in a relative or friend
moving to a new location

EMOTIONAL UPSET
marital strife
work-related problems
guilt over sexual conflicts
concerns about health
test anxiety

ENVIRONMENTAL FACTORS
sleeping in an unfamiliar bed, surroundings
excessive noise, light, temperature
extremes in weather
too much, inadequate, uncomfortable attire and/or bedding

SYSTEMIC FACTORS
ingesting alcohol before bedtime
eating a large meal before bedtime

DISRUPTIONS IN NORMAL ROUTINE
medical examination
elective surgery
hospitalization
acute pain

DESYNCHRONIZATION OF CIRCADIAN RHYTHM
rapid time zone change——jet lag
variable shift work

MEDICATIONS CAUSING INSOMNIA
antihistamines--including H2 blockers
bronchodilator--including zanthinederivatives
corticosteroids
illicit drugs--stimulant, cocaine, amphetamines, narcotics
thyroid replacement
diuretics
anticholinergics
antidepressants--MAO inhibitors
antihypertensives--beta blockers, quinidine (nightmares)
chemotherapy

41

APPENDIX C

DISORDERS CAUSING CHRONIC INSOMNIA

PRIMARY SLEEP DISORDERS
sleep apnea
nocturnal myoclonus
restless legs syndrome
hypnic jerks

MEDICAL DISORDERS
allergies, sinusitis-—difficulty in breathing
asthma-~nocturnal cough
arthritis, myalgia—-pain
chronic obstructive pulmonary disease--shortness of breath
coronary or pulmonary insufficiency--angina
diabetes, nocturnal diuresis, hypoglycemia at noc-nightmares
dementia
epilepsy
fibrositis
gastroesophageal reflux disease, esophagitis--pain
hypertension--ear1y AM wakening, 25% OSA
hyperthyroidism--increased difficulty falling asleep
Parkinson’s disease—-increased time awake, decreased REM
PMS—-hormonal shifts
peptic ulcer disease--pain or indigestion
nocturnal cardiac ischemia
headaches--migraines, cluster, sinus

PSYCHIATRIC DISORDERS
major depression
anxiety
panic disorder
obsessive/compulsive disorder
borderline personality disorder
post-traumatic stress syndrome
adjustment disorders
anorexia nervosa
dementia
alcohol and substance abuse
phobias

PSYCHOLOGICAL DISORDERS
pre—existing emotional problems
inadequate coping strategies
internalization of emotions
persistent hypochondria
obsessive worrying

\IONU'iub

10.
11.

12.

13.

14.
15.

42

APPENDIX D

SLEEP HYGIENE

Maintain a regular sleep schedule with a regular arising
time and set number of hours of sleep. This will strengthen
circadian rhythm.

Make certain bedroom is quiet, comfortable, cool, and
secure. May need to sound screen room (ear plugs, “white”
noise, fan, opaque shades, heavy curtains) to muffle outside
noises or light.

Keep bedroom for sleep only, not for TV, readings, eating,
or work. Sexual activity is the only exception. This, too,
will reinforce cues to initiate sleep.

Hide alarm clock to avoid clock watching.

Avoid naps.

Avoid worry or frustration in bed.

Schedule time to wind down and relax before going to bed.
Quiet activities (i.e., hot bath, reading, meditation) will
help relaxation before going to bed and reinforce cues to
initiate sleep.

Do not consume caffeine after noon; caffeine is metabolized
within 8-12 hours.

Avoid alcohol 3-5 hours before bedtime as it may fragment
sleep.

If necessary, restrict fluids at bedtime.

Avoid heavy meals or hunger at bedtime. Instead have light
snack of milk, tuna, cheese, crackers. Avoid heavy or spicy
foods which may cause indigestion.

Abstain from stimulating drugs (caffeine, decongestants) in
the evening.

Get regular exercise around midday. Walk 2-3 miles/day.
Aerobic or strenuous exercise should be 6 hours before
bedtime.

Get out of bed if awake.

If unable to sleep, get out of bed (see Stimulus Control).

Sources: Becker, 1993; Hauri, 1993; Jamieson & Becker, 1992;
Lahmeyer, 1995; Nakra et al., 1991; Rakel, 1993; Walsh &
Mahowald, 1991.

43

APPENDIX E

ASSESSMENT TOOL FOR ENVIRONMENTALLY-INDUCED INSOMNIA

I. SLEEP INVENTORY

CLIENT DIRECTIONS: The following are questions to help us evaluate your sleep
difi‘iculties. Most answers are short, but when more information is needed, please answer
as completely as possible.

How long (weeks, months, years) have you been experiencing insomnia?
How many times a week?

Do you have difficulty going to sleep? Difficulty staying asleep?
Does your insomnia interfere with your daytime activities or school or work?
If so, please explain how:

 

 

 

 

 

Bedtime Routines:

A. How many hours do you sleep each night during the week?
Do you feel refreshed when you wake up?

B. Do you “sleep in” on weekends?

Do you feel refreshed when you wake up?

What time do you typically go to bed?

What time do you typically wake up?

Do you wake up during the night? If yes, how often?
Why?

W90

Are you able to go back to sleep?

On the nights you wake up, do you feel refreshed in the morning?
Do you have to keep busy to stay awake during the day?
How often do you fall asleep while watching TV?
Have you ever fallen asleep while driving? How often?
Do you sleep well while on vacation?

Do you eat in bed? Watch TV? work?
Describe your routine before bedtime (EXAMPLE: Do you take a bath, exercise,
listen to music, read, have a snack?)

 

at: on

E'“?5

44

Before going to bed, do you have a cocktail? or smoke?

Have you ever used home remedies to help you sleep?
Which ones worked?

 

 

Which ones didn’t work?

What makes your insomnia worse?

What other problems have you had since your insomnia started?

45

II. SLEEP ENVIRONMENT
CLIENT DIRECTIONS: The following questions relate to your sleeping arrangements
and the environment in which you sleep. Most of these questions can be answered “yes ”
or “no ” or with a checkmark

A. Do you sleep alone? With a partner? Pets? Children?

B. What type of bed do you sleep in?

C. Are you a light__ or heavy_— sleeper?

D. Is your partner a light__ or heavy_ sleeper?
B. How many pillows do you use?—

F. What is your usual (favored) sleeping position?

Side Back Stomach

 

 

 

 

G. What is the usual temperature in your room?
For you, is this temperature too hot? or too cold?
H. Is your room dark?
Does light bother you? Does light wake you up?
I. Is your room quiet?
Does noise bother you? Does noise wake you up?
J. Do you snore?
Does your bed partner snore? Does it wake you up?

 

 

K. Are there other things not mentioned above that disturb your sleep?
Please describe them.

46

III. SLEEP ASSESSMENT

 

FOR COMPLETION BY HEALTH CARE PROVIDER Yes Describe How Interfere:

 

PAST MEDICAL HISTORY (PMH)

If yes. describe how condition interferes with sleep

Allergies
Asthma-COPD-emphysema
Arthritis-RA
CAD-CI—IF-MI-Angina
HA-seizures—dementia

 

 

 

 

 

 

SYMPTOMS DURING SLEEP

If yes, describe how client is bothered in sleep
Cough
Shortness of breath
Nasal congestion
Pain
HA
Angina
Arthralgia
Joint
Muscle
Dysmenorrhea
Esophagitis
Nocturia
Any extremity movements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS/SOCIAL HABITS
Rx meds

OTC meds, herbs, vitamins

Smoking

Caffeine

Exercise routine

 

 

 

 

 

 

 

PSYCHO—SOCIAL HISTORY
Routine during work/school hours

Any known precipitating factors for
“Why you’re not sleeping”

 

Situational stress, crisis, loss, grief
History of psychological dx
Depression
Anxiety (worrier)

 

 

 

 

 

 

 

REFERENCES

References

American Sleep Disorder Association, 1992. Circadian
rhythm, a look at the body’s natural time clock. Author.

 

 

Anch, A. M., Browman, C. P., Mitler, M. M., & Walsh, J.
K. (1988). Sleep: A scientific perspective. Englewood
Cliffs, NJ: Prentice Hall.

 

Ancoli-Isreal, S. (1989). Epidemiology of sleep
disorders. Clinics in Geriatric Medicine, 5(2), 347-362.

 

Arkin, A. M., & Antrobus, J. S. (1991). The affects of
external stimuli applied prior to and during sleep on sleep
experiences. In S. J. Ellman & J. S. Antrobus (Eds.), The

mind in sleep psychology and psychophysiology (pp. 265-307).
New York: Wiley.

 

Baer, E. D. (1993). Philosophical and historical basis
of primary care nursing. In M. O. Mezey & D. O. McGivern
(Eds.), Nurses, nurse practitioners: Evolution to advanced
practice (pp. 102-116). New York: Springer.

 

Becker, P.M., Jamieson, A. O., & Brown, W. D. (1993).
Insomnia: Use of a “decision tree” to assess and treat.
Postgraduate Medicine, 93(1), 66-85.

 

Berry R. (1995). Sleep related breathing disorders. In
R. George (Ed.), Chest medicine: Essentials of pulmonary and
critical care medicine (pp. 247-272). Baltimore, MD:
Williams and Wilkins.

 

Bixler, E. O., Kales, A., & Soldatos, C. (1979). Sleep
disorders encountered in medical practice: A national survey
of physicians. Behavioral Medicine 6, 13-21.

 

Bixler, E. O., Kales, A., Soldatos, C. R., Kales, J.
O., & Healy, S. (1979). Prevalence of sleep disorders in Los
Angeles Metropolitan Area. American Journal of Psychiatry,
136(10), 1257-1262.

Bonnet, M. H. & Arand, D. L. (1992). Caffeine use as a
model of acute and chronic insomnia. Sleep, 15(6), 526-536.

 

47

48

Bonnet, M. H. & Arand D. L. (1995). 24-hour metabolic

rates in insomniacs and matched normal sleepers. Sleep,
18(7), 581-588.

Bonnet, M. H. & Arand D. L. (1996). The consequences of
a week of insomnia. Sleep, 19(6), 453-461.

 

Bootzin, R. R. (1984). Evaluation of stimulus control
instructions, progressive relaxation and sleep hygiene as
treatment for insomnia. In R. E. Koellawp (Ed.), Sleep 1984:
Proceeding of the Seventh European Congress on Sleep
Research. New York, NY: Gustav Fischer Verlag.

 

 

Calaverley, P. M. (1993). Medical problems during
sleep. British Journal of Medicine, 307, 6898.

 

Childs-Clarke, A. (1990). Stimulus control techniques
for sleep onset insomnia. Nursing Times, 86(35), 52—53..

 

Cohen, F. L. (1992). Sleep Promotion. Nursing
Interventions: Essential Nursing Treatments, (pp. 109-119).
Philadelphia, PA: Saunders.

 

Coleman, R. M., Roffwarg, H. P. (1982). Sleep—wake
disorders based on a polysomnographic diagnosis: A national
cooperation study. Journal of the American Medical
Association, 247(7), 997-1003.

 

 

De Graaf, K. R., Marriner-Tomey, A., Mossman, C. L., &
Slebodnik, M. (1989). Florence Nightingale Modern Nursing.
In A. Marriner-Tomey (Ed.), Nursing theorists and their work
(pp. 65-72). St. Louis, MO: Mosby.

 

Dinner, D. S., Erman, M. K., & Roth, T. (1992). Help
for geriatric sleep problems. Patient Care, 29(1), 166-189.

 

Eastman, C. 1., Lin, L., Fogg, L. F. (1995). Circadian
rhythm adaptation to stimulated night shift work: Effect of
nocturnal bright light duration. Sleep, 18(6), 399-407.

 

Edinger, J. D., Fins, A. I., Gaeke, J. M., McMillian,
D. K., Gersh, T. L., Krystal, A. D., & McCall, W. V. (1996).
The empirical identification of insomnia subtypes: A cluster
analytic approach. Sleep, 19(5), 398-411.

 

Erman, M. K. (1987). Insomnia. Psychiatry Clinics of
North America, 10(4), 769-773.

 

 

49

Espie, C. A. (1993). Practical management of insomnia:
Behavioral and cognitive techniques. British Journal of
Medicine, 306, 6876.

 

 

Everitt, D. E., Baker, M. & Avorn; J. (1990). Clinical
decision-making in the evaluation and treatment of insomnia.
The American Journal of Medicine, 89(9), 357-361.

Fillingim, J. M. (1992, April). Insomnia diagnosis and
treatment in general practice. Physician Assistant, 47-56.

 

Flanagan, P. (1976, April). Finding the true cause of
insomnia. Practical Psychology for Physicians, 22-24.

 

Foley, D. J., Monjan, A. A., Brown, S. L., Simonsick,
E. M., Wallace, R. B., & Blazer, D. G. (1995). Sleep
complaints among elderly persons: An epidemiologic study of
three communities. Sleep, 21(6), 425-431.

 

Ford, D. E. & Kamerow, D. B. (1989). Epidemiologic
study of sleep disturbances and psychiatric disorders.
Journal of American Medical Association, 262(11), 1479-1484.

 

Gillin, J. C., & Byerley, W. F. (1990). The diagnosis
and management of insomnia. The New England Journal of
Medicine, 332(4), 239-247.

 

 

Gilleminault, C. (1995). Nondrug treatment trials in
psychophysiologic insomnia. Archives of Internal Medicine,
155, 838-844.

 

Harsh, J. & Badia, P. (1990). Stimulus control and
sleep. In R. R. Bootzin, J. F. Kihlstrom, & D. L. Schacter
(Eds.), Sleep and cognition (pp. 58-66). Washington, DC:
American Psychological Association.

 

Hauri, P. J. (1982). Evaluating disorders of initiating
and maintaining sleep (DIMS). In C. Guilleminault (Ed.),
Sleeping and waking disorders: Indications and techniques
(pp. 225—244). Menlo Park, CA: Addison-Wesley.

 

Hauri, P. J. (1993). Counseling about insomnia: A
method and some preliminary data. Sleep, 16(4), 344-349.

 

Hauri, P. J. & Esther, M. S. (1990). Insomnia. Mayo
Clinic Proceedings, 65, 869-882.

 

50

Hawkins, J. W. & Thibodeau, J. A. (1989). The nurse
practitioner and clinical nurse specialist: Current practice
issues. (2nd ed.). New York: Tiresias Press.

 

Jamieson, A. O. & Becker, P. M. (1992). Management of
the 10 most common sleep disorders. American Family
Physician, 45(3), 1262-1268.

 

 

Kales, J. D., Kales, A., Bixler, E. O., Soldatos, C.
R., Cadieux, R. J., Dashurba, G. J., & Vela Bueno, A.
(1984). Bio-psychological correlates of insomnia, V:
Clinical characteristics and behavior correlates. American
Journal of Psychiatry, 141(11), 1371-1375.

 

Koetters, T. L. (1989). Clinical practice and direct
patient care. In A. B. Hameric (Ed.), The Clinical Nurse
Specialist in Theory and Practice. Philadelphia, PA: WB
Saunders.

 

 

Kryger, M. H., Steljes, D., Pouliot, Z., Neufeld, H., &
Odynski, T. (1991). Subjective versus objective evaluation
of hypnotic efficacy: Experience with Zolpidem. Sleep,
14(5), 399-407.

Lahmeyer, H. (1994, December). Insomnia: What is behind
the “vicious circle”? Consultant, pp.1739-1744.

 

Lahmeyer, H. (1995, January). Insomnia: How to help
patients get a good night’s sleep. Consultant, pp.108-111.

 

Leddy, 8., Pepper, J. M. (1993). Conceptual Bases of
Professional Nursing. New York: JB Lippincott.

 

 

Lichstein, K. L., Wilson, N. M., Noe, S. L., Aguillard,
R. N., & Bellur, S. N. (1994). Daytime sleepiness in
insomnia: Behavioral, biological and subjective indices.
Sleep, 17(8), 693-702.

 

Marriner-Tomey, A. (1996). Decision making process,
decision making tools. Guide to Nursing Management (5th
ed.). St. Louis, MO: Mosby.

 

McEvoy, G. (1995). American Hospital Formulary
Services: 1995 Drug Information. Bethesda, MD: AHFS.

 

 

McGivern, D. O. (1993). The evolution to advanced
nursing practice. In M. D. Mezey & D. O. McGivern (Eds.)
Nurses, nurse practitioners: Evolution to practice (pp. 3-
31). New York: Springer.

51

McKay, R. (1992). Perspectives on Nursing Theory. (2nd
ed). Philadelphia: Lippincott.

 

Mellinger, G. D., Balter, M. B., & Uhlenhuth, E. H.
(1985). Insomnia and its treatment. Archives of General
Psychiatry, 42(3), 225-232.

 

 

Mendelson, W. B. (1993). Insomnia and related sleep
disorders. Psychiatric Clinics of North America, 16(4), 841-
851. '

 

Mendelson, W. B. (1995). Long-term follow-up of chronic
insomnia. Sleep, 18(8), 698-701.

 

Miller, C. A. (1993). Interventions for sleep pattern
disturbances. Geriatric Nursing, 14(5).

 

Morin, C. M., Culbert, J. P., & Schwartz, S. M. (1994).
Non-pharmacological interventions for insomnia: A meta-

analysis of treatment efficacy. American Journal of
Psychiatry, 151(8), 1172-1180.

 

 

National Institute of Mental Health. (1984). Consensus
Conference of drugs and insomnia. Journal of the American
Medical Association, 251(18), 2410-2414.

 

 

Nakra, B. R. S., Grossberg, G. T., & Peck, B. (1991).
Insomnia in the elderly. American Family Physician, 43(2),
477-482.

 

Nightingale, F. (1946/1996). Notes on nursing: What it
is and what it is not. Philadelphia: Lippincott.

 

 

Orr, W. C. & Altshuler, K. Z. (1982). Managing Sleep
Complaints. Chicago: Yearbook Medical Publishing.

 

 

Pagel, J. F. (1994). Treatment of insomnia. American
Family Physician, 49(6) 1417-1421.

 

Pankhurst, F. P. & Horne, J. A. (1994). The influence
of bed partners on movement during sleep. Sleep, 17(4), 308-
315.

 

Quera-Salva, M. A., Orluc, A., Goldenberg, F., &
Guilleminault, C. (1991). Insomnia and use of hypnotics:
Study of a French population. Sleep, 14(5), 386-391.

 

52

Radecki, S. E. & Brunton, S. A. (1993). Management of
insomnia in office-based practice, national prevalence and
therapy patterns. Archives of Family Medicine, 2(11), 1129-
1133.

 

Rakel, R. E. (1993). Insomnia: Concerns of the family
physician. The Journal of Family Practices, 36(5), 551-557.

 

Regestein, Q. R. (1987). Specific effects of
sedative/hypnotic drugs in the treatment of incapacitation
chronic insomnia. The American Journal of Medicine, 83(11),

909-915.

 

Regestein, Q. R., Dombrosia, J., Hallett, M., Murawski,
B., Paine, M. (1993). Daytime alertness in patients with
primary insomnia. American Journal of Psychiatry, 150(10),
1529-1533.

 

Roth, T., Roehrs, T. A., Stepanski, E. J. & Rosenthal,
L. D. (1990). Hypnotics and behavior. American Journal of
Medicine, 88(S3A), 4383A-46S3A.

 

 

Roth, T., Roehrs, T. A., & Vogel, G. (1995). Zolpidem
in the treatment of transient insomnia: A double blind
randomized comparison with placebo. Sleep, 18(4), 246-251.

 

Selanders, L. C. (1993). Florence Nightingale: An
Environmental Adaptation Theory. Newbury Park, CA: Sage.

Selanders, L. C. (1996). Nightingale as nurse theorist.
Theoria, 5(5), 4-11.

 

Silva, J. A. C. E., Chase, M., Sartorius, N., & Roth,
T. (1996). Special report from a symposium held by the World
Health Organization and the World Federation of Sleep
Research Societies: An overview of insomnia and related
disorders-recognition, epidemiology, and rational
management. Sleep, 19(5), 412-416.

 

Spielman, A. J., Caruso, L. S., & Glovinsky, P. B.
(1987). A behavioral perspective on insomnia treatment.
Psychiatric Clinic of North America, 10(4), 541-551.

Torres, G. (1987). Florence Nightingale. In J. B.
George (Ed.), Nursing theories the base for professional
nursing practice (pp. 31-42). Englewood Cliffs: Prentice
Hall.

 

53

Walsh, J. K. & Fillingim, J. M. (1990). Role of
hypnotic drugs in general practice. American Journal of
Medicine, 88(S3A), 34-38.

 

 

Walsh, J. K. & Mahowald, M. W. (1991). Avoiding the
blanket approach to insomnia, targeted therapy for specific
causes. Postgraduate Medicine, 90(1), 211-224.

 

Webb, W. B. (1994). Sleep as a biological rhythm: A
historical review. Sleep 17(2), 188-194.

Weyerer, S., & Dilling, H. (1991). Prevalence and
treatment of insomnia in the community: Results from the
Upper Bavarian field study. Sleep 14(5), 372-389.

Wysowski, D. K. & Baum, C. (1991). Outpatient use of
prescription sedative-hypnotic drugs in the United States,
1970-1989. Archives of Internal Medicine, 151(18), 1779-
1783.

 

 

Young, T., Paltn, M., Dempsey, J., Skatrud, J., Weber,
8., & Badr, S. (1993). The occurrences of sleep-disordered
breathing among middle-aged adults. The New England Journal
of Medicine, 328(17), 1230-1235.

 

 

Zhdanoua, I. V., Wurtman, R. J., Morabito, C.,
Piotrovska, V. R. & Lynch, H. J. (1996). Effects of low oral
doses of melatonin given 2-4 hours before habitual bedtime,
on sleep in normal young humans. Sleep, 19(5), 423-431.

 

Zorick, F. J., Roth, T., Hartze, K. M., Piccione, P.
M., & Stepanske, E. J. (1981). Evaluation of persistent
insomnia. American Journal of Psychiatry, 138(6), 769-773.

 

 

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