Effectively Managing Inpatient Insomnia · Risk and Aggravating factors CONDITIONS Psychiatric conditions adjustment disorders, anxiety, bereavement, depression Respiratory cough,

Effectively Managing Inpatient InsomniaTaylor Brazelton RN, MSN, AGCNS-BC

ObjectivesThe learner will be able to describe the impact of insomnia on older adults

The learner will be able to explain sleep challenges in the inpatient setting for older adults

The learner will be able to apply pharmacologic and nonpharmacologic interventions to promote sleep in the hospitalized older adult

Case StudyIt’s 2am and you get a call from a nurse on the cardiac telemetry unit requesting sleep medication for your patient Ms. Jones. Ms. Jones is an 82 year old female admitted for chest pain. She has a history of COPD. BMI is 35.

SleepNormal age related changes

Earlier bedtime, earlier wake time

Changes in circadian rhythm

Decrease production and quality of melatonin, decrease in vasoactive intestinal polypeptide, and vasopressin-expressing neurons

Shorter

less time in slow wave sleep (NREM2 stage) and REM

Fragmented

Daytime sleepiness

InsomniaDifficulty falling asleep or maintaining sleep

Severity is determined by frequency, duration, and intensity

3 nights per week or more

Greater than one month

Impacts day time functioning

Amount of time awake during normal sleep time

ImpactHigher health care costs

$100 billion USD per year Depression and mood disorders, HTN, MI, DM

Cognitive impairment

Stress on relationships

Automobile accidents

Increased mortality

31.93% of medication for treatment of insomnia is used outside of doctor’s recommendation

Insomnia in Older Adults

40%-50% of insomnia is chronic sleep onset or maintenance insomnia

Women > men

Poorer quality of life

Decrease in function/ability to complete ADLS

Hospitalization, nursing home, home care

Risk and Aggravating factors

CONDITIONS

Psychiatric conditionsadjustment disorders, anxiety, bereavement, depression

Respiratorycough, dyspnea, sleep apnea

GI/GUnocturia, GERD

Neuroparasthesias, parkinsons, stroke, dementia

Pain

MEDICATIONS

Alcohol/caffeine

Psychi.e antidepressants

Cardiacdiuretics

Respiratorybronchodilators

Inpatient challengesTime of admission

Bed availability

Acute illness requiring care/treatment

Nursing protocols/assessments

Scheduling of procedures

Lack of private rooms

Inpatient Management

Inpatient interventionsBe mindful when putting in orders

Work with pharmacists to limit dosages and/or frequencies of high risk medications/sedative hypnotics

(Adeola, 2018)

Hospital Elder Life Program© 1999

Educate patients/families about their sleep medications

Consider deprescribing

Pharmacological TreatmentPoints to consider:

Short term use

Use in combination with behavioral therapies

Added risk for fall

Is it sleep maintenance or sleep onset issue?

Half life of medications

Choosing Wisely®“Avoid use of hypnotics as primary therapy for chronic insomnia in adults; instead offer cognitive-behavioral therapy, and reserve medication for adjunctive treatment when necessary.”

Patient education resources on Choosing Wisely® regarding “Sleeping Pills for Insomnia”

“Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium.”

Pharmacological Treatment

CAUTION

Beer’s List- sleep medications potentially inappropriate

Benzodiazepines

Anticholinergic

Z drugs

zolpidem, zaleplon, eszopiclone

Antipsychotics

CONSIDER

Melatonin

Mirtazapine (Remeron)-insomnia, anorexia, nervousness

Trazadone (Desyrel)-antidepressant, sedating

Case Study

You are rounding when a day shift nurse on a med-surg unit asks you about one of your patients who is requesting a sleeping pill. Mr. Robertson is an 80 year old male with a BMI 18. He was admitted for abdominal pain and has a history of depression, CAD, HTN, cataracts. Mr. Robertson informs you that he just “can’t turn off his brain at night.”

Nonpharmacological TreatmentPoints to consider:

Cognitive behavioral therapy first line treatment

If request for sleep medication, ask more questions-

History of sleep apnea?

How long/when does it occur?

Review discharge medications

i.e. Are sedative-hypnotics discontinued prior to discharge?

Nonpharmacological Treatment

Day

Encourage day light, open blinds

Minimize day time naps

Encourage mobility- reduce time in bed

Monitor caffeine intake

Night

Do not wake patients at night

Encourage family to bring own pillow/blanket

Close blinds at night, adjust temperature

Toileting schedule

Quiet- Offer ear plugs, nurses phones on vibrate

Individualize care to patients schedule

Hospital Elder Life Program©1999Sleep Protocol

Volunteers:Relaxation- guided imageryMusic/Care TVMilk/TeaWarm blanketClose blindsDim lightsBack rub/hand massages

Interdisciplinary:Reschedule labs, medications, vital signs other procedures Evaluate timing of caffeine and diuretics

Case StudyMs. Brooks is an 86 year old female patient recently admitted to the neurology unit. from the ER. You check in with the nursing staff before seeing the patient, and the staff report that the patient has been napping for most of the day. Her family is concerned she will be up all night as she is also a light sleeper at home. She has a history of mild cognitive impairment, high cholesterol, hysterectomy. The family is asking to speak with the physician regarding how they can help her sleep.

Thank you!

ReferencesAdeola, M., Azad, R., Kassie, G. M., Shirkey, B., Taffet, G., Liebl, M., & Agarwal, K. (2018). Multicomponent Interventions Reduce High-Risk Medications for Delirium in Hospitalized Older Adults. Journal of the American Geriatrics Society. doi:10.1111/jgs.15438

ABIM. (2018). Choosing Wisely®. Retrieved August 16, 2018, from http://www.choosingwisely.org/

Cohen-Zion, M., & Ancoli-Israel, S. (2009). Sleep Disorders. In Hazzard's Geriatric Medicine and Gerontology (6th ed., pp. 677-681). McGraw Hill.

Hadden, L. (2013). Insomnia. In Core Curriculum for the Advanced Practice Hospice and Palliative Registered Nurse (Vol. 1, pp. 117-129). Pittsburgh, PA: Hospice and Palliative Nurses Association.

Hospital Elder Life Program. (2018). Retrieved August 16, 2018, from https://www.hospitalelderlifeprogram.org/

Leahy, L. G. (2017). Caution is Key When Prescribing for Older Adults. Journal Of Psychosocial Nursing & Mental Health Services, 55(12), 7-10. doi:10.3928/02793695-20171113-01

Leggett, A., Pepin, R., Sonnega, A., & Assari, S. (2016). Predictors of New Onset Sleep Medication and Treatment Utilization Among Older Adults in the United States. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 71(7), 954-960. doi:10.1093/gerona/glv227

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Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2018). Geriatrics at your fingertips. New York: American Geriatrics Society.

Spira, A. P., Kaufmann, C. N., Kasper, J. D., Ohayon, M. M., Rebok, G. W., Skidmore, E., & ... Reynolds, C. F. (2014). Association Between Insomnia Symptoms and Functional Status in U.S. Older Adults. Journals Of Gerontology Series B: Psychological Sciences & Social Sciences, 69S35-S41.

Wennberg, A. M., Canham, S. L., Smith, M. T., & Spira, A. P. (2013). Optimizing sleep in older adults: Treating insomnia. Maturitas, 76(3), 247-252. doi:10.1016/j.maturitas.2013.05.007

Wickwire, E. M., Shaya, F. T., & Scharf, S. M. (2016). Health economics of insomnia treatments: The return on investment for a good nights sleep. Sleep Medicine Reviews, 30, 72-82. doi:10.1016/j.smrv.2015.11.004