RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PERFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / Mr. Balaraj C K
1st Year M. Sc. Nursing
Shantidhama college of Nursing
Sunkadakatte, Magadi Main Road
Bangalore
2. / NAME OF THE INSTITUTION / SHANTIDHAMA COLLEGE OF NURSING
Sunkadakatte, Magadi Main Road
Bangalore
3. / COURSE OF STUDY AND SUBJECT / 1st Year M. Sc. Nursing
Medical Surgical Nursing
4. / DATE OF ADMISSION TO COURSE / 11-06-2012
5. / TITLE OF THE TOPIC / An experimental study to assess the effectiveness of selected life style modifications on quality of sleep among older adults

6. BRIEF RESUME OF THE INTENDED WORK:

6.1 INTRODUCTION

“Mat never returns after passing away is - Youth

Which never passes away after arriving is - Old age”.

It is true that once we are old, we will only grow older and never younger.

As ageing occurs people often experience normal changes in sleeping patterns. People may become sleepy earlier, wake up earlier, or enjoy less deep sleep. Although these changes are a normal part of aging, disturbed sleep, waking up tired every day, and other symptoms of insomnia are not a normal part of aging. Sleep is just as important to our physical and emotional health in senior years as it was when younger.1

No matter what a person’s age is, sleeping well is essential to physical health and emotional well-being. For seniors, a good night’s sleep is especially important because it helps improve concentration and memory formation, allows the body to repair any cell damage that occurred during the day, and refreshes the immune system, which in turn helps to prevent disease.1

Many physicians consider sleep to be a barometer of a person’s health, like taking his or her temperature. Older adults who don’t sleep well are more likely to suffer from depression, attention and memory problems, and excessive daytime sleepiness. He or she is likely to suffer more night time falls, have increased sensitivity to pain, and use more prescription or over-the-counter sleep aids. Insufficient sleep can also lead to many serious health problems in older adults, including an increased risk of cardiovascular disease, diabetes, weight problems, and breast cancer in women.2

While sleep requirements vary from person to person, most healthy adults tend to require between seven and a half to nine hours of sleep per night to function at his or her best. A recent study by the National Institutes of Health suggests that healthy older people may require about one and a half hours less sleep than younger adults, or an average of seven and a half hours per night. The study indicates that seniors sleep less even when given the opportunity for more sleep because of age-related changes in the ability to fall asleep or remain asleep.1

While the results of the study may not be conclusive, it’s important to focus more on how a person feels following a night’s sleep rather than the specific number of hours he spends asleep. Quality is as important as quantity. Some seniors mistakenly believe they have a sleeping problem because they go to bed expecting to be asleep for eight or nine hours of sleep a night, and may even needlessly start using medications to help them sleep more. Frequently waking up, not feeling rested or feeling tired during the day are better indications that they are not getting enough sleep at night and may have a sleep problem that needs to be addressed.3

As a person ages his body produces lower levels of growth hormone, so he'll likely experience a decrease in slow wave or deep sleep. When this happens he produces less melatonin, meaning he'll often experience more fragmented sleep (more rapid sleep cycles) and more awakenings between sleep cycles. As the circadian rhythm (the internal clock that tells you when to sleep and when to wake up) changes, he may also find himself wanting to go to sleep earlier in the evening and waking up earlier in the morning. If the elderly doesn’t adjust bedtimes to these changes, they may find that they have difficulty falling and staying asleep.3

It should be noted that older adults tend to wake up more often during the night. Consequently, they may have to spend longer in bed at night to get the hours of sleep they need, or may have to make up the shortfall by taking a nap during the day. In most cases, such sleep changes are normal and don't indicate a sleep problem.4

Many cases of insomnia are caused by underlying but very treatable causes. While emotional issues such as stress, anxiety, and depression can cause insomnia, the most common causes in seniors are a poor sleep environment and poor sleep and daytime habits. Try to identify all possible causes of your insomnia; once you figure out the root cause, you can tailor treatment accordingly.2

Poor sleep habits, including a poor sleep environment and poor daytime habits can be the main causes of sleep problems and low-quality sleep in seniors. In many cases, older adults develop these poor sleep habits over a lifetime but find they create more and more problems as they age. Fortunately, these habits are easy to improve.5

People are biologically programmed to sleep not only for a long period in the middle of the night but also for a short period in the middle of the day. Naps can enhance visual, motor, and spatial skills, and have even been shown to decrease the risk of coronary heart disease. So, if you don’t feel fully alert during the day, a nap may be just what you need. For many people, taking a brief nap can provide the needed energy to perform fully for the rest of the day. Experiment with napping to see if it helps you.6

A recent study by Feinberg School of Medicine at Northwestern University found that aerobic exercise resulted in the most dramatic improvement in patients' reported quality of sleep, including sleep duration, on middle-aged and older adults with a diagnosis of insomnia.

The participants aged 55 and up, exercised for two 20-minute sessions four times per week or one 30-to-40-minute session four times per week. Participants worked at 75 percent of their maximum heart rate on at least two activities including walking or using a stationary bicycle or treadmill. The regular aerobic exercise improved the participants' sleep quality from a diagnosis of poor sleeper to good sleeper. They also reported fewer depressive symptoms, more vitality, and less daytime sleepiness.7

6.2. NEED FOR THE STUDY

Aging is a universal phenomena and it is considered the normal inevitable biological process. It has been defined as a ‘progressive decline in the physiological capacity leading to a decreased ability to adapt to stressors’ – the loss of adaptability of an individual organism over time. The global population of the elderly people is increasing all over the world which was estimated at 600 million in the year 2000. It is expected to reach 1.4 billion in 2030. Of this rise, more than half will be in Asia.8

In India, the number of persons aged 60 years and over was 12 million at the turn of century. This has increased six fold to about 71 million in 2001 and is expected to be currently in the region of 80 million. The proportion of population aged 60 years and above is also rising. It was 5.63% in 1961, 7.1% in 2001, and is expected to be 9.8% in 2021. This makes India a “greying” nation, with the growth rate of elderly segment being greater than the growth rate of the population as a whole. It is expected that by 2021 the growth rate of elderly will be 1.5 times higher than the growth rate of general population.9

With the advent of the nuclear family, urbanisation, migration, break-up of the joint family system, generation gap, influence of western culture and changed lifestyles there is no space for the elders in the families living in the congested urban society. Due to this, they are compelled to live in the old age homes. There are currently about 354 old age homes in India among which Kerala ranks the highest in number with 93.10

Basic necessities of an individual are food, shelter, clothing and air. Sleep also is a basic necessity of life important for health and wellbeing just as air, food and water. National Sleep Foundation (2002) reported that millions of people do not get enough sleep and many suffer from lack of sleep. Nurses must help patients to achieve optimum rest and sleep in order to expedite the process of healing and recovery.11

Sleep deprivation has profound effects on an individual’s functioning abilities. Whether he is in good health or not, adequate rest and sleep is vital for optimal, physical and psychological functioning of the individual. Without adequate amount of rest and sleep, the ability to concentrate, make judgements and participate in daily activity decreases. During illness there may be actual or potential sleep disturbances, and this lack of sleep extends the time needed to recover from illness. Therefore, for the sick and the old, rest and sleep must be considered as one of the important components of their therapy.12

It is found that various non-pharmacological techniques like back massage, relaxation, imagery and music audiotape are effective in promoting sleep in elderly people. One can relax without sleeping, but sleep rarely occurs until one is relaxed. A commonly used relaxation technique is Progressive Muscle Relaxation Therapy, which teaches to rest effectively and to reduce tension in the body.12

A quasi experimental study was conducted on 32 elderly in an old age home in Kerala about the effect of relaxation therapy on quality of sleep. The pre-intervention data was collected on the first day using a structured interview schedule and sleep pattern was observed using an observation checklist. For the next two days, relaxation therapy was given and data was collected. The findings have shown that the mean subjective assessment of quality of sleep score in post-test was higher than pre-test score and found that the relaxation therapy was an effective method to improve the quality of sleep.13

A pre-experimental study was conducted to find the effectiveness of Progressive Muscle Relaxation Therapy upon the sleep pattern of 30 subjects suffering from sleep deprivation. Progressive Muscle Relaxation Therapy was administered to the subjects for three days and their sleep was assessed before and after PMRT. Majority of the subjects (73.3%) had moderately adequate sleep and 26.6% had inadequate sleep before progressive muscle relaxation therapy whereas after progressive muscle relaxation therapy, most of them had adequate sleep (66.6%) and none had inadequate sleep.13

The effort of today is “not to heal, but to protect and prolong ageing.” According to this, the aged persons should be as healthy as possible and reasonably meaningful conforming to the WHO slogan “it is not sufficient to add years to life, but it is more important to add life to years”. The investigator’s personal experience with the elderly made her realize the importance of promoting sleep by nursing interventions and other measures and designed a study with life style modifications to promote sleep among elderly. 13

6.3. REVIEW OF LITERATURE

The term review literature refers to the activities involved in identifying and searching for information of the state of knowledge of the topic. This term is also used to designate a written summary of the state of the art on a research problem. The investigator carried out extensive review of literature on the research topic in order to gain deeper insight into the problem as well as to collect maximum relevant information for building up the study. This was accomplished by using Medline, internet and surveyed the latest journals and books.

A research study was conducted to test whether exercise would improve subjective sleep quality and activity in depressed elders. A 10-week randomized controlled trial was utilized. Intervention consisted of a supervised exercise program three times a week on an attention-control group. The results showed that exercise significantly improved sleep quality, depression, strength and quality of life.15

An evaluative study was conducted on 40 subjects in an old age home to find the effect of Progressive Muscle Relaxation for stress and sleep disturbances among hypertensive elderly. The stress levels and sleep pattern of the sample were assessed using the stress rating scale and scale for general pattern of sleep. Following this, the group was subjected to the progressive muscle relaxation therapy daily for 30 minutes for a period of 2 weeks. Results revealed that there was significant reduction in level of stress and sleep disturbances among the subjects after practicing the progressive muscle relaxation techniques.16

A comparative study was conducted in Kingston about the sleep experience of medical and surgical patients during a hospital stay. During 3 consecutive nights, patients (n = 110) self-reported sleep quality using the Verran and Snyder Sleep Scale (VSH) and potentially disruptive factors using items from the Factors Influencing Sleep Questionnaire (FISQ). Surgical patients, on the first night, received more procedural care (p = .001), less sedative medication (p < .001), reported more sleep disturbance (p = .02), less sleep effectiveness (p = .03), and more need for sleep supplementation (p = .03). Variance in sleep effectiveness was explained by the FISQ score, age, and length of time in hospital (F = 6.86, p < .001).. The study concluded that environmental and personal factors, factors that are amenable to therapeutic interventions, strongly influence the sleep experience.17