A Study to assess the effects of Nursing Intervention on Quality of Sleep among elderly people with sleep disturbance residing in selected oldagehomes at Trichy in Tamilnadu

Dr. J. Fermina^1*, Prof. Dr. S. Revathi²

¹Maternal and Child Health Officer, Govt. ANM Training School, Samayanallur, Madurai, Tamilnadu.

²Principal, Sri Ramachandra College of Nursing, Sri Ramachandra University, Ramachandra Nagar, Chennai, Tamilnadu.

*Corresponding Author Email: fermijoseph@gmail.com

ABSTRACT:

Background: Sleep is an important component for establishing a proper physical, mental and emotional well-being of an individual. It is a highly complex and organized phenomenon and its structure tend to change with advancing age. The consequences of chronic sleep problems are considerable among older adults. It highlights the importance of treating sleep problems in the elderly. The non-pharmacological interventions can be the better choice to manage sleep problems in elderly. Objective: To evaluate the effectiveness of nursing intervention on quality of sleep among elderly people with sleep disturbance. Methods: The study design was quasi experimental, non-randomized, pretest posttest, control group design. A total of 180 participants, 90 in each experimental and control group were included. Quality of sleep was assessed by Pittsburgh Sleep Quality Index. The nursing intervention used for this study includes Sleep Hygiene Education and Progressive Muscle Relaxation. The elderly people in experimental group received 16 weeks of nursing intervention including one week learning session and 15 weeks practice session. Results: There was a highly significant difference between the control group and experimental group on overall sleep quality (p<.001) and also there was a significant difference in all the components of quality of sleep. Conclusion: Sleep disturbance is common among elderly. In geriatric population with sleep disturbance, sleep hygiene education and progressive muscle relaxation are the effective means of interventions in improving their quality of sleep.

KEYWORDS: Sleep disturbance, Quality of sleep, Nursing Intervention, Sleep Hygiene Education, Progressive Muscle Relaxation, elderly people.

INTRODUCTION:

Sleep is the sweet balm that soothes and refreshes us after a long day of work and play. Sleep is a state of consciousness that happens every 24 hours. It is a period of rest and recuperation for the body and much needed ‘down time’ for the brain. The functions of sleep are usually characterized as being protective and restorative.

On an average, people spend one third of their lives asleep. Although the duration of sleep varies among individuals, most healthy adults remain wakeful for 16 hours and need eight hours of sleep at night.¹

As people age, they tend to have a harder time falling asleep and more trouble staying asleep than when they were younger. Various studies have found that insomnia is a common geriatric problem and most people accept sleep difficulties as a fact of the ageing process.^1,2

Hence, it is not surprising that the elderly persons’ report of being less satisfied with their sleep and more tired during the day. But it is a common misconception that sleep needs decline with age. In fact, research demonstrates that our sleep needs remain constant throughout adulthood.²

Poor sleep habits such as irregular sleep-wake times and daytime napping may contribute to disturbed sleep pattern in the elderly. Aging weakens a person’s homeostatic sleep drive after age 50. The length of the circadian cycle stays roughly the same over the lifespan but the amplitude of the circadian rhythm may decline somewhat with aging.³

With aging, less time is spent in deep, dreamless sleep. Older adults experience on an average of 3 or 4 awakenings each night, and are more aware of being awake. The awakening results in less time spent in deep sleep and is related to other factors such as the need to get up to urinate, anxiety, and discomfort or pain associated with chronic illnesses.⁴

Until now, the most common treatment modality for sleep disturbance has been the use of hypnotics.⁵ This approach has general disadvantages among which are tolerance development⁶ and reduction of deep sleep in the long-term use.⁷

In addition, toxic effects caused by high levels of medication use and altered drug metabolism,⁸cognitive and psychomotor retardation which may lead to falls, fractures and car accidents⁹ are some of the other side-effects reported about the pharmacological approach of sleep disturbance in the elderly. The negative impacts of pharmacological treatment make it inevitable to find an alternate to treat the elderly subjects with chronic sleep disturbance. Considering the possible impact of sleep disturbance on health, it is important to pay special attention to sleep quality among older adults. In the present study, an attempt is made to examine the effects of sleep hygiene education and progressive muscle relaxation on quality of sleep among the elderly people with sleep disturbance.

MATERIALS AND METHODS:

A quasi experimental, non-randomized, pretest posttest, control group design was used to assess the effects of nursing intervention on quality of sleep among the elderly people with sleep disturbance. The target population of the study was the elderly people with sleep disturbance residing in four old age homes of Trichy city, Tamil Nadu. The convenience sampling technique was used to select the four old age homes and for assigning old age homes to experimental group and control group. The consecutive sampling technique was used to select the study participants from the oldagehomes.

The instruments used for the study were standardized Pittsburgh Sleep Symptom Questionnaire – Insomnia (PSSQ_I) to screen the elderly people with sleep disturbance, Pittsburgh Sleep Quality Index (PSQI) to assess the quality of sleep during pretest and posttest in both experimental and control group. In addition, the investigator developed subject data sheet to collect data regarding demographic profile of the elderly people and Structured Practice Questionnaire (SPQ) to assess the practice of nursing intervention by the elderly people in experimental group.

PSSQ_I is a standardized tool in rating scale format and it consists of 13 items within three components such as sleep symptom criterion, duration criterion and daytime impairment criterion. PSQI is a standardized tool, consisted of 9 questions. The first 4 questions are open ended questions and the questions 5 through 9 are in 4- point rating scale, the scores ranging from 0 to 3. Fifth question of the rating scale is divided into 10 sub questions to assess the cause of sleep disturbance. The SPQ was developed primarily to monitor how effectively the nursing intervention followed by the elderly people. It consisted of 2-parts with a total of 50 items in a rating scale and the total score is 150.

The nursing intervention used for this study includes Sleep Hygiene Education (SHE) and Progressive Muscle Relaxation (PMR). Sleep hygiene education refers to the sleep related behaviours and environmental conditions that promote an atmosphere conducive to improve the quality and quantity of sleep. The sleep hygiene measures included were as follows: bed time behaviours, day time behaviours and environmental instructions. Progressive muscle relaxation refers to tensing and relaxing various muscle groups throughout the body in a fixed order which produces a deep state of relaxation and it is used as a bed time ritual before sleep at night by the elderly people.

The duration of nursing intervention was 16 weeks which consisted of one week learning session and 15 weeks practice session without supervision. The study participants were taught about SHE for once during the learning session and PMR training for one week. The certificate of ethical clearance was obtained from the Institutional Ethics Committee, K.A.P. Viswanatham Govt. Medical College, Tiruchirapalli, Tamilnadu. Written Informed consent was obtained from all the study participants.

Interview technique was used to collect the data from the elderly people. The screening was done among the elderly people using PSSQ_I to identify the elderly persons with sleep disturbance. After screening, 192 were identified as having sleep disturbance in all four oldage homes out of which 180 elderly people were fulfilled the inclusion criteria. All the 180 elderly people with sleep disturbance were included in the study using consecutive sampling technique 90 in the experimental group from two oldage homes and 90 in the control group from other two oldage homes.

Data was analyzed using Statistical Package for the Social Sciences (SPSS) version 18 for windows. Descriptive and inferential statistics were used to summarize the data and to test the study hypotheses.

RESULTS:

Table 1: Distribution of Elderly People According to their Background Variables (N=180)

Variable	Categories	Control group (n=90)		Experimental group (n=90)
Variable	Categories	n	%	n	%
Age	60- 65 years	40	44.41	48	53.30
	66- 70 years	35	38.89	28	31.15
	>70 years	15	16.70	14	15.55
Sex	Male	25	27.80	25	27.80
Sex	Female	65	72.20	65	72.20
Religion	Hindu	83	92.20	78	86.70
	Christian	7	7.80	10	11.10
	Muslim	1	-	2	2.20
Marital Status	Single	13	14.40	17	18.90
	Married	26	28.90	9	10.00
	Widow/Widower	46	51.10	58	64.40
	Divorced	1	1.10	-	-
	Separated	4	4.40	6	6.70
Educational Status	Illiterate	25	27.80	52	57.80
	Primary	56	62.20	38	42.20
	Secondary	9	10.00	-	-
Financial Status	Dependent	68	75.60	80	88.90
Financial Status	Independent	22	24.40	10	11.10
Number of Children	No child	36	40.00	40	44.40
	1 child	5	5.60	-	-
	>1 child	49	54.40	50	55.50
Period of Stay in Oldage home	< 6 months	7	7.80	4	4.40
	6 months 1 year	9	10.00	3	3.30
	>1 year	74	82.20	83	92.20
Previous Practice of Relaxation Technique	Yes	-	-	-	-
Previous Practice of Relaxation Technique	No	90	100.00	90	100.00

Table 3: Comparison of Mean Difference Scores of Overall Sleep Quality and Its Different Sleep Components between Control Group and Experimental Group (N=180)

Variable	Experimental group (n=90) Difference (Post – pre)		Control group (n=90) Difference(Post– pre)		Independent t- value
Variable	M	SD	M	SD	Independent t- value
Overall sleep quality	6.55	2.69	0.84	1.11	24.08^***
Sleep components
Sleep duration	1.16	0.94	0.04	0.39	11.22^***
Sleep disturbances	0.46	0.50	0.76	0.43	17.64^***
Sleep latency	1.30	0.59	0	0	20.93^***
Daytime dysfunction	1.12	0.50	0.01	0.49	16.32^***
Habitual sleep efficiency	1.26	0.95	0.01	0.57	10.80^***
Subjective sleep quality	0.13	0.40	0	0	03.14^*
Use of sleeping medication	0.60	0.56	0.01	0.11	10.23^***

Note.* (p<.05), *** (p<.001)

The analysis revealed that there was a highly significant difference between the control group and experimental group on overall sleep quality and also there was a significant difference in all the components of quality of sleep.

Table 4: Level of Practice of Sleep Hygiene Education and Progressive Muscle Relaxation among the Elderly People in Experimental Group (N=90)

Level of practice of SHE and PMR (Score)	N	%
Unsatisfied (0 – 50)	-	-
Moderately Satisfied (51-100)	16	17.8%
Satisfied (101-150)	74	82.2%

Table 4 shows that majority of the elderly people in experimental group had satisfied level of practice on sleep hygiene education and progressive muscle relaxation.

DISCUSSION:

Sleep is a highly complex and organized phenomenon and its structure tend to change with advancing age. It is an essential means of energy conservation, with falling metabolic rate during sleep is necessary for the restitution of brain and body functions.

The hypothesis was: There will be a significant increase in the sleep quality score among elderly people who receive nursing intervention than those who do not receive the nursing intervention.

This hypothesis was supported by the study finding (Table 3) that there was a highly significant difference in the mean difference score (p<0.001) of the quality of sleep between the experimental group (Mean Difference = 6.55) and control group (Mean Difference = 0.84). Further, there was also a significant difference in the mean difference score in all seven components of quality of sleep (sleep duration, sleep disturbance, sleep latency, daytime dysfunction, habitual sleep efficiency, subjective sleep quality and the use of sleeping medication). Hence, the hypothesis was accepted.

The findings of the study are consistent with the studies done all over the world as well as in India. A study in Japan reported that there was a significant improvement in sleep quality among the study participants after the practice of sleep hygiene in addition with behavioral training for a period of three months.¹⁰

Similarly, Pech and Kearney¹¹ compared the sleep hygiene education and progressive muscle relaxation (problem-solving therapy combined with behavioral sleep strategies) with stimulus control instruction and progressive muscle relaxation (standard cognitive therapy combined with behavioral sleep strategies) in the treatment of insomnia in Canberra, Australia. The study found that both treatments produced significant improvements in the sleep quality of study subjects.

A clinical trial by Sun, Kang, Wang and Zeng¹² among the older adults examined the possibility of a self-relaxation intervention in improving sleep quality and cognitive functions at Wangyuehu Community in Changsha, China. The study found that mindfulness based stress reduction or progressive muscle relaxation practice for a period of one year improved the sleep quality and cognitive functions in older adults. Similarly, in India, a meta-analytic review by Saddichha¹³ reported that the non-pharmacological strategies such as stimulus control therapy, relaxation therapy and cognitive therapies had better results on the management of chronic insomnia. The other strategies like sleep restriction and sleep hygiene education had moderate to less than moderate effects on chronic insomnia.

A single subject research by Alexandru, Robert, Viorel and Vasile¹⁴found that the effectiveness of muscle relaxation and sleep hygiene were similar in treating primary insomnia.

Similarly, a randomized clinical trial found a significant improvement in maintaining consistent bedtime, rising time, less number of naps in day among the active treatment subjects who practiced sleep hygiene than the control subjects.¹⁵

In the control group, it was found that all the study participants had poor sleep quality both on the pretest and posttest (PSQI score > 5) whereas, in experimental group, 39 out of 90 elderly people (43%) had good quality of sleep on posttest (Table 2).

A study by Bankar, Chaudhari and Chaudhari,¹⁶ on the effects of long-term yoga exercises on sleep quality among elderly in Nagpur, India reported that after intervention, the subjects with good sleep quality were increased in number than the subjects with poor to moderate sleep quality.

The practice of nursing intervention by the elderly people during the study period was found satisfactory (Table 4). The participants felt that the sleep hygiene education and progressive muscle relaxation helped them in improving their sleep and overall wellbeing. They felt that practising the nursing intervention was easy and did not disturb their daily routines. They also expressed that the sleep hygiene practices improved their knowledge about sleep related behaviours and helped them to remove the myths related to sleep.

The study has some limitations. They include: 1) The responses towards quality of sleep and practice of nursing interventions must have been influenced by recall bias and also the responses to the questions were subjective in nature. 2) The daily practice of nursing intervention by the elderly was not monitored. Hence, the practice of nursing interventions by the elderly people in experimental group may not have been accurate. It was not possible for the single researcher to monitor the practice of nursing intervention by the elderly people in experimental group. 3) The researcher could not control some of the environmental factors which may have influenced the positive effects of intervention like snoring noise by the neighborhood in dormitories and mosquito bite.

CONCLUSION:

Sleep disturbance is a common condition among the elderly population. In geriatric population with sleep disturbance, practicing the nursing intervention (i.e) sleep hygiene education which highlights the sleep promotion behaviours and progressive muscle relaxation which creates a deep sense of relaxation are the effective means of interventions in improving quality of sleep among the elderly people. The findings of the study are consistent with literature and have support from studies conducted throughout the world. However, based on the method of sample selection and considering the limitations of the study, the findings may not be generalizable to the elderly people living in oldage homes in other parts of India.

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Received on 10.01.2017 Modified on 11.04.2017

Asian J. Nur. Edu. and Research.2017; 7(4): 519-523.

DOI: 10.5958/2349-2996.2017.00102.1

Quality of Sleep (PSQI Score)	Control group (n=90)				Experimental group (n=90)
	Pretest		Posttest		Pretest		Posttest
	f	%	f	%	f	%	f	%
Good (≤5)	-	-	-	-	-	-	39	43
Poor (>5)	90	100	90	100	90	100	51	57