• Sleep disturbances and mental health issues in the older adult – an overview

    by Alan Batt. Last modified: 03/03/14

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    Introduction

    Growing old is ‘a liberation’ as Jacob (1981) informs us. Liberation from some of life’s responsibilities and the opportunity to experience a newfound lifestyle – many older people find this liberation. However with older age comes the vulnerability to increased ill health. Health is the major factor that determines an older adult’s lifestyle and their psychological well being (Daly and O’Connor, 1984; Fahey, 1994).

    Care of the older adult and their many complex conditions and clinical presentations is a challenging task for the paramedic (Nolan, Davies and Grant, 2001; Hickey, Speers and Prohaska, 1997), and with an ever increasing older population, it is a challenge that is becoming more common.

    In ill health it is very easy for the paramedic to forget the multifaceted problems experienced by patients, including the psychological and social implications of illness. Approaching all aspects of the patient’s care and care of their family is a challenge for the paramedic, and one which all paramedics must rise to in a professional and responsible manner.

    Here we will discuss the implications of sleep deprivation & fragmentation on the well being of the older patient, and the effects of mental health issues on the patient and their family and carers. These are only two of many aspects of care that the multidisciplinary team must bear in mind when caring for the older person.

    Sleep Disorders

    Increased age can bring with it an increased prevalence of sleep disorders (Tribl et al., 2002). Whilst these disorders do not always pose a threat to an older person’s health, severe sleep disorders can have major implications on the patient themselves, their families and their carers (Montgomery and Dennis, 2003).

    Severe insomnia (sleep deprivation) can cause fatigue, cognitive disturbances, stress for carers and families, and mental health problems such as depression which shall be discussed later in this article. Research carried out by Schwartz et al. in 1998 also suggests that sleep disorders are a risk factor for myocardial infarction in the older adult.

    Sleep fragmentation is the inability to maintain sleep, and the patient suffers regular waking periods. This is a commonly reported problem in the older person (Montgomery and Dennis, 2002). Sleep deprivation and fragmentation are serious issues, and ones which do not seem to receive the attention they warrants when one considers the major psychological and physical effects that they can have on a patient.

    In the elderly patient there are many factors that can influence the duration and quality of sleep experienced. According to studies by Christensen (2005) and Reid (2001), the hospital setting in particular is an area that can negatively impact on a patient’s sleep, due to factors such as noise, lighting, heating and other environmental variables. Sleep is an important factor for all human beings, and is necessary more so during illness for its’ restorative and healing effects (Stanley, 2005).

    Elderly patients often complain that their sleep is interrupted and not deep enough to allow adequate rest (Reid, 2001). Nocturia may affect the older person’s sleep cycle, affecting both men and women, with a prevalence of 30-40% in men (Reynard, Cannon and Abrams, 2004). Pathological conditions such as congestive heart failure, myocardial infarction, COAD (chronic obstructive airway disease) and dementia can all affect the sleep duration and quality of the older person.

    Chronic pain, such as that experienced with osteoarthritis and rheumatoid arthritis can severely impact on sleep patterns. For instance, according to the Arthritis Foundation of Ireland (2014), almost 1 million people have arthritis in one or more joints in their body. Paramedics must bear in mind that older people are more likely to suffer from pain than other patients (Snyder & Christmas, 2003).

    Older people tend to nap more frequently during the day than younger adults, and this may impact in their ability to sleep adequately at night, as may the patient’s intake of caffeine and other stimulants (Martin, Shochat and Ancoli-Israel, 2000). Body temperature is also associated with the circadian rhythm; the bodies wake and sleep cycle. A lowered body temperature is associated with a more fragmented and lower quality sleep.

    The Paramedic’s Role

    Treatment of the underlying medical condition if one is present is a vital factor that needs to be addressed. Educating patients on sleep interventions such as reduction of caffeine intake and avoidance of alcohol, tobacco and other stimulants late in the evening can help the patient.

    Limiting fluid intake in the evening may reduce the incidence of nocturia. Appropriate pain management is also vital to allow the older patient to achieve an adequate period of rest free of pain (Snyder & Christmas, 2003).

    Passive warming, such as encouraging the patient to take a warm bath before bedtime can help to increase core body temperature, and can assist with the onset of sleep, and in a study by Mishima et al. (2005) subjects displayed an improved quality of sleep after passive warming.

    Depression

    According to Montgomery and Dennis (2003), the link between sleep disorders and depression in the elderly is very strong, and can be hard to separate. Sleep disorders are a risk factor for depression, and equally depression is a risk factor for sleep disturbances (Norman & Redfern, 1997)

    Approximately 10 -15% of all older people over the age of 60 suffer from depression that warrants medical intervention (Wilson et al., 2005). Koenig et al. (1992) report that the rate of depression in the hospitalised older population is even higher, ranging from 15 to 46%. Females have a higher predisposition than males, and increased age is linked with an increased risk of depression.

    Depression in older patients has been shown to result in increased morbidity and mortality according to Wilson and Mottram (2003), and Quach et al. (2013) in the MOBILIZE Boston study. It can also exacerbate the outcomes of medical illnesses (Alexopoulos, 2005). For example, a study carried out by Romanelli et al. in 2002 displayed that patients’ suffering from depression post-myocardial infarction were four times more likely to die than those who were not suffering from depression, within four months.

    The causes of depression in the older adult are varied and can be difficult to detect. Older adults with chronic medical conditions have a higher pre-disposition to depression than their healthier counterparts. However, it should be noted that older patients often overestimate their well-being, and may still be depressed (Daly and O’Connor, 1984).

    The consequences of depression can range from cognitive impairment, agitation and apathy to severe physical effects such as malnutrition and cachexia, myocardial infarction and even suicide (Dinan, 1999). Patients may present with suicidal thoughts, feelings of despair, guilt and hopelessness, anxiety, anger/fear, disorientation and even hallucinations or delusions (Snyder & Christmas, 2003).

    The Paramedic’s Role

    The management of depression involves a multidisciplinary approach, involving pharmacotherapeutic and psychotherapeutic interventions (Carepnito-Moyet, 2004). Paramedics should be aware of the effects and side effects of any medications used to treat depressive states in the elderly, and should be aware that some medications can take a number of weeks to have a therapeutic effect (Bledsoe & Clayden, 2012). Ensuring that the patient complies with medication is an important step in treating psychiatric disorders.

    Paramedics should reorient the patient if necessary, and spend time talking and listening to them. They should also observe the patient’s weight and fluid intake. Assisting the patient with personal hygiene and dressing should also be considered, whilst maintaining a level of independence.

    Conclusion

    Sleep disorders and depression are two common presentations in the older population, but they are also two that are difficult to assess and detect. The paramedic needs to be aware of the presenting complaints of depression, and needs to constantly assess at-risk patients for evidence of depression (Norman & Redfern, 1997)

    Sleep disorders can have a major impact on the physical and psychological well being of the older adult, and can very quickly lead to a depressive state, resulting in increased morbidity and mortality (Nolan et al., 2001). Overall, there is a multifaceted challenge presented to all healthcare staff with the care of the older patient.

    As Martin et al. (2000) reminds all healthcare staff, there should be no cause for patients to suffer from poor sleep or depression, especially in the hospital setting as the resources and tools to combat and treat these conditions are now widely available.

    References (non-PubMed)

    Arthritis Foundation of Ireland (2014) Arthritis – The Facts. [http://www.arthritisireland.ie/go/information/about_arthritis] Accessed December 10th 2005.

    Bledsoe B, Clayden D (2012) Prehospital Emergency Pharmacology. Boston: Pearson

    Daly M and O’Connor J (1984) The World of the Elderly: The Rural Experience. A report for The National Council For The Aged. Dublin: Glendale Press

    Fahey T (1994) “Theories of Ageing and Attitudes to Ageing in Ireland” In: National Council on Ageing Round Table Discussion. Dr. Steevens’ Hospital, Dublin 25th March, 1994. Unpublished

    Hickey T, Speers M and Prohaska T (eds) (1997) Public Health and Aging. London: Johns Hopkins University Press.

    Jacob N (1981) Growing Old – A View From Within. Pennsylvania: Pendle Hill Publications

    Naidoo J, Wills J (2000) Health Promotion: Foundations for Practice. Edinburgh: Bailliere Tindall.

    Nolan M, Davies S and Grant G (eds) (2001) Working with older people and their families. Buckingham: Open University Press

    Norman I, Redfern S (eds) (1997) Mental Health Care for Elderly People. New York: Churchill Livingstone.

    Reynard J, Cannon A, Abrams P (2004) Conservative management of nocturia in adults (Protocol). The Cochrane Database of Systematic Reviews 2004 (1)

    Snyder D, Christmas C (eds) (2003) Geriatric Education for Emergency Medical Services. Massachusetts: Jones and Bartlett

    Stanley N (2005) The physiology of sleep and the impact of ageing. European Urology Supplements. 3 (6) p17-23

    Wilson K, Mottram P. (2003) Long-term treatments for older depressed people (Protocol). The Cochrane Database of Systematic Reviews 2003 (1)

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    Dinan TG. The physical consequences of depressive illness. BMJ. 1999 Mar 27;318(7187):826. PMID: 10092241.

     
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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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