Overview

Excessive sleepiness, sometimes called excessive daytime sleepiness, is common in older adults.  Fatigue manifests as difficulty in sustaining a high level of physical performance; excessive sleepiness refers to the inability to maintain alertness or vigilance becasue of hypersomnolence.  Many factors can affect nighttime sleep and result in daytime sleepiness in older adults.  These include psychological disorders, symptoms of chronic illnesses (e.g., pain), medication side effects, environmental factors, and lifestyle preferences.  Increases in sleepiness can result from age-related changes in chronobiology and sleep disorders.  In older adults, the most common primary sleep disorders are obstructive sleep apnea (OSA), restless leg syndrome, and insomnia.  The extent to which changes in sleep patterns experienced by older adults are caused by normal physiological alterations, pathological events, sleep disorders, or poor sleep hygiene remains unclear.  Hospitalization and institutionalization can also interfere with sleep quality or quantity.  There are many effective treatments for sleep disorders, but the first step is to identify the cause of excessive daytime sleepiness and then to quantify and aggressively treat this condition in the older adult.  

Nursing Standard Practice Protocol: Excessive Sleepiness

Eileen R. Chasens, RN, DSN and Mary Grace Umlauf, RN, PhD, FAAN

Reprinted with permission from Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition, © Springer Publishing Company, LLC. Text may be purchased here.

Evidence-Based Content - Updated July 2012

The information in this "In Depth" section is organized according to the following major components of the NURSING PROCESS:

Goal
Overview
Background
Etiology and Epidemiology
Parameters of Assessment
Nursing Care Strategies
Evaluation/Expected Outcomes
Follow-up Monitoring
References

Goal

Older adults will maintain an optimal state of alertness while awake and optimal quality and quantity of sleep during their preferred sleep interval.

Overview

Although normal aging is accompanied by decreased "deep sleep," sleep efficiency, and increased time awake after sleep onset, these changes should not result in excessive daytime sleepiness. Daytime sleepiness is not only a symptom of sleep disorders but also results in decreased health and functional outcomes in the older adult.

Background

  1. Definition 

Excessive sleepiness: somnolence, hypersomnia, excessive daytime sleepiness, subjective sleepiness. Sleepiness is a ubiquitous phenomenon, experienced not only as a symptom in a number of medical, psychiatric, and primary sleep disorders but also as a normal physiological state by most individuals over any given 24-hour period. Sleepiness can be considered abnormal when it occurs at inappropriate times or does not occur when desired.1

Etiology and Epidemiology

  1. Excessive sleepiness may be caused by difficulty initiating sleep, impaired sleep maintenance, waking prematurely, sleep disorders, or sleep fragmentation.
  2. There are many types of sleep diagnoses and the most common disorders reported by older adults are obstructive sleep apnea (OSA), insomnia, and restless legs syndrome.
  3. Many sleep disorders share excessive sleepiness as a common symptom, but this symptom is often not evaluated or treated because health care providers are uninformed about the nature of sleep disorders, the symptoms of these disorders, and the many effective treatments available for these conditions.

Parameters of Assessment

  1. A Sleep History (see Table 5.1 in protocols book*) should include information from both the patient and family members. People who share living and sleeping spaces can provide important information about sleep behavior that the patient may not be able to convey.
  2. The Epworth Sleepiness Scale 2 is a brief instrument to screen for severity of daytime sleepiness in the community setting. See: Try This Issue 6.2 - The Epworth Sleepiness Scale
  3. The Pittsburgh Sleep Quality Index (PSQI) 3 is useful to screen for sleep problems in the home environment and to monitor changes in sleep quality. See: Try This Issue 6.1 - The Pittsburgh Sleep Quality Index (PSQI)

Nursing Care Strategies

  1. Vigilance by nursing staff in observing patients for snoring, apneas during sleep, excessive leg movements during sleep, and difficulty staying awake during normal daytime activities. 4, 5
  2. Management of medical conditions, psychological disorders, and symptoms that interfere with sleep, such as depression, pain, hot flashes, anemia, or uremia. 4, 5
  3. For patients with a current diagnosis of a sleep disorder, ongoing treatments such as continuous positive airway pressure (CPAP) should be documented, maintained, and reinforced through patient and family education. 3 Nursing staff should reinforce patient instruction in cleaning and maintaining positive airway pressure equipment and masks.
  4. Instruction for patients and families regarding sleep hygiene techniques to protect and promote sleep among all family members (see Table 5.3 in protocols book*). 5
  5. Review and, if necessary, adjustment of medications that interact with one another or whose side effects include drowsiness or sleep impairment. 4
  6. Referral to a sleep specialist for moderate or severe sleepiness or a clinical profile consistent with major sleep disorders such as OSA or restless leg syndrome. 5
  7. Aggressive planning, monitoring, and management of patients with obstructive sleep apnea when sedative medications or anesthesia are given. 5
  8. Ongoing assessment of adherence to prescriptions for sleep hygiene, medications, and devices to support respiration during sleep. 5

Evaluation and Expected Outcomes

  1. Quality Assurance Actions
    1. Provide staff education on the major causes of excessive sleepiness (i.e., OSA, insomnia, restless leg syndrome).
    2. Provide staff with in-services on how to use and monitor CPAP equipment.
    3. Have individual nursing units conduct environmental surveys regarding noise level during the night hours and then develop strategies to reduce sleep disruption due to noise and care patterns.
    4. Add sleep as a parameter of the admission assessment for patients and provide written instructions for patients using CPAP at home to always bring the equipment with them to the hospital. Include sleep quality (e.g. Pittsburgh Sleep Quality Index).
    5. Utilize post-hospital surveys of patient satisfaction with their sleep while in the hospital, and provide feedback for nursing staff.
  2. Quality Outcomes: Improved quality and/or quantity of sleep during normal sleep intervals as reported by patients and staff.

Follow-up Monitoring

  1. Depending on the diagnosis, follow-up may include long-term reinforcement of the original interventions along with support for adhering to treatments prescribed by a sleep specialist. For example, patient compliance with CPAP therapy for OSA is critical to its efficacy and should be assessed during the first week of treatment. 6 All patients benefit from positive reinforcement while trying to acclimate to nightly use of a positive airway pressure device.
  2. CPAP masks may require minor adjustments or refitting to find the most comfortable fit. Most such changes are needed during the acclimation period, but patients should be encouraged to seek assistance if mask problems develop. 6 In the acute-care setting, respiratory care technicians are valuable in-house resources when staff from a sleep center are not readily available.
  3. During the initial treatment phase of insomnia, sleep deprivation may cause rebound sleepiness, which should subside over time. Follow-up should include ongoing assessment of napping habits and sleepiness to track treatment effectiveness. 5 
  4. If obesity has been a complicating health factor, weight loss is a desirable long-term goal. With reduction in daytime sleepiness, the timing is ripe for increasing the activity level. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include regular exercise, which is also consistent with cardiovascular health and long-term diabetes control. 4

For Definition of Levels of Quantitative Evidence Click Here

References

  1. Shen, J., Barbera, J., & Shapiro, C.M. (2006). Distinguishing sleepiness and fatigue: Focus on definition and measurement. Sleep Medicine Reviews, 10(1), 63–76.
  2. Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540–545.
  3. Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer, D. J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. Evidence Level IV: Nonexperimental Study.
  4. Ancoli-Israel, S., & Martin, J.L. (2006). Insomnia and daytime napping in older adults. Journal of Clinical Sleep Medicine, 2(3), 333-342. Evidence Level VI.
  5. Avidan, A. Y. (2005). Sleep disorders in the older patient. Primary Care: Clinics in Office Practice, 32(2), 563–586. Evidence Level I: Systematic Review.
  6. Weaver, T. E., Chugh, D. K., Maislin, G., Schwab, R. J., George, C. F. P., Kader, G. A., et al. (1997). Impact of obstructive sleep apnea on the conduct of daily activities. Sleep Research, 26, 530. Evidence Level IV: Nonexperimental Study.

Last updated - July 2012

Journal Articles

Ancoli-Israel, S. (2000) Insomnia in the elderly: a review for the primary care practitioner. Sleep, 23 Suppl 1:S23-30

Chasens, E. R., & Umlauf, M. G. (2003). Nocturia: A problem that disrupts sleep and predicts obstructive sleep apnea. Geriatric Nursing. 24(2). 76-81,105.

Epstein, D. Sleep disorders (Vol. Ed.). (2002). Nursing Clinics of North America,37.

Gooneratne, N. S., Weaver, T. E., Cater, J. R., Pack, F. M., Arner, H. M., Greenberg, A. S., & Pack, A. I. (May 2003). Functional outcomes of excessive daytime sleepiness in older adults. Journal of the American Geriatrics Society, 51(5), 642-9.

Lee, K. A. (2001). Sleep and fatigue. Annual Review of Nursing Research, 249-73.

Lee, K. A., Landis, C., Chasens, E. R., Dowling, G., Merritt, S., Parker, K., Redeker, N., Richards, K., Rogers, A., Shaver, J., Umlauf, M. G., & Weaver, T. (2004) Sleep and chronobiology: Recommendations for nursing education.Nursing Outlook, 52(3): 126-33.

Lamberg, L. (July 16, 2003). Illness, not age itself, most often the trigger of sleep problems in older adults. JAMA, 290(3), 319-23.

Whitney, C. W., Enright, P. L., Newman, A. B., Bonekat, W., Foley, D. & Quan, S.F. (1998). Correlates of daytime sleepiness in 4578 elderly persons: the Cardiovascular Health Study. Sleep, 21, 27-36

Last updated - February 2005