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Empira 8/30/2017
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Restorative Sleep Vitality: Making a Night and Day
Difference
PresentedBy:Empira
SarahBrown,BS,RN,LNHAExecutiveDirector
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Disclosure of Commercial Interests
Iconsultforthefollowingorganization:EmpiraMembersandotherclientsandvendorsuponrequest.
ListtheNameofYourEmployer:‐ExecutiveDirector‐Empira‐ProviderowedqualityimprovementconsortiumforAgingServices
Ifconsultantfororganizations,onlylistthenamesofthecompaniesforwhichyouconsult.
‐Listallcommercialinterests.Empira
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Who is Empira?
Empira 8/30/2017
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Who is Empira?
Non‐profitqualityimprovementconsortiumincluding:
25nursinghomesinmetroandruralMinnesota
Rootedinavisionforholisticexcellenceandqualityoflifeforolderadults.
Ifyouwanttogofastgoalone,ifyouwanttogofargotogether.
– AfricanProverb
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“I did then what I knew, when I knew better I did better”
–MayaAngelou
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Sleep Program Goals
Residenthaverestfulrestorativesleep,undisturbedsleepatnight.
Residentsareactivelyengagedandawakeduringtheday.
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Clinical Practice
StandardofPractice:istheusualthingthatisdoneinaparticularsituation.
BestPractice:isprovidingaservicethatisrecognizedascorrectormosteffective.
Harper‐Collins English Dictionary
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Ineffective Interventions
• Focusingattentiononsolutionsandnotonthecauses
• Implementingasmanyinterventionsaspossible– andhopingoneofthemwillwork
• Staggeringinterventions• Notmatchingtheinterventionstothecauses
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Standards of Practice
• Nutrition• SyringeFeeding
• Safety• Restraints
• FallPrevention• MerryWalkers
• Woundtreatment• LightTherapy• TurningandRepositionEvery2hours
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Ftag 327 Hydration
Thefacilitymustpassfreshwatereveryshifttoensureproperhydrationandhealth.
Thefacilitymustprovideeachresidentwithsufficientfluidintaketomaintainproperhydrationandhealth.
Thefacilitymustpassfreshwatereveryshifttoensureproperhydrationandhealth.
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If you remember nothing else...
BeCurious:• DoIknowwhyIamdoingitthisway?• WhatIamtryingtoaccomplish?• Whatistherootcauseoftheoutcome?• Whatistheimpacttoallstakeholders?• Isthereabetterway?• Whatdoesresearchsay?BeBold:• Whenyourcuriositygetsthebestofyoushowyour
couragetomaketheworldabetterplaceforthoseyouserve.
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Root Cause Analysis
IfIhadanhourtosolveaproblemandmylifedependedonit.I’dspend55minutesthinkingabouttheproblemand5minutesthinkingaboutthesolutions.‐AlbertEinstein
A7
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Root Cause Analysis
Identify the Root Causes
Select interventions
and/or solutions to eliminate or reduce causes
Improve the
outcomes
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What outcomes do you want to improve?
Slide 13
A7 awesome quoteAuthor, 12/6/2017
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Aging
Pain Falls
Infections
Pressure Ulcers
Behavioral Expressions
Poly Pharmacy
Antipsychotic MedicationDepressionAnxiety
Cognitive Impairment
Incontinence
Weight loss
Functional Decline
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Increased Aging Population
Health
Health
Decline
Morbidity
Life Expectancy
Health Morbidity
Morbidity
Medical Intervention
Anti‐Aging
Past
Present
Future
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Why Do We Age?
CellularDamageDeclineinCellularRepairCellularSenescence‐ InabilitytoReplicateCausedby:• Genetics• Lifestyle• Environment
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Strategies to Improve the Aging Experience
Prevention/DelayAging• Lifestylechoicesthatmaximizecellularfunction
• Slowtheprocessofcellulardamage
• Promotecellularrepair• Maintaincellularreplication
• Exercise• Nutrition• Hydration
• Restorativesleep• Avoidexposuretoharmful
influences
MorbidityManagement• Lifestylemodifications• Elicitperson‐centeredgoals• Coordinatecare• Prioritizecarethatimprovesmultipleconditions
• Stayuptodateonclinicalpracticeguidelines
• Earlyinterventionwithchangeofcondition
• Avoidunnecessaryinterventions
• Preventcomplications
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Prevention/Delayed Aging
Thegoalofnursingis“toputthepatientinthebestconditionfornaturetoactupon
him”.FlorenceNightingale
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A Day in the Life of Mabel
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“Sleep is the one little thing that will make everything better in your
life.”‐Arianna Huffington
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Why is Sleep Important?
• Itistherestartforourbodies.• Itistheonlytimewehavephysicalrestoration.
• Itistheonlytimewehavepsycho‐socialrestoration.
• 1/3ofourlifeisspentasleep So.. what comes
first poor sleep or aging?
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Restorative Sleep: A Basic Human Need
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Restorative Sleep
RestorativeSleep:Onecontinuous significantsleepperiodin24hoursday,ideallylasting7‐9hoursandoccurringatnight.
UninterruptedSleep=RestorativeSleep
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Sleep Fragmentation
SleepFragmentation:Sleepthatisinterruptedthroughoutthenightinhibitingtheopportunityforrestorativesleepthatisrequiredforoverallhealthandwellbeing.
InterruptedSleep=FragmentedSleep
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Why is Restorative Sleep so important?
ImpactontheMind ImpactontheBody
• Cell&TissueRepairRegeneration
• Cellulargrowth• Hormoneregulation• Immunity
• MemoryCemented
• EmotionsProcessed
• StressRelieved
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Fragmented Sleep
Pain Falls
Infections
Pressure Ulcers
Behavioral Expressions
Poly Pharmacy
Antipsychotic MedicationDepressionAnxiety
Cognitive Impairment
Incontinence
Weight loss
Functional Decline
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Why Do We Sleep and Wake?
Circadian Rhythm SleepWake Homeostasis
Why dowe sleep? MelatoninDarkness
AdenosineActivity
Whydo we wake? SerotoninLight
Cortisol Rest
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Circadian RhythmTime of Day
A13
Slide 30
A13 great slideAuthor, 12/6/2017
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Sleep Wake HomeostasisActivity Level
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How Do We Sleep?
1. 4‐5sleepcyclespernight
Thereare4stagesofsleepinacycle1. Stage12. Stage23. Stage34. REM
Ineachsleepcyclewegothroughthesleepstages.Ifweareawakenedwestartbackatstageonewhenwefallbacktosleep A18SB1
SB2
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Sleep Stage 1 5%
• StageN1lasts5‐15minutes.N1isthetransitionstageofthebrainfromfastactivebrainwaves(asintheawakestate)toslowerbrainwaves.
• Musclesbegintorelaxandloosetonicitysometimessuddentwitchesandjerkingmayoccur
• Eyesmovemoreslowly,theheartbeginstoslowdown,breathingbecomesdeeperandslower
• Thepersonisstilleasilyawakenedandeasilyreactstoenvironmentalnoise.
Slide 32
A18 awakenedAuthor, 12/6/2017
SB1 Sarah Brown, 2/14/2018
SB2 Sarah Brown, 2/14/2018
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Sleep Stage 2 45%
• Muscularactivitydecreasesmore,eyeactivitystopsorrarelymoves,heartratesignificantlyslowsandconsciousawarenessoftheexternalenvironmentdisappears.
• Brainwavescontinuetoslowdown.
• Thepersonisnotaseasilyarousedfromthislevelofsleepandusuallyonlyreactstoloudorselectednoisesintheenvironment.
• Thisstagehasbriefimagedreamsthatthebrainworksto:save,file,trash.
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Sleep Stage 3 25%
• Stage3isdeepsleeporslow‐wavesleep.• Thebrainiscompletelyatrest.Alleyemovement
andmuscleactivityceases.• Stage3iswherethegreatestamountofskin,deep
tissueandoverallhealingandregenerationofthehumanbodyoccurs.
• Thegreatestamountofhealingoccursatthisstageduetothegreatestformationofwhitebloodcells,T4cells,redbloodcellre‐oxygenationandcellularrepairandregeneration.
• Itisverydifficulttowakesomeonefromthisdeepsleepstage.
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Sleep Stage REM 25%
• Respirationsbecomeveryrapid,irregularandshallow.Theheartrateincreasesandthebloodpressurerises.
• REMsleepincludesrapideyemovementsaswellasaveryrapidbrainwaveactivitysimilartobeingawake.
• Thisstageisassociatedwithhealingtheemotionalandpsychologicalhealthofthebody.Episodicdreamsandlongstories,relievestress,processemotions,detoxourfeelingsof:fear,anger,happyandsad.Italsocementsmemories.
• Muscularparalysisoccurs.
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Why does Restorative Sleep need to be continuous?
7-9 Hours
Cycle 1 Cycle 2 Cycle 3 Cycle 4 Cycle 5
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Outcomes of Poor Sleep
ImpactontheMind• ImpairedImmunity• HeartDisease• HormonalChanges• IncreaseCancerRisk• PoorBalanceandStrength• IncreasedPainSensitivity• AccidentProne• HighBloodPressure• Obesity• Impairedgrowthand
healing
ImpactontheBody• MemoryImpairment• Depression• Anxiety• Delusions• Paranoia• Hallucinations• Disorganizedspeech
A19
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Could Restorative Sleep Improve Aging Service Challenges?
PainFallsInfectionsPressureUlcersBehavioralExpressionsPolyPharmacyAntipsychoticMedicationMedicationErrors
DepressionAnxietyCognitiveImpairmentIncontinenceWeightlossFunctionalDecline…
Slide 38
A19 is something missing here?Author, 12/6/2017
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Creating the Best Condition
Circadian Rhythm SleepWake Homeostasis
PromotingRestorative Sleep at Night
Exposure to Darkness orAmber light
ConsolidatedSleep
Promoting active and purposeful engagement during the day
Exposure to Sunlight or
Full Spectrum Light
Activity and Expend Energy
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Top 10 Sleep Disturbances
1. Noise2. Light3. Sleepingenvironment4. Napping5. Medications6. Continenceneeds7. Pain8. Positioning9. Activity/inactivity10. Diet
Harvard Medical School Study 2010
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Sleep Disturbances #1: Noise
Noise#1disrupterofsleep.Noisethatwasmostdisruptive:• Staffconversations• especiallywhenresidentsthoughttheyheard
theirname,theirconditionorcareneedsbeingdiscussed
• Loudpersonalalarms
Slide 41
A20 great slideAuthor, 12/6/2017
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Sleep Disturbances #2: Light
• Residentreceivedtoomuchlightwhentheyweretryingtosleep.
• Hallwaylightslefton• Lightsturnedonduringrounding
• Residentsreceivelessthantheminimumamountoffullspectrumlightneededtosetcircadianrhythmduringtheday.
• 10,000luxofdirectsunlightfor30minutesof• 1,000luxoflightfor120minutes
A21
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Sleep Disturbances #3: Sleeping Environment
• Uncomfortablesleepingsurfaces• Mattress• Pillows• Blankets• Pajamas
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Sleep Disturbance #4: Napping
• Toomuchnappingduringthedaycanimpairnaturalsleep/wakecycle
• Ideallynappingshouldbelimitedto30minutesorlessperday.
Slide 43
A21 so what does one do about lighting when this is needed for fall prevention?Author, 12/6/2017
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Sleep Disturbance #5: Medications
• Insomniaandsleepinessisacommonsideeffectofmanymedications.
• Timingofmedicationadministration• Cascadinginterventionsduetopolypharmacy.
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Sleep Disturbance #5: Medications
Psychosis difficulty concentrating
sleep changes
anxiety
suspiciousness
delusions
hallucinations
disorganized speech
depression
anxiety
difficulty functioning
Fragmented Sleep difficulty concentrating
sleep changes
anxiety
suspiciousness
delusions
hallucinations
disorganized speech
depression
anxiety
difficulty functioning
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Sleep Disturbance #6: Continence Needs
• Nocturia‐ Frequentawakeningstousethebathroomatnight.
• StandardPracticeofroundingevery2hours
• Timingoflaxatives,stoolsofteners,food,fluids,diureticsinterferingwithsleep.
A22
Slide 48
A22 check this wordingAuthor, 12/6/2017
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Sleep Disturbance #7 Pain
• Discomfort/Restlessness• Increasedpainsensitivity
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Sleep Disturbance #8: Positioning
Standard2hoursroundingpracticestoturnandreposition.A23
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Sleep Disturbance #9 Activity
• Boredom• Lackofengagement• Lackofpurpose• FunctionalLimitations
Slide 50
A23 so, how does one reconcile this?Author, 12/6/2017
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Sleep Disturbance# 10: Diet
• Foodandfluidintakedirectlyeffectseliminationstatus.
• Lackunderstandingoftheimpactcertainfoodshadonpromotingand/ordisturbingsleep.
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“I did then what I knew, when I knew better I did better”
–Maya Angelou
“Now you know better, it is your turn to do better.”
–Empira
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WHAT WILL YOU DO BETTER?
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QUESTIONS?
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Thank you!
For more information please visit www.empira.org
Sarah Brown‐ [email protected]
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TheinformationinthispresentationisintellectualpropertyofEmpira.
Toprotectthefidelityofourprograms,redistributionwithoutconsentandproper
attributionisprohibited.
Foradditionalinformationpleasevisitwww.empira.org