Improving Sleep Quality in Older Adults: Are We Getting it Right? Ageing involves physiological c
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Improving Sleep Quality in Older Adults: Are We Getting it Right?
Ageing involves physiological changes that occur naturally in the body. These contribute to a loss of functioning capacities and an increased incidence of age-related diseases. One consequence of ageing is the increased risk of falls. Falls are multifactorial, with an array of contributing factors that increase the risk of falling. It is common for older adults to take more than four medications a day, which increases the risk of falls. Furthermore, there are specific medications that significantly increase falls and, as such, their use is questionable. Age-related diseases and pain accompanied by age-related changes to sleep patterns make chronic insomnia a common problem for older adults. Subsequently, older adults are more likely to take naps during the day; as a result, they have shortened sleep time and experience periods of wakefulness during the night hours. All of these contribute to a disturbance in sleep quality and quantity. Benzodiazepine anxiolytics and nonbenzodiazepine receptor agonists (Z-drugs) are two classes of medications prescribed for sleep disorders. Although their safety and efficacy are questionable, both classes of medications are prescribed routinely to older adults for disrupted sleep. Older adults commonly report poor sleep quality, and management involves prescribing benzodiazepines and Z-drugs. However, these also increase the risk of falls in older adults. Balancing medication regimes is essential, but it requires the implementation of medication reviews.
KEYWORDS: older adult; ageing; sleep; falls; medications; polypharmacy
PopUlation aGeinG is a widely explored global phenomenon with longevity at the forefront. Medical advancements and general health improvements have increased the number of older people globally. Advancements are set to continue as the proportion of adults over 80 years of age continues to rise (Boccardi, 2019; World Health Organisation [WHO], 2011). This means the expectation of providing quality care in gerontology will intensify.
The process of ageing involves multifactorial complexities. Countless theories attempt to explain the ageing process, but there remains one certainty – age-related physiological changes
in the body involve both intrinsic and extrinsic factors (Jaul & Barron, 2017). As ageing transpires, so too does the risk of age-related diseases not attributable to a normal physiological occurrence (WHO, 2011). Instead, age becomes a non-modifiable risk factor for decreasing health (Dağler et al., 2014; WHO, 2011). This means with increased age, the incidence of disease and disability increases.
Falls and medications, particularly poly- pharmacy (taking more than four medications a day), are geriatric syndromes (Magnusson et al., 2019). According to Magnusson et al., geriatric syndromes contribute to a person’s diminished ability to cope with physiological changes within the body’s organ systems. This makes the person susceptible to various stressors. Normally, homeostatic mechanisms will immobilise the stressors; but in this instance, these mechanisms are significantly weakened, if not completely disenabled. What normally follows is a decrease in functional capacity (WHO, 2011). While geriatric syndromes are not classified as a specific disease, there is a correlation between disease, the syndromes and normal physiological ageing (Magnusson et al., 2019).This knowledge empha- sises the frailty of the older adult, even in wellness.
Disruptions to normal sleep patterns are an age-related physiological change. Therefore, the older a person becomes, the more likely they are to experience poor sleep quality and quantity (Min, Kirkwood, et al., 2016; Meiner & Yeager, 2019;Wennberg et al., 2013). Chronic insomnia is common in older adults (Min, Nadpara, et al., 2016; Meiner & Yeager, 2019), and as a result, older adults are likely to be prescribed sleep- enhancing medications. The most common medications are either benzodiazepines or Z-drugs (de Jong et al., 2013). These medications are high-risk, modifiable factors that contribute to falls (de Jong et al., 2013; Krause et al., 2019). Identification of risk factors for falls is essential because the consequences of fall scan affect older adults’ quality of life and, at their worst, be life-threatening. The purpose of this review is to explore the correlation between insomnia, sleep-enhancing medications and falls in older adults.
MethOd
A literature search of peer-reviewed studies was conducted. The databases searched included ProQuest, ScienceDirect, PubMed, CINHAL and Cochrane Library. Keywords for the search included:olderadult;sleepingmedication;seda- tives; insomnia; falls and nursing guidelines. The search criteria excluded research more than 10yearsoldandincludedbothquantitativeand qualitative studies. The review located a range of international literature, mostly from America and Australasia.
detriMental eFFectS OF FallS FOr Older adUltS
Both intrinsic and extrinsic factors contribute to falls.Advanced age is one such contributing factor (Min, Kirkwood, et al., 2016). For instance, Browne et al. (2014) found that 50% of people over 80 years old are predetermined to fall at least once within 12 months. Even more so, falling equates to an increased need for healthcare. Bakken et al., (2014) found that 4.4% of older adults encounter a fracture following a fall, with the neck of femur (NOF) being the most common of all fractures. An injury such as this means a person is likely to require surgery with ongoing healthcare and support mechanisms to return their pre-fall independence (Costa-Dias et al., 2014). Soft-tissue injuries, skin tears and head injuries are also common (de Jong et al., 2013). These injuries also need ongoing treatment and support. Also of significance is the emotional impact of falls, for even if no physical injury has occurred, the emotional impact of falls can be severe. Older adults may experience depression and feelings of fear and anxiety following a fall, leading to an overall reluctance to remobilise (de Jong et al., 2013). Falls can be an enormous burden on the well-being of the older adult and the health system.
As a person’s age increases, so too does the incidence of disease and disability. Along with treatment and management of health- related problems, medication prescribing also increases. Subsequently, older adults are likely to be prescribed more than four medications a day, resulting in polypharmacy (de Jong et al., 2013). Older adults often experience acute changes to their health, which commonly increases the likelihood of change to, or increase in the daily intake of, medications (Browne et al., 2014). Age-related changes, decreasing health status and polypharmacy contribute to the increased incidence of adverse effects of medications (Browne et al., 2014; de Jong et al., 2013; Krause et al., 2019).The reason for these effects is found within pharmacokinetics as ageing impacts on distribution, metabolism and elimination of medications in the body (Health Quality & Safety Commission New Zealand, 2017; Mion
26 Whitireia Journal of Nursing, Health & Social Services 28/2021 Pages 25-32
& Sandhu, 2016). Another reason pertains to pharmacodynamics, more specifically, whereby the half-life of medications increases (Levy, 2013). Polypharmacy aside, the most common adverse effects experienced by older adults include sedation, hypotension, bradycardia, tachycardia and asystole episodes. Combined, these impact a person’s balance and gait (Browne et al., 2014; Health Quality & Safety Commission New Zealand, 2017), and the incidence of falling increases.
Whilst polypharmacy is another risk factor in falls (Browne et al., 2014; Costa-Dias et al., 2014), the authors found that some classes of medications are associated with a significant increase in the risk of falling. These include benzodiazepines and Z-drugs. Both these classes of medications are prescribed widely to older adults for poor sleep quality and quantity (de Jong et al., 2013), with both classes of medication known to contribute to falling
SleeP QUalitY and QUantitY
While sleep patterns are individual, sleep quality and quantity restore a person’s energy levels and prepare them for the day ahead (Meiner & Yeager, 2019). Sleep is regulated by the circadian rhythm, a homeostatic mechanism in the form of a 24-hour biological clock that controls time asleep and time awake (Potter et al., 2016). The hypothalamus maintains overall control, but other regions of the brain also controlled by the hypothalamus – namely the limbic region, the reticular activating system (RAS), and the thalamus – are also believed to have an influence (Potter et al., 2016).
Sleep occurs in cycles.There are five stages of sleep within one sleep cycle: four stages of non- REM sleep and one stage of REM sleep. Most sleep time is spent in non-REM sleep, where a person will experience changes to blood pressure, pulse, respiratory rate and consciousness (Meiner & Yeager, 2019). As sleep begins to occur, the person has an awareness of their surroundings, however, as muscles relax and blood pressure, pulse and respiratory rate decrease, they drift deeper into unconsciousness Throughout the night a person will
experience four to six cycles of sleep; each cycle lasting no more than two hours. However, only one-quarter of sleep time is spent in the REM cycle, which is the stage that contributes to a person’s ability to feel relaxed and rested for the upcoming day
External forces may disrupt the circadian rhythm’s normal sleep and wake cycle. These in- cludefactorssuchastimezones;one’senvironment, including the seasons, living arrangements and shiftwork; stress; illness; medications, including over-the-counter medications; and illegal drugs In addition, ageing, especially advanced age, disrupts the circadian rhythm As a result of age-related changes, older adults commonly experience sleep disturbances, particularly within the non-REM stages of sleep. For instance, there is an increase in the time it takes a person to drift into sleep (stage one), resulting in an overall loss of deep sleep in the following three stages .Subsequently, they report difficulty with the onset of sleep and spend more time awake during the night In combination with the external factors mentioned, older adults often wake early in the morning, meaning they need to nap during the day. Overall, these practices are believed to cause further disruption to the circadian rhythm Therefore, finding ways to restore the circadian rhythm is crucial to one’s health. Subsequently, Meiner and Yeager (2019) state that pharmaceutical and non- pharmaceutical strategies are accepted practices to combat this.
While ageing contributes to loss of sleep quality and quantity, other equally contributing factors include arthritis-related diseases and peripheral vascular disease, both of which contribute to chronic pain and further decrease sleep Other factors are the incidence of snoring, dyspnoea, restless leg syndrome, muscle cramps and polyuria
addition, dementia, depression and anxiety also feature in poor sleep patterns (Bourgeois et al. 2014; Meiner & Yeager, 2019). This knowledge suggests that there are multiple reasons why older adults have disrupted sleep. It is suggested, therefore, that strategies need to focus less directly on poor sleep and more on these entities that contribute to poor sleep.
Insomnia is characterised by a shorter dur- ation of sleep quantity, which may become a chronic problem. Sateia et al. (2017) found that most of the general population experience insomnia at one time or another; however, chronic insomnia is more common among older adults. They also make the correlation between insomnia and various chronic illnesses with related symptoms, but they also stress that chronic insomnia is not a part of the normal ageing process
Treatment for insomnia comes in two forms: prescribed pharmacological methods or over-the- counter medications and non-pharmacological therapeutic interventions (While there are numerous non-pharmacological and over-the-counter treat- ments available; the use of prescribed medi- cations remains the most sought-after treatment and this has seen an upsurge in prescribing ‘sleep-enhancing’ medications, especially to older adults However, the use of pharmacological treatments is not without its problems. This is particularly so in older adults who take more than four medications a day Medications are a contributing factor in geriatric syndromes; the more medications a person takes, the greater the likelihood of adverse effects (Browne et al., 2014; de Jong et al., 2013; Krause et al., 2019). One significant adverse effect is the increased risk of falls (Lee et al., 2017). Further to this is the correlation between sleep-enhancing medications and repeated falls, along with an increased risk of injury from falls This means that the use of medications, particularly sleep-enhancing medications, increases older adults’ vulnerability by having a significant impact on personal safety,
particularly as the risk of falls escalates. This indicates that strategies should focus more on causes of disrupted sleep and less on prescribing sleep-enhancing medications.
theBenZOdiaZePineS
Benzodiazepines are one of many in a range of pharmacological treatments for disrupted sleep. They were first introduced in the United States in the 1960s to reduce anxiety (Browne et al., 2014; Sateia et al., 2017). Their efficacy as a muscle-relaxant-sedative, with anxiolytic and anticonvulsant properties, led to them being the most prescribed medication of the 1970s (Schroeck et al., 2016). Originally, benzodiazepines were perceived as a relatively safe medication, with a low dependence rate (Schroeck et al., 2016). However, it was later found that dependence was common, as too were rebound sleep disturbances and an increased likelihood of withdrawal symptoms even when no longer taking them (Dobia et al., 2019). Also common is the incidence of adverse effects that include drowsiness, dizziness, cognitive impairment, poor muscle coordination and falls – withincreasedfracturesandfunctionalincapacity associated with immobility (Ailabouni et al., 2017; Fitzgerald & Vietri, 2015; Min, Kirkwood, et al., 2016; Schroeck et al., 2016). In spite of theseadverseeffects,Schroecketal.(2016)stated that benzodiazepines remain three times more likely than any other medication to be prescribed to older adults to treat long-term insomnia. One such benzodiazepine is temazepam, which is favourable in improving sleep patterns and quality (Tariq & Pulisetty, 2008). Despite its favourability, the same concerns remain, as Dobia et al. (2019) and Schroeck et al. (2016) caution that if temazepam is prescribed, there needs to be strict guidelines around administering only the lowest dose and keeping to a short duration.
the nOnBenZOdiaZePine SedatiVe-hYPnOticS
The growing number of adverse effects of benzodiazepines led to the development of nonbenzodiazepine sedative-hypnotics (Z-drugs) in the 1980s (Schroeck et al., 2016). One
28 Whitireia Journal of Nursing, Health & Social Services 28/2021 Pages 25-32
common medication of this form is zopiclone, which is believed to cause fewer adverse effects and less dependency than its counterparts.
Z-drugs became a commonly prescribed medication to treat sleep disorders (Schroeck et al., 2016). Prescribing is particularly significant in aged residential care facilities, with 55% of residents being prescribed Z-drugs, compared to 10% of independent adults being prescribed this medication (Bakken et al., 2014; Bourgeois et al., 2014; Lee et al., 2017). Lee et al. (2017) and Bakken et al. (2014) also found that beginning doses were higher and the duration of use was longer than recommended, but nonetheless, prescribing to persons over 90 years of age was common practice. This suggests that older adults in institutionalised living are more likely to encounter insomnia than older adults living independently. However, it also implies a correlation between poor sleep quality, decreasing wellness and increased disability. It further suggests that it is the influence of health-related issues that play a contributing role in insomnia This reinforces the need for strategies that focus on health-related issues rather than the prescribing of medications to treat sleep disorders.
Benzodiazepines were originally believed to be more harmful than Z-drugs. Yet, the use of Z-drugs, particularly long-term, remains questionable, as incidence of falling-related injuries increases (McMillan et al., 2013). Furthermore, the correlation between Z-drugs and increased incidence of serious injury, particularly fractures and motor vehicle accidents, causing hospitalisation, has been documented Similarly to benzodiazepines, guidelines about dosage and duration of prescribing Z-drugs is in question. In older adults, the recommended duration for these medications is short term, with a suggestion of no longer than five weeks, and if insomnia does not resolve after 10 days, further assessment is necessary This implies that Z-drugs, like benzodiazepines, have serious safety issues, and prescribing guidelines are problematic.
MedicatiOn reViewS
Older adults are at high risk of adverse effects associated with medication administration Therefore, it remains important to consider the efficacy and safety of certain medications while considering the potential adverse effects they may cause – particularly the risk of falling This consideration can occur in the form of medication reviews.
The timing of medication reviews is also a necessary consideration. Church et al. (2015) found that many medication reviews occurred when the person was hospitalised or had a change in their current health status. Instead, the authors believe reviews gather more information and are far more effective when the person is well. Browne et al. (2014) agreed that medication reviews during periods of poor health are too late to help in achieving quality care.
Regular medication reviews for older adults are undertaken by a multidisciplinary team of healthcare professionals from medical, pharmaceutical and nursing fields. Krause et al. (2019) and Jaul and Barron (2017) state that this is important because of the combined knowledge about normal physiological ageing, pathophysiology and geriatric syndromes coupled with the ability to identify any change to current health status and risk factors that impact on quality of life.
Both benzodiazepines and Z-drugs increase the incidence of falls in older adults .While it is not possible to stop ageing or cure chronic pathophysiological conditions, the way in which medications are prescribed can be modified. De Jong et al. (2013) state that by reducing doses, the incidence of falling decreases. This makes the implementation of medication reviews an effective strategy in the care of older adults.
Advanced age is a non-modifiable risk factor for falls. The impact of falling has devastating consequences for older adults. As such, identifying risk factors and implementing strategies to reduce the incidence of falls is necessary.
Altered sleep patterns occur in response to age-related physiological changes in the body, making older adults more liable to encounter poor sleep quality and quantity. Whilst ageing cannot be ceased or altered, there are other external factors that affect health status and increase the likeliness of disability.This makes the assessment of sleep multifactorial.
Benzodiazepines and Z-drugs are prescribed to manage and treat altered sleep patterns, but they are not without problems, especially when they are prescribed to older adults. There is an increased incidence of adverse effects and these significantly contribute to falls.
A fine balance exists between medicating and minimising the adverse effects of medications. Improving prescribing regimes and evaluating the appropriateness of medications for older adults will decrease many of the problems
associated with medications – particularly falls. Bringing together a multidisciplinary team to undertake comprehensive medication reviews that will examine a person’s sleep patterns, their risk of falling and their current medications will address the efficacy of the drugs and the safety of older adults.
Falls are the largest cause of injury in older adults; they are also associated with high morbidity and mortality. Reducing the incidence of falls requires healthcare professionals to identify risk factors. As a person ages, sleep patterns change, and insomnia becomes common. Older adults are often prescribed benzodiazepines and Z-drugs to counteract this. However, these two classes of medications are known to increase the risk of falls. If there is to be quality care for older adults, reducing the prescription of these drugs is necessary.
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