Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
Evaluating excessive sleepiness in the older adult.
Bibliographic Source(s)
Umlauf MG, Chasens ER, Weaver TE. Excessive sleepiness. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 47-65. [35 references]
Guideline Status
This is the current release of the guideline.
Disease/Condition(s)
Excessive sleepiness (may also be called excessive daytime sleepiness or hypersomnolence) Sleep disorder
Guideline Category
Assessment of Therapeutic EffectivenessEvaluationManagement
Clinical Specialty
Family PracticeGeriatricsNursingSleep Medicine
Intended Users
Advanced Practice NursesHealth Care ProvidersNursesStudents
Guideline Objective(s)
To identify the signs of excessive sleepiness (ES) and rate these symptoms using a standardized numerical scale To describe the signs and symptoms for the most common causes of ES in older adults: obstructive sleep apnea, restless leg syndrome, insomnia, and narcolepsy To plan appropriate interventions for the patient with ES To provide nursing care that incorporates Sleep Hygiene Measures To educate patients and families about sleep disorders and Sleep Hygiene Measures To modify medical interventions and routines that interfere with sleep maintenance and sleep quality To identify and refer patients needing evaluation by sleep medicine specialists To support patients in complying with treatment regimens for sleep disorders
Target Population
Older adults
Interventions and Practices Considered
Assessment Strategies Sleep history assessment Use of clinical measures to assess excessive sleepiness (ES), including the: Epworth Sleepiness Scale Multivariable Apnea Prediction Index Functional Outcomes of Sleep Questionnaire Pittsburgh Sleep Quality Scale Review of overnight sleep-studies (polysomnography), with or without measures of daytime sleepiness: Multiple Sleep Latency Test Maintenance of Wakefulness Test Evaluation of the patient's knowledge and performance of sleep hygiene measures Assess for signs and symptoms of the most common disorders causing excessive sleepiness: Obstructive sleep apnea (OSA) Insomnia Restless leg syndrome (RLS) and periodic leg movement disorder Narcolepsy Nursing Care Strategies Manage medical conditions, psychological disorders and/or symptoms, and medications that can interfere with sleep Develop individualized plans of care that: Include active treatment of known sleep disorders Incorporate Sleep Hygiene Measures Ongoing assessment of adherence to prescriptions for sleep hygiene, medications, and/or devices to support respiration during sleep (e.g., continuous positive airway pressure [CPAP]); instruction and reinforcement Refer symptomatic patients to sleep specialists
Major Outcomes Considered
Cognitive function/impairment Social and occupational performance Quality and quantity of sleep Driving safety
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Medline and CINAHL were the electronic databases used.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not applicable
Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Not stated
Description of Method of Guideline Validation
Not stated
Major Recommendations
Parameters of Assessment A careful history should be taken that includes 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. Several strategies have been developed to take a sleep history that are outcomes of the Academic Sleep Awards program sponsored by the National Heart, Lung, and Blood Institute (NHLBI). Two formats are included in table format (see the original guideline document) to outline key points in obtaining key information from older patients and their family members. For patients with a current diagnosis of a sleep disorder, documentation and continuation of ongoing treatments, such as continuous positive airway pressure (CPAP), should be maintained and reinforced by patient and family education. Nursing Care Strategies Management of medical conditions, psychological disorders and/or symptoms that interfere with sleep such as: depression, pain, hot flashes, anemia, or uremia. Review and/or adjust medications that have interactions and/or side effects that include drowsiness or sleep impairment. Instruction in and/or nursing delivery of Sleep Hygiene Measures (see below). Medical referral to a sleep specialist for moderate and severe conditions of excessive sleepiness (ES) and/or a clinical profile consistent with major sleep disorders, such as obstructive sleep apnea (OSA) and restless leg syndrome (RLS). Aggressive planning, monitoring and management of sleep disordered breathing with anesthesia or when sedative medications may be used, especially when positive airway pressure devices are used at home. Ongoing assessment of adherence to prescriptions for sleep hygiene, medications and/or use of devices to support respiration during sleep. Instruction in and/or reinforcement of use, cleaning and maintenance of positive airway pressure equipment and masks. Follow-up Monitoring Depending upon diagnosis, follow-up may include long-term reinforcement of the original interventions along with supporting the patient to adhere to prescriptions from the sleep specialist. Rebound sleepiness may also occur during the initial treatment phase. This occurs because of sleep deprivation and should subside over time. Follow-up should also include ongoing assessment of napping and sleepiness. If obesity has been a complicating health factor, weight reduction may also be a desirable patient goal in the long term. With reduction in daytime sleepiness, the timing is ripe for increasing activity level. Treatment of sleep disorders should include planning for strategic changes in lifestyle that include regular exercise, which is consistent with cardiovascular rehabilitation and long-term diabetic control. Sleep hygiene measures should be continually reassessed. Sleep Hygiene Measures Use the bed only for sleeping (or sex). Develop consistent and rest-promoting bedtime routines. Maintain the same bedtime and waking time every day. Exposure to bright sunlight is desirable upon awakening, but should be avoided just prior to bedtime. Upon awakening, get up out of the bed slowly, no matter what time it is. If awakening during the night, avoid looking at the clock; frequent time checks will heighten anxiety and make sleep onset more difficult (turn the clock around!). Avoid naps entirely or limit naps to 10 to 15 minutes duration. Sleep in a cool and quiet environment. Patients who cannot sleep after 15 or 20 minutes should get up and go into another room, read or do a quiet activity using dim lighting until they are sleepy again. (Don't watch television, which emits too bright a light.) Sleeping alone is more restful than sleeping with another person or pets. If pets or bed partners add to the problem, moving to the couch for a couple of nights might be useful or restricting pets from sharing the bed may be necessary. Prior to bedtime avoid the following: caffeine and nicotine after 12 noon alcohol intake (more than 3 drinks) large meals or exercise 3 to 4 hours before bedtime emotional upset or emotionally charged activities
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is not specifically stated for each recommendation.
Potential Benefits
Improve quantity and/or quality of sleep during normal sleep intervals. Reduce sequelae and occurrence of excessive sleepiness (ES). Improve cognitive functioning and functional status and improve social and occupational performance.
Potential Harms
Not stated
Qualifying Statements
Not stated
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting BetterLiving with Illness
IOM Domain
Effectiveness
Bibliographic Source(s)
Umlauf MG, Chasens ER, Weaver TE. Excessive sleepiness. In: Mezey M, Fulmer T, Abraham I, Zwicker DA, editor(s). Geriatric nursing protocols for best practice. 2nd ed. New York (NY): Springer Publishing Company, Inc.; 2003. p. 47-65. [35 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
2003
Guideline Developer(s)
The John A. Hartford Foundation Institute for Geriatric Nursing - Academic Institution
Guideline Developer Comment
The guidelines were developed by a group of nursing experts from across the country as part of the Nurses Improving Care for Health System Elders (NICHE) project, under sponsorship of The John A. Hartford Foundation Institute for Geriatric Nursing.
Source(s) of Funding
Supported by a grant from The John A. Hartford Foundation.
Guideline Committee
Not stated
Composition of Group that Authored the Guideline
Primary Authors: Mary Grace Umlauf, RN, PhD, University of Alabama School of Nursing; Eileen R. Chasens, RN, DSN, School of Nursing and the Center for Sleep and Respiratory Neurobiology, University of Pennsylvania; Terri E. Weaver, RN, PhD, CS, FAAN; School of Nursing and the Center for Sleep and Respiratory Neurobiology, Division of Sleep Medicine, Department of Medicine, University of Pennsylvania
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Copies of the book Geriatric Nursing Protocols for Best Practice, 2nd edition: Available from Springer Publishing Company, 536 Broadway, New York, NY 10012; Phone: (212) 431-4370; Fax: (212) 941-7842; Web: www.springerpub.com.
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This summary was completed by ECRI on May 30, 2003. The information was verified by the guideline developer on August 25, 2003.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.
NGC Disclaimer
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