Effect of Sleeping Instruction on Reducing Insomnia among Elderly

Introduction

Sleep is a vital physiological process with important restorative functions, and plays a role in biological function of central importance for most living things (Tucker, 2020). Studies on the physiology of sleep have shown that a variety of highly relevant processes take place during sleep, such as energy conservation, metabolic regulation, memory consolidation, elimination of waste substances, activation of the immune system. (Jha V & Jha S., 2020). 

With age, several changes occur that can place one at risk for sleep disturbances including increased prevalence of medical  and psychiatric comorbidities, increased medications use, age related changes in various circadian rhythms, and environmental and life style changes (Heidari & Huege., 2020). One of the major changes that commonly accompany the aging process is an often profound disruption of an individual’s daily sleep-wake cycle lead to sleep impairments (Jurado-Fasoli, et al., 2020).

Insomnia disorder is an economic burden and public health concern. It is mostly seen in older age groups, and often considered a normal aging phenomenon)  Freeman, et al., 2020). Many studies have suggested the etiology of insomnia may be related to many factors such as genetics, biochemistry, neuroendocrine, immune, and psychosocial factors (Li, Y et al., 2020).Insomnia impairs the individual functioning and diminishes the quality of life, as it associated with low score of mental and physical component summary of quality of life (Gothe, et al .,2020) .

Sleep hygiene is non-pharmacologic measures to increase the quantity and quality of clients’ sleep. Sleep hygiene encompasses health education on sleep rituals, habits and restful environment. Current research suggests that non-pharmacological interventions, specifically, changes made to the environment, could potentially increase the sleep quality of geriatric patients (Harrelson., 2017).

Nurses are expected to be aware of their possible causes, in order to early recognize them and support the proposal of interventions to minimize them. From a nursing perspective, insomnia can be considered a human response to a health condition or a life process, i.e., a nursing diagnosis. The NANDA International, Inc. (NANDA-I) Diagnosis Classification defines Insomnia as a disruption in amount and quality of sleep that impairs functioning (Guandalini, et al., 2020).

It is essential that healthcare professionals understand the normal distribution of the sleep stages to understand changes that occur to sleep related to disease, cognitive changes, and reactions to medication. Nurses should remember that numerous factors can contribute to sleep stage distribution and circadian cycle disruptions interrelated factors must be considered, including medical, psychiatric, and cognitive comorbidities, as well as the use of sedatives and hypnotics. (Hedges, & Gotelli., 2020).

Significance of the study:

Sleep disorders are relatively poorly undiagnosed and untreated despite poor sleep strongly affects the daily lives of millions of people around the world. Insomnia can cause significant morbidity if not addressed properly. (Richter,et al .,2020). The increase in the aged population will bring with it a huge burden of sleep related health problems. Although ageing is a global phenomenon, little data are available on regional trends in sleep related problems (WHO, 2019). 

Hence, the present study conducted to reducing Insomnia among older adults attending the setting of study. Insomnia is highly prevalent, especially at advanced age. It is a high societal, medical cost and associated with increased health service utilization. (Timalsina, 2017). Therefore, awareness regarding insomnia and sleep hygiene education among elderly should be raised for early detection and appropriate management of insomnia in order to decrease sleep related health problems. (Chhantyal & Timalsina, 2017).

Aim of the study:

Evaluating the effect of sleeping instruction on reducing insomnia among elderly.

Subjects and Methods

Research Design: 

A quasi-experimental design was used to achieve the aims of the study.

Subjects (sample):

Purposive sample of (60) elderly, their age ranged between 65-75years that are diagnosed with insomnia. 

For the sample size n, this calculator employs the following formula:

n = N*X / (X + N – 1),

Where,

X = Z_α/2² ­*p*(1-p) / MOE²,

And Z/2 is the critical value of the Normal distribution at /2 (for example, for a 95percent confidence level, is 0.05 and the critical value is 1.96), MOE is the margin of error, p is the sample proportion, and N is the participant scale. The sample size formula (n=60) has been subjected to a Finite Population Correction.

Inclusion criteria:

• Newly diagnosed elderly with insomnia age eligible for study 65years to 75 years.    
• Male and female regardless education level.

Exclusion criteria:

• Receiving Drugs that effect on sleep.  
• Suffering with Mental or Psychological disorder.
• Refuse to participate.

Setting:

This study was carried out at sleep disturbance outpatient clinic in Aswan University Hospital &Geriatric Social Club in Aswan City.

Study Duration:

The fieldwork and data collection for this study lasted three months using the data collection tools, from the beginning of June 2018 till the end of august 2018.

Tools of data collection:

Two tools were utilized to collect pertinent data for study includes:

First Tool:

A structured interview questionnaire sheet was developed by researcher after revising extensive literature review. (Abd Allah, et al., 2014) (Abd Allah, et al., 2016) (El -Gilany, et al., 2017). It was collected before, after and follows up from educational instruction and it consists of two parts:

1^stpart: Demographic characteristics of the study elderly:

Includes data such as; age, sex, educational level, current occupation, residence, marital status, income, income source.

2^nd part: Medical data:

It was involve questions about chronic disease, medications regimen, and day time problems caused by inadequate sleep, habits before Sleeping and environmental factors affect sleep.

Second Tool: Athens insomnia scale (AIS): This scale was developed by (Soldatos et al,2003).

The scale is a useful screening tool in reliably establishing the diagnosis of insomnia .This scale used to evaluate insomnia through a detailed sleeping history during the last month. It consists of eight items. The first five items cover night-time symptoms of insomnia (difficulty initiating sleep, difficulty maintaining sleep and early morning awakening, total sleep period, and overall quality of sleep), while the last three items ask for daytime consequences of disturbed sleep (problems with sense of well-being, overall functioning, and sleepiness during the day).

Scoring system: The eight items of the AIS were rated from zero to 3, (with 0 corresponding to no problem at all and 3 to very serious problem. The elderly subjects are asked to grade the severity of these complaints (absent = 0, mild = 1, severe = 2, and very severe = 3). Elderly subject who had a total score 6 points or higher was considered as a positive case for insomnia.

Educational Booklet to enhance effective Sleeping Practice among Elderly: The researcher preparedEducational Booklet to enhance effective Sleeping Practice among elderly. The booklet information based on review of relevant literature (Melinda Smith, et al., 2020) about insomnia, habits and environmental factors that interfering with sleep and how to avoid these factors. This booklet was reviewed by supervisors.

Tools validity and Reliability:

The tools were tested for content validity by assent of five expertises from the faculty of nursing (a jury of five expert's opinion). The tool was tested for internal reliability by using Cronbach’s alpha. The test–retest reliability correlation coefficient found almost 0.90 at a 1-week interval. As far as external validity is concerned, the correlations of the AIS-8 and AIS-5 with the Sleep Problems Scale were 0.90 and 0.85, respectively.

Pilot Study:

A pilot study conducted on 10% of the total study sample represent 6 person from study sample. In order to test clarity, applicability and feasibility of the tools.  

Ethical Consideration:

An official permission and administration permission to conduct the study was obtained; Approval of participating cases was taken through Oral consents. Elderly were informed about the purpose, procedure, benefits, nature of the study; follow up and his/her had the right to withdraw from the study at any time. Strict Confidentiality and anonymity of each and Informed them that obtained data will not be included at any further researches without a second consent.

Study Procedure: 

The researcher has started to collection data used an interview questionnaire sheet (First tool) and (Second tool). Collection of study data was done two days/week. The researcher was interviewing the patients individually and explained the purpose of the study briefly and nature of study to the studied elderly.    The intervention was offered to the studied sample in the form of sessions (5 sessions) for small group .the time consumed for answering the study tools ranged from 30 to 45 minutes. The total sample was divided into small groups (5 elderly in each group). All groups received the same content using the same teaching methods, media, discussions, and the same booklet. Follow up; after one month from giving instructions.

Limitation of the study:

• Time available for follow up not enough as many patients.
• Participants suffered from transportation and difficulty of mobility due to health status, physical condition and financial problems. 

Statistical analysis:

The collected data organized categorized, tabulated and analyzed using SPSS ver. 24. Data presented in tables and charts using numbers and percentage, statistics and associations done using mean, standard deviation SD, t- test and p- value, Significant of the result: non significance (P>0.05), *: Significance (p<0.05) **: moderate significance (P<0.001) ***: highly significance (P<0.000).

Results and data analysis:

Table (1): Relation between insomnia &demographic data in study sample pre educational protocol

 N.S: non significance (P>0.05), *: Significance (p<0.05) **: moderate significance (P<0.001)  ***: highly significance (P<0.000).

The table (1) Demonstrated relation between insomnia &demographic data in study sample pre educational protocol. There was no statistical significance difference between age, sex and level of education with insomnia at (P>0.05), while there was statistical significance difference between Marital status, occupation before retirement, living condition, current job status and income with insomnia at (P<0.05).

Table (2): Relation between insomnia and medical history data in study sample.

N.S: non significance (P>0.05), *: Significance (p<0.05) **: moderate significance (P<0.001)  ***: highly significance (P<0.000).

Table (2) illustrated relation between insomnia and medical history data in study sample. There was statistical significance difference between orthopedics and chest disease with insomnia at (P<0.05).

Table (3): Relation between Habits before sleeping and insomnia in study sample.

N.S: non significance (P>0.05), *: Significance (p<0.05) **: moderate significance (P<0.001)  ***: highly significance (P<0.000).

Table (3) Showed relation between Habits before sleeping and insomnia in study sample. There was statistical significance difference smoking and insomnia at (P<0.05). While, there was moderate statistical significance between relax before bed time, establish regular time for sleep and watching TV, reading at bed at (P<0.001).in addition to there was highly statistical significance difference with each of eating much food before time to bed, drinking caffeinated drink 4hrs before bedtime, drinking a lot before bedtime, napping or reading at bed and regular waking up early and exposure to light during day at (P<0.000).

Figure (1): Relation between Environmental factors & insomnia in study sample.

Fig (1): represented Relation between Environmental factors & insomnia in study sample. There was statistical significance difference between insomnia with each of proper darkness, mattress and pillow are comfortable and noise at (P<0.05).