Lying awake for hours, tossing and turning, worrying, having satisfactory, pleasant and sufficient sleep is sometimes a problem for all of us, let alone someone with dementia, who recognizes their environment less and less, who exchanges day and night rhythm and has little to do during the day. But what exactly are sleeping problems, and how do you achieve good care?
Health Behavioural Registered Nurse Koen Manders has developed The Sleep Method, a step-by-step guide for a qualitatively better night’s sleep.
One of the most important reasons for admission to a nursing home is issues with sleep: nocturnal restlessness, sleeping problems, or a caregiver who can no longer handle the care (at night). Unfortunately, sleeping medication, such as Temazepam, or a tranquilizer, such as Oxazepam, are still readily used. This has to change. The Dutch Care and Coercion Act* (abbreviated as WZD) also requires this.
It is known that sleep has a restorative function, both for the body and for brain activity. Cognitive processes, including memory and concentration, are given the chance to recover and ‘reset’. Furthermore, it is not yet fully known what the purpose of sleep is. Three processes that affect sleep are:
- Biological clock (circadian rhythm): this nucleus in the hypothalamus regulates, through hormone levels, a recurrent structure of sleep and wake of approximately 24 hours.
- Sleep rhythm: sleep is not a fixed state, but a rhythm that lasts from 90 to 120 minutes, in which various brain activities take place. This can be roughly divided into deep sleep, light sleep and REM sleep (dream sleep).
- Sleep demand: The need for sleep increases during the day and decreases again during the night.
Long-term disruption of sleep can lead to many complaints. Symptoms such as cardiovascular disease, obesity, depression or anxiety can arise. It also affects one’s mood, concentration and memory reduced autonomy and independence can occur. If this happens occasionally, it likely isn’t cause for concern. If this is a regular occurrence, it may be an issue, especially if it is recurring for several nights in a row.
As age progresses, so-called gerontological changes occur in and around sleep:
- Biological clock (circadian rhythm): the hormone levels and body temperature linked to the sleep and wake cycle become less apparent. The number of consecutive hours of sleep at night decreases and the need for a nap during the day increases.
- Sleep rhythm: sleep becomes less deep, and sleep remains more in light sleep and REM sleep. There is also more change between the phases, and the rhythm is no longer constant.
- Sleep demand: demand builds up faster and is more difficult to release during the night.
Sleep hygiene
A good night’s sleep starts during the day. A few tips to help achieve this are:
• A quiet and dark bedroom
• Keep screens (such as tablet, smartphone, television, etc) out of bedroom
• Make sure to only do relaxing activities, such as reading, at least an hour before bedtime
• Avoid caffeinated and alcoholic drinks several hours before bedtime
• Schedule a moment of worry during the day to come up with solutions to problems
• Refrain from eating heavy meals in the hours before bedtime
• Exercise regularly, but no later than three hours before bedtime
• Ensure an environment with sufficient light during the day
• Avoid naps or power naps during the day
• Try to get up at exactly the same time every day, even on weekends
The first intervention for sleeping problems is often the use of sleep medication. This entails many risks. The cognitive impairments as a result of dementia are additionally enhanced, as are daytime fatigue and an increased risk of falls. In addition, medication is also known to block the restorative functions of sleep, so that someone can relax, but this, for example, makes it more difficult to process difficult experiences. The Care and Coercion Act (WZD) has been developed to protect clients against unnecessary and unsafe use of these substances. The WZD regulates involuntary care for clients with dementia. This includes the use of behaviour-influencing medication and freedom restricting treatments , such as the closed door, bed rails or the weighted blanket. ?The basic principle is that the situation is looked at in a multidisciplinary way, whereby mainly sought for alternatives; is short terms: No… unless. ?
The search for alternatives is central to the WZD. Involuntary care may only be used if it can be demonstrated that sufficient alternatives have been investigated. But what are the alternatives? For the night, people often think of an extra low bed, or extra supervision, for example in the form of an infrared sensor, are sufficient, but there is no suitable guideline to answer these questions. Apart from sleep hygiene (see box), there is therefore no ready-made answer to sleeping problems. The night situation is different for everyone, including clients with dementia. This is why it is good to systematically search for suitable solutions geared to the individual patient’s needs.
The sleeping position
Everyone has a different position in bed. One prefers to sleep on their stomach, and another changes position every half hour. In hospitals, patients are traditionally placed on their backs in bed, so that the nurses can easily reach everything. Moreover, this is a healthy posture for the body. This preference of care employees is also reflected in home care or in a nursing home. That is what is taught in training. However, if someone has trouble changing their posture due to apraxia or physical problems, but prefers to sleep on their right side, it can be a long night.
The Sleep Method is to help you find suitable solutions. It is a method that analyzes the sleeping situation on the basis of six steps and offers solutions to help the personal situation. Literature, studies and various practical experiences form the basis of the method, which bundles numerous interventions and divides them over the various steps. The method has been developed to offer alternative solutions. This gives care workers, informal caregivers and specialists a chance to look more broadly at the preferences of the client, and gives the opportunity to think of what might suit the individual client. In this way, customization and a person-oriented solution can be offered to the client with sleeping problems. The request from the WZD is also met with opportunities to take a broad look at alternatives and to only proceed with involuntary intervention only when these alternative options have been exhausted.
The sleep history is the basis of the sleeping method. In this first step, information is collected that can be used to identify which sleeping problems there are, and which solutions or interventions can be linked to these in the later steps. This is done, among other things, with a sleep/wake calendar, supplemented with questionnaires for the client, caregiver or care staff. This step is seen as a baseline measurement.
The sleep history is the basis of the sleeping method. In this first step, information is collected that can be used to identify which sleeping problems there are, and which solutions or interventions can be linked to these in the later steps. This is done, among other things, with a sleep/wake calendar, supplemented with questionnaires for the client, caregiver or care staff. This step is seen as a baseline measurement.
In step 2, we first look at various possible causes. Based on the information collected during the observation phase, together with the involved disciplines, such as occupational therapist, doctor and home care, we look at issues that may underlie poor sleep. These could be issues such as:
• Pain
• Itches
• Posture or discomfort
• Incontinence problems
• Sleep disorders
• Medication
Or any other number of physical causes.
This step, together with step 4, is the most important step within the Sleep Method. The aim is to look at the individual situation and to have it match the client’s needs better. This is especially important, especially when admitted to a nursing ward, though it can also provide surprising solutions and ideas to the home situation. The sleeping climate and the preconditions can already be enough to stimulate a good night’s sleep. These are a few things you may want to consider:
• Bedtime routines
• Bed linen and own pillow
• Nightwear
• Decoration and furniture of the room
• The temperature of the room. Elevated skin temperature is associated with drowsiness, deeper sleep and less frequent waking. This is why it is important to ensure you have a cool environment and warmth under the covers.
Every client is different, and the interventions are different for every client. This is why it is impossible to list all possible interventions. However, it is important to let go of one’s own values and preferences and to look with an open mind at the client and their preferences, however small or strange they may be.
Alternative interventions include the use of signposting, dynamic stimuli, light therapy, day structure, and many other options that promote good sleep. In this step we look for appropriate interventions that can be added to the personal situation surrounding the client.
One form of a dynamic stimulus is a musical pillow. This pillow offers music or sound close to the head so that the client is distracted from sounds and ensures less of the desire to get up and be distracted by these sounds. The purpose of signage is to make it more visible where a client can find the toilet, for example. This can be done, for example, with illuminated arrows, or an image of the toilet on the outside of the bathroom door.
A recognizable daily rhythm is also important. A good variety of activity and rest matches the sleep needs of the elderly. In addition, this ensures recognisability and the client is less likely to withdraw or become bored.
If there is enough variety, an activity can also be offered in the evenings. A nice bath, something to eat while watching television or a game. This ensures that the time at which the older person goes to bed shifts and so does the time of waking up in the night. A win-win situation.
The last two steps concern the use of signals, and influence the freedom of movement or the use of sleep medication. With all these resources, it is important to take the considerations of the WZD into account and to compare these results. Sometimes a situation calls for the deployment of involuntary care, for example, if the client cannot find peace at night. Medication can sometimes offer a short-term solution, but also consider options that affect freedom of movement, such as a ball blanket, a tent bed, bed rails or an extra low bed. If a client cannot get out of bed by themself, the bed imposes a restriction. If a client cannot get up from the extra low bed, the complete step-by-step plan of the WZD must be followed, as this amounts to a restriction to the freedom of movement.
Sleep medication is only included in the method as a last resort. For some clients, this is a godsend, but there are few resources that actually offer better quality of sleep. The effect of medication is mainly to stun the client. Sleep medication can offer a temporary solution to, for example, stabilize the day and night rhythm again. That is why the means are mentioned and included in the sleeping method. Sleep medication always falls under the means that influence behaviour and the complete step-by-step plan of the WZD must always be followed for this to be taken into consideration.
While going through the steps, various disciplines can be consulted, such as an occupational therapist, family doctor, nurse and home care. The support of a dementia case manager / adviser can also help with this. They can all think along and supplement when you get stuck as a care professional, informal carer or client.
Author: Koen Manders
Website: www.kmconsulatatie.nl
kmconsulatatie@outlook.nl
Translation: Google, J. Weststrate, H. Cunningham
First published in: Denkbeeld February 2022
Picture: YUMMYBUUM/ADOBESTOCK
* Note: The Dutch Care and Coercion Act differs from the New Zealand legislation.
Bell mat
The bell mat is an example of a signal that can be used at night. This mat is available in different variants:
• in bed under the bottom sheet or under the mattress to receive a signal when the client moves more or less
• as a mat on the floor next to the bed. If the client stands on this, the care worker receives a signal. They can then consider whether the client needs assistance and offer guidance if necessary. This aid can also be used during the day when the client is sitting in a chair in his room.
