Who is Empira?...Empira 8/30/2017 2 © Who is Empira? Non‐profit quality improvement consortium...

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

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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?

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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

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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.

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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

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Could Restorative Sleep Improve Aging Service Challenges?

PainFallsInfectionsPressureUlcersBehavioralExpressionsPolyPharmacyAntipsychoticMedicationMedicationErrors

DepressionAnxietyCognitiveImpairmentIncontinenceWeightlossFunctionalDecline…

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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

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A20 great slideAuthor, 12/6/2017

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Sleep Disturbances #2: Light

• Residentreceivedtoomuchlightwhentheyweretryingtosleep.

• Hallwaylightslefton• Lightsturnedonduringrounding

• Residentsreceivelessthantheminimumamountoffullspectrumlightneededtosetcircadianrhythmduringtheday.

• 10,000luxofdirectsunlightfor30minutesof• 1,000luxoflightfor120minutes

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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.

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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.

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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

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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‐ Sbrown@empira.org

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TheinformationinthispresentationisintellectualpropertyofEmpira.

Toprotectthefidelityofourprograms,redistributionwithoutconsentandproper

attributionisprohibited.

Foradditionalinformationpleasevisitwww.empira.org