Reviewing the literature is a prerequisite to understand the. areas already covered and analyzed in the related field of

Transcription

1 18 REVIEW OF LITERATURE Reviewing the literature is a prerequisite to understand the areas already covered and analyzed in the related field of investigation in the past. Such a review helps to find out the relevance or insufficiency of the findings, or approach, for the investigation of the problem at hand. In this chapter an attempt has been made to review the related literature, with the aim of assessing the effectiveness of nursing interventions and relaxation techniques on sleep among senior citizens residing in old age homes in Puducherry. The literature related to the present study is from the following areas. Section I : Sleep and ageing Section II : Prevalence of sleep disturbances among the elderly Section III : Prevalence of sleep disturbances among the elderly residing in old age homes Section IV : Factors responsible for sleep disturbances among the elderly

2 19 Section V : Literature related to nursing interventions to promote sleep among the elderly Section VI : Literature related to relaxation techniques to promote sleep among the elderly with sleep disturbances. SECTION I : SLEEP AND AGEING Metz and Bunnell (1990) have described sleep problems among the elderly people in a study they conducted to clarify the relationship between day-time napping and nocturnal sleep disturbances by surveying 132 older adults (aged 6895). They found out that age had the greatest effect on napping in the older subjects taking more frequent and longer naps. Although a nonsignificant trend suggests that the duration of naps may be associated with difficulty in initiating nocturnal sleep, no significant relationship was observed between any reported napping dimension and indications of nocturnal sleep disturbances. Gonozatez Garcia et al. (1991) conducted a study to assess the number of elderly people at risk of suffering from insomnia. A total of 329 elderly persons were interviewed. The result of this study was that of the total interviewed one-third of them were elderly people aged above 60 and they were at high risk of insomnia. Becker and Jamieson (1992) attempted to explore and prove that insomnia and day-time sleepiness in an elderly patient may be

3 20 normal and they occur as a consequence of ageing. They found that inadequate sleep hygiene was common in the aged. Flinsliver and Hertz (1993) suggested that the sleep problem in the elderly persons was extraordinarily common. Johntson (1994) explored that sleep problems in older adults were so common that nearly half of hypnotic prescriptions were written for persons aged over 65 years. Practitioners should evaluate the factors that cause sleep disturbances, such as, medical and psychiatric illness, dementia, alcohol and polypharmacy. Ohayon (1996) conducted an epidemiological study on insomnia in the general population. The study was conducted with a representative sample of 5,622 subjects aged 60 years. The experiments showed that 20.1% of the older persons were unsatisfied with their sleep; 16% were administered sleepenhancing medication; 16.2% were taking pharmacological treatment to reduce anxiety and 81.6% were receiving only pharmacological treatment for more than 6 months. Bundlie (1998) suggested that sleep pattern disturbances increased with age. The causes for this were multiple, such as dementia and nocturnal agitation. They further added that changes in the sleep pattern occur with ageing. Nearly 50% of older

4 21 Americans experience some sleep problems. The elderly complained that their sleep was more fragmented. Gentili and Edinger (1999) stated that elderly people with disturbances in sleep pattern should be discouraged from using hypnotics. They also stated that sleep complaints were common among older people who often exhibited multiple contributing factors causing insomnia. Neubauer (1999) suggested that sleep disturbances in the elderly typically included difficulty in falling asleep, less time spent in deeper stages of sleep, early morning awakening and less total sleep time, poor sleep habits such as irregular sleep wake times and day-time napping. He further stated that these factors may contribute to insomnia. Caffeine, alcohol and some other medication were also found to interfere with sleep and cause sleep disturbances. Benet (2000) described that ageing was one of the important factors in determining the physiology of sleep. During the ageing process several other factors contributed to the deterioration of sleep in elderly persons. Common complaints among the aged were difficulty in initiating sleep and maintaining sleep. Vitiello (2000) stated that with advancing age the normal sleep cycle begins to breakdown, resulting in reduction in the

5 22 deeper stages of sleep and often there could be profound increase in the fragmentation of nighttime sleep by periods of intrusive wakefulness. Avidan (2002) stated that sleep disorders were common among older adults. Thus it is important for health-care professionals to be aware of the treatment for these disorders. Lamberg (2003) in his study quoted that ageing not only causes sleep disorders but most often triggers sleep problems in older adults. Mazza et al. (2004) reviewed many articles and suggested that geriatric patients often complain about sleep disorders, but many of the typical sleep disturbances with the elderly were considered to be normal consequences of old age and were under diagnosis and treatment. Nearly 50% of the aged persons are diagnosed with sleep disturbances, such as sleep-disordered breathing, periodic limb movements, restless leg syndrome, circadian rhythm disorders, excessive day-time sleepiness and obstructive sleep apnea syndrome. This has to be properly treated with non-pharmacological interventions. Liu and Liu (2005) conducted a study to examine sleep habits, insomnia and use of hypnotic medications in the elderly in China. A cross-sectional study was conducted on 1,820 individuals,

6 23 aged 65, of which 1,679 (92.2%) were interviewed at home, including 720 men and 909 women. The result of the study was that 32.9% of the sample suffered from insomnia; 18.9% exhibited symptoms of insomnia with daytime consequences; and 6.5% were using hypnotic drugs. The conclusion was that the elderly may be characterized as going to bed early and waking up early. Cooke and Ancoli Israel (2006) explained that for many older adults ageing is associated with significant changes in sleep. There are a variety of causes, including circadian rhythm disturbances, insomnia, depression, medical illness and medications. Treatment should address the primary sleep problem and should result in significant improvement in the quality of life and daytime functioning in older adults. Wolkove et al. (2007) described that ageing was associated with general, well-described changes in patterns of sleep with a phase advance in the normal circadian sleep cycle. Older people tend to go to bed earlier in the evening and also wake up earlier. They also wake up more frequently during the night time and experience fragmented sleep. Prevalence of many sleep disorders increase with age. Insomnia, whether primary or secondary, coexisting with illness or medication is very common among elderly people. Disturbances like insomnia, rapid eye movement, sleep behavior disorder, periodic leg movement disorders, restless leg

7 24 syndrome and snoring sleep apnea are increasingly seen among older people. Ancoli-Israels, Ayalon and Care Salzman (2008) reported that the most common complaints of the older adults concern with difficulty in initiating or maintaining sleep. The sleep complaints are not only associated with old age but also with medications or changes in the circadian rhythm. For this, pharmacological or nonpharmacological treatment should be suggested by conducting further research. Misra and Malow (2008) reported that older patients were at a risk of a variety of sleep disorders. The clinical consequences of sleep disturbances include disturbed cognition, psychomotor retardation and increased risk of accidents and injury. This needs an intensive assessment of the elderly, with a multidisciplinary approach. SECTION II: PREVALENCE OF SLEEP DISTURBANCES AMONG THE ELDERLY Foley et al. (1995) conducted a comparative study to assess the sleep pattern and also assess sleep complaints among the elderly persons from three communities. The aim of the study was to assess the frequencies of five common sleep complaints, such as difficulty in falling asleep, waking up, early morning awakening,

8 25 need to nap and not feeling rested. Over 9,000 participants aged 65 years and older were taken from the National Institute on Ageing Multi-Centered Study. From this 20% of the sample reported no complaints of the above-mentioned problems. Between 23% and 24% reported symptoms of one of the above-mentioned problems; half of the subjects reported at least one of these complaints; while another half reported that at least one of these complaints was present most of the time. Of the total participants 75% never felt rested after waking up in the morning and complained of more than one symptom of the above-mentioned problems. In this analysis, 9% had more than two symptoms of the above-mentioned problems. Sleep disturbances, particularly among the older persons, often may be secondary to coexisting diseases. Leger et al. (2000) conducted a study to assess the prevalence of sleep pattern disturbances among the elderly individuals. A survey was carried out among 12,778 elderly in France. Results showed that 73% of the individuals reported sleep problems, 29% reported one sleep problem with one reason three times per month, 19% reported sleep problem three times per week because of day-time impairment and 9% reported more than one sleep problem because of many more reasons and complained of day-time consequences and were classified as severe insomniacs.

9 26 Ohayon and Roth (2001) studied the contributing factors and the factors responsible for insomnia among the general population. A cross-sectional telephone survey of 24,600 of the general population showed that 27.2% had difficulty in initiating sleep, 10.1% had difficulty in maintaining sleep, 18.9% had early morning awakening, 10.9% had non-restorative sleep, 8.9% had sleep disturbances at least three times/week and 48.5% of them were concomitantly suffering from sleep/mental disorder. Hoffmans (2003) study described that normal ageing was accompanied by sleep pattern changes which may result in excessive day-time sleepiness and affect the quality of life in older adults. More than half of the adults aged more than 65 years and living in old age homes had some difficulty in sleeping. Nurses should understand normal changes in sleep that accompany ageing, and should be able to differentiate the symptoms of serious sleep disorders to ensure holistic care to the older adults. Ancoli and Israel (2005) reported that older people experience difficulty in sleeping. The chief complaints of the older adults were waking not feeling rested, waking too early, trouble falling asleep, day-time napping, nocturnal waking and difficulty initiating sleep. Sleep disturbances in older adults are not a natural consequence of ageing but rather a treatable condition with

10 27 cognitive behavioral therapy which is effective in improving and promoting sleep. Godard, Barrou and Vermy (2006) described that sleep complaints and disorders were frequent in geriatric patients with a prevalence rate of 57%. The primary goal was to search for the cause of secondary insomnia, such as organic or psychiatric diseases or medications. Behavioral therapy such as sleep hygiene therapy was found to be essential to treat sleep disorders. Ouslander et al. (2006) conducted a study to improve nighttime sleep in nursing home residents. A controlled clinical trial was conducted, in which 1,077 subjects were assessed. Of them 638 (59%) were eligible, 230 underwent baseline assessment, 173 were exposed to interventions such as day-time physical activity and evening bright light exposure. Enhanced non-pharmacological intervention were developed and tested. Voyer et al. (2006) reviewed the related articles on a crosssectional study (n=2332) conducted among the senior citizens living in long-term care facilities. The aim of this review was to determine the prevalence of insomnia and its associated factors in elders. Findings indicated that 104 (6.2%) participants suffered form insomnia, 17% exhibited at least one symptom of insomnia and more than half of the subjects were benzodiazepine users. The

11 28 authors concluded that insomnia was fairly a major problem among the elderly people in long-term care residence and alternative interventions suited to the long-term care residents should be developed. Hochstrasser (2010) conducted an epidemiological investigation on subjectively reported sleep disturbances and suggested that 26.2% of the general population had average sleep disturbances. They suffered from moderate to severe sleep disturbances. The investigators defined sleep disorders as the prevalence of disorders in initiating and maintaining sleep associated with daytime sleepiness and found it to be prevalent among 1.6% of the population. The study of female gender showed that increasing age was a major risk factor for sleep disturbances. Psychological and psychiatric stress, especially anxiety and depression, was associated with sleep disturbances. SECTION III : PREVALENCE OF SLEEP DISTURBANCE AMONG ELDERLY RESIDING AT OLD AGE HOMES Cadieux et al. (1992) reviewed that sleep disorders in older patients could be due to ageing process, physical disorders, psychological problems, certain drugs or a combination of these. A complete physical examination and a thorough assessment of sleep history help in selecting appropriate treatment. Adequate sleep

12 29 hygienic measures should be taken to improve the quality of life of patients when they are asleep and awake. Gerard and Albert (1994) conducted a study to find the impact of exogenous influences on sleep disturbances among the elderly people staying in institutions. The results of this study showed that there were more sleep problems found in the institutionalized elderly. Ancoli et al. (1997) in their study found that the ability to sleep among the institutionalized elderly was more disturbed and disrupted. Martin et al. (1999) stated that sleep disorders of the older people which are caused by specific problems such as medical illness and medications can also have a negative effect on sleep. Effective management of these can significantly improve sleep among the older adults. Sleep in institutionalized older adults was even more disturbed than sleep of community-dwelling older people, and special considerations can be made to improve the quality of sleep in an institutional setting. Martin et al. (2007) conducted a study on nonpharmacological interventions such as reduced night-time noise and light, structured physical activity to improve the activity rhythm among people residing in homes. The study results showed that

13 30 these interventions were effective in improving the sleep pattern among the people residing in homes. Adam, Gordon and John (2010) reported after reviewing many articles that sleep problems in the older adults were common and the disturbances in sleep were associated with increased mortality. These problems were more common among the institutionalized population, for they were associated with poor sleep initiation, maintenance of sleep and increased day-time napping. Institutionalized individuals have to be taken care by proper treatment by the nursing personnel present in the institutions. SECTION IV : FACTORS RESPONSIBLE FOR CAUSING SLEEP DISTURBANCES AMONG ELDERLY Martin et al. (2000) reviewed sleep disturbances which were common among the older adults. These disturbances were often secondary to medical illness or use of medication or were due to specific problems such as sleep-disordered breathing, periodic limb movement and circadian rhythm disturbances causing older people to awake early in the morning. In institutionalized elderly sleep becomes more disturbed and fragmented than community-dwelling older adults. Accurate assessment and diagnosis are crucial for the management of the sleep disturbances.

14 31 Christina and Kanneth (2001) suggested the need for the assessment and treatment of secondary insomnia, which should be mainly focused on the treatment of the primary cause. Shochat et al. (2001) suggested that sleep disturbances among the elderly people may not be due to the ageing process but rather are likely to be caused by many factors that are amenable to treatment. The factors include medical and psychiatric problems, medication and circadian rhythm changes, all of which can cause difficulties during sleep at night. Jeenifer Warner (2003) surveyed 1,500 people between the age groups of 55 and 84. He found that more than two-third of older adults suffer from sleep problems such as insomnia. The author also suggested a strong link between a number of diagnosed medical conditions and the quality of the sleep. The sleep disorders were associated with depression, stroke, heart diseases, lung diseases, arthritis, hypertension, etc. Ancoli-Isreal (2004) in their study reviewed that complaints about sleep were common among the older adults, yet they were not normal consequences of an old age. It may be due to the medical conditions such as chronic diseases, psychiatric disorders and medications. In addition to this is the change in the circadian rhythm that accompanies ageing and which is concerned with early

15 32 evening lethargy and early morning awakening that causes sleep disorders. Foley et al. (2004) conducted a study to find the association between sleep problems and chronic diseases in the older adults. They used responses from a self-reported standardized questionnaire from 1,500 community-dwelling men and women aged 5485 years. Results showed that a majority of the participants (83%) reported one or more medical conditions, nearly one-fourth in an elderly group that responded (age 6584 years) suffered from major co-morbidity (four or more conditions) and depression. Body pain was an associated problem or the more prevalent symptom of insomnia, and the other conditions associated were arthritis, diabetes, lung diseases, stroke, osteoporosis problems, breathing pause, snoring, day-time sleepiness, restless leg syndrome and insufficient sleep (<6h rightly). More results suggested that sleep complaints were common among the older adults and they were often secondary to their co-morbid conditions due to ageing process. SU, Huang and Chou (2004) conducted a study on prevalence and risk factors of insomnia among elderly residing in urban areas. The aim of the study was to find out the risk factors of insomnia among the elderly residing in urban areas. A crosssectional study was conducted among 2,045 non-institutionalized

16 33 individuals aged 65 years and above from urban areas. The result of the study of Taiwans bore the data that 8.4% found it difficult to fall asleep and to maintain sleep or exhibited early morning awakening associated with sleep disturbances. The factors were nocturnal micturation 20.6%, frequent use of hypnotics 3.2%, pulmonary disease 2.4%, excessive day-time sleepiness 1.8%, body pain 2.6% and depression 2.2%. These were strongly associated with insomnia in the elderly women. The result of this study shows that people living the urban areas have a low insomnia prevalence rate. Avidan (2005) stated that older people often suffered from sleep disturbances caused by age-related physiological changes, retirement, polypharmacy, changes in circadian rhythm and loss of spouse. Bephage (2005) stated that sleep was the basic activity of life. Sleep architecture referred to the mechanism of sleep and the stages of the sleep, and sleep hygiene referred to interventions used to promote sleep. In health-care settings environmental factors such as noise and light pollution were considered as the common factors which caused disturbances in the sleep pattern. Effective care had to be given to achieve good sleep architecture. Rosen (2005) discussed that the three sleep symptoms that elderly people normally exhibited were difficulty with sleep onset,

17 34 problems occurring during sleep and difficulty in awakening from sleep. These symptoms developed when there was a problem in one or more of the nine fundamental process domains that control sleep. These domains were circadian, hemeostatic, developmental, cardiorespiratory, neurological, psychiatric behavior, drugs, alcohol and medical problems. He concluded that successful treatment of sleep problems depends upon the correct identification of sleep process that causes sleep symptoms. Alonso and Estenbaraz (2006) reported that sleeping difficulties that affect individuals were directly proportional to their ages. The pharmacological treatment to this difficulty had its negative effect. The health-care professionals had to assess the factors that precipitated sleep disturbances and positive care had to be given according to that. Koch (2006) conducted a study with an objective to determine the most effective tools for the assessment and diagnosis of sleep problems, as well as to identify the most effective strategies for the promotion of sleep. He suggested that experiencing reduced sleep quality is often associated with normal ageing. However this may be exacerbated for residents of aged-care facilities. External factors such as noise and light may impact negatively upon sleeping patterns. The study concluded that the interventions to promote sleep such as reduction in environmental noise and promotion of

18 35 day-time activity are likely to be the most effective for promoting sleep, lack of sleep, disturbed sleep and the overdose of medication, especially sedations which reduce the quality of life for older people. Effective, safe interventions should be promoted and practiced by nurses. Harrington and Lee (2007) have discussed in a review that sleep disturbances were more common among the older adults. The elderly population reported more symptoms which were caused by various factors including use of medications and medical and psychiatric illness. The consequences of sleep disturbances included cognitive impairment, day-time sleepiness and poor quality of life. Vaz Fragoso and Gill (2007) reviewed various articles and suggested that older persons reported sleep complaints such as insomnia and day-time drowsiness. This may be due to reduction in circadian sleep and decrease in hemostasis and the advancement of sleepwake cycle, which was characterized by the older people being alert in the morning and drowsier in the early evening. Sleep disturbances reflected the ways in which ageing leads to reduction in the health status, loss of physical function, etc. This is known as geriatric syndrome. Medical, physical, cognitive and psychological treatment had to be given.

19 36 Ancoli-Isreal, Ayalon and Salzman (2008) described that the most common complaints of older adults were related to difficulty in initiating or maintaining sleep, which results in insufficient sleep, an increased risk of falls, decreased memory, concentration and poor quality of life. Ageing alone was not the sole reason for sleep disturbances. The major reasons for this kind of disturbances were co-morbid conditions with medical and psychiatric illness and the use of medications. The review concludes that both pharmacological and non-pharmacological interventions to promote sleep should be worked on in future research. Ohayon (2008) conducted a study to assess nocturnal awakenings in the elderly population and its co-morbidity effect on their health. The study concluded that among the 8937 noninstitutionalized samples one-third of the general population were affected with nocturnal awakening. It had its own co-morbid organic and psychiatric disorders that needed appropriate treatment. Results showed that 35.5% of the sample reported awakening at least 3 nights/week, 23% of them at least once every night, 4.5% of them 5 or 6 nights/week and 7.9% of them 3 or 4 nights/week. Ohayon (2008) studied nocturnal awakening, its frequency and its effect on the physical and psychological health. This was a cross-sectional study which revealed that nocturnal awakening was

20 37 more associated with the population with more daytime impairment, which occured in one-third of the general population. Ancoli-Israel (2009) confirmed that older adults slept for about 7 hours a night, while the sleep architect changes with age most often were associated with an age-related condition rather than the age. Sleep difficulties associated with co-morbidities and the presence of multiple medical conditions were found to be detrimental to sleep quality. Careful health assessment was necessary to screen sleep complaints and disorders among the older population. Maurice and Ohuvun (2009) conducted a study to define the prevalence and importance of nocturnal awakening in the elderly population and its association with the physical diseases and psychiatry disorders. A cross-sectional study was conducted through telephone. Results showed that 31.2% of the sample reported waking up 3 nights/week and 7.4% of the sample had difficulty in resuming sleep after they woke up. The results of the study showed that nocturnal awakenings were highly prevalent in the general population and highly associated with physical and psychological disorders. Hung and Chen (2011) discussed that sleep disturbances were the most common of the problems faced by geriatrics. The

21 38 pharmacologic treatment had its own side effects. The nonpharmacological treatments included exercises, cognitive behavior therapy, multiple strategies, music and acupressure. In general, moderately intensive walking was effective in promoting sleep among the elderly. Therefore they suggested that the future research should develop sleep promotion strategies to improve sleep quality among the elderly. SECTION V : LITERATURE RELATED TO NURSING INTERVENTIONS TO PROMOTE SLEEP AMONG ELDERLY Clapin and French (1986) conducted a study in the longterm care facilities on the administration of medication for sleep problems by the nurses. Due to the serious effects of the pharmacological interventions, a study was conducted by the nurses using sleep history to assess the factors involved in changes in the sleep patterns of elderly persons in the long-term care facilities. The results indicate that nursing sleep history is often underutilized. Future research is expected to improve the quality of assessment for general well-being of the elderly population in longterm care facilities. Ancoli-Israel (1991) described that as people age they complain more about disturbed sleep such as insomnia, increased time of staying asleep in bed and sleep fragmentation. They reviewed

22 39 results of 12 years of research in elderly and the research showed that 2442% had 5 or more apnea per sleep. Bachman (1992) quoted that sleep disorders were especially common among elderly persons and may be the result of psychiatric illness, medical problems, poor sleep habits and primary sleep disorder. Further, they described that many persons may benefit from behavior strategies such as improved sleep hygiene. Mullun Katora and Bellew (1994) suggested that quality sleep was necessary for physical and psychological health. Sleep disturbances are common and its prevalence increases with advancing age. Physiologically, sleep in elderly differs from that in younger adults both in terms of quantity and quality. Sleep disturbances in old age may be associated with many physical and psychological conditions. Management strategies include attention to sleep hygiene and behavioral treatment. Morgan and Claws (1999) introduced several sleep management methods in nursing practice. Floid et al., (2000) summarized 12 non-pharmacological interventions used by nurses to promote sleep. Some of the interventions are relaxation techniques, noise management, circadian repatterning and sleep hygiene. Dawson and Vandenheuvel recommended a non-

23 40 pharmacological intervention such as reduced exposure to light that regulates the circardian system. Ho et al. (2002) reviewed various papers and presented the findings on the utilization of bright light to entrain the sleepwake cycle in order to improve perceived quality of sleep. The result of this study is that an increased effectiveness in regulating the circadian rhythm includes bright light as one of the nonpharmacological nursing interventions for sleep promotion. Schneider (2002) explored insomnia as a problem in all stages of life, but that it was particularly common after age 65. A number of factors such as medications, advanced age, psychological influence and medical illness may disturb sleep hygiene. Evaluation by careful study of the history and physical examination is necessary. Treatment of underlying conditions and non-pharmacologic improvements are the first-line therapy for sleep hygiene. Wang, Mang and Tsai (2005) reviewed seven studies evaluating the efficacy of cognitive behavioral therapy (CBT) for persistent primary insomnia. Stimulus control, sleep hygiene education and cognitive restructuring were the main intervention components.

24 41 Brain (2006) reviewed the literature on the management of chronic insomnia among elderly persons. The results of the review were that pharmacologic interventions led to adverse effects due to their prolonged administration, and that the best method to increase sleep was non-pharmacologic treatment which had no side effects. Therefore more non-pharmacological interventions should be utilized. Nabil and Kamel (2006) suggested that insomnia was the prevalent problem in the later part of life. Of the elderly 50% experienced sleep disturbances. Sleep problems among the elderly people were often mistakenly considered as a normal part of ageing and it was typically untreated and non-pharmacological interventions were underused by health-care professionals. But it was associated with co-morbid illness such as pain, arthritis, musculoskeletal pain, allergies, gastro-esophageal reflux diseases, nocturia, urinary retention, incomplete bladder emptying behavior, excessive daytime sleepiness, environmental causes and use of medications. The authors suggested some non-pharmacological interventions which included going to bed only when sleepy, minimizing light exposure, eating a light snack, resting and retiring at the same time, eating and exercising on a regular schedule, periodic schedule of sleep and waking up which helps to maintain

25 42 circadian rhythm. The authors recommended combating stress by the use of relaxation techniques and behavioral therapies. Schiff (2006) reported that insomnia was a more common symptom of old age. Their study showed the effectiveness of nonpharmacologic treatments. It indicated that non-pharmacologic treatments such as back massage and sensitive touching had provided a good prognosis among persons with sleep pattern disturbances. Wolkove, Elkholy, Baltzan and Palayew (2007) in their study observed that insomnia was a common problem among older people when it occurred secondary to another medical condition. It was treated with benzodiazepines. It led to day-time fatigue and it was one of the main side effects. Sleep hygiene was one of the most important measures to promote sleep among the elderly than the administration of drugs. Godard et al. (2010) stated that sleep disorders and asociated complaints were more common in geriatrics, with a prevalence rate of 57%. This resulted in increased mortality and morbidity rate. The primary goal was to provide good sleep hygiene therapy as it was essential for the individuals. Hellstrom et al. (2010) reported that sleep disturbances were common among the elderly staying in institutions. Although several

26 43 studies had explored this phenomenon, there still is a lack of knowledge about the effect of nursing interventions in a health-care setting for promoting sleep. The review will help in securing a greater position for nursing interventions in the study of sleep pattern disturbances. After reviewing many articles they suggested that the nursing interventions such as sleep hygiene, music, natural sound and vision, relaxation, massage and aroma therapy were more effective in promoting sleep among elderly. SECTION VI : LITERATURE RELATED TO RELAXATION TECHNIQUES TO PROMOTE SLEEP AMONG ELDERLY WITH SLEEP DISTURBANCES Montgomery and Dennis (2002) studied that the prevalence of sleep problems among adults increased with age and this may lead to depression, cognitive impairments and deterioration of quality of life. Their study to assess the efficacy of physical exercises and relaxation techniques to cure sleep pattern disturbances revealed that there was an improvement in the sleep pattern. Pallesen et al. (2003) conducted a study on behavioral treatment of insomnia in older adults. Subjects numbering 55 and aged 60 years and above participated in the study. It involved a comparison of two interventions in the behavioral treatment of sleep (sleep hygiene stimulus control and sleep hygiene + relaxation

27 44 tape). The results showed that the two interventions were effective in promoting sleep in terms of sleep onset latency and total sleep time. Morin et al. (2007) defined insomnia as difficulty in falling asleep, staying asleep or experiencing restorative sleep with associated impairment (or) significant distress. They reviewed articles published between January 1996 and January They identified non-pharmacological options such as stimulus control, sleep hygiene education, sleep restriction, relaxation therapy biofeedback and cognitive behavior therapy. Irwin et al. (2006) in their meta-analysis of randomized control trials found moderate to large effects of behavioral treatment on subjective sleep outcome. Cognitive behavioral treatment and relaxation were reviewed as a treatment modality for the improvement of sleep quality, sleep latency and waking after sleep onset among the older persons. Mahowald and Bornemann (2007) reported that sleeping disorders in old age was a frequent complaint of elderly patients. But poor sleep was not a normal part of ageing. Sleep problems among the older adults were due to insomnia. To promote sleep non-pharmacological treatments such as relaxation therapy, sleep hygiene, stimulus control, sleep restriction and cognitive and behavioral therapies were given.