Sleep is a basic physiological need that all human beings experience. It is such an important and overwhelming need that we spend about one third of our lives asleep. Unsatisfactory sleep results in irritability, increased pain sensitivity, decreased daytime alertness, and apathy (Webb, 1975). Satisfactory sleep enhances our sense of well-being (Shirmer, 1983). The adverse effects that result from sleep loss are of particular concern to the aged, who may already be experiencing decreased cognitive or physical functioning from other causes (Johnson, 1988). When these factors are combined, the aged are particularly vulnerable to environmental hazards leading to falls, burns, and automobile accidents. Institutionalization could result (Burnside, 1988).
To ensure a good night’s sleep, many people follow a bedtime routine before going to bed. Mangusson (1953) suggested that the ritual of performing certain activities for an hour every night before retiring is of great significance to some people. Sleep is disturbed when these activities are neglected. For others, the awareness of these routines is not particularly important. These individuals may be unaware that they have a bedtime routine because it may be as inconspicuous as the way they arrange their bodies and covers for sleep. Even without this awareness, these acts provide comfort and encourage sleep onset (Luce & Segal, 1969).
Hauri (1968) investigated the influence on each of the 15 subjects for these three pre-sleep activities: 6 hr of relaxation, 6 hr of concentrated study, and 6 hr of strenuous physical activity. None of these activities influenced sleep stability. In contrast, Baekeland (1968, 1969) found that watching stressful films and listening to tape recordings before bedtime influenced subjects’ sleep patterns and dream content. Johnson (1986, 1988) found that institutionalized and noninstitutionalized older women reported sleep disturbances regardless of the use of bedtime routines. However, those disturbances were more pronounced in subjects who did not follow a certain routine each night.
Several researchers (Goldson, 1981; Johnson, 1985; Regestein, 1980; Webb, 1975) have found that sleep patterns change with age. By the age of 60, the number of nocturnal awakenings increases from about one to four to six per night (Hayter, 1980). The time to sleep onset increases from about 5 min to 18 min in the late 70s. By 90 years of age, total sleep time has decreased to about 6 hr per night (Regestein, 1980).
Sleep patterns in the aged may be further disturbed by the lack or disruption of bedtime routines. Although men demonstrate greater objective sleep changes as they age, women report greater sleep disturbances (Baekeland & Hoy, 1971; Johnson, 1985; Webb 1975). These objective and subjective sleep changes may make both older men and women vulnerable to the perceived lack of a bedtime routine. Although limited research has been conducted to assess the subjective sleep changes in the aged, there is a lack of research that identifies their bedtime routines and how these routines may differ according to gender. This lack of knowledge makes the comprehensive care of the noninstitutionalized elderly difficult.
Therefore, the purpose of this study was to identify and describe the self-reported nocturnal sleep patterns and bedtime routines of older men and women living in their own homes. The relationship and differences between these routines and patterns according to gender were also investigated.
RESULTS
The results of this study indicate that all of the subjects perceived some disturbance in their sleep patterns. As can be seen, older women perceived their sleep patterns to be more disturbed than did older men.
Of the 24 women reporting a bedtime routine, the majority washed their faces, bathed, brushed their teeth, and prayed before going to bed. Eight women reported watching television, 8 read, and 9 listened to music before retiring. None of the women reported taking medication, snacking, or drinking as part of their routine. All of the 24 women indicated that their routine was very important to them.
Of the 23 men reporting a bedtime routine, the majority watched television, snacked, had a drink, and brushed their teeth. Ten men reported walking the dog as part of their routine, while 6 men reported bathing as a nightly activity. In contrast to the older women, none of the men read, listen to music, or prayed before going to bed. They also indicated that their routine was very important to them.
When the relationship between the self-reported nocturnal sleep patterns and perceptions of following a bedtime routine was investigated, it was found that subjects with a routine had fewer sleep complaints than those without a routine.
Looking at the differences between the self-reported sleep patterns of subjects who did and did not perceive having a routine, it was found that sleep was least disturbed in older men who followed a routine. They tended to feel calmer at bedtime, have shorter sleep onset, and have fewer awakenings than older women with or without a routine and older men without one. They also perceived moving less while asleep, sleeping more soundly, and feeling more refreshed on awaking. As a result, older men with a routine reported being more satisfied with their sleep than subjects in the other three groups.
Differences among these groups also revealed that older women without a bedtime routine reported the most disrupted sleep patterns. They had longer sleep onset latencies, awakened more often, perceived more movement while asleep, and had less total sleep time than the other subjects. Consequently, they were the least refreshed on awaking and the most dissatisfied with their sleep.
DISCUSSION
As suggested by previous researchers, the elderly do perceive changes in their sleep patterns (Regestein, 1980; Webb, 1975). These changes are usually disturbing to them, but are particularly distressing to older women (Johnson, 1985). In this study, the older men perceived fewer sleep pattern disturbances than older women. They felt calmer at bedtime, fell asleep faster, awakened less often, and moved less while asleep. Consequently, they felt more refreshed in the morning and more satisfied with their sleep than the women. These findings are supported by Hayter (1980) and Webb (1975) who found that men do not complain of sleep disturbances as often as women.
Bedtime routines were very important to all of the subjects who perceived having one. These findings agree with those of Luce and Segal (1969) and Mangusson (1953) and suggest that habitual pre-sleep activity is comforting to the individual and enhances sleep. Interestingly, the activities composing the routines of older men and women differ. Men tended to include food, drink, television, and walking in their pre-sleep routine. Women preferred more hygienic activities, prayed, read, and listened to music. They also watched television. Sleep was more satisfying for those who followed a routine, particularly the men. It may be that their activities are more relaxing to them than those selected by the women. Food and drink are associated with comfort and satisfy basic needs, while light exercise enhances sleep.
It is also possible that because women perceive their sleep as more disturbed, their routines are not as comforting to them. The routines do, however, provide some satisfaction, because the sleep patterns of older women with a routine are less disturbed than those without one.
There are several implications of these findings for nurses who work with the noninstitutionalized elderly. First, it is important to recognize that sleep patterns do change with age. Although older men may be less disturbed by these changes than older women, they are not exempt from them. They did, in fact, perceive some disruptions in their sleep. Consequently, nurses should expect to hear concerns about unsatisfactory sleep from their older clients. Nurses should carefully assess the aged adult’s sleep patterns, the occurrence of any noticeable changes in these patterns, and how these changes affect them. Because the lack of sleep can interfere with daytime alertness and functioning, older clients with disrupted sleep patterns should be cautioned about performing activities requiring attention to safety. Decreased attentiveness can result in falls and automobile accidents (Burnside, 1988). It may also interfere with the completion of household tasks and social activities.
Second, these findings will assist the nurse to realize that bedtime routines can enhance the sleep patterns of older adults. For those individuals already following a routine, its continued use should be encouraged. For clients who do not recognize following a certain routine, the nurse should assess and identify activities that may be used each night to enhance sleep. This is particularly important for older women. Routines identified in this study as conducive to relaxation can be suggested to those clients who have no pre-sleep activity. The nurse may also suggest that women try some of the activities found useful by men and vice versa.
Finally, it is important to remember that further research is needed to identify nonpharmacological interventions to enhance sleep satisfaction in older adults. Additional research is also needed to further identify the sleep patterns of the elderly and how they are influenced by various factors, such as medication, illness, institutionalization, and diet. Because nurses have contact with many aging clients and hear concerns about their sleep, it is logical that they should be on the forefront of this research.