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Inadequate sleep-sleep of poor quality or insufficient duration or both-has been linked to health problems ranging from cognitive impairment to compromised immunity. Insomnia occurs more frequently after age 70, and more than half of adults ages 65 and older report at least one chronic sleep complaint. The Pittsburgh Sleep Quality Index is easily used to assess the quality and patterns of sleep in older adults. It consists of 18 questions covering seven areas in which sleep problems occur and can be completed in about 10 minutes. For a free online video demonstrating the use of this index, go to http://links.lww.com/A261.
Madeline Song, age 82, arrived at the ED two days ago, after she fell at home and briefly lost consciousness. (This case is a composite based on my experience.) It was determined that she had a possible subdural hematoma and new-onset anemia, and she was admitted to the medical-surgical unit for observation. On admission she was alert and able to give a health history coherently. Ms. Song has several chronic illnesses: osteoarthritis in both hips, lumbar spinal stenosis, mild congestive heart failure, and hypertension. She has been taking the following prescribed medications: furosemide (Lasix) 40 mg twice daily; oxycodone with acetaminophen (Percocet), two 7.5 mg/325 mg tablets at night; acetaminophen (Tylenol) 1 g twice daily, as needed; and atenolol (Tenormin) 25 mg in the morning. Although it's not prescribed, she also takes ibuprofen (Advil and others) 400 mg up to three times daily "when the pain is bad," as well as a daily multivitamin. Her insurer has authorized a hospital stay of five days, with a longer stay if surgery proves necessary.
The night-shift RN, Harold Bell, has noticed that the lights have been on in Ms. Song's room for two nights. The day-shift nurse has noted that she is sleeping a lot during the day. Mr. Bell finds her sitting in a bedside chair. He introduces himself and says, "I've noticed that you've been awake during the past two nights. Do you have trouble sleeping?" "Yes," Ms. Song says, "sleeping a full night is a rare thing for me, and it's even harder in the hospital."
Watch a video demonstrating the use and interpretation of the Pittsburgh Sleep Quality Index at http://links.lww.com/A261.
Get more information on why it's important for nurses to screen older patients for sleep difficulties, as well as why the Pittsburgh Sleep Quality Index is the right tool for the job.
This is the tool in its original form. See page 48.
Unique online material is available for this article. URL citations appear in the printed text; simply type the URL into any Web browser.
The Pittsburgh Sleep Quality Index (PSQI) provides a subjective measure of sleep quality and patterns.1 The tool focuses on sleep quality during the previous month, although some studies have used shorter periods of sleep (such as two days2 and one week3).
The PSQI, a self-administered questionnaire, includes four open-ended questions and 14 questions to be answered using event-frequency and semantic scales. (The latter use paired words of opposite meaning, such as good-bad.) The tool looks at seven areas: subjective sleep quality, sleep latency (the time it takes to fall asleep), sleep duration, habitual sleep efficiency (the ratio of total sleep time to time in bed), sleep disturbances, the use of sleep-promoting medication (prescribed or over-the-counter), and daytime dysfunction.
The first questions address the patient's usual bedtime and rising time, as well as how long it takes to fall asleep and how many hours of sleep are obtained per night. Next, the assessment quantifies specific physical and psychological events, such as waking during the night, having to use the bathroom, being unable to breathe easily, coughing or snoring, feeling too hot or cold, having bad dreams, and having pain. The patient is also asked how often she or he uses sleep-promoting drugs, how often it's been hard to stay awake during daylight activities, and how often it's been difficult to "keep enthusiasm up to get things done." Last, the patient rates overall sleep quality on a semantic scale ranging from "very good" to "very bad."
While the patient can complete the PSQI independently, a nurse can administer it verbally if the patient has an iv line in the writing hand, for example, or cannot read or write. Sensory and cognitive deficits, literacy level, and language needs should be assessed before beginning. If vision is impaired, the questionnaire can be enlarged. Self-administration can help patients feel empowered and save nurses time, but as with any self-administered tool, there's some risk that directions or questions will be misunderstood.
When administering the PSQI to a patient, the nurse should read the directions and questions exactly or nearly exactly as written; this ensures consistency and reliability. The nurse may also need to engage the patient and encourage participation-for example, making eye contact and ensuring that patients with hearing aids are wearing them. Closing the door and drawing a curtain around the bed reduce noise and secure privacy. (To see the section of the online video that discusses the assessment of sleep using the PSQI, go to http://links.lww.com/A262.)
The PSQI includes a scoring key for calculating a patient's seven subscores, each of which can range from 0 to 3. The subscores are tallied, yielding a "global" score that can range from 0 to 21. A global score of 5 or more indicates poor sleep quality; the higher the score, the worse the quality. (See The Pittsburgh Sleep Quality Index, page 47, for more details.)
Each question measures a specific area in which sleep problems occur. The seven components assessed and their associated questions are as follows:
* Component 1, subjective sleep quality-question 9
* Component 2, sleep latency-questions 2 and 5a
* Component 3, sleep duration-question 4
* Component 4, habitual sleep efficiency-questions 1, 3, and 4
* Component 5, sleep disturbances-questions 5b through 5j
* Component 6, use of sleep-promoting medications-question 6
* Component 7, daytime dysfunction-questions 7 and 8
It takes about 10 minutes to administer the questionnaire and tally the responses.
Although the PSQI has been translated into several languages-including Hebrew, Korean, German, Chinese, and Japanese-the translations may not be readily available; nurses should contact the developers of such translations to request a copy. Having an interpreter administer the tool to non-English speakers can be problematic; individual knowledge and skills vary, and an informal translation may be inaccurate, skewing the results.
To watch the segment of the online video in which an expert discusses how sleep disturbances affect the lives of older patients, go to http://links.lww.com/A263.
Mr. Bell asks Ms. Song if he can ask her some questions about her sleep. Ms. Song agrees, and they begin.
Mr. Bell: "Ms. Song, when have you usually gone to bed?" Ms. Song: "At home I go to bed around 11 PM."
Mr. Bell: "How long has it taken you to fall asleep each night?" Ms. Song: "It usually takes about two hours." Mr. Bell records 120 minutes on the PSQI score sheet.
Mr. Bell: "When have you usually gotten up in the morning?" Ms. Song: "Not until 7 AM."
Mr. Bell: "How many hours of sleep do you get each night?" Ms. Song: "About four."
Mr. Bell explains that next, he'll ask about possible reasons for Ms. Song's sleep difficulties during the past month. He adds, "As I ask each question, I'd like you to think about whether it has happened 'not during the past month,' 'less than once a week,' 'once or twice a week,' or 'three or more times per week.'"
Mr. Bell: "During the past month, have you had trouble sleeping because you can't get to sleep within 30 minutes?" Ms. Song: "Well, almost always."
Mr. Bell: "So, three or more times per week. And during the past month, how often have you had trouble sleeping because you wake up in the middle of the night or early morning?" Ms. Song: "Oh, that happens all the time. Every night I have to get up to go to the bathroom. Those water pills are a big problem."
Mr. Bell: "How often have you had trouble sleeping because you can't breathe well?" Ms. Song: "Oh, never."
Mr. Bell: "How often have you had trouble sleeping because you cough or snore?" Ms. Song: "Well, I don't cough, and I don't think I snore. My husband has never complained."
Mr. Bell: "How often have you had trouble sleeping because you feel too cold?" Ms. Song: "Sometimes in the winter I get cold."
Mr. Bell: "And has it affected your sleep during the past month, including your time in the hospital?" Ms. Song: "No."
Mr. Bell: "How often have you had trouble sleeping because you feel too hot?" Ms. Song: "Never."
Mr. Bell: "How often have you had trouble sleeping because you have bad dreams?" Ms. Song: "Sometimes in my dreams people are chasing me, and I'm afraid they're going to hurt me."
Mr. Bell: "Do you have the bad dreams less than once a week, once or twice a week, or three or more times a week?" Ms. Song: "Those bad dreams come about twice a week. It's hard to shake them."
Mr. Bell: "How often have you had trouble sleeping because of pain?" Ms. Song: "I have pain most of the time. I try to take Tylenol when I go to bed, and sometimes I'll also take a couple of Advils. About once a week I have to take that special Tylenol [oxycodone and acetaminophen], but it makes me groggy in the morning."
Mr. Bell: "So once a week you have trouble sleeping because of pain?" Ms. Song: "Yes."
Mr. Bell: "Are there any other reasons why you've had trouble sleeping during the past month?" Ms. Song: "Sometimes the noise from the subway wakes me up."
Mr. Bell: "How often does that happen?" Ms. Song: "A few times per week."
Mr. Bell: "Three or more times per week?" Ms. Song: "Yes."
The nurse says that he has a few more questions.
Mr. Bell: "During the past month, how often have you taken medicine to help you sleep? This could be prescribed or over-the-counter medicine." Ms. Song: "My doctor won't give me any more sleeping pills. So I tried one that a friend of mine was getting at the drugstore, but it didn't help me much."
Mr. Bell: "And when did you use it?" Ms. Song: "Last week, just one night, and it didn't work."
Mr. Bell: "Now, during the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activities?" Ms. Song: "I don't drive anymore: I can't with my arthritis. My husband tells me that I've been falling asleep when we play mah jong with our neighbors."
Mr. Bell: "So have you been falling asleep once or twice a week or three or more times a week during the past month?" Ms. Song: "Probably once or twice a week."
Mr. Bell: "During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done?" Ms. Song: "I usually get tired by the late afternoon, and then I don't feel like doing much."
Mr. Bell: "Is that happening once or twice a week or three or more times a week?" Ms. Song: "Unfortunately, it's three or more times a week. I wish I could do more."
Mr. Bell: "My last question is this: during the last month, how would you rate your sleep quality overall? Would you describe it as 'very good,' 'fairly good,' 'fairly bad,' or 'very bad?'" Ms. Song: "My sleep has been fairly bad. Can you help me?"
Mr. Bell: "I think there are some ways I can help you tonight and for when you go home. I'll calculate your score, and then we'll talk more."
Using the scoring key, Mr. Bell calculates the subscores as follows: component 1: 2; component 2: 3; component 3: 3; component 4: 3; component 5: 2; component 6: 1; component 7: 3. Ms. Song's PSQI global score is 17. Her major barriers to sleep are nightmares, environmental noise, pain, and nocturia.
Mr. Bell explains to Ms. Song that her PSQI score indicates an overall poor quality of sleep. He explains that sleep-promoting medications won't prevent interruptions to sleep caused by environmental noise, bad dreams, or the need to void. He tells her that he'll talk with the health care team about altering the timing of her diuretic and limiting fluids after 6 PM, as well as perhaps changing her pain medication to one that doesn't cause morning grogginess. He says that he'll arrange for the social worker to talk with her about managing the bad dreams and about follow-up care after she's discharged. Ms. Song says she feels relieved and would like to learn more about sleep. Mr. Bell gives her the National Institute on Aging fact sheet on sleep in older adults (http://www.niapublications.org/agepages/PDFs/A_Good_Nights_Sleep.pdf). After assessing her current pain level-she says, "I'm not really in pain, but the bed's uncomfortable"-Mr. Bell straightens the bed linens and repositions her. Ms. Song says she thinks she may be able to sleep.
Before he goes off duty, Mr. Bell discusses Ms. Song's PSQI results with the day-shift nurse and the rest of the health care team. To reduce nocturia, he suggests that the diuretic be given only in the morning and that the nursing staff offer more fluid before 6 PM and less thereafter. He also requests an order for a consultation with the social worker, who can determine whether counseling and evaluation of the home environment through a community agency might be an appropriate response to Ms. Song's nightmares. For pain, Mr. Bell advocates a change from oxycodone and acetaminophen to transdermal lidocaine (Lidoderm), which might reduce lower back pain without causing morning grogginess. The physician agrees to a trial of transdermal lidocaine during Ms. Song's hospitalization. Last, Mr. Bell discusses Ms. Song's sleep problems with her insurance company's nurse care manager, who can help coordinate care with Ms. Song's community physician and the company's chronic care management team. (For more information, see Catching Those Zs in the Hospital, online only at http://links.lww.com/A420.)
The PSQI has been used in studies with populations including community-dwelling and hospitalized older adults3-6 and people with disorders including depression,7 dementia,8 type 2 diabetes,9 and cardiovascular disease10; it has demonstrated consistent reliability and validity. Data on the psychometric properties of the PSQI are as follows (for an explanation of psychometric properties, see "Define Your Terms," October 2007):
* Reliability. The PSQI has demonstrated acceptable internal consistency with Cronbach's [alpha] coefficients ranging from 0.77 to 0.83, with the lower value reported for a Japanese version of the tool.1,11,12 The PSQI's stability over time is also good, as shown by test-retest Cronbach's [alpha] coefficients of 0.85 to 0.87.1,2
* Validity. The PSQI can distinguish between people who have problems with sleep and people who don't. In the original research, the cutoff score of 5 for the global PSQI score correctly identified the sleep quality of 88.5% of all patients.1
* Sensitivity. The PSQI was shown initially to have a sensitivity of 89.6%, meaning that it could identify those with poor sleep quality almost 90% of the time.1 A subsequent study found the sensitivity to be 98.7%, although it dropped to 93.4% when the cutoff global score was raised from 5 to 6.2 Another study found that sensitivity was 85.7% when the cutoff global score was 5.5.12
* Specificity. The PSQI has been shown to have a specificity of 86.5% in identifying people without poor sleep (those who have global PSQI scores of less than 5).1
Studies using the PSQI have demonstrated that depression predicts sleep problems and sleep problems can predict depression, including among older adults.7,13 For more information about the use of the PSQI in people with depression, go to http://links.lww.com/A421.
The PSQI has also been used with patients with dementia. Boddy and colleagues studied sleep quality in five groups: older adults who were healthy, those with Parkinson's disease with and without dementia, those with Lewy body dementia, and those with Alzheimer's disease.8 PSQI scores were markedly higher in people with Parkinson's disease and Lewy body dementia than in healthy people. (Unexpectedly, people with Alzheimer's disease had the lowest PSQI scores of all, which suggests that "their pathophysiology is anatomically and/or temporally distinct.")
Because cognitive function varies among patients with any type of dementia, nurses should assess the patient's ability to understand the questionnaire before administering the PSQI.
Other tools include the Epworth Sleepiness Scale (ESS; http://www.hartfordign.org/publications/trythis/issue06.pdf) and the Functional Outcomes of Sleep Questionnaire (FOSQ; http://www.atsqol.org/sections/instruments/fj/pages/fosq.html). But the eight-question ESS focuses on excessive daytime sleepiness rather than on the quality of sleep, and the 30-item FOSQ assesses "the impact of disorders of excessive sleepiness" on five domains of everyday living.
Go to http://links.lww.com/A261 to watch a nurse use the Pittsburgh Sleep Quality Index to assess sleep quality in a hospitalized patient and discuss how to administer it and interpret results. Then watch the health care team plan interventions.
View this video in its entirety and then apply for CE credit at http://www.nursingcenter.com/AJNolderadults; click on the How to Try This series link. All videos are free and in a downloadable format (not streaming video) that requires Windows Media Player.
For more information on this and other geriatric assessment tools and best practices go to http://www.ConsultGeriRN.org-the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program. The site presents authoritative clinical products, resources, and continuing education opportunities that support individual nurses and practice settings.
Visit the Hartford Institute site, http://www.hartfordign.org, and the NICHE site, http://www.nicheprogram.org, for additional products and resources. Other useful resources include the American Academy of Sleep Medicine (http://www.aasmnet.org), the National Center on Sleep Disorders Research (http://www.nhlbi.nih.gov/about/ncsdr), and the National Sleep Foundation (http://www.sleepfoundation.org).
Visit http://www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
1. Buysse DJ, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28(2):193-213. [Context Link]
2. Backhaus J, et al. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res 2002;53(3):737-40. [Context Link]
3. Lai HL. Self-reported napping and nocturnal sleep in Taiwanese elderly insomniacs. Public Health Nurs 2005;22(3):240-7. [Context Link]
4. Dogan O, et al. Sleep quality in hospitalized patients. J Clin Nurs 2005;14(1):107-13. [Context Link]
5. Byles JE, et al. The experience of insomnia among older women. Sleep 2005;28(8):972-9. [Context Link]
6. Liu X, Liu L. Sleep habits and insomnia in a sample of elderly persons in China. Sleep 2005;28(12):1579-87. [Context Link]
7. Motivala SJ, et al. Impairments in health functioning and sleep quality in older adults with a history of depression. J Am Geriatr Soc 2006;54(8):1184-91. [Context Link]
8. Boddy F, et al. Subjectively reported sleep quality and excessive daytime somnolence in Parkinson's disease with and without dementia, dementia with Lewy bodies and Alzheimer's disease. Int J Geriatr Psychiatry 2007;22(6):529-35. [Context Link]
9. Knutson KL, et al. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med 2006;166(16):1768-74. [Context Link]
10. Newman AB, et al. Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study. J Am Geriatr Soc 1997;45(1):1-7. [Context Link]
11. Carpenter JS, Andrykowski MA. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res 1998;45(1 Spec No):5-13. [Context Link]
12. Doi Y, et al. Psychometric assessment of subjective sleep quality using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J) in psychiatric disordered and control subjects. Psychiatry Res 2000;97(2-3):165-72. [Context Link]
13. Chapman JB, et al. Sleep quality and the role of sleep medications for veterans with chronic pain. Pain Med 2006;7(2):105-14. [Context Link]
Once thought of as a "passive, dormant" part of daily life,1 sleep is now understood to include vital physiologic processes: it helps to "maintain mood, memory, and cognitive performance [and] plays a pivotal role in the normal function of the endocrine and immune systems."2 But many older adults may not be getting adequate sleep. In 2003 the National Sleep Foundation polled 1,506 older adults ages 55 to 84 and found that about two-thirds had one or more symptoms of a sleep problem "at least a few nights a week."3 The prevalence of insomnia rises with age, affecting 23% to 41% of adults ages 70 and older, with women ages 80 to 89 having the highest prevalence rate, according to one review.4 And a large epidemiologic study of more than 9,000 adults ages 65 and older found that more than half reported at least one chronic sleep problem "occurring most of the time."5
Sleep disturbances or deprivation or both have been linked with a range of negative outcomes, including compromised endocrine and immune function, cognitive impairment, hypertension, impaired healing of damaged tissues, and obesity, among others.2,6,7 One study found that sleep duration and quality were predictors of glycemic control in patients with type 2 diabetes.6 When the patients' quality of sleep improved, their glycemic control (as measured using glycosylated hemoglobin levels) improved also. A recent review found that 17 of 23 cross-sectional studies in adults "supported an independent association between short sleep duration and increased weight," although the strength of the association waned with age.8 In the Cardiovascular Health Study, 5,201 adults 65 years of age and older were surveyed regarding sleep disturbance. The researchers concluded that people with "confirmed angina were 1.6 times more likely to report difficulty falling asleep," although it wasn't clear whether poor sleep caused or resulted from the heart condition.9 The National Institute for Neurological Disorders and Stroke notes that sleep deprivation can cause or exacerbate confusion, depression, and pain.10 A lack of or inadequate sleep contributes to slowed responses and difficulty concentrating and making decisions, which may explain in part why older adults who sleep poorly fall more often in the home11 and have more accidents while driving.1
What are the costs associated with poor sleep? Insomnia's fiscal costs are wide ranging. They stem from vehicular accidents caused by driver fatigue, work accidents related to fatigue-related attention deficits, sleep assessments, and pharmacologic and nonpharmacologic interventions to treat sleep disturbances. A 1994 review of the economic effects of insomnia estimated its annual fiscal cost to be $92.5 billion to $107.5 billion in the United States alone.12 The current annual cost is probably higher. In a recent retrospective study of 75,558 elderly patients with insomnia and 75,558 without insomnia, researchers determined that direct health care costs-inpatient, outpatient, ED, and pharmacy costs for all diseases within a six-month period-averaged $1,143 higher among patients with insomnia than among controls.13
Early detection and intervention for sleep disturbances among older adults can likely help reduce the financial burden associated with sleep-related accidents and illness and promote better quality lives.12,13 (For a related article, see Sleep Disruption in Older Adults, May 2007.)
For more information on this and other geriatric assessment tools and best practices go to http://www.ConsultGeriRN.org-the clinical Web site of the Hartford Institute for Geriatric Nursing, New York University College of Nursing, and the Nurses Improving Care for Healthsystem Elders (NICHE) program.
Visit the Hartford Institute site, http://www.hartfordign.org, and the NICHE site, http://www.nicheprogram.org, for additional products and resources. For example, on the Hartford site you will find an interactive clinical vignette called "Geriatric Syndromes-Falls and Nutrition/Fluids" that includes use of the Katz ADL and Lawton IADL tools.
Go to http://www.nursingcenter.com/AJNolderadults and click on the How to Try This link to access all articles and videos in this series.
1. National Sleep Foundation. Let sleep work for you. 2007. http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2421185/k.7198/Let_Sleep_Wor. [Context Link]
2. National Sleep Foundation. Sleep-wake cycle: its physiology and impact on health. Washington, D.C.; 2006. http://www.sleepfoundation.org/atf/cf/%7BF6BF2668-A1B4-4FE8-8D1A-A5D39340D9CB%7D. [Context Link]
3. National Sleep Foundation. 2003 Sleep in America poll. Washington, D.C.; 2003 Mar 10. http://www.kintera.org/atf/cf/%7BF6BF2668-A1B4-4FE8-8D1A-A5D39340D9CB%7D/2003Sle. [Context Link]
4. Lichstein KL, et al. Insomnia in the elderly. Sleep Med Clin 2006;1(2):221-9. [Context Link]
5. Foley DJ, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995;18(6):425-32. [Context Link]
6. Knutson KL, et al. Role of sleep duration and quality in the risk and severity of type 2 diabetes mellitus. Arch Intern Med 2006;166(16):1768-74. [Context Link]
7. Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med 2008;24(1):51-67. [Context Link]
8. Patel SR, Hu FB. Short sleep duration and weight gain: a systematic review. Obesity (Silver Spring) 2008. [Context Link]
9. Newman AB, et al. Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study. J Am Geriatr Soc 1997;45(1):1-7. [Context Link]
10. National Institute of Neurological Disorders and Stroke. National Institutes of Health. Brain basics: understanding sleep. Bethesda, MD; 2007 May 21. NIH Publication No.06-3440-c. http://www.ninds.nih.gov/disorders/brain_basics/understanding_sleep.htm. [Context Link]
11. Brassington GS, et al. Sleep problems as a risk factor for falls in a sample of community-dwelling adults aged 64-99 years. J Am Geriatr Soc 2000;48(10):1234-40. [Context Link]
12. Stoller MK. Economic effects of insomnia. Clin Ther 1994;16(5):873-97; discussion 854. [Context Link]
13. Ozminkowski RJ, et al. The direct and indirect costs of untreated insomnia in adults in the United States. Sleep 2007;30(3):263-73. [Context Link]
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