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Chronobiol Med > Volume 6(2); 2024 > Article
Gnanandurai and Kasimariyappan: Effect of Care-as-Usual Plus Intervention on Sleep, Fatigue, and Quality of Life Among Geriatric Persons With Insomnia

Abstract

Objective

Aging is the process of growing old, regardless of chronological age, which begins at conception and ends at death. Sleep-related phenomena reported more frequently by older than by younger adults are sleeping problem, daytime sleepiness, daytime napping, and the use of hypnotic drugs. The study aimed to determine the effect of care-as-usual plus intervention on sleep, fatigue, and quality of life of geriatric persons with insomnia.

Methods

Fifty elderly individuals having sleep disturbance, fatigue, and affected quality of life were selected based on convenient sampling method and divided into two groups. A pre-test and post-test evaluation were administered with the Insomnia Severity Index, Daily Fatigue Impact Scale, and Older People Quality of Life–Brief.

Results

A statistical analysis was performed using Wilcoxon signed rank test and Mann–Whitney U test. The results indicated that care-as-usual plus intervention significantly improved sleep, fatigue, and quality of life among geriatric individuals with insomnia (p=0.002).

Conclusion

The study concluded that care-as-usual plus intervention was effective among geriatric population on improving sleep, fatigue, and quality of life.

INTRODUCTION

Growing old is the process of aging, irrespective of the age, which is measured from conception to death [1]. It is a natural physiological and developmental process that starts at conception and concludes at death, gradually reducing one’s functioning capacities [2].
According to the World Health Organization (WHO), the majority of industrialized nations recognize individuals who are chronologically advanced and above as elderly. Traditionally, 65 years of age has been considered the threshold for being elderly. The United Nations defines the older population as those who are 60 years of age or older, classified as follows: individuals aged up to 76 years are considered aged, those up to 85 years are considered old, and those more than 85 years are considered quite old [2]. A continuous drop in an organism’s age-specific fitness components brought on by internal physiological degradation [3]. CIMAmong the elderly, prevalent issues include heart disease, cerebrovascular accident, arthritis, diabetes, dementia, Alzheimer’s disease, respiratory illnesses, falls, loss of vision and hearing, psychological issues, and restricted bodily function.
The most significant factor linked to the rising incidence of sleep diseases is advanced age. Among the sleep-related phenomena that older adults report more commonly than younger adults are hypnotic drug use, daytime sleepiness, napping during the day, and sleeping problems. One of the main types of sleep problems is dyssomnia, with sleep apnea, nocturnal myoclonus, restless legs syndrome, and primary insomnia being the most common. Other conditions that frequently affect older persons’ ability to sleep include dyspnea, heartburn, and nocturia [4]. Poor sleep is a result of not having a daily routine or social or professional responsibilities. A 70-year-old who is in good health may wake up multiple times during the night without experiencing any medical issues.
Older individuals’ sleep difficulties could be caused by any of the following: Alzheimer’s disease, alcohol, modifications to the body’s internal clock leading to early evening drowsiness, chronic long-term illnesses including heart failure, state of the nerve system and brain, not putting in a lot of activity, discomfort brought on by illnesses like arthritis, often urinating during the night, and stimulants like nicotine and caffeine [5,6].
The symptoms include having trouble falling asleep, having trouble recognizing day from night, waking up early in the morning, and frequently waking up during the night (for example owing to nocturia. It is often acknowledged that the prevalence of insomnia symptoms rises with age, reaching over 50% in individuals 69 years of age and older. The yearly prevalence rates of insomnia [7].
Occupational therapy is a procedure that helps people of all ages—from young children to the elderly—develop, maintain, and regain the abilities necessary to carry out meaningful and essential everyday tasks [8]. In order to ensure that everyone in the patient’s support team—parents, guardians, teachers, and so on—understands their responsibilities regarding the patient’s care plan, occupational therapists also train and collaborate with them. Occupational therapists assist senior citizens with daily tasks like eating, dressing, and taking a shower by teaching them exercise and rehabilitation strategies. Occupational therapists assist patients in increasing their range of motion, strength, and dexterity in their fine and fundamental motor abilities [9].
The goal of geriatric rehabilitation is to improve residual junctional capability and restore functioning in older adults with debilitating impairments through a multidisciplinary, diagnostic, and evaluative approach [10]. Despite the incapacitating effects of disease and accidents, the goal of geriatric rehabilitation is to restore and maintain the optimum level of function. This includes maintaining independence and the procedure. The goal of enhancing the quality of geriatric rehabilitation is to replace the conventional disease- or illness-oriented model with an interdisciplinary team approach that emphasizes function [11]. Rehabilitation is typically required to make up for functional losses following acute illness, trauma, and prolonged inactivity that results in concomitant mental and physical decline. The restoration and maintenance of an optimal level of function, despite the incapacitating impact of illness and trauma, are the aims of geriatric rehabilitation [12].
Occupational therapists believe that meaningful and purposeful activities have the therapeutic potential to improve health and well-being. Occupational therapists provide care for a person’s emotional, cognitive, physical, and social aspects within the framework of their wider lifestyle [13]. The main focus of occupational therapy is helping patients achieve functional independence with a variety of self-care skills. Training may include diverse community skills including shopping, laundry, paying bills, and balancing a chequebook, as well as activities of daily living like eating, swallowing, grooming, bathing, dressing, toileting, and personal hygiene [14]. Occupational therapists can help residents of senior living facilities increase their social interaction and leisure activity involvement [15].
Researchers report that sleeplessness and fatigue are more prevalent among geriatric population. For further evidence in 2020 a pilot randomized controlled trial was conducted to examine the effectiveness of occupational therapy-based sleep intervention on quality of life and fatigue in patients with multiple sclerosis [16]. Although insomnia among geriatric population raises concerns among healthcare providers there is a paucity of research on insomniac geriatric population. Considering the implications of insomnia among geriatric persons, this paper draw attention to insomnia, fatigue and quality of life of geriatric persons with insomnia.
Even though the previous studies explained about the significant importance of effectiveness of occupational therapy-based intervention on improving sleep, fatigue and quality of life in patients with multiple sclerosis [16] but there is no study on effectiveness of care-as-usual plus intervention for improving sleep, fatigue, and quality of life among geriatric persons with insomnia.
Considering the above facts to benefit geriatric persons, careas-usual plus intervention proves to be beneficial. To develop the further theory, it was important to investigate the effectiveness of care-as-usual plus intervention on improving sleep, fatigue, and quality of life among geriatric persons with insomnia. Thus, this study will be useful to ascertain the importance of care-as-usual plus intervention on improving sleep, fatigue, and quality of life among geriatric persons with insomnia.
In total, 50 samples with subthreshold to moderate insomnia, affected quality of life, and fatigue were recruited and samples with severe insomnia was excluded. Age group between 65–86 years and geriatric people with sleep disturbance were included. Geriatric people who have severe cognitive impairment and geriatric people who have physical disability and geriatric people with other psychotic symptom were excluded from the study. The subjects’ sleep, fatigue, and quality of life were measured using Insomnia Severity Index (ISI), Daily Fatigue Impact Scale (DFIS), and Older People Quality of Life–Brief (OPQOL-Brief), and cognitive scoring were measured using Mini-Mental Status Examination (MMSE) [16].

METHODS

The recruited participants were explained about the objectives of the study and obtained a consent form. Demographic details and clinical details, including their sleep pattern, quality of life, and fatigue were measured using ISI, DFIS, and OPQOL-Brief, and cognitive scoring were measured using MMSE. The samples were divided equally, 25 samples in the experimental group and 25 samples in the control group. After the baseline data is obtained, the experimental group underwent care-as-usual plus intervention. The therapy consists of totally 72 sessions, each session last for about 45 minutes (Table 1). Pre-test was taken before the therapy session was introduced and post-test was assessed on last session. The experimental group underwent care-as-usual plus intervention whereas the control group underwent conventional occupational therapy sessions. After the completion of the intervention session (36 sessions), the OPQOL, MMSE, DFIS, and ISI were used in both the control and experimental group participants to find out the effectiveness of care-as-usual plus intervention on sleep, fatigue, and quality of life among geriatric persons with insomnia (Figure 1).

Statistical method

A quantitative study was carried out by the analysis of inferential statistics in this study. Mean and standard deviation (minimum– maximum) were used as a measurement criteria on repeated basis for the result. The descriptive statistics examined records distribution to summarize the data. The results were measured and categorized in number (%).
The significance levels of p values are classified as follows: strongly significant (p<0.01), moderately significant (0.01<p<0.05), and suggestively significant (0.05<p<0.10). Since the sample size (n=50) was selected using convenient sampling, nonparametric method was used to test the statistical differences between pre-test and post-test scores of control and experimental groups. Mann–Whitney U test and Wilcoxon signed rank test were used to test the statistical differences between pre-test and post-test scores of both the group. Mann–Whitney U test was used in finding hypothesis being tested identifies whether there exists statistically significant difference in consideration of the treatment given. An alpha level of p=0.05 was measured to be statistically significant. The statistical analysis was conducted using IBM SPSS version 23.0 (IBM Corp., Armonk, NY, USA).

RESULTS

Table 2 presents the outcomes of care-as-usual plus intervention therapy, assessed through DFIS, ISI, and OPQOL scores. Post-test DFIS scores differed significantly between experimental and control groups (13.0 vs. 38.0; p<0.001) (Figure 2A). Similarly, significant differences were observed in post-test ISI scores (19.1 vs. 31.9; p=0.002) (Figure 2B) and OPQOL-Brief scores (16.08 vs. 34.92; p<0.001) (Figure 2C), indicating improved outcomes in the experimental group compared to controls.

DISCUSSION

The study aimed to find out the effect of care-as-usual plus intervention on sleep, fatigue, and quality of life among geriatric persons with insomnia. A total of 50 samples were selected using convenient sampling and allocated to experimental and control groups which consists of 25 samples each. The age of the selected population ranged from 65–85. The study included both male and female participants. The levels of insomnia in both experimental and control group were measured by ISI, fatigue was measured using DFIS, and quality of life was measured using OPQOL-Brief. The experimental group underwent care-as-usual plus intervention for a period of 6 months, three sessions per week with a duration of 45 minutes per session whereas conventional occupational therapy was given to control group. The effectiveness of the intervention was analyzed by comparing the pre-test and posttest values of the control group and experimental group.
Sleep is a normal reversible, recurrent state of reduced responsiveness to external stimulation accompanied by complex and predictable changes in physiology [17]. This study showed significant and positive results in improving sleep, fatigue, and quality of life in geriatric population using care-as-usual plus intervention. This is well aligned with a pilot randomized clinical trial study conducted to examine the effectiveness of occupational therapybased sleep intervention on quality of life and fatigue in patients with multiple sclerosis. Occupational therapy plus intervention group significantly improved across all items and was found to be a useful strategy in improving quality of life and fatigue in patients with multiple sclerosis [16].
Fatigue is often described as a lack of energy and motivation, both physical and emotional. Fatigue is also a response to physical and mental activities [18]. In view of the many studies pointing to fatigue management and its importance, current study showed significant improvement in fatigue among geriatric population and thus similar results were supported by a research study on occupational therapy treatment for management of fatigue in individuals with multiple sclerosis. The intervention was based on a 5-week program and follow-up was performed 3 months after the end of administration. Post-test after the 3 months of intervention concluded that there is statistically significant data for all outcomes with p<0.05 [19].
WHO defines quality of life as an individual perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectation, standards, and concern [20]. This quasi-experimental study demonstrated higher level of improvement of quality of life among geriatric population and thus in a similar vein, a study on occupational therapy to improve the quality of life for older people with mild to moderate dementia in a memory clinic. The pilot data reveals that newly developed occupational therapy program can possibly improve some of the parameters of measurement of physical performance, mood, memory, and quality of life in older patients with cognitive impairment [21].
Thus, this study showed that care-as-usual plus intervention was effective among geriatric population on improving sleep, fatigue, and quality of life.

Limitation

The limitations include a small sample, the study was not compared by gender differences. The study was conducted only for shorter duration, since convenient sample technique was used, the generalization of the result could not be done.

Conclusion

This study demonstrates the effectiveness of care-as-usual plus intervention in significantly improving sleep, reducing fatigue, and enhancing quality of life among geriatric individuals with insomnia. Statistical analysis revealed a highly significant improvement in the experimental group compared to the control group following the intervention. These findings suggest that integrating care-as-usual plus intervention can effectively address sleep disturbances, fatigue, and overall quality of life in older adults with insomnia. Moving forward, healthcare strategies may consider adopting this approach to enhance outcomes for this population.

NOTES

Conflicts of Interest

The authors have no potential conflicts of interest to disclose.

Availability of Data and Material

The datasets generated or analyzed during the study are not publicly available due to request from their caregivers but are available from the corresponding author on reasonable request.

Author Contributions

Conceptualization: Benielraja Gnanadurai. Funding acquisition: Preethi Mariyappan. Investigation: Preethi Mariyappan. Methodology: Preethi Mariyappan. Project administration: Benielraja Gnanadurai. Validation: Benielraja Gnanadurai. Supervision: Benielraja Gnanadurai. Visualization: Preethi Mariyappan. Writing—original draft: Preethi Mariyappan. Writing—review & editing: Preethi Mariyappan, Benielraja Gnanadurai.

Funding Statement

None

Acknowledgments

None

Figure 1.
Flow diagram of the study. ISI, Insomnia Severity Index; DFIS, Daily Fatigue Impact Scale; QPQOL-Brief, Older People Quality of Life–Brief.
cim-2024-0006f1.jpg
Figure 2.
Mean comparison of post-test DFIS (A), ISI (B), and OPQOL-Brief (C) scores of control and experimental groups. ISI, Insomnia Severity Index; DFIS, Daily Fatigue Impact Scale; QPQOL-Brief, Older People Quality of Life–Brief.
cim-2024-0006f2.jpg
Table 1.
Details on the actual intervention content consisting of 72 sessions
Sessions Details of the intervention
Session 1–2 Pre-test was done by administering OPQOL–Brief, DFIS, and ISI.
Session 3–4 Introduction of the therapist and brief explanation about the therapy was given to the selected population. Education about sleep disorder.
Gathering information about their occupational profile of sleep and day time work routine.
Session 5–6 Assessing their bedroom and explaining in detail about temperature, noise, light of bedroom.
Session 7–8 Education about the importance of aerobic exercise like walking, and basic exercise including both upper extremity and lower extremity.
Session 9–10 Daily activity schedule was set based on occupational profile.
Session 11–12 Environmental modification was done by modifying the environment like light, temp, noise etc.
Session 13–14 Introducing Jacobson progressive muscle relaxation. Leisure time activity was also introduced.
Session 15–16 Recreational activity was scheduled to kill time during morning hours and also to avoid morning sleep cycle (activity: free drawing, addressing performance deficits/barriers to activities of daily living particularly bed mobility and toileting).
Session 17–18 Group therapy. Topic–talking about one self.
Session 19–20 Reading newspaper and sharing any knowledge from the given paper.
Session 21–22 Engaging clients in deep breathing exercise.
Session 23–24 Feedback about previous sessions was conducted.
Session 25–26 Aerobic exercises were given.
Session 27–28 Patient education about decreasing caffeine intake, sleep hygiene, smoking cessation, and alcohol intake.
Session 29–30 Jacobson progressive muscle relaxation.
Session 31–32 Carom board activity was given as a part of group therapy.
Session 33–34 Review about previous sessions and providing necessary changes.
Changes in activity schedule was also made.
Session 35–36 Activity: gardening.
Session 37–38 Aerobic exercises were given.
Session 39–40 Modifying the environment based on clients need.
Session 41–42 Memory games was conducted.
Session 43–44 Jacobson progressive muscle relaxation.
Session 45–46 Group based activity: remembering the past through songs and sharing their memories with team mates.
Session 47–48 Activity: coconut shell painting.
Session 49–50 Jacobson progressive muscle relaxation, breathing exercises was administered.
Session 51–52 Visiting garden and watering their saplings.
Session 53–54 Sharing pictures and explaining memories associated with those pictures.
Session 55–56 Education about time management for doing their occupation and keeping balance among them.
Session 57–58 The last modifications and final consultation were given.
Session 59–60 Group based activity: musical chair.
Session 61–62 Aerobic exercises and visiting garden.
Session 63–64 Teaching coping skills, stress management and time management for doing occupation and keeping balance among them.
Session 65–66 JPMR, engaging clients in deep breathing exercise.
Session 67–68 Activity: story narration.
Session 69–70 Review all exercises, trainings, and final advice. Received feedback.
Session 71–72 Post-test was done using OPQOL-Brief, DFIS, and ISI.

OPQOL-Brief, Older People Quality of Life–Brief; DFIS, Daily Fatigue Impact Scale; ISI, Insomnia Severity Index; JPMR, Jacobson progressive muscular relaxation

Table 2.
Statistical analysis of post-test assessment of experimental and control groups
Test Post-test score
U p
Control (n=25) Experimental (n=25)
DFIS 38.0 13.0 -6.099 <0.001*
ISI 31.9 19.1 -3.134 0.002*
OPQOL-Brief 34.92 16.08 -4.598 <0.001*

* significant at 1% (p<0.01) level.

ISI, Insomnia Severity Index; DFIS, Daily Fatigue Impact Scale; QPQOL-Brief, Older People Quality of Life–Brief

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