RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

A STUDY TO ASSESS THE EFFECTIVENESS OF DEEP BREATHING

EXERCISES IN PROMOTING SLEEP AMONG OLDER ADULTS IN SELECTED

OLD AGE HOMES AT KOLAR DISTRICT.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

MR.DENNIS.D.ROBINSON

A.E. & C.S. PAVAN COLLEGE OF NURSING KOLAR,KARNATAKA.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1.NAME OF THE

CANDIDATE

MR.D.DENNIS ROBINSON

1ST YEAR,M.Sc.NURSING.

2.NAME OF THE

INSTITUTION

A.E & C.S. PAVAN COLLEGE OF NURSING

BANGALORE CHENNAI BY PASS ROAD,

KOLAR-563101.

3.COURSE OF THE

STUDY AND SUBJECT

M.SC. NURSING 1ST YEAR

MEDICAL AND SURGICAL NURSING

4.DATE OF ADMISSION

TO THE COURSE09-06-2010

5. TITLE OF TOPIC

A STUDY TO ASSESS THE

EFFECTIVENESS OF DEEP BREATHING

EXERCISES IN PROMOTING SLEEP

AMONG OLDER ADULTS IN URBAN

AREAS AT KOLAR DISTRICT,

KARNATAKA.

2

6. BRIEF RESUME OF INTENDED WORK

INTRODUCTION

“Sleep - the most beautiful experience in life.”

(W.C.FIELDS)

Hypno-, a word of Greek origin means sleep. It is derived from the ancient

Greek God of sleep “Hypnos”. Somnus, the ancient Roman god of sleep from

which a root word called somnia is derived. Sleep is necessary and vital biological

function. It is essential to a person's physical and emotional well being. Without

adequate rest, the brain's ability to function can quickly deteriorate. An average of 7

or 8 hours of sleep each night is necessary to feel fully alert during the day. This is

usually also true for people age 65 or older4.

Sleep is actually an active and organized process. Sleep is a physical and

mental resting state in which a person becomes relatively inactive and unaware of

the environment. In essence, sleep is a partial detachment from the world, where

most external stimuli are blocked from the senses5.

Sleep is governed by a number of factors. Some of the factors are under our

control, such factors helps us to check our sleep level, and there are some factors

beyond our control. Chief among these is our internal biologic clock that regulates

our biologic rhythm (also called a circadian rhythm) over a 24-hour period. Sleep

also has an internal organization regulated by different areas of the brain2.

Normal sleep physiology is divided into non–rapid eye movement (NREM)

and rapid eye movement (REM) sleep. NREM sleep is further divided into

progressively deeper stages of sleep: stage N1, stage N2, and stage N3 (deep or

delta-wave sleep)9. As NREM stages progress, stronger stimuli are required to result

3

in an awakening. Stage R sleep (REM sleep) has tonic and phasic components.

Most dreaming takes place during REM sleep.As stated earlier, circadian rhythms

also known as the biological clock determines the sleep. A cycle that lasts 24 hours

is called circadian. The body’s internal clock (circadian rhythms) plays an

important role in regulating sleep/wake cycles. Circadian rhythms change over the

lifespan, and older adults often find their sleep affected by these changes10.

Sleep patterns and sleep quality change throughout the lifespan. Normal sleep

changes are expected and predictable as people enter later adulthood. The most

notable change in older adults’ sleep architecture is a decrease in the amount of

deep sleep (stages 3). In addition, the percentage of REM sleep decreases slightly

in older age. Older adults’ sleep is typically more fragmented; that is, sleep is more

often interrupted by wakefulness. In fact, the change in sleep need across

adulthood is minimal; however, many factors impact the ability of older adults to

obtain sufficient sleep at night8.

By the time an adult is over 65 years old, his or her sleep-wake cycle may not

seem to work as well as it did when he or she was younger. As the age progresses,

the body makes less of the chemicals and hormones that help us sleep well (growth

hormone and melatonin).Older adults are more likely to report daytime sleepiness

and to nap as compared to younger adults. Typically, the timing of sleep shifts to an

earlier time (ie, advances) from adulthood to old age. For some individuals, this

change in the timing of sleep is benign; however, for others this change is

problematic12.

If the sleep problems are not treated or if not taken any measures to alleviate

these problems may to lead consequences. The consequences of untreated sleep

problems may include significant emotional, behavioral, and cognitive dysfunction.

4

The magnitude of these sequelae is inversely proportional to overall ability to adapt

and develop in spite of the sleep disturbance12.

The main purpose of this study is to promote sleep among older adults as the

sleep disturbance is more common and prevailing among the older age group.

Promotion of sleep aids in better and healthier life style by which most of the

serious health consequences and imbalance can be avoided. The prevalence of sleep

disorders in older age group is about 50%. Hence, old age people are the extreme

ones who suffer with sleeping disorders and I chose this area of speciality to

conduct the study and find ways for undisturbed sleep for older adults.If these

groups of people are educated the outcome would be beneficial to them and can lead

a normal healthy life30.

6.1. NEED FOR THE STUDY

Sleep is central to health and well-being, but as people get older, the quality of

their sleep can deteriorate. Many older people are prescribed medications to help

them sleep, but these can lead to problems, and we have been exploring the possible

role that technology could play to help maintain and improve sleep. This is a really

novel approach for supporting quality sleep in older people and the project has

underlined the important role that technology could play3.

Six to eight hours per day is the average amount of sleep a person needs. That's

about one-third of a lifetime! As a population, we sleep about 1 to 1.5 hours less

than we did 100 years ago6.

A statistical data showed that 40-60% of all elderly adults have insomnia in the

course of year. 2 out of 3 older people have insomnia at some point in their lives.

5

Over 70 million Americans suffer from disorders of sleep and wakefulness. Of

those, 60% have a chronic disorder. Women are twice as likely as men to have

difficulty falling and staying asleep. Over half of those over the age of 65

experience disturbed sleep. Those over 65 make up about 13% of the US

population, but consume over 30% of prescription drug and 40% of sleeping pills14.

The American Academy of Family Physicians (1999) reports over 50 percent of

people 65 years old and older live with the effects of sleep disorders, such as sleep

deprivation symptoms, sleep apnea and periodic limb movement disorder5.

As of 2006, persons 65 years of age or older comprise approximately 12% of

the United States population, but by 2030 the proportion of older adults will rise to

20%.This older portion of the national population is increasing twice as fast as other

age groups, so that by 2030 the number of persons 65 year of age or older in the

United States will effectively double to 72 million22. In this rapidly expanding older

portion of the national population, one of the major changes that commonly

accompany the aging process is an often profound disruption of an individual’s daily

sleep-wake cycle.

According to ICMR survey(India) as many as 69% of older individuals

complain about sleep problems such as disturbed or light sleep, frequent

awakenings, early morning awakenings, and undesired daytime sleepiness. Such

disturbances can lead to impaired daytime function and seriously compromise

quality of life. Age alone does not cause sleep problems. Disturbed sleep, waking up

tired every day, and other symptoms of insomnia are not a normal part of aging17.

Instead, poor sleep habits, untreated sleep disorders, medications, or medical

problems can contribute to sleeplessness3.

6

The possible effects of sleep deprivation include depression, heart disease,

hypertension, irritability, slower reaction times, sleep and health in the elderly. With

the increase of people’s age, the likelihood of sleep disorders increases. In older

adults, sleep disorders can lead to serious health consequences7.

In the year 2009, there were an estimated 605 million elderly adults in the

world, of which 400 million are living in low-income countries. By 2025, the

number of elderly adults is expected to raise more than 1.2 billion with about 840

million of them in low income countries. For the year 2003 the SRS estimates are

7.2% of total population were above the age of 60 years43.

Hypertension and sleep apnea are linked, for example, and problems with

breathing during sleep can contribute to heart problems. Older adults who take sleep

medications or experience sleep deprivation symptoms may also be at an increased

risk of falls or accidents11.

According to VAHI, report of the Independent commission on Health in India

conducted a study in 2004 revealed that the prevalence of sleep disorder and sleep

quality among old age group constitutes one of the most common difficulties faced

by older adults with 58% reporting sleeping difficulties at least a few nights per

week. However, sleep problems remain untreated in up to 85% of people, and,

among those who receive treatment and sedative-hypnotic medications remain the

treatment of choice18.

The government of India of health survey and development committee reported

that such pharmacologic management may have particularly deleterious effects in

older adults, including daytime confusion, drowsiness, falls and fractures, and

adverse interactions with other medications. The National Sleep Foundation poll of

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older adults found a close relationship between the health and quality of life of older

adults, and their sleep quantity and quality. “The NSF poll found that the better the

health of older adults, the more likely they are to sleep well. Conversely, the greater

the number of diagnosed medical conditions, the more likely they are to report sleep

problems. Additionally, among older adults, more positive moods and outlooks as

well as having more active and "engaged" lifestyles are associated with sleeping 7–9

hours and fewer sleep complaints15.”

Many older adults are interested to know the measures for undisturbed sleep.

There are number of measures in aiding and promoting sleep. One of them is deep

breathing exercises. Other measures either need to be performed under supervision or

need in depth knowledge about the mechanism and underlying physiology behind it.

Deep breathing exercise is the easiest one which can be done without any aids

and can be performed without supervision or help. This can be performed effectively

in home care setup. The present study is an attempt to asses the effectiveness of deep

breathing exercise in promoting sleep among older adults. Hence, the study becomes

more apt to the situation and more relevant. This motivated me to undertake this

study to evaluate the effectiveness of deep breathing exercise in promoting sleep

among older adults in selected old age homes at Kolar district.

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6.2. REVIEW OF LITERATURE

The review of literature in a research report is a summary of current knowledge

about a particular problem, to provide a basis for conducting the study.

Literature review is one of the major components of the research process.

According to Polit & Hungler (1999), literature review to the activities involved in

identifying & searching for information on a topic & developing & understanding of

the state of knowledge on the topic.

It provides essential information to assist in critiquing the literature review

section. An extensive review was done to gain insight into the selected problem.

The related literature for the project is divided under 3 headings:

I. Studies related to aging and sleeping pattern: A geriatric phenomenon.

II. Studies related to prevalence of sleep disturbance among older adults.

III. Studies related to effectiveness of deep breathing exercise in promoting

sleep among older adults.

I. STUDIES RELATED TO AGING AND SLEEPING PATTERN: A GERIATRIC PHENOMENON.

A study was conducted to determine the sleep problems among 9,000 persons

aged 65 years and older in the National Institute on Aging. The study results showed

that over one half of the men and women reported at least one chronic sleep problem.

Typical symptoms of sleep problems in the elderly include difficulty falling asleep

9

and maintaining sleep(38%), early-morning awakening(31%) and excessive daytime

sleepiness(24%). The study concluded that most of the older adults are suffering with

sleep problem and need some interventions.

A study was conducted to assess the typical sleep disturbances in the elderly in

All India Institute of Medicine Sciences, New Delhi in the year 2003 to 2005 among

2150 elderly adults. The results showed that Sleep disorders are estimated to affect

nearly 87% of older persons. Most frequently the elderly suffer from Sleep

Disordered Breathing (38%), Periodic Limb Movements in Sleep (45%), Restless

Legs Syndrome (24%), morning headaches(43%), circadian rhythm disorders(16%),

excessive daytime sleepiness(56%), Obstructive Sleep Apnea Syndrome (13%), and

insomnia(34%).

A study was done to narrate sleep and aging, prevalence of disturbed sleep and

treatment considerations among 100 older adults. The study showed that sleep

patterns changes with age(93%), it is the change in the ability to sleep that

precipitates sleep complaints in older adults. Staying awake(39%), waking too

early(24%), trouble falling asleep(27%), daytime napping(19%), nocturnal

waking(65%), and difficulty initiating or maintaining sleep(58%) are among the chief

sleep complaints of older adults. The study concluded that poor sleep include

difficulty in sustaining attention, slowed response time, difficulty with memory, and

decreased performance.

A study conducted to assess the pattern of sleep disturbances among 285 older

adults in sub-urban community in Mumbai . The results of the study revealed that

more symptoms associated with poor sleep initiation and maintenance and increased

daytime napping. Sleep problems may be caused by various factors, including

medication use(46.3%), medical and psychiatric illnesses(40.9%), and primary sleep

disorders(38.4%). The consequences of poor sleep quality may include cognitive

10

impairment(37%), daytime sleepiness(79%), and reduced quality of life(14.7%).

Thus the study concluded that sleep is the most important factor in old age which

promotes comfort in life of elderly adults.

A study was conducted to assess the sleep pattern in elderly adults in New

York. The results showed that, sleep is a basic biologic function that changes with

normal aging and in many pathologic states. Some of the changes with aging are so

profound that it is difficult to separate normal aging from disease. The result

indicated some of the common sleep disorders among elderly population are

insomnia(28%), sleep-disordered breathing(23%), periodic limb movements of

sleep(26%), and the rapid eye movement sleep-behavior disorder(18%).

Older adults are objectively sleepier in the day, indicating they are not getting

enough sleep at night. Their sleep is disrupted by circadian rhythm changes, disorders

such as sleep disordered breathing (apnea) and periodic limb movements in sleep

(PLMS), medical illness, psychiatric illness, medication use, and poor sleep habits.

The physician should address each of these causes, thereby improving the night-time

sleep and daytime functioning of the older adult. Both medical and psychiatric

conditions as well as the medications used to treat them lead to sleep complaints in

older adults. Circadian rhythm disturbances and primary sleep disorders may also

result in sleep complaints. Efficacious pharmacologic interventions were the

nonbenzodiazepine hypnotics zolpidem, zaleplon, and eszop-iclone. Sleep

disturbance is not a natural consequence of aging, but rather a treatable condition.

11

II. STUDIES RELATED TO PREVALENCE OF SLEEP DISTURBANCE

AMONG OLDER ADULTS.

A study was done to assess the association between sleep problems and chronic

disease in older adults, among 1506 community-dwelling men and women aged 55-

84 years in Punjab. The result showed that majority of the participants (83%)

reported one or more of 11 medical conditions and nearly one in four elderly

respondents (age 65-84 years) had major comorbidity (i.e. four or more conditions).

Depression(34%), heart disease(58.4%), bodily pain(86%) and memory

problems(95.1%) were associated with more prevalent symptoms of insomnia.

The National Sleep Foundation conducted a national survey among adults 55

to 84 years of age living in the United States. The primary objective of this poll was

to describe the relationships between sleep, common medical conditions and other

aspects of health and lifestyle. A majority of older adults (62%) sleep seven or more

hours on weeknights, and 69% obtain this amount on weekend nights. However,

13% of older adults sleep less than six hours on weeknights, and 11% obtain this

amount of sleep during weekends.

A slightly higher proportion of 65-84 year-olds get nine or more hours of sleep

(8%), compared to 55-64 year-olds (5%). A significant proportion of older adults

rate their sleep as fair to poor with 55-64 year-olds (26%) more likely to rate the

quality of their sleep this way than 65-84 year-olds (21%). Many reported that the

quality of their sleep is about the same as it was ten years ago, more 55-64 year-olds

(34%) than 65-84 year-olds (25%) report that their sleep quality has gotten somewhat

or much worse. Women (32%) were more likely than men (24%) to rate the change

in quality of their sleep as somewhat or much worse.

12

A study was done among 427 elderly people aged 65 yr and over in the city of

San Diego, California to determine the sleep pattern and its disturbances. In this

sample of elderly, 19% reported being somewhat or very troubled with their sleep

whereas 81% reported being moderately or very satisfied. Twenty-one percent felt

they got too little sleep, 2% reported getting too much sleep and 77% reported

enough sleep each night. In addition, 25% reported trouble falling asleep at least once

per week while 75% reported no trouble falling asleep at night. When asked about

experiences with excessive daytime sleepiness (EDS, i.e. feeling sleepy or struggling

to stay awake during the daytime), 39% reported experiencing EDS at least one per

week while 61% said they never experienced EDS.

A population based cohart study was done using overnight polysomnography

to investigate 625 subjects sleep-disordered breathing among the age group of 50-60

years in Wisconsin. Participants were classified as habitual snorers according to

whether they reported habitual (almost every night or every night) snoring, snorting,

or breathing pauses, or extremely loud snoring. The participation rate was 43%.

There are three major findings from the study. First, there is a wide spectrum of

undiagnosed sleep-disordered breathing among adults, ranging from a few episodes

of apnea or hypopnea during sleep to 89 abnormal breathing events per hour of sleep.

Second, undiagnosed sleep-disordered breathing, as indicated by five or more

episodes of apnea or hypopnea per hour of sleep, is prevalent among both women

(9%) and men (24.7%) of older age. Finally, 4% of men and 2% of women in the the

age group above 70 years are likely to meet maximam diagnostic criteria for the sleep

apnea syndrome.

A sleep cohort study was done using overnight polysomnography to investigate

sleeping hours among 50-60 years of adults in Wisconsin.625 subjects were selected

among them men vs women comparison was done. The sleep disturbances among 13

men(34.37%)and women(13.74%)were noticed. The study concluded older adults

especially males suffered more of sleep disorders and when psychological support

and mild physical exercises they showed much improvement in sleep hours.

A cross-sectional study was done to investigate the prevalence of disturbed

sleep and the association of disturbed sleep with medical conditions and service use

among older adults. A sample of 6961 household residents aged 60 and over was

recruited from a population-based random sample. Each subject was examined in a

face-to-face interview. The results of the study showed that overall prevalence of

disturbed sleep was 33.7%, with the condition being more prevalent in women

(37.2%) than in men (27.4%). The overall rate of medical consultations was 78%, and

higher in those with sleep disturbance (males 73% vs 27%; females 80% vs 20%)

compared to persons without disturbed sleep. The overall rate of hospitalizations was

20.2%. In logistic regression analyses, being female, of low income, low education,

younger age, with psychiatric morbidity, pneumonia, urinary infection,

dermatological problems and/or hypertension were significantly associated with self-

reported sleep disturbance. Ethnicity, civil status or outpatient visits in the previous

six months and hospitalizations in the previous year were not associated with self-

reported sleep disturbance.

Thus self-reported sleep disturbance was a frequent problem in the study

population and was associated with gender, income, education, lower age and

medical conditions. There was no association between sleep problems and use of

medical services in the surveyed population.

14

III. STUDIES RELATED TO EFFECTIVENESS OF DEEP BREATHING

EXERCISE IN PROMOTING SLEEP AMONG OLDER ADULTS.

A study was conducted to determine the effects of moderate-intensity exercise

training on self-rated (subjective) sleep quality among healthy, sedentary older adults

reporting moderate sleep complaints. There were volunteer sample of 29 women and

14 men (of 67 eligible subjects) aged 50 to 76 years who were sedentary, free of

cardiovascular disease, and reported moderate sleep complaints.

Moderate-intensity exercise training was implemented. Exercise consisted

primarily of four 30- to 40-minute endurance training sessions (low-impact aerobics;

brisk walking) prescribed per week at 60% to 75% of heart rate reserve based on peak

treadmill exercise heart rate. The study concluded that older adults with moderate

sleep complaints can improve self-rated sleep quality by initiating a regular

moderate-intensity exercise program.

A pioneer study was carried out on deep breathing exercises in promoting the

level of sleep among elder citizens in selected urban areas at Ramachandra Medical

college and Hospital.Chennai. the sample size included 436 out of which 57.3%

accepted the fact related to the effectiveness of deep breathing exercises in promoting

sleep. Hence a method of deep breathing exercises was taught to the senior citizens

and the study concluded that 92.4% of older people were able to sleep without much

difficulty after the demonstration.

A study conducted on deep breathing exercise for sleep showed that one of the

biggest obstacle to get sleep is effectively shutting the mind down. Old age people

often go to bed exhausted, but unable to turn off the noise in their heads. They are

15

bombarded with mental images of what happened today, what is going to happen

tomorrow and what should have happened yesterday.

Deep breathing exercises serve two purposes: They calm the central nervous

system and act as a meditation to quiet the mind. While deep breathing works well on

its own, it is doubly effective when combined with other relaxation techniques.

Always do breathing exercises at bedtime, when you are already in bed.

16

STATEMENT OF THE PROBLEM

A Study To Assess The Effectiveness Of Deep Breathing Exercises In Promoting

Sleep Among Older Adults In Selected Old Age Homes At Kolar District.

6.3. OBJECTIVES OF THE STUDY

To assess the existing level of sleep among older adults

To determine the effectiveness of deep breathing exercise in promoting sleep

among older adults.

To find out the association between the level of sleep in older adults with their

demographic variables.

6.4. OPERATIONAL DEFINITIONS

ASSESS :It refers to the evaluation of the level of sleep among older

EFFECTIVENESS: It refers to significant improvement in the level of sleep as

determined by significant difference between pre implementation and post

implementation scores of deep breathing exercises.

DEEP BREATHING EXERCISE: Deep breathing is a technique for relaxation in

which attention is focused on breathing that can be mastered with practice,

incorporated into daily routine activities and preformed almost anywhere. When

regularly practiced, the deep-breathing relaxation technique can be a useful tool not

only for tension and stress relief, but also to revitalize and to promote sleep.

17

SLEEP: Sleep is a naturally recurring state characterized by reduced or lacking consciousness, relatively suspended sensory and non-motor activity - inactivity of nearly all voluntary muscles. It is distinguished from quiet wakefulness by a decreased ability to react to stimuli, but it is more easily reversible than hibernation or coma. Sleep is a heightened anabolic state, accentuating the growth and rejuvenation of the immune, nervous, skeletal and muscular systems.

OLDER ADULT: it refers to the age at which a person became eligible for statutory

and occupational retirement pensions. The person who has attained 60 years and

above is called elderly or older adult.

6.5. ASSUMPTIONS

Older adults may have inadequate level of sleep.

The teaching programme on deep breathing exercise among older adults will

promote sleep.

Effectiveness of deep breathing exercise in promoting sleep is influenced by

variables such as age, sex, religion, educational qualification, socio-economic

status, occupation, methods of recreation, rest and sleep hours, chronic illnesses

and type of treatment.

6.6. HYPOTHESES

H1 There will be significant difference between pre implementation and post

implementation of deep breathing exercise and its effectiveness among old age group.

H2 There will be significant association between the post implementation score

and their selected demographic variables of older adults.

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6.7. DELIMITATIONS

The period of study will be limited to 6 weeks.

The sample size is limited to 60.

The study is limited to older adults.

6.8. VARIABLES

DEPENDENT VARIABLES: Level of sleep among older adults.

INDEPENDENT VARIABLES: Teaching programme on deep breathing

exercises among older adults.

ATTRIBUTED VARIABLES: Age, sex, religion, educational qualification,

socio-economic status, occupation, methods of recreation, rest and sleep hours,

chronic illnesses and type of treatment.

7. MATERIALS AND METHODS

7.1. SOURCES OF DATA:

Older adults in old age homes at Kolar district.

7.2. METHODS OF DATA COLLECTION:

7.2.1. RESEARCH APPROACH:

The research approach used for this study was an Evaluative approach.

7.2.2. RESEARCH DESIGN:

Quasi-experimental research design.

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7.2.3. SETTING OF THE STUDY:

The study will be conducted at selected old age homes in Kolar district.

7.2.4. POPULATION:

All the Older adults in old age homes at kolar district.

7.2.5.SAMPLE:

Older adults in the age group between 50 to 70 years.

7.2.6.SAMPLE SIZE:

60 Samples

7.2.7. SAMPLING TECHNIQUE:

Simple random sampling technique by lottery method.

7.2.8.SAMPLING SIZE:

Sample of 60 older adults.

7.2.9. SAMPLING CRITERIA:

Inclusion Criteria

Older adults between 50 to 70years of age.

Older adults who are residing in old age homes at kolar.

Older adults who understand Kanada and English.

Older adults who are willing to participate.

Both male and female older adults are included.

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Exclusion Criteria

Older adults who are having other chronic illnesses.

Older adults who are uncooperative.

7.2.10.TOOLS FOR DATA COLLECTION:

The instrument selected in research should be as far as possible the vehicle that

obtains the best data for drawing conclusions to the study. The study consists of the

following tools:

SECTION-A: DEMOGRAPHIC DATA:

The first part of the tool consists of demographic data variables such as age,

sex, education, socio-economic status, occupation, methods of recreation, rest and

sleep.

SECTION-B: CHECK LIST FOR MEASURING THE LEVEL OF SLEEP:

The second part of the tool consists of check list to score the level of sleep

among older adults.

7.2.11.METHODS OF DATA COLLECTION:

A structured interview schedule with check list scoring to measure the level of

sleep will be adapted by the researcher to collect the data from subjects. The purpose

of the study will be explained to involve in the study. Pre-test to subjects will be

conducted and teaching program will be implemented. Post-test assessment will be

done after 7 days of implementation of the teaching program. Tentative period of the

study will be 6 weeks. The tool for data collection will be prepared and after

validation by the experts, the further refinement of the tool will be done. The pilot

study will be conducted before the main study.

21

7.2.4 DATA ANALYSIS AND INTERPRETATION

The data will be analyzed by using descriptive and inferential statistics.

Descriptive statistics such as frequency, mean, mean percentage, standard deviation

are used. Inferential statistics such as paired t-test, and chi-square are used. Chi-

square test will be used to find out the association between level of sleep score with

selected demographic variables.

7.3. DOES THE STUDY REQUIRE ANY INTERVENTIONS TO BE

CONDUCTED ON HUMAN OR ANIMALS? IF SO DESCRIBE BRIEFLY?

Yes. The study require interventions (deep breathing exercises in promoting

sleep) to be conducted among older adults.

7.4. HAS THE ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

Yes prior to the study permission will be obtained from the concerned

authorities to conduct the study in selected old age homes at kolar district and also

from the research committee of Pavan College of Nursing, Kolar to conduct study

and the purpose of the study will be explained to the respondents.

22

8. LIST OF REFEERENCES:

1. Brunner and suddharth’s Text book of medical surgical Nursing. 11th edition.

Lippincott Publications, 2004;7539-195.

2. Lewis, Sharon.L. Text book of medical surgical Nursing. 7th edition. Mosby

Elsevier Publication. Page No. 81,82.

3. Basavanthappa B.T., Nursing Research. 1st edition. New Delhi. Lordson

Publishers private limited,1998; Page No: 86-93.

4. Black M J, Hawks H J. Medical – Surgical Nursing. 7th edition. New Delhi.

Elsevier India private limited. (2005); Page No: 2073-2082

5. Denise P.F. Nursing Research principles and methods. 7 edition. Lippincott

publication, Williams and Williams, New york,2004: Page No.776-782.

6. Learby Z. Oth Essential guide for doing research. 1st edition. vistarr

publications: 2005; Page No. 85-90.

7. Ebersole P. Hess P: Geriatric Nursing and healthy aging, 2nd edition, St

Louis, 2005, Mosby publications,pg no-121.

8. Turvey CL et al: Attitudes about impaiment and depression in elders

suffering from chronic heart failure, 2003,pg no-117,.

23

9. Harper ME ea al: Ageing oxidative stress, and mitochondrial uncoupling,

2004;pg no-182

10. Hughes KA. Reynolds RM: Evolutionary and mechanistic theories of

aging, 2005;pg no:421

11. Robine JM, Michel JP: Looking forward to a general theory on

population aging, 2004,J Gerontol pg no;590.

12. Mayne ST: Antioxidant nutrients and chronic disease: Use of biomarkers

of exposure and oxidative stress status in epidemiologic research, 2003 pg

no-133

13. Shay JW, Wright WE: Senescence and immortalization: role of telomeres

and telomerase, Carcinogenesis 26:867, 2005.

14. Lue NF: Adding to the ends: what makes telomerase processive and how

important is it? Bioessays 26:955, 2004.

15. Fabris N: Neuroendocrine-immune interactions: a theoretical approach to

aging, Arch Gerontol Geriatr 12:219, 1991.

16. Bjomerem A et al: Endogenous sex hormones in relation to age, sex,

lifestyle factors, and chronic diseases in a general population: the Tromso

Study, J Cin Endocrinol Metab 89:6039, 2004.

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17. Traustadotir T, Bosch PR, Matt KS: The HPA axis response to stress in

women: effects of aging and fitness, Psychoneurotic endocrinology 30:392,

2005.

18. Boren E, Gershwin ME: Inflammation-aging: autoimmunity, and the

immune-risk phenotype, Autoimmune Rev 3:401, 2004.

19. Fleming KC:A history of old age in America. In Legato M, editor:

Principles of gender – specific medicine, San Diego, 2004, Elsevier

Academic Press.

20. Roberts B: Gender-specific aspects of the experience of coronary artery

disease. In Legato M, editor, Principles of gender-specific medicine, San

Diego. In Legato Academic Press.

21. Wilcox S et al: Psychosocial and perceived environmental correlates of

physical activity in rural and older African American and white women,

J Geronto B Pshchol Sci Soc Sci 58:P329, 2003.

22. Borders TF: Rural community dwelling elders reports of access to

care: are there Hispanic versus non-Hispanic white disparities? J Rural

Health 20:210, 2004.

23. Stromberg A: The crucial role of patient education in heart failure,

Eur J Heart Fail 16:363, 2005.

25

24. Stergiopoulos V, Hermann N: Old and homeless: a review and survey of

older adults who use shelters in an urban setting, Can J Psychiatry 48:314,

2003.

25. AACN, John A Hartford Foundation Institute for Geriatric Nursing:

Older adults: recommended baccalaureate competencies and

curricular guidelines for geriatric nursing care. Available at

www.aacn.nche.edu/Education/gercomp.htm

26. Given B et al: Burden and depression among caregivers of patients

with cancer at the end of life, Oncol Nurs Forum 16:1105, 2004.

27. Pinquart M.Sorenson S: Associations of caregiver stressors and uplifts

with subjective well-being and depressive mood: a analytic comparison,

Aging ment Health 8:438, 2004.

28. National Academies of Sciences, Bonnie R, Wallace R, editors: Elder

abuse: abuse, neglect and exploitation in an aging American,

Washington, Dc, 2002, National Academies Press.

29. Lachs MS, Pillemer K: Elder abuse, Lancet 364 (9441):1263, 2004.

30. Fulmer T, Peveza G: Neglect in the elderly patient, 1998, pg no-457,.

31. Hawes C, editor. Elder abuse in residential long-term care settings:

what is known and what information is needed, Washington, DC,

2003, National Academies Press.

26

32. Dyer CB et al: The high prevalence of depression and dementia in

elder abuse or neglect:pg no-205, 2000.

33. Fulmer T: Elder abuse and neglect assessment,2003.

34. Centers for Medicare and Medicaid Services: Medicare and you: 2006.

www.medicare.gov/piblications/pubs/pdf/10050.pdf

35. Hodgson N et al: Biobehavioral correlates of relocation in the frail

elderly: salivary cortisol, affect, and cognitive function, J pg-1856

36. Hajjar ER et al: Adverse drug reaction risk factors in older outpatients,

Pharmacotherapy page-82.

37. Klarin I, Wimo A, Fastbom J: The association of inappropriate drug use

with hospitalization and mortality: a population – based study of the very

old, Drugs Aging 69.

38. Edwards M: Assessing for depression and mood disturbance in later

life, pg no492.

39. Juurlink DN et al: Medical illness and the risk of suicide in the elderly,

Arch International Med :pg no1179, 2004.

40. Luckman and Sorensen’s, Text book of medical surgical Nursing, 4th

edition, Missouri, W.B. Sounders publications, Page No. 115.

27

41. Parahoo.K: 2006 Nursing research principles process and issues: 2nd

edition: China, macmillan publications Page No. 92-95.

42. Polit D.f. Back C.T, 2004 Nursing research principles and Methods, 7 th

edition, Philadelphia, lippincott publications page No. 3-700.

43. Rao. V, 1996, Bio-Statistics, 1st ed

44. ition, New Delhi, Jaypee Brothers Medical Publishers, Page No. 100-105.

45. http://www.righthelat.com/topic/sleep studies.

46. http://www.tayiorand trancls.merapress.com.

47. Grace,P.(Unpublished Thesis,M.Sc Nursing. Dr.M.G.R

University,chennai);2004.

28

9. Signature of the Candidate

10. Remarks of the Guide

11.

Name and designation of

11.1. Guide

11.2. Signature

11.3. Co-guide

11.4. Signature

11.5. Head of the

Department

11.6. Signature

12.

12.1. Remarks of the

Principle.

12.2. Signature

29