NURSING CARE IN THE ELDERLY PATIENT: mayo 2013

THE END OF LIFE CARE

Palliative Care helps the patient with a terminal illness feels better, because it provides relief from pain and symptoms of disease. Palliative care doesn't make put off death, but it gives comfort and peace instead of cure.
In addition, this type of care also focuses on providing emotional support to the patient and his family.

THE MAIN OBJECTIVE OF PALLIATIVE CARE IS TO IMPROVE THE PATIENT'S QUALITY OF LIFE

I consider that the most important nursing intervention in this type of patients, is to get the patient accepts his death as an inevitable part of the life cycle and can encourage the grieving person to take time to cry or to express his feelings and concerns. However, many times is not easy to get it because the patient doesn't believe that he will die or refuses to talk about his illness.

It's true that many professionals are afraid to confront the communication with these type of patients, especially if the patient is young or they may feel unprepared and have difficulty dealing with a death. But this situation should change, because our duty is to reduce the patient's anxiety about death.

Firs of all, nursing must discover if the patient wants to have information about his terminal situation. If the patient wanted receive information, nursing would adjust the information of patient's rate assimilation. In addition, it's important that the information is distributed in several sessions to ensure the understanding, and the most important: the hope should never be removed but neither should be generated.

When the patient is diagnosed with a terminal illnes, he passes through five stages. The five stages of the Dra.Kübler-Ross stage model are the best-known description of the emotional and psychological responses that many people experience when faced with a life-threatening illness or life-changing situation. These stages, don't necessarily follow in a specific order, because a person may move in and out of stages unpredictably and erratically.
For this reason, nurses should be able to identify the stage where is the patient, according to the patient's behaviour, since this model helps to identify individuals who are experiencing severe or protacted grief. In addition, nurses should be able to identify individuals who may need a grief counselor who has special training and tecniques to help the person.

In conclusion, I consider that the palliative cares provide a better qualify of life (physically and psychologically) to the patiente, since his illnes, because people who receive palliatives cares can spend more time with his family, friends... because these cares help to the patient feels better. But I think that the most important of palliative cares are that they allow a dignified death, because the family's patient and patient have a support from health professionals which provides them support and the means to go through this hard process. In addition, palliative cares allow the patient to be accompained when it comes his time to die. And finally, these cares bring quiet to the family, because the family is normally satisfied by the care received and in this way, the family won't experience guilt feelings when the patient dies.

*** KÜBLER-ROSS'S STAGES OF GRIEF

1926-2004

DENIAL

The patient doesn't accept the possibility that he has a terminal illness for which there is not cure.

2. ANGER

The patient has anger because begins to believe that the new is true and suffers from thinking about all the unresolved things.

3. BARGAINING

The patient try to identify whether they could have done something different to prevent the death. some may make resolutions to change their behavior or lifestyle based on this reflections. Then, the patient establishes a pact with a superior entity (religious beliefs) or with the doctor and finally, the patient adds another promise which express his willingness to not ask for anything more if the first pact is fulfilled.

The patient adds another promise that expresses its willingness to not ask for anything more if the first is true.

4. DEPRESSION

The patient begins to understand that the pact not be produce, and is aware that death is inevitable

5. ACCEPTANCE

The patient is aware that death is inevitable and in some cases, inmediate.

" CONSIDER THE RATIONALE OF TRYING TO PROLONG LIFE BY ADDING TIME TO THE PERIOD OF DYING"

GERIATRIC SYNDROMES: URINARY INCONTINENCE

URINARY INCONTINENCE is the involuntary loss of urine in sufficient amount or frequency to be a social or hygiene problem.

A large percentage of the geriatric people suffers from problems with urinary elimination (nearly 30-50% of independent-living elderly and 50-75% of institutionalized elderly). This problem occur from changes in he function of the urinary system, or in the other body systems such as musculoeskeletal or nervous system.

I think that urinary incontinence is a problem which cause emotional and social problems for persons because it can lead to guilt and frustation and social isolation.In addition, it can be costly, because the person need to purchase expensive undergarments and replace or launder clothing more frequently. For this reason, nursing should teach to the patient some strategies to control urinary incontinence and offer emotional support.

There are a lot of types of urinary incontinence:

Stress incontinence: leakage of urine during conditions that increase intraabdominal pressure such as exercise, laughing, coughing, sneezing...
Urge incontinence: It's the most frequent, and is caused by involuntary contraction of the detrusor muscle of the bradder. The person who has this incontinence are often unable to hold back the orine long enough to reach a toilet.
Overflow incontinence: it's usually due to chronic bladder ouflow obstruccion such as prostatic disease, obstructive nephropathy or acute/chronic urinary retention.
Functional incontinence: situations which the patient is unable to reach the toilet in time for such reasons as poor mobility or poor relationship between the aging person's abilities and his or her environment.
Total or mixed incontinence:it's caused by neurologic changes, bladder muscle spasms, trauma or diseases affecting the bladder or sphincter muscles which cause a continuous and unpredictable loss of urine.

Some nursing interventions to contol urinary incontinence are:

LIFESTYLE CHANGES: losing weight, quitting smoking, not drinking alcohol and caffeine,preventing constipation...
TIMED VOIDING: Urinate on a set schedule, for example, every hour. The patient can slowly extend the time between bathroom trips.
Stress the importance of GOOD SKIN CARA AND HYGIENE after episodes of incontinence.
BLADDER CONTROL TRAINING: Urinary incontinence is more frequent in women as in men, for this reason, I talk about KEGEL EXERCISES, because I consider that they are very effective to strengthen the pelvic floor muscles and helps back the flow urine of women.
EMOTIONAL SUPPORT.

Bibliografia

GERIATRIC SYNDROMES: CONSTIPATION

CONSTIPATION is defined as having a bowel movement than 3 or fewer times per week. Constipation occurs when the colon absorbs too much water or if the colon's muscle contractions are slow. As a result stools can become hard, dry, painful, small in size or difficult to eliminate.

Almost everyone experiences constipation at some point in their life, but the constipation's prevalence increases with age, being more prevalent from 60 years. The 25% of the elderly experience constipation and that is mor commonly a problem for women. For this reason, it's a important topic of aging, for its complications and impact on the elderly's quality of life.

Constipation is a symptom, not a disease, so that it's important to know the causes of constipation:

Lack of physical activity (especially in the elderly)
low-fiber diet
Drink little water (deydration).
Changes in life such as pregnancy, aging, travel,etc
Ignoring the urge to have a bowel movement
Mechanical problems such as obstruction, neoplasias, herniations,etc.
Functional problems such as hemorrhoids,diverticula, anal fissure, anal prolapse, irritable bowel syndrome, chronic idiopathic constipation,etc.
Some conditions such as stroke (the most common).
Specific diseases such as diabetes mellitus, uremia, hypokalemia, hypomagnesemia, hypocalcemia, hypothyroidism, neurological diseases (parkinson, dementia, depression...), etc.
Drugs (opiates) or abuse of laxatives.

Nursing should be able to advise the population constipated about the best life habits, because in this way, they can prevent the appearance of constipation's complitations such as fecalomas.

Therefore, the mainstays of treatment for constipation are the following:

DIET: increase intake of dietary fiber (eating more fruits, vegetables and grains) and an adequate fluid intake (2000ml/day)
PHYSICAL ACTIVITY: Exercise must be individualized in each patient. Regular exercise helps your digestive system stay active and healthy, above all, exercises to strengthen the pressure abdominal and pelvic floor
INTESTINAL EDUCACTION: Schedule or encourage toileting at times when the person's defectaion urge is strongest. It's recommended to be 10-15 minutes sitting in the WC after breakfast (gastrocolic reflex). If the patient can't defecate, he will repite the same process after lunch and dinner.
POSITION the person to facilite ease of elimination
Provide PRIVACY for elimination.
LAXATIVES, SUPPOSITORIES OR ENEMAS only if the other methods have not been effective.

Bibliografia

GERIATRIC SYNDROMES: FALLS & INSTABILITY

Falls are a frequent problem of aging and they can be responsible of an important health's loss in the older persons. In addition, falls can cause moderate to severe injuries, such as hip fractures and head injuries, and can increase the risk of early death.
For this reason, it's very important to prevent falls in older persons with high risk of fallen.

Elderly people who have a high risk of fallen are:

People > 75 years and/or with history of falling.
People who have visual and auditory problems.
People who have central nervous system disorders such as dementias or deliriums (cognitive impairment).
People with disabilities such as gait and balance disorders.
People who have some chronic pathologie.
Frail elderly and muscle weakness.
Emotional disorders such as confusion, depression or denial's physical limitations.
The more medicactions person take, the more likely person is to fall.
Some medications can increase a person's risk of falling such as hypnotics, antidepressants, diuretics, antihypertensives and sedatives. The most important factor to predict falls is the sedative's consumption.

PRIMARY PREVENTION

Fortunately, is a public health problem that is largely preventable. For this reason, I think that nursing must be alert to launch a falls prevention plan and have many skills to explain this population which are the most higher risk situations.

In this way, nursing can prevent falls and all its physical consequences such as contusion, bruises and fractures or psychosocial consequences post-fall syndrome (first, decreased mobility and inability to perform daily living's activities caused by the pain and bruises and finally, caused by the anxiety and fear of falling again)

I found these videos which explain the foundations of primary prevention of falls:

EXERCISE
HOME CARE

To value the risk of fall, nursing should use the following scales:

Bibliografía

GERIATRIC SYNDROMES: DEMENTIAS

This topic is very extensive, so I have decided to focus on Alzheimer's disease.

ALZHEIMER'S DISEASE is the most common form of dementia in the elderly. It is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks.

I have found this explanatory video of National Institutes of Health which explains the pathophysiology of Alzheimer's disease.

CLIK TO WATCH VIDEO: INSIDE THE BRAIN: UNRAVELING THE MYSTERY OF ALZHEIMER'S DISEASE

Nowadays, scientist don't know the causes of Alzheimer's disease. It's believe that there are genetic, chemical, viral, environmental and lifestyle factors involved in Alzheimer's development. However, it's known that the age is the main risk factor but other factor such as the presence of the apolipoprotein E gene appear to indicate an increased risk for development of the disease.

To assess the cognitive deterioration there are some scales:

GLOBAL DETERIORATION SCALE OF REISBERG
MINI-EXAM COGNITIVE OF LOBO
CLOCK TEST

ALZHEIMER'S DISEASE EVOLUTION

Alzheimer's development usually begins after age 60 years and the type and severity of symptoms as well as the order of their appearance, differ from person to person. It's characterized by a memory problems, intellectual impairment and personality changes.

I consider that It's important don't overlook the first symptoms and don't consider them as "THINGS OF THE ELDERLY", as sometimes happens.

There are three phases:

Alzheimer's disease begins slowly. Memory problems are the first warning signs of cognitive loss. There are other signs that indicate Alzheimer's disease is beginning, such as word-finding, vision/spatial issues and impaired reasoning or judgement.

1. INITIAL PHASE

It's clear that as the Alzheimer progresses, symptoms worsen. For example, memory and communication problems are more frecuently Appear other problems such as getting lost, trouble handling money and paying, repeating questions, taking more time to complete normal daily tasks and having some mood and personality changes.

2. MIDDLE PHASE

Memory problems and confusion grow worse, and people begin to have problems recognizing family and friends. In addition, they can't be able to learn new things, difficultly doing tasks that involve a lot of things at the same time (getting dressed). They may have hallucinations, delusions, paranoia and behave impulsive.

3. FINAL PHASE

In this phase, the person can't be able to communicate and is completely dependent on others for their care. In addition, the person may be in bed most or all the time.

NURSING CARE

I think that to be patient with these persons is the most important, because they aren't aware of many things.

An important nursing intervention with this type of patients is ensuring the communication with them. The nurse should use the following resources:

Ask yes/no questions whenever possible
Observe nonverbal communication
Use touch to communicate empathy
Speak slowly using short, simple sentences
Repeat, rephrase, and restate messages
Decrease environmental distractions
The patient may have problems to understand the facial expressions, for this reason, nurses should approach the patient always with a smile.
Establish eye contact before starting communication
As trying to capture the attention of the patient, nurses should avoid scare them. For this reason, the best form to capture de attention of the patient is touching gently his hand or arm
Provide visual cues whenever possible
Use pictures of familiar items
Allow ample time for responses
Explain basic communication techniques to family
Consult with speech therapist regarding other communication techniques.

Nursing should recommend some changes in the patient's home:

Smoke and carbon monoxide detectors in or near the kitchen and in all bedrooms
Emergency phone numbers and the person’s address near all phones
Lock up or remove these potentially dangerous items from the home such as medicines, alcohol, cleaning and household products, poisonous plants, guns and other weapons, scissors,knives, power tools, machinery...
Check all rooms for adequate lighting. Use nightlights in bathrooms, bedrooms, and hallways
Put a glass-ceramic, use plastic plates, cup and cutlery.
Install secure locks on all outside windows and doors, especially if the person is prone to wandering. Remove the locks on bathroom doors or dangerous rooms to prevent the person from accidentally locking himself or herself in.
Keep the house free from clutter. Remove scatter rugs and anything else that might contribute to a fall.
Each room must be marked with a easy picture or word.
Paint the front door of the same color as the wall and always closed.
Put a shower and anti-slip floor in the bathroom.
Remove mirrors of bathroom or bedroom.
Close the dangerous rooms (kitchen or bathroom).

Nowadays, there isn't cure for Alzheimer's disease, but the Alzheimer's disease development can be prevented with these brain-healthy lifestyles.

Regular exercise
Healthy diet
Mental stimulation
Quality sleep
Stress management
An active social life

I consider that mental stimulation is the most effective strategie for decrease Alzheimer's development, because they provide a great mental workout and they can help to build our capacity to form and retain cognitive associations.

FOR EXAMPLE:

Learn something new, study a foreign language, learn sign language, practice a musical instrument, read newspaper or a good book.
Practice memorization
Enjoy strategy games, puzzles, riddles or sudokus
Follow the road less traveled because it's help to vary our habits regularly to create new brain pathways.

Bibliografia

GERIATRIC SYNDROMES: IMMOBILITY

Mobility or displacement capacity is very important to have autonomy and it's a essential component of people's lives.

In the elderly, mobility depends on the interaction between:

Personal factors: abilty, motor skills, cognitive or sensorial-perceptual capacity, health level and self-confidence level.
Environmental and external personal factors: physical,architectural and family's or caregiver's attitudes.

IMMOBILITY is defined as a decreased ability to perform activities of daily living due to a deterioration of motor function.

In the elderly, a immobilized patient has more risk of medical complications than other patients.

There are two types of immobility:

The relative immobility: the geriatric person has a sendentary lifestyle but is be able to move with more/less independance
The Absolute immobility: the geriatric person has a very restricted mobility and this situation causes a chronic bed rest.

The relative immobility's risk is the chronic bed rest while the absolute immobility's risk is the institutionalization, morbimortality and caregiver's syndrome.

CAUSES

The immbolity has a lot of causes, but the most frequents are:

Musculoskeletal diseases such as osteoarthritis, osteoporosis, fractures (hip or lower extremities), rheumatic diseases, etc.
Neurological diseases such as stroke, parkinson, dementias, neuropathic diseases, etc.
Cardio-respiratory diseases such as chronic obstructive pulmonary disease (COPD), severe heart failure, schemic heart disease, peripheral vascular disease (arterial or venous), etc.
Neurosensory Diseases such as visual and auditory deficit, benign positional vertigo, etc.
Psychological causes such as depression.
Endocrine-metabolic causes such us diabetes mellitus, hypothyroidism, hydroelectrolytic disorders,etc.
Generalized weakness: neoplasm, malnutrition,anemias, etc.
Iatrogenic causes such as drugs or hospitalization.
Environmental causes such as architectural barriers, physical obstacles or absence of support elements (cane, crutches, wheelchair...).
Social Factors such as loneliness or absence of social support.

To understand the importance of immobility is necessary to say that 50% of the geriatric patients who are chronic bed rest, they die in 6 months

COMPLICATIONS

Organic complications: muscular atrophy, contractures, pressure ulcers, ankylosis, deep venous thrombosis, pulmonary thromboembolism, constipation, urinary incontinence, sensory deprivation...
Psychological complications: depression, delirium, fear of falling, psychomotor regression...
Social complications: social isolation, institutionalization or inability to self-care.

To value the mobility there are some scales, for example: TINETTI'S SCALE and TIMED UP AND GO TEST

PREVENTION

I think that is very important to prevent the immobility, because as we have seen previously, it causes a lot of health problems. For this reason, geriatric people who have a relative mobility should do regular exercise because in this way the person increases his muscle strength, bone density, coordination, balance, joint flexibility and his heart will be more healthy. In addition, to do exercise decreases anxiety and depression, and promotes the socialization.

The regular exercise decreases the mortality risk and helps people look and feel better. But the most important is that physical activity can extend years of active independent life, reduce disbility and improve the quelity of life for geriatric people.

Some exercises which are recommended for older people are:

LYING DOWN:

Strech your arms and legs; take a deep breath.
Grab each leg with both hands below the knee and pull toward your chest slowly.
With your arms at your sides, bend at the elbow and curl your arms as if making a muscle.
Fold your hands on your stomach; raise your arms over your head toward the headboard.
Clap your hands directly above your head.
Lift each leg off the bed, but try not to bend your knee. Use an arm to help.

SITTING

Shrug your shoulders forward, then move them in a circle, raising them high enough to reach your ears.
Touch your elbows together in front of you.
Twist your whole upper body from side to side with your hands on your hips.
Ben forward and let your arms dangle; try to touch the floor with your hands.
While still sitting, move each of your knees up and down as if you are walking; each time your right foot hits the ground, count it as one. Lift your knee high.

STANDIG UP

Using your arms, push off from the bed and stand up; if you get dizzy, sit down and try again.
Hold your arms out and turn them in big circles
With hands at your side, bend at the waist as far as you can to the right side, then to the left.
Keep your feet planted on the ground and twist your upper body at the waist form side to side with your arms swinging; when you twist to the right, count it as one.
While holding onto the edge of the bed or back of a chair, bend your knees slightly.

WALKING PLACES

Walking is good exercise because it helps toning muscles,maintaining flexibility of joints and is good for the heart and circulatory system. Walking for 20 minutes a day, 3 times a week can be effective.
When walking, push off from your toes and land on your heel. Swing arms loosely at your sides. Begin with 10-minute walk and buil to 20 to 30 minutes.
Walking up stairs requires effort. Place one foot flat on a step, push off with other and shift your weight. Use a railing for balance if necessary.
Wear supportive shoes and use whatever aids are necessary.

COME ON, STAND UP!

CARE OF AGING SKIN AND MUCOUS MEMBRANES

The skin undergoes several changes with aging. For this reason, the skin has more risk of injury in this stage.

A PRESSURE ULCER is an area of skin that breaks down when something keeps rubbing or pressing against the skin. The tissue that is subjected to excessive pressure doesn't receive enough blood and this situation causes a tissue ischemia and increases the risk of breakdown.

Ulcer development depends on the amount of pressure, the length of time pressure is exerted and the underlying status of the tissues. For this reason, the bony prominences are where more ulcers appear.

Some complications of pressure ulcer are the infection. The bacteria multiply, the healing is disrupted and damaged tissues.The main symptoms are hot, inflammation, hot, blush and pain.

Pressure ulcers most commonly occur on these locations:

There are a lot of risk factors which cause a pressure ulcer, but the most important are:

Immobility and inactivity are the most important risk factors which cause ulcer development because the patient lies or sits too long in the same position.
Skin aging and skin diseases.
Person have a disease that affects blood flow, including diabetes or vascular disease.
Urinary or Bowel incontinence.
Loss of thermal sensation and pain.
Person who have another condition that affects his mental status such as Alzheimer's disease.
Malnutrition.
Wrinkles on clothes or sheets and objects touching the skin.

It's very important to use the NORTON SCALE to value the risk of develop pressure ulcer. This scale has a sensitivity of 73-92% and a specificity of 61-94%.

Physical Condition	Mental Condition	Activity	Mobility	Incontinent	TOTAL SCORE
Good	Alert	Ambulant	Full	Not	4
Fair	Apathetic	Walk/Help	Slightly	Ocasional	3
Poor	Confused	Chairbound	Very limited	Usually/urine	2
Very bad	Stupor	Bed	Immobile	Doubly	1

Norton Rating between 5 to 9 VERY HIGH RISK
Norton Rating between 10 to 12 HIGH RISK
Norton Rating between 13 to 14 MEDIUM RISK
Norton Rating >14 LOW RISK

An other scale used to value the pressure ulcer risk is:

THE BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK.

CLASSIFICATION

Pressure ulcers are unstageable when the skin at the base of the ulcer is covered by necrotic tissue.

STAGE I: Erythema that when pressed, doesn't turn white/ There isn't epidermis's involvement.
STAGE II: The skin blisters or forms an open sore. The area around the sore may be red and irritated./ Partial-thickness skin loss including epidermis.
STAGE III: Full-thickness skin loss and injury or necrosis of the subcutaneous tissue.
STAGE IV: Full-thickness skin loss and injury or necrosis of the subcutaneous tissue, muscle and bone.

CLICK TO WATCH VIDEO: PRESSURE ULCERS

GENERAL TREATMENT

The treatment is choosen according to the pressure ulcer's stage and the main objetive is heal the injury.

STAGE I: Relieve pressure and hyperoxygenated fatty acids.
STAGES II,III and IV: Debride necrotic tissue, clean with physiological saline or antiseptics (debridement or infection), bacterial infection prevention, decrease pain, choose the adequate dressing according to the pressure ulcer's characteristics: exudate level, infection, ulcers's stage...

PREVENTION

Keep the skin clean and dry, above all, after urinating or having bowel movement.
Moving and changing position frecuently (at last every 2 hour)
Use items that help reduce pressure (decubitus mattress, pillows, foam padding...)
Control uranary incontinence and bowel incontinence.
Eat well-balance meals and drink plently of water.

CLICK TO WACH VIDEO: PRESSURE ULCERS PREVENTION (in spanish)

I consider that the most pressure ulcer development may be prevented with a good health care.
It's true that nurses sometimes haven't got enought time for all patients, but they should pay more attention to this type of patientes, above all the patients who have high risk of pressur ulcer's development.

WE MUSTN'T FORGET THAT 95% OF THE PRESSURE ULCERS ARE AVOIDABLE

Bibliografía

MEDLINEPLUS

NURSING CARE IN THE ELDERLY

A Nursing's Care Process have a five parts:

VALUATION based on 14 basic needs of Virginia Henderson.
DIAGNOSIS
CARE'S PLANNING
EJECUTION
EVALUATION OF THE CARE'S PLANNING

The nursing's care process is very useful to establish individualized care's plan. The objetives are:

Identify the patient's health status.
Establish a care's plan.
Provide specific interventions.

VIRGINIA HENDERSON

Architect of nursing and mother of us all. (1897-1996)

"The nurse is temporarily the consciousness of the unconscious, the love of life for the suicidal, the leg of the amputee, the of the newly blind, a means of locomotion for the infant, knowledge and confidence for the mother, the mouthpiece for those too weak or withdrawn to speak and so on."

Virginia Henderson was a nurse who created the care model based on 14 basic needs:

Breathe normally.
Eat and drink adequately.
Eliminate body wastes.
Move and maintain desirable positions.
Sleep and rest.
Select suitable clothes-dress and undress.
Maintain body temperature within normal range by adjusting clothing and modifying enviroment.
Keep the body clean and well groomed and protect the integument.
Avoid dangers in the environment and avoid injuring others.
Communicate with others in expressing emotions, needs, fears or opinions.
Worship according to one's faith.
Work in such a way that there is a sense of accomplishment.
Play or participate in various forms of recreation.
Learn discover or satisfy that leads to normal development and health and use the available health facilities.

I'm going to explain carefully the need "Sleep and rest", because I consider that it's very important that people have an adequate sleep pattern, above all, the geriatric people.
Many older people experience problems related to sleep and some of these problems result from changes that normally occur with aging, while other may be caused by acute or chronic health problems. For this reason, nurses must be able to understand normal sleep patterns and to identify common age-ralated changes in sleep patterns for to assess, plan and intervene effectively.

A unsuitable sleep pattern would be:

A person who sleeps < 5 hours.
Frequent sleep interruptions (difficultly sleeping, nightmares, early awakenings...)
The rest isn't satisfactory. The person is irritable, fatigued, without energy.
A person who doesn't know the best conditions for sleep.
A person who does stressful exercises before sleep.

Some nursing diagnoses used to this basic need can be:

Alteration of the sleep pattern
Sleep deprivation
Acute confusion
Chronic confusion

In these situations, nursing interventions should direct the patient toward an adequate sleep pattern:

Go to bed only when the patient is sleepy.
Wake up every day at the same time.
Avoid staying in the bed more time than necessary.
Avoid napping during the day.
Control the fluid intake before bedtime.
Increase physical activity because in this way, the patient will be more tired.
Explain to the patient the ideal sleep environment: ambient light, fresh room, without noise...
Wear comfortable clothing to sleep.
Perform relaxation techniques before sleep.
Avoid the consumption of alcohol, caffeine or hypnotics.
Avoid heavy meal before sleep.
Explain the normal sleep changes that occur in aging.
Consult with the doctor the possibility of prescribing medication.

SWEET DREAMS

SOME SLEEP ASSESSMENT SCALES