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To nap or not to nap?
TO NAP OR NOT TO NAP? The older the person, the longer and more frequent the nap. JEAN HAYTER How many older persons take daytime naps? Are there differences between nappers and nonnappers on the basis of work status? Sex? Age? What is the relationship between napping and nighttime sleep? And, finally, what should older persons be told when they ask about the desirability of napping? Little attention has been given to such questions, yet they are important ones for all nurses who work with older persons. Nurses in longterm care facilities, for instance, often discourage daytime napping. Elders who nap are frequently concerned or embarrassed about it, and those who do not nap sometimes say they avoid it for fear it will interfere with nighttime sleep. In spite of these concerns, older persons apparently do nap more than younger persons(1-3). In the course of a study on agerelated changes in sleep, some interesting information was obtained about napping(4). Questionnaires were completed and sleep charts Jean Hayler, RN, EdD. FAAN, is a profe ssor at the College of Nursing, Uni vers ity of Kentucky, Louisville.
104 Geriatric Nursing March/April 1985 .
kept for two weeks by 212 healthy, noninstitutionalized men and women . These subjects were selected randomly from a pool of more than 1,000 potential research subjects compiled from voter registration lists by the Uni versity of Kentucky's Multidisciplinary Center for Gerontology. Ages ranged from 65 to 93 years, with 115 (54.2 percent) of the subjects between 65 and 74, 77 (36.3 percent) between 75 and 84, and 20 (9 .2 percent) who were 85 or older. These subjects provided information about numerous aspects of their sleep, but this report is limited to findings about their naps . Extent of Napping
were working for pay, almost half of them part-time. When asked to rate their health status, 160 (76 percent) rated it excellent or good, and only two rated it poor. Ninety (42 percent) subjects lived alone; most of the others lived with a spouse or other relative. Some Comparisons Although only 12 reported that they exercised regularly, all except 25 (12 percent) adhered to some sort of a schedule, and 46 (21.7 percent) followed a definite routine. No differences were found between nappers and nonnappers on the basis of sex, work status, living arrangements, their health status, amount of exercise, or schedule of daily activities. These data suggest that napping does not result from boredom or inactivity.
Eighty (38' percent) of the 212 subjects reported taking at least one nap every day; only 13 (6 percent) reported more than one nap a WHAT ABOUT DRUGS THAT MIGHT day. During the two-week period ALTER NORMAL SLEEP? Only 26 (12 that subjects kept a record of their percent) of the 212 subjects resleep, 104 (49 percent) took a nap ported taking sedatives or tranquilat least once, but only 14 took a nap . izers at all, and none reported regueach of the 14 days. lar use of either type of drug. Only Of the 80 subjects who reported 10 of the 80 subjects who reported that they usually take at least one that they usually take a nap said nap daily, 54 sleep less than one they sometimes take a sedative or hour, 19 sleep one to two hours, and tranquilizer, and only 7 of the 104 7 sleep more than two hours. The subjects who took a nap at least average nap is 30 minutes, taken once during the two-week study usually in the afternoon. took a sedative or tranquilizer durNinety-two subjects (43 percent) ing that time. No significant differwere men and 120 (57 percent) ences were found between nappers women. Fifty-seven (27 percent) and nonnappers on the basis of sed-
"Napping by older persons is nothing to be concerned about and does not cause wakeful nights. It's a mailer of individual need."
ative and tranquilizer use. There were, however, some interesting differences in the napping behavior among subjects of different ages. As Table 1 shows, significantly fewer subjects between the ages of 65 to 74 reported napping than subjects 75 to 84 (chi square = 8.39, df = 1, P < .01). No differences were found between subjects 75 to 84 and those 85 or older. Thus there seems to be an increase in the frequency of napping, beginning at age 75. Marked differences were also found in the total time spent napping by persons of different ages (see Table 2). Subjects 65 to 74 reported significantly less time spent napping than subjects 75 to 84 (chi square = 10.459, df = 3,p < .02), and the latter group spent less time napping than subjects 85 and over (chi square = 9.62, df = 3, P < .05). These findings indicate that the total time spent napping increases with age. Because the amount of time spent napping in-
creases after age 85 (chi square = 23.125, df = 3, p < .001) but the number of naps does not, the length of naps evidently increases after age 85. HOW LONG A NAP? Subjects in the 65 to 74 age group reported an average of 14 minutes; those aged 75 to 84 reported 26 minutes; and the average nap time for subjects 85 and over was 72 minutes. This confirms that the time spent napping increases progressively with age, markedly so after age 85. Napping and Nighttime Sleep The studies referred to earlier indicate that the amount of time awake during the night increases with age(l-3). To determine whether napping might be an attempt to compensate for sleep lost at night, the amount of time spent napping and the amount of time awake during the night were compared; both averaged 30 minutes. There were no significant differences between nappers and non-
nappers, however, in terms of the number of times awake or the total time awake during the night. These findings therefore suggest that daytime napping is not an attempt to compensate for sleep lost during the night. The data were further analyzed, using Pearson r, to see if there was a significant correlation between the amount of time awake during the night and the amount of time spent napping. When all 212 subjects were studied, including those (N = 24) who spent no time either awake at night or napping, the correlation was found to be 0.074. When this group was excluded, the correlation was -0.13. Finally, when data pertaining to the 80 daytime nappers were examined, the correlation was 0.015. These extremely low correlations confirm that napping is not an attempt to compensate for sleep lost at night. They indicate, instead, that although there is an increase in both the time sI?ent napping and the
Geriatric Nursing March/April 1985 lOS
Table 1.
NAPPERS and NON-NAPPERS , ACCORDING to AGE NUMBER AND PERCENTAGE OF SUBJECTS
Age
Tota l N
No n-Napp ers N %
Nap pers N %
65-74
115
33
28.7
82
71.3
75-84
77
38
49.4
39
50.6
85+
20
9
45.0
11
55 .0
Total
212
80
132
time awake during the night as age increases, each change is independent of the other. WAS TOTAL SLEEP TIME DIFFERENT FOR NAPPERS AND NONNAPPERS? When nap time was included, nappers were found to get significantly more sleep than nonnappers (chi square = 11.49, df = 5, p < .05). When nap time was excluded, however, total sleep time did not differ between the two groups. In other words, nap time simply augments the amount of sleep one would otherwise get and increases total sleep time. For further insight into the effect of napping on nighttime sleep, data were examined for the 90 subjects who reported taking daytime naps on some, but not all, days during
the two-week study period. It turned out that there was no significant difference between the amount of sleep these subjects obtained the night after the first recorded daytime nap, and the amount obtained the night after the first day on which they had no nap. This provides convincing evidence that daytime napping does not affect nighttime sleep. Implications for Elders WHAT, THEN, SHOULD OLDER PERSONS
BE
TOLD
WHEN
THEY
ASK
ABOUT THE DESIRABILITY OF NAPPING? First, they could be told that, as for everything else, there is great individual variability with regard to sleep needs. Some older persons may need naps and others not.
Total Time Spent Napping
Table 2.
TOT AL TIME ASLEEP for NAPS
-Total Age
N
No Naps N %
-
-
-
Over 1 hr.
Less than 30min . Ok N
30 min . to 1 hr. N 0/0
N
%
-
65·74
115
82
71.3
11
9 .6
16
13.9
6
5.2
75·84
77
39
50.6
9
11 7
17
22.1
12
156
85+
20
11
550
0
0 .0
1
5.0
8
40 0
They could also be told that many of them would probably benefit from daytime naps, especially in the afternoon. This is because afternoon naps provide more of the deep sleep that restores the body physically, while REM sleep, or the sleep that restores the body mentally, predominates during morning naps(l). This may mean that many older persons need afternoon naps to restore their energy at that time of day. There was no evidence in this study to indicate that naps decrease nighttime sleep; on the contrary, naps apparently augment the sleep the person would otherwise get. Consequently, there would seem to be no reason for older persons to avoid, sleeping during the day for fear that doing so will keep them awake at night. If napping is a need of many elderly: persons, and if they increase their total sleep time and replenish their energy by-napping, there is no reason for older persons to feel embarrassed or concerned about napping. Neither is there any reason for nurses to discourage napping among older persons. Residents in long-term care facilities are not as well as the subjects in this study, who were living at home and caring for themselves, so the former group may need daytime naps even more than these healthy study subjects did. Perhaps older persons in long-term care facilities, particularly those over 75 years of age, should be encouraged to take daytime naps. Day care facilities for older persons might perhaps be encouraged to provide accommodations for these participants to take naps. Napping by older persons is nothing to be concerned about and does not cause wakeful nights. It's a matter of individual need. References I. Webb. W. B. Sleep. the Gentle Tyrant. En-
Total
212
132
106 Geriatric Nursing March/April 1985
20
-
34
26
glewood Cliffs, NJ, Prentice-Hall, 1975. 2. Tune, G. S. Sleep and Wakefulness in normal human adults. Br.Med.J. 2:269-271. 3. Strauch. I., and Wollschlarger, M. Sleep behavior in the aged. IN The Nature of Sleep. ed. by V. Javanouic. Stutgart, Germany, Fisher. 1973. 4. Hayter, Jean. Sleep behavior of older persons. Nurs.Res. 32:242-246, July-Aug. 1983.
104 Geriatric Nursing March/April 1985 .
kept for two weeks by 212 healthy, noninstitutionalized men and women . These subjects were selected randomly from a pool of more than 1,000 potential research subjects compiled from voter registration lists by the Uni versity of Kentucky's Multidisciplinary Center for Gerontology. Ages ranged from 65 to 93 years, with 115 (54.2 percent) of the subjects between 65 and 74, 77 (36.3 percent) between 75 and 84, and 20 (9 .2 percent) who were 85 or older. These subjects provided information about numerous aspects of their sleep, but this report is limited to findings about their naps . Extent of Napping
were working for pay, almost half of them part-time. When asked to rate their health status, 160 (76 percent) rated it excellent or good, and only two rated it poor. Ninety (42 percent) subjects lived alone; most of the others lived with a spouse or other relative. Some Comparisons Although only 12 reported that they exercised regularly, all except 25 (12 percent) adhered to some sort of a schedule, and 46 (21.7 percent) followed a definite routine. No differences were found between nappers and nonnappers on the basis of sex, work status, living arrangements, their health status, amount of exercise, or schedule of daily activities. These data suggest that napping does not result from boredom or inactivity.
Eighty (38' percent) of the 212 subjects reported taking at least one nap every day; only 13 (6 percent) reported more than one nap a WHAT ABOUT DRUGS THAT MIGHT day. During the two-week period ALTER NORMAL SLEEP? Only 26 (12 that subjects kept a record of their percent) of the 212 subjects resleep, 104 (49 percent) took a nap ported taking sedatives or tranquilat least once, but only 14 took a nap . izers at all, and none reported regueach of the 14 days. lar use of either type of drug. Only Of the 80 subjects who reported 10 of the 80 subjects who reported that they usually take at least one that they usually take a nap said nap daily, 54 sleep less than one they sometimes take a sedative or hour, 19 sleep one to two hours, and tranquilizer, and only 7 of the 104 7 sleep more than two hours. The subjects who took a nap at least average nap is 30 minutes, taken once during the two-week study usually in the afternoon. took a sedative or tranquilizer durNinety-two subjects (43 percent) ing that time. No significant differwere men and 120 (57 percent) ences were found between nappers women. Fifty-seven (27 percent) and nonnappers on the basis of sed-
"Napping by older persons is nothing to be concerned about and does not cause wakeful nights. It's a mailer of individual need."
ative and tranquilizer use. There were, however, some interesting differences in the napping behavior among subjects of different ages. As Table 1 shows, significantly fewer subjects between the ages of 65 to 74 reported napping than subjects 75 to 84 (chi square = 8.39, df = 1, P < .01). No differences were found between subjects 75 to 84 and those 85 or older. Thus there seems to be an increase in the frequency of napping, beginning at age 75. Marked differences were also found in the total time spent napping by persons of different ages (see Table 2). Subjects 65 to 74 reported significantly less time spent napping than subjects 75 to 84 (chi square = 10.459, df = 3,p < .02), and the latter group spent less time napping than subjects 85 and over (chi square = 9.62, df = 3, P < .05). These findings indicate that the total time spent napping increases with age. Because the amount of time spent napping in-
creases after age 85 (chi square = 23.125, df = 3, p < .001) but the number of naps does not, the length of naps evidently increases after age 85. HOW LONG A NAP? Subjects in the 65 to 74 age group reported an average of 14 minutes; those aged 75 to 84 reported 26 minutes; and the average nap time for subjects 85 and over was 72 minutes. This confirms that the time spent napping increases progressively with age, markedly so after age 85. Napping and Nighttime Sleep The studies referred to earlier indicate that the amount of time awake during the night increases with age(l-3). To determine whether napping might be an attempt to compensate for sleep lost at night, the amount of time spent napping and the amount of time awake during the night were compared; both averaged 30 minutes. There were no significant differences between nappers and non-
nappers, however, in terms of the number of times awake or the total time awake during the night. These findings therefore suggest that daytime napping is not an attempt to compensate for sleep lost during the night. The data were further analyzed, using Pearson r, to see if there was a significant correlation between the amount of time awake during the night and the amount of time spent napping. When all 212 subjects were studied, including those (N = 24) who spent no time either awake at night or napping, the correlation was found to be 0.074. When this group was excluded, the correlation was -0.13. Finally, when data pertaining to the 80 daytime nappers were examined, the correlation was 0.015. These extremely low correlations confirm that napping is not an attempt to compensate for sleep lost at night. They indicate, instead, that although there is an increase in both the time sI?ent napping and the
Geriatric Nursing March/April 1985 lOS
Table 1.
NAPPERS and NON-NAPPERS , ACCORDING to AGE NUMBER AND PERCENTAGE OF SUBJECTS
Age
Tota l N
No n-Napp ers N %
Nap pers N %
65-74
115
33
28.7
82
71.3
75-84
77
38
49.4
39
50.6
85+
20
9
45.0
11
55 .0
Total
212
80
132
time awake during the night as age increases, each change is independent of the other. WAS TOTAL SLEEP TIME DIFFERENT FOR NAPPERS AND NONNAPPERS? When nap time was included, nappers were found to get significantly more sleep than nonnappers (chi square = 11.49, df = 5, p < .05). When nap time was excluded, however, total sleep time did not differ between the two groups. In other words, nap time simply augments the amount of sleep one would otherwise get and increases total sleep time. For further insight into the effect of napping on nighttime sleep, data were examined for the 90 subjects who reported taking daytime naps on some, but not all, days during
the two-week study period. It turned out that there was no significant difference between the amount of sleep these subjects obtained the night after the first recorded daytime nap, and the amount obtained the night after the first day on which they had no nap. This provides convincing evidence that daytime napping does not affect nighttime sleep. Implications for Elders WHAT, THEN, SHOULD OLDER PERSONS
BE
TOLD
WHEN
THEY
ASK
ABOUT THE DESIRABILITY OF NAPPING? First, they could be told that, as for everything else, there is great individual variability with regard to sleep needs. Some older persons may need naps and others not.
Total Time Spent Napping
Table 2.
TOT AL TIME ASLEEP for NAPS
-Total Age
N
No Naps N %
-
-
-
Over 1 hr.
Less than 30min . Ok N
30 min . to 1 hr. N 0/0
N
%
-
65·74
115
82
71.3
11
9 .6
16
13.9
6
5.2
75·84
77
39
50.6
9
11 7
17
22.1
12
156
85+
20
11
550
0
0 .0
1
5.0
8
40 0
They could also be told that many of them would probably benefit from daytime naps, especially in the afternoon. This is because afternoon naps provide more of the deep sleep that restores the body physically, while REM sleep, or the sleep that restores the body mentally, predominates during morning naps(l). This may mean that many older persons need afternoon naps to restore their energy at that time of day. There was no evidence in this study to indicate that naps decrease nighttime sleep; on the contrary, naps apparently augment the sleep the person would otherwise get. Consequently, there would seem to be no reason for older persons to avoid, sleeping during the day for fear that doing so will keep them awake at night. If napping is a need of many elderly: persons, and if they increase their total sleep time and replenish their energy by-napping, there is no reason for older persons to feel embarrassed or concerned about napping. Neither is there any reason for nurses to discourage napping among older persons. Residents in long-term care facilities are not as well as the subjects in this study, who were living at home and caring for themselves, so the former group may need daytime naps even more than these healthy study subjects did. Perhaps older persons in long-term care facilities, particularly those over 75 years of age, should be encouraged to take daytime naps. Day care facilities for older persons might perhaps be encouraged to provide accommodations for these participants to take naps. Napping by older persons is nothing to be concerned about and does not cause wakeful nights. It's a matter of individual need. References I. Webb. W. B. Sleep. the Gentle Tyrant. En-
Total
212
132
106 Geriatric Nursing March/April 1985
20
-
34
26
glewood Cliffs, NJ, Prentice-Hall, 1975. 2. Tune, G. S. Sleep and Wakefulness in normal human adults. Br.Med.J. 2:269-271. 3. Strauch. I., and Wollschlarger, M. Sleep behavior in the aged. IN The Nature of Sleep. ed. by V. Javanouic. Stutgart, Germany, Fisher. 1973. 4. Hayter, Jean. Sleep behavior of older persons. Nurs.Res. 32:242-246, July-Aug. 1983.