# A 78-year-old hospitalized client reports difficulty falling asleep. The client drinks 3 cups of coffee daily, naps for 2 hours each afternoon, and watches television in bed until late. Which intervention should the nurse implement first to promote sleep?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=363165&lang=en  
> language: en  
> subject: Rest and Sleep  
> category: BCC

## Question

A 78-year-old hospitalized client reports difficulty falling asleep. The client drinks 3 cups of coffee daily, naps for 2 hours each afternoon, and watches television in bed until late. Which intervention should the nurse implement first to promote sleep?

## Option

1. Request a prescription for diphenhydramine 25 mg orally at bedtime as a safe sleep aid for older adults
2. Request a prescription for zolpidem 5 mg at bedtime as short-term therapy for insomnia in the elderly
3. Limit caffeine after noon, shorten daytime naps, and remove the television from the bedroom routine **✔ Correct answer**
4. Schedule a gentle back massage for 30 minutes before the client's usual bedtime to induce relaxation

**Correct answer: 3**

## Explanation

Nonpharmacologic sleep hygiene is the first-line intervention for insomnia in older adults. Reducing caffeine after noon, limiting long daytime naps, and removing screen time from the bedroom directly address the modifiable contributors. Diphenhydramine is on the Beers Criteria as inappropriate in older adults due to anticholinergic and fall risk. Zolpidem is a controlled hypnotic with confusion and fall risk and is added only after sleep hygiene fails. A back massage may help but is less impactful than removing the underlying triggers.

## In-depth explanation

Clinical Judgment
NCLEX prefers nonpharmacologic interventions first for sleep promotion in older adults. Pharmacologic sedation in this age group carries fall and delirium risk. Sleep hygiene directly addresses caffeine, naps, and screen exposure — the three modifiable triggers in this scenario.

Memory Tip
Sleep hygiene first — drugs last in older adults

KR vs US
Beers Criteria (US-based) is also referenced by Korean geriatric guidelines. Both flag diphenhydramine and benzodiazepines as inappropriate for older adults. NCLEX consistently rewards sleep hygiene and behavioral interventions over sedatives.

## Clinical scenario

Clinical Practice Guide
American Academy of Sleep Medicine and AGS Beers Criteria 2023:
- First-line for chronic insomnia in older adults: cognitive behavioral therapy for insomnia (CBT-I) + sleep hygiene.
- Caffeine cutoff at least 6 hours before bedtime.
- Daytime naps limited to ≤30 minutes before 3 PM.
- Screen-free bedroom and consistent wake time.
- Avoid diphenhydramine, benzodiazepines, and high-dose zolpidem in older adults.

Caution
Sedating medications increase the risk of nighttime falls, hip fractures, and delirium. Always trial nonpharmacologic measures first and document client response before requesting pharmacologic sleep aids.

## Key concepts

- **Sleep hygiene** — A set of behavioral and environmental practices that promote consistent quality sleep: regular sleep-wake times, dark and cool bedroom, screen-free wind-down period, caffeine and alcohol limits, and limited daytime napping. First-line for insomnia.
- **Beers Criteria** — AGS-published list of medications considered potentially inappropriate for older adults (≥65). Includes most first-generation antihistamines (diphenhydramine), long-acting benzodiazepines, and many anticholinergics. Updated every 3 years.
- **CBT-I** — Cognitive behavioral therapy for insomnia. Structured 4-8 week program addressing maladaptive sleep beliefs, stimulus control, sleep restriction, and relaxation. AASM Grade A recommendation as first-line for chronic insomnia.

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