RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, …



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA.

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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 COURSE |09-06-2010 |

|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. |

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 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. 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. 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.

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 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.

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 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 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.

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.

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 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.

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 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.

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.

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.

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.

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.

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.

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.

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|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 | |

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