Sleep disturbances in the institutionalized aged

The Relationship between Sleep Disturbances and Agitation in a Nursing Home

Nursing staff rated the manifestations of agitation and the characteristics of sleep in 408 nursing home residents. In addition, level of cognitive impairment was independently rated by nurses and social workers. Multiple regressions revealed that both sleep disturbances and cognitive impairment were important variables for explaining agitated behaviors. Moreover, the practice of awakening residents during the night for toileting was found to be significantly related to a greater number of aggressive behaviors (e.g., hitting) and physically nonaggressive behaviors (e.g., pacing) during the day. Implications of these findings for the caregivers of agitated nursing home residents are discussed.

Quality of sleep and related factors during chemotherapy in patients with stage I/II breast cancer

BACKGROUND

Insomnia causes severe distress in patients with breast cancer who receive chemotherapy. Few studies have focused on using objective methods to assess sleep. This study explored the quality of sleep and related factors in patients with breast cancer during chemotherapy.

METHODS

The participants were 16 women with stage I or II breast cancer receiving their third cycle of chemotherapy with cyclophosphamide, epirubicin and fluorouracil, or cyclophosphamide, methotrexate and fluorouracil. The effects of chemotherapy on sleep were assessed on the 8th and 9th days of the third cycle, i.e. the active phase in terms of side effects, and the last 2 days before the start of the fourth cycle for comparison. Instruments used to assess sleep quality and related factors included actigraphy, the Hospital Anxiety and Depression Scale (HADS), the Symptom Distress Scale (SDS), the Fatigue Visual Analogue Scale (FVAS), the Epworth Sleepiness Scale (ESS), and sleep logs.

RESULTS

During the active phase, patients showed an anxiety tendency with an average HADS score of 7.8 +/- 3.8. The average FVAS score was 4 +/- 2, indicative of mild fatigue, and SDS score (1.8 +/- 0.3) also indicated mild symptom distress. The number of awakenings each night was 2.2 +/- 1.6 by sleep logs, and the total time spent awake during these episodes was 47.8 +/- 26.1 minutes by Actiwatch. Sleep efficiency measured by Actiwatch in the active phase was 82.1 +/- 9.4% below the normal limit. Daytime sleepiness assessed by ESS showed mild sleepiness (6.0 +/- 3.5) in the active phase.

CONCLUSION

The study showed poor sleep quality and daytime sleepiness in patients with breast cancer during the active phase of chemotherapy. Chemotherapy may bring symptom distress to patients and adversely influence sleep quality.

Use of Sleep-Promoting Medications in Nursing Home Residents

This paper reviews the use of sleep-promoting medications in nursing home residents with reference to risks versus benefits. Up to two-thirds of elderly people living in institutions experience sleep disturbance. The aetiology of sleep disturbance includes poor sleep hygiene, medical and psychiatric disorders, sleep apnoea, periodic limb movements and restless leg syndrome. One key factor in the development of sleep disturbance in the nursing home is the environment, particularly with respect to high levels of night-time noise and light, low levels of daytime light, and care routines that do not promote sleep. Clinical assessment should include a comprehensive medical, psychiatric and sleep history including a review of prescribed medications. Nonpharmacological interventions for insomnia are underutilised in many clinical settings despite evidence that they are often highly effective. International studies suggest that 50-80% of nursing home residents have at least one prescription for psychotropic medication. Utilisation rates vary dramatically from country to country and from institution to institution. The most commonly prescribed medications for sleep are benzodiazepines and nonbenzodiazepine hypnotics (Z-drugs). The vast majority of studies of these medications are short-term, i.e. < or =2 weeks, although some longer extension trials have recently been carried out. Clinicians are advised to avoid long-acting benzodiazepines and to use hypnotics for as brief a period as possible, in most cases not exceeding 2-3 weeks of treatment. Patients receiving benzodiazepines are at increased risk of daytime sedation, falls, and cognitive and psychomotor impairment. Zaleplon, zolpidem, zopiclone and eszopiclone may have some advantages over the benzodiazepines, particularly with respect to the development of tolerance and dependence. Ramelteon, a novel agent with high selectivity for melatonin receptors, has recently been approved in the US. Use of the antidepressant trazodone for sleep in nondepressed patients is somewhat controversial. Atypical antipsychotics should not be used to treat insomnia unless there is also evidence of severe behavioural symptoms or psychosis.

Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer's disease patients

Sleep in the nursing home environment is extremely fragmented, possibly in part as a result of decreased light exposure. This study examined the effect of light on sleep and circadian activity rhythms in patients with probable or possible Alzheimer's disease. Results showed that both morning and evening bright light resulted in more consolidated sleep at night, as measured with wrist actigraphy. Evening light also increased the quality of the circadian activity rhythm, as measured by a 5-parameter extended cosine model (amplitude, acrophase, nadir, slope of the curve, and relative width of the peak and trough). Increasing light exposure throughout the day and evening is likely to have the most beneficial effect on sleep and on circadian rhythms in patients with dementia. It would behoove nursing homes to consider increasing ambient light in multipurpose rooms where patients often spend much of their days.

Management of night-time urinary incontinence in residential settings for older people: an investigation into the effects of different pad changing regimes on skin health

Absorbent pads are the main method of managing urinary incontinence in residential settings for older people. Improvements in technology have resulted in highly absorbent products which may be worn all night, but the effects of prolonged pad wearing on aged skin are unknown. The aim of this study was to examine the effects of two different pad changing regimes on skin health. A cross-over design was used. Subjects from residential settings were randomly allocated to one of two pad changing regimes: a frequent pad changing regime or a less frequent pad changing regime. Each regime lasted 4 weeks and was followed by the alternative regime. Skin measurements were taken twice during each regime using (i) the Diastron Erythema meter, (ii) a visual grading scale, (iii) the Servomed evaporimeter, and (iv) a pH meter. The primary outcome variable was the Diastron Erythema meter index. Eighty-one subjects completed the study. No significant differences were found in the severity of erythema, or skin pH, between regimes. Measurements of trans-epidermal water loss were significantly higher in the less frequent pad changing regime indicating that skin was 'wetter' (P = 0.01; 95% CI: 2.89-21.39). Five subjects developed grade 2 pressure ulcers (abrasions) during the less frequent pad changing regime, but none in the frequent pad changing regime; this result was not significant (P = 0.1; 95% CI: 0-1.09). No evidence was found that a less frequent pad changing regime has an effect on skin erythema or pH. There is evidence that skin is wetter which may make it more vulnerable to friction and abrasion. The statistically non-significant finding of greater incidence of grade 2 pressure ulcers is a cause for concern and merits further investigation because of the clinical significance of loss of skin integrity.

Sleep disturbances among nursing home residents

STUDY OBJECTIVES

This study assesses the prevalence and characteristics of sleep disturbances among an entire nursing home population, consisting of 29, mainly demented, long-term patients.

DESIGN AND SETTING

Sleep was evaluated for 14 consecutive days using actigraphic measurements and nursing staff observations. No alterations were made in every-day routines or medications during the observation period.

MEASUREMENTS AND RESULTS

Actigraphy showed a mean sleep onset latency of one hour and a mean wake after sleep onset of more than two hours, while there was no findings of early morning awakening. Mean sleep efficiency was 75%, and more than 13 hours were spent in bed. 72% of the subjects had sleep efficiency below 85%. Nursing staff reported sleep onset latency of more than 30 minutes in 158 of the 203 analysed days, while early morning awakening was reported in only 12 of 203 days. Actigraphical measurements and nursing staff observations gave similar results. The validity of actigraphy in this population is discussed.

CONCLUSION

Sleep disturbances were common among the residents in this nursing home. Sleep onset latency was prolonged, and the patients experienced frequent wake bouts after sleep onset. The diminished ability of sustained sleep may have been influenced by the prolonged time in bed.

Effects of bright light at lunchtime on sleep of patients in a geriatric hospital I

The effects of lunchtime bright light exposure in patients of a geriatric hospital were investigated. Ten inpatients (six women and four men; mean age +/- SD: 81.2 +/- 8.8 years) with sleep disturbances were studied for 9 weeks. Nurses performed daily ratings for sleep-wakefulness disturbances. Approximately 8000 lx bright light exposure was performed for 3 weeks in the light therapy room. Before and after exposure, ocular function was evaluated. Clinical ratings of sleep-wakefulness improved in eight patients. The score of difficulty in falling asleep and drowsiness in the morning declined during the light exposure. The score of drowsiness in the afternoon decreased during the post-light exposure. Post-exposure ocular disturbances were not found.

Circadian rhythm abnormalities of wrist activity of institutionalized dependent elderly persons with dementia

BACKGROUND

The study objective was to clarify the descriptive characteristics of circadian rhythm abnormalities of wrist activity of the institutionalized elderly with dementia.

METHODS

We studied 82 elderly persons with dementia who were institutionalized in a long-term medical care facility. The ambulatory continuous monitoring of their wrist activity was conducted for 7 days at 1-minute intervals. The time series data were analyzed using the double-plotted chronogram, spectral analysis was performed using the fast Fourier transformation and periodogram analysis was performed as well.

RESULTS

The frequency of circadian rhythm abnormalities of wrist activity rhythm in elderly persons with dementia was 57.3% (47 out of 82). The abnormalities were classified into four categories: severely impaired circadian rhythm type with no boundary between day and night, free-running rhythm type, decreased circadian amplitude type, and accentuation of ultradian rhythm type.

CONCLUSION

This four-category classification system provides a scientific approach for studying the mechanisms of circadian activity rhythm abnormalities of elderly persons with dementia.

Effects of activity of daily living and gender on circadian rhythms of the elderly in a nursing home

The objective of this study was to confirm the effects of ADL (Activity of Daily Living) and gender on circadian rhythms of the elderly in a nursing home. Twenty-one elderly volunteers, aged over 65 years, were divided in four groups depending on their ADL and gender: subjects with almost no problem in ADL (H males, H females) and those who were almost bedridden (L males, L females). Oral temperature, heart rate, blood pressure, time of sleep and wake, subjective sleepiness, overall feeling and vitality were measured every 4 hours during the day continuously for six days. The circadian rhythm was calculated by using the least squares fit of cosine function. Subjective sleep quality was also surveyed. In the sleep/wake rhythm, the mesor was significantly higher in L males compared to the other groups and the amplitude was significantly lower in L females compared to other groups. The subjective sleepiness was higher in L males compared to the other groups and L females showed a higher sleepiness compared to H females. No significant difference among the group was observed in subjective sleep quality. In conclusion, these results indicate that the subjective sleepiness and sleep/wake rhythm differ depending on ADL and gender, although no significant difference was observed in physiological parameters. ADL and gender based difference in subjective sleepiness and sleep/wake rhythm should be taken into account with regard to the care of the elderly in nursing homes.

[Effects of bright light on cognitive disturbances in Alzheimer-type dementia]

We investigated the effectiveness of bright light therapy on cognitive disturbances and its effect on circadian (sleep-wake) rhythm in Alzheimer-type dementia (ATD). Twenty-seven patients with ATD were treated with bright light therapy in the morning for 4 consecutive weeks. We evaluated the cognitive functions and circadian rhythms of the patients as a whale, and as members of two groups (one: questionable and mild dementia: the other: moderate and severe dementia; both groups classified by the severity criteria of Clinical Dementia Rating). We assessed circadian rhythms by actigraphy and cognitive states by Mini-Mental-State Examination (MMSE) and Alzheimer's Disease Assessment Scale (ADAS) before and after light therapy. Bright light therapy improved circadian rhythm. Although bright light therapy had no Significant effect on the Severity of dementia, it improved the MMSE scores, cognitive functions of ADAS scores (memory > language) and non-cognitive functions of ADAS scores (behavior = mood), especially in the questionable and mild dementia group. These results suggest that bright light therapy improves cognitive functions with the modification of circadian rhythm, especially in the early stages of ATD.

Hourly profiles of sleep and wakefulness in severely versus mild-moderately demented nursing home patients

The purpose of the current study was to examine differences in hour-by-hour sleep/wakefulness profiles between severely and mild-moderately demented patients, and to assess how many elderly patients remain almost fully asleep or nearly fully awake in each hour of a 24-hour period. Sleep/wakefulness patterns of 67 demented nursing home residents (mean age = 85.7 years) were recorded using Actillume recorders. One 24-hour period was used, and numbers of minutes spent asleep or awake were computed for every hour. There were 46 severely demented patients, and 21 mild-moderately demented patients. The amount of sleep and wakefulness recorded for each hour was compared between the two groups. In addition, the frequencies of patients who remained asleep for more than 90% of each hour, and of those who sustained wakefulness for more than 90% of each hour were computed for every hour, and comparisons were again made between the two groups. Multivariate analysis of variance showed a significant effect of dementia group on the percent of sleep/wakefulness over 24 hours (p = 0.028). Subsequent t-tests performed separately for each hour revealed significant differences between the two dementia groups in 13 out of the 24 hours. Significant differences in the frequencies of patients asleep > 90% or awake > 90% of each hour were centered around the early night and early morning hours. Patients with mild-moderate dementia showed a disproportionate amount of wakefulness during the night, whereas, in addition, patients with severe dementia showed a disproportionate amount of sleepiness during the day. With the progression of dementia, both the capacity to maintain sleep and the capacity to maintain wakefulness are impaired, and result in complete fragmentation of sleep/wakefulness during the night and day.

Factors that disturb sleep in nursing home residents

The purpose of this cross-sectional survey was to examine subjective sleep quality, and identify factors that disturb sleep in cognitively intact nursing home (NH) residents. We interviewed 51 cognitively intact NH residents using a validated instrument, the Pittsburgh Sleep Quality Index (PSQI). Questions regarding the environment, symptoms suggestive of restless leg syndrome, and periodic leg movements were also asked. Three individuals were unable to answer all the questions and, therefore, analyses were performed on 48 subjects. Seventy-three percent of the subjects were identified as "poor" sleepers based upon a total PSQI score > 5. Factors that disturbed the residents' sleep three or more times a week were: nocturia (71%), environment-related noise or light (38%), pain (33%), feeling too hot (6%) and leg cramps (6%). On multiple regression analysis, poor sleep correlated with depressive symptoms and comorbidity, not with age or gender. Poor sleep quality is common among cognitively intact NH residents. In our study, nocturia, environmental factors and pain were the most commonly perceived causes of sleep disturbance. Poor sleep independently correlated with depressive symptoms and comorbidity. These findings should be kept in mind when evaluating sleep complaints in the nursing home.

Different manifestations of circadian rhythms in senile dementia of Alzheimer's type and multi-infarct dementia

Using an actigraph and a long-term body temperature (BT) monitoring system, we simultaneously monitored rest-activity (R-A) and BT rhythms in patients with senile dementia of Alzheimer's type (SDAT; n = 20) or multi-infarct dementia (MID; n = 21) for 5-7 consecutive days. The SDAT group exhibited a well-organized BT rhythm with significantly higher amplitude compared with the MID group. The SDAT group also showed significant positive correlation between the total daily activity as well as percentage of nighttime activity and the degree of dementia, while no such tendency was observed in the MID group. The different properties of the biological rhythm disorders among the SDAT and MID groups possibly underlie their sleep and behavioral disorders.

Psychoactive medications in the long-term care setting: differing perspectives among physicians, nursing staff, and patients

Differences in perceptions among nursing home patients, nursing staff, and physicians were compared in this preliminary study regarding nighttime disorders and psychoactive medications. Nighttime disorders, including both insomnia and behavior problems, are prevalent among institutionalized elderly and are frequently managed with psychoactive medications. All nursing home patients receiving psychoactive medications, the nursing staff, and the physicians involved in their care were interviewed regarding the description, etiology, management, and impact of the nighttime disorder including side effects of the prescribed medications. Overall, the differences in responses among the three groups ranged from 47% to 63%. While both physicians and nurses reported problems more often than did the patients, nurses reported problems more frequently than did physicians. This preliminary study suggests that patients, nursing staff, and physicians perceive nighttime disorders and their management differently. These differences point to the need for improved methods of communication and education to mutually identify the targeted disorder and develop appropriate management.

Neurologic Concerns in Long-Term Care

Nursing home residents exhibit a number of different neurological disorders, including behavioral symptoms associated with dementia, sleep disturbances, and drug-induced disorders such as tardive dyskinesia. Behavioral symptoms are frequently treated with antipsychotic agents. However, there is growing evidence that these agents are frequently used inappropriately. While some patients may benefit from pharmacological intervention, it is doubtful that the majority will show dramatic improvement. Some sleep disturbances may be effectively treated with drugs, although they should be used in conjunction with environmental and behavioral interventions. The overuse of psychoactive drugs, particularly the neuroleptics, may result in neurological complications. Pharmacists have a role in ensuring that drugs are used for appropriate indications in elderly nursing home residents and in identifying drug-induced disease.

Night life: nocturnal behavior patterns among hospitalized elderly

1. In contrast to previous studies where elderly living in an institution were found to demonstrate a consistent, predictable pattern of nocturnal activity, hospitalized elderly were found to be asleep less and awake more over a period of 3 consecutive nights. 2. Medication, treatments, and assessment were scheduled with little regard for the hospitalized elderly's need for restorative sleep. 3. Each time an elderly patient was awakened, it took him or her at least 30 minutes to return to sleep. 4. Nurses are advised to determine and maintain as much as possible the patient's usual bedtime routine, keep interruptions during the night to a minimum, schedule medications and treatments efficiently, decrease noise, and medicate for pain as appropriate.

The Zurich Study. VII. Insomnia: symptoms, classification and prevalence

This study describes sleep behaviour and insomnia in a representative cohort of a Swiss population. Interviews were carried out prospectively from age 20-21 to 27-28 years, starting with 292 males and 299 females. Females usually go to bed earlier and sleep 30 min longer than males. Taking into account length and periodicity of insomnia we can distinguish occasional insomnia (OI), repeated brief insomnia (RBI), and continued insomnia (CI), defined by operational criteria. The prevalence of sleep problems is stable from age 21-28, at 36%-40%. CI (prevalence 8%-10%) and RBI (13%-19%) are both medical problems in terms of treatment by professionals (10%-17%) or self-medication (7%-12%). The majority of insomniacs cope with sleep problems in various other ways. Frequency and patterns of symptoms of insomnia are described.

Daily sleep patterns observed among institutionalized elderly residents

The sleep/wake patterns of 16 institutionalized demented women were visually monitored hourly for 14 consecutive days. Individual mean total sleep time varied markedly from 5.0 to 12.1 hours per 24 hours. Unexpectedly, amounts of day sleep and night sleep correlated positively, suggesting a general sleep tendency manifested throughout the 24-hour day. Consistent individual sleep patterns and high inter-day correlations were found. A high degree of individuality in the sleep/wake patterns was also found, contrary to expectations that elderly obtain less sleep than others. Night sleep in the institutionalized elderly was not lessened by daytime sleep. Visual monitoring of sleep/wake patterns generated reliable data.

Long-acting and short-acting benzodiazepines in the elderly: kinetic differences and clinical relevance

A review of available information about the pharmacokinetics of pro-nor-diazepam-like compounds in the elderly shows substantial impairment of the metabolism compared to oxazepam-like benzodiazepines, which are metabolized with virtually no change in this age group. Results of clinical trials point in the same direction, although small numbers of patients, different criteria for measuring clinical benefit and adverse reactions and different dosages for various periods of time make the comparison difficult. Qualified clinical guidelines are mainly to reduce dosage and use oxazepam-like compounds in the elderly, but routine clinical practice does not seem to apply these recommendations. Further research is therefore needed, mainly in the area of clinical practice, to describe the 'real' situation of benzodiazepine prescription for in-patients and out-patients in terms of risk-benefit ratio of drug treatment and to monitor the changes occurring when a more rational approach is introduced as regards the need for treatment, dose and duration of treatment.