Sleep Disturbances in Long-Term Care

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Nighttime sleep disruption is characteristic of long-term care residents, is typically accompanied by daytime sleepiness, and may be caused by a multitude of factors. Causal factors include medical and psychiatric illness, medications, circadian rhythm abnormalities, sleep disordered breathing and other primary sleep disorders, environmental factors, and lifestyle habits. There is some suggestion that these factors are amenable to treatment; however, further research on the implementation of treatments within the long-term care setting is needed. Additional work is also needed to understand the administrative and policy factors that might lead to systemic changes in how sleep is viewed and sleep problems are addressed in long-term care settings.

Section snippets

Sleep/wake patterns in long-term care residents

Nearly any visitor to a long-term care facility will see evidence of sleep/wake pattern disturbance among residents. Among long-term care residents, self-reported difficulties with sleep are even more common and more severe than among older adults living at home in the community. Residents are commonly asleep intermittently at all hours of the day, even during mealtime periods. Although older community-dwelling adults are more likely to take naps than younger adults, the typical long-term care

Primary sleep disorders in long-term care residents

No large-scale epidemiologic studies have been conducted to examine the prevalence of primary sleep disorders in long-term care facilities. One could assume, however, that sleep disorders that increase in prevalence with advancing age are at least as common among patients in long-term care facilities as in older adults in community settings, such as sleep disordered breathing (SDB), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), and rapid eye movement (REM) sleep behavior

Medications, medical illnesses, and psychiatric disorders

Long-term care residents are frequently in poor physical health: many suffer from dementia, depression, or both, and nearly all take multiple medications to manage medical and psychiatric conditions. On average, residents of long-term care facilities take five to eight different medications every day, and many take more than 10 medications per day [4], [13]. Given that most residents use many medications, it is extremely likely that one or more of these medications impact nighttime sleep,

Circadian rhythm disruption

Circadian rhythm disruption also contributes to sleep problems in long-term care residents. In older adults, circadian rhythms may be blunted in amplitude and can be shifted to abnormal times, and circadian rhythms are commonly altered among individuals with dementia (see Table 1). In one study, long-term care residents had less stable circadian rhythms of activity compared with older people living at home, regardless of cognitive status [16]. Other studies have found a relationship between

Long-term care facilities at night

Long-term care facilities are more similar to in-patient hospital settings than to home environments. Typically, residents share rooms, and the nighttime environment is not conducive to sleep because of frequent noise and light interruptions, which occur several times per hour, on average [24]. Long-term care residents must endure these interruptions on an extended, nightly basis. Research has shown that much of the noise produced in the facility is caused by staff, often while they provide

Pharmacologic treatment of sleep problems

Extensive long-term care reforms enacted with the Omnibus Budget Reconciliation Act (OBRA) of 1987 (which became effective in 1991) included limits on the use of psychoactive medications in the long-term care setting. Although OBRA regulations specifically target antipsychotic medications, the interpretive guidelines that accompany these regulations also limit the use of anxiolytic agents and sedative-hypnotics, but not antidepressants. Use of regulated psychoactive medications must be

Nonpharmacological treatment of sleep problems

The NIH State-of-the-Science Conference on Insomnia also concluded that cognitive behavioral therapy (CBT) is as effective as prescription medications for brief treatment of chronic insomnia, with indications that beneficial effects of CBT (in contrast to those produced by medications) may last well beyond termination of treatment [35]. While it could be difficult to conduct CBT with patients with dementia because of cognitive limitations, several groups of investigators have undertaken studies

Summary

In summary, nighttime sleep disruption is characteristic of long-term care residents, is typically accompanied by daytime sleepiness, and may be caused by a multitude of factors. Causal factors include medical and psychiatric illness, medications, circadian rhythm abnormalities, SDB and other primary sleep disorders, environmental factors, and lifestyle habits. There is some suggestion that these factors are amenable to treatment; however, further research on the implementation of treatments

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      Citation Excerpt :

      For example, more than one-half of LTC residents have some form of dementia or cognitive impairment,39 which may increase sleep fragmentation and excessive daytime sleepiness.40 Nearly all residents take multiple medications to manage medical and psychiatric conditions.41 It is highly likely that some medications impact nighttime sleep and/or daytime alertness.

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    Supported by NIA UCLA Claude Pepper Older Americans Independence Center (5 P60 AG010415), NCI CA112035 CBCRP 11IB-0034, M01 RR00827, NIA AG08415, and the Research Service of the Veterans Affairs San Diego Healthcare System.

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