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Improving Sleep Management in the Elderly
This supplement is sponsored by Takeda Pharmaceuticals North America, Inc.
Improving Sleep Management in the Elderly
“If sleep does not serve an absolutely vital function, then it is the biggest mistake the evolutionary process ever made.” --Alan Rechschaffen, University of Chicago
Introduction
Sleep, which occupies a third of our lives, is a vital function that affects cognition and performance, as reflected by mental and physical health. The problem of insomnia in older adults living in long-term care (LTC) settings is multifactorial, involving aging biology, sleep physiology, behavior, and environment. All of these factors can feed on each other to create a vicious cycle of little sleep and high stress. This white paper is a practical guide for the management of insomnia in LTC settings, which include skilled nursing and assisted living facilities.
The purpose of this guide is to help clinicians more effectively recognize, assess, treat, and monitor insomnia in the elderly residing in LTC. Specific objectives include:
•Explain the nature of normal sleep and insomnia
•Describe the prevalence of insomnia in older adults
•Identify the clinical, economic, and regulatory implications of insomnia
•Examine the impact of new regulations and guidelines
•Summarize practical methods to recognize, evaluate, treat, and monitor insomnia
The Nature of Insomnia
Insomnia may be defined as complaints of disturbed sleep in the presence of adequate opportunity and circumstance for sleep.1 While people who reside in long-term care facilities are residents, we use the term “patient(s)” throughout this document since we are addressing individuals within the context of treating a medical condition.
Classification of Insomnia
The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)™ lists the main characteristics of insomnia as recurring, difficulty falling asleep, difficulty maintaining sleep, and nonrefreshing sleep, accompanied by impairment of function.2 All or some of these should be present at the time of diagnosis. Patients may express dissatisfaction with sleep quantity or quality. The impact of insomnia is significant and includes distress (eg, fatigue, moodiness) and impairment in social or emotional areas, decreased quality of life (QOL), or impairment of daily functioning. Insomnia may be characterized as acute or chronic depending on its duration.
Acute insomnia (also called transient insomnia) is often caused by emotional or physical discomfort and is marked by individual episodes that do not last longer than several weeks.1 If left untreated, acute insomnia may develop into chronic insomnia. By definition, chronic insomnia lasts a minimum of 30 days, but some clinicians assert that it has to last 3 months or longer to be classified as being chronic.1 Chronic insomnia is characterized by 1 or more of the following symptoms: difficulty falling asleep, difficulty maintaining sleep, and waking up too early.
Primary Versus Comorbid Insomnia
In addition to duration, insomnia can also be classified as primary or comorbid (formerly referred to as secondary insomnia) (Table 1).3 By definition, the term primary insomnia implies no other known cause of sleep disturbance. Subgroups of primary insomnia include idiopathic and psychophysiologic insomnia.4 Patients with primary insomnia exhibit unique patterns of cognitive hyperarousal and physiological arousal.5-8 In the laboratory, the biological mechanisms of primary insomnia have been associated with increased global cerebral glucose metabolism during sleep and while awake, as well as a reduced relative metabolism in the prefrontal cortex while awake. Furthermore, there is evidence of hypothalamic-adrenal hyperactivity. These patients may not be sleepy, but are fatigued and have daytime functional impairment.
Comorbid insomnia was formerly known as secondary insomnia. The term secondary insomnia is no longer preferred because it implies an understanding of pathophysiology and underlying cause of this disease that may not yet have been achieved. The majority of insomnia in clinical practice is of the comorbid type, and may in part explain the higher prevalence of insomnia in older adults. The development of comorbid insomnia has been associated with medical and neurological conditions, psychiatric disorders, primary sleep disorders, environmental and behavioral factors, and pharmacologic agents.3,9
Other sleep disorders such as sleep apnea, periodic limb movement disorder, and restless legs syndrome may present with symptoms of insomnia.10 Treatment options for sleep apnea include weight loss, exercise, continuous positive airway pressure (CPAP), ear/nose/throat (ENT) surgery, positional therapy (avoidance of supine sleeping position), and dental appliances. A number of medications are used for the treatment of periodic limb movement disorder and restless legs syndrome.10
Risk Factors for Insomnia
Studies have identified a variety of risk factors for insomnia outlined in Table 2. These include mental/psychiatric illness11 and multiple medical conditions,12 as well as other risk factors perhaps more relevant to a younger population.2,3,13-16
Defining Insomnia as a Disease/Syndrome/Condition
To understand the nature and impact of insomnia as a disease, syndrome, or condition, it is important to note that the essential function of sleep is more dependent on quality rather than quantity. This is especially true in the elderly given its impact on sleep and concomitant daytime functioning and activities of daily living (ADLs), causing signs and symptoms both day and night.1 The impact of insomnia symptoms and signs spreads over 24 hours. The nighttime experience is characterized by difficulty falling asleep and staying asleep, as well as a sense of light sleep. The results of poor nighttime sleeping lead to daytime fatigue and poor concentration, as well as excessive sleepiness (especially in acute insomnia) or excessive arousal (especially in chronic insomnia).
Biology of Sleep and Insomnia
The circadian sleep-wake cycle comprises the following phases: rapid eye movement (REM) sleep, stage 1-2 sleep, stage 3-4 sleep, and wakefulness.17 REM sleep and non-REM sleep (stages 1-4) are the two distinct brain stages that have been observed to occur in sleep. During sleep we transition through these different stages, first through the non-REM stages and then to REM sleep, which occurs primarily in the early morning hours. The typical young adult falls asleep within 20 to 30 minutes and quickly goes into the deep stages of sleep (the slow-wave sleep, when metabolic activity decreases), which is thought to be the most refreshing stage of sleep.15 During normal aging, some may have difficulty achieving or maintaining REM sleep.10 Thus, as we age there is less deep sleep and more awakening during the night. Patients with dementia-associated pathologic aging might also experience difficulty achieving or maintaining REM sleep.
The Neurology of Sleep
The mechanism of the sleep-wake cycle is well understood as involving circadian and homeostatic processes regulated in the hypothalamus, as reviewed by others.18-20 During the day, in the normal wake portion of the sleep-wake cycle, suprachiasmatic nucleus (SCN) activity in the hypothalamus promotes arousal and maintains a state of wakefulness.21-23 At night, SCN arousal is attenuated, which allows normal sleep to occur.21,23 Sleep-wake regulation is mediated by the interaction of the homeostatic and circadian systems through various substrates, some of which are potential pharmacologic targets for the treatment of insomnia.
One potential pharmacologic target is melatonin, which is secreted by the pineal gland. The adenosine receptor, targeted by caffeine (which is an adenosine receptor antagonist), builds up during the day and gets dissipated in the base of the forebrain during the night. Gamma-aminobutyric acid (GABA), the predominant inhibitory neurotransmitter in the central nervous system (CNS),24 has a special role in the ventrolateral preoptic nucleus.25,26 Benzodiazepine receptor agonists (BzRAs) bind to benzodiazepine receptor sites on the GABAA receptor complex and facilitate GABA action on the chloride ion channel to hyperpolarize neurons.27 This more polarized state results in a greater inhibitory effect that promotes sedation.27
Effects of Aging on the Sleep-Wake Cycle
Aging impacts circadian rhythm and sleep at various levels, resulting in effects on quality of life (Table 3).28,29 Changes occur in stages, leading to decreased total sleep time at night, reduction in sleep efficiency, and shortening of slow-wave sleep periods.28 Older people get less sleep during the night, but they may take naps during the day, so that the total sleep time may be the same. Aging is also associated with a decrease in deep sleep and an increase in wake time after sleep onset (WASO). Thus, while overall sleep quantity may not be affected, sleep quality deteriorates.
As people age, their natural circadian rhythm may become less responsive to external stimuli, such as changes in natural light during the course of the day.30 This weakened synchronization may lead to irregular sleep-wake periods. In some older adults, the sleep-wake cycle shifts or moves ahead in the 24-hour day, creating a condition called advanced sleep-phase syndrome (ASPS).31 Some people with ASPS get sleepy earlier in the evening (around 7 to 8 PM) and wake up very early in the morning (around 3 or 4 AM), without being able to fall back asleep. Others with ASPS might nod off in the early evening while watching television, reading, or doing crossword puzzles, and then experience trouble falling asleep or staying asleep when they later go to bed.
It is important to note that the onset of most of the changes in sleep patterns in a healthy adult occur between the ages of 40 and 60 years—healthy aging per se does not result in insomnia.28 Sleep disorders or problems are not an inevitable consequence of aging and should be addressed as soon as they are identified.
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Possible Underlying Causes of Insomnia in Older Adults
Certain conditions that are more prevalent in older adults may lead to insomnia. As discussed, some older adults have altered sleep regulation and circadian rhythms that lead to difficulty in initiating and maintaining sleep, as well as less sleep required, whereas others may develop insomnia because of medical (eg, chronic pain, pulmonary disease, sleep apnea), neurologic (eg, nocturnal myoclonus), and psychiatric conditions (eg, depression).32 Other important causes of insomnia in older adults are psychosocial factors (eg, isolation, loneliness, bereavement, decreased activity, financial constraints) and other late-life stressors, such as declining health and relocation to a different living situation.30 Table 4 lists comorbidities associated with insomnia that have been observed in the LTC setting. Environmental factors more pertinent to LTC that may aggravate insomnia include high noise level, unnatural or unusual light, patient care routines inconsistent with previous daily routines while living at home, lack of time outside the facility with natural light exposure and fresh air, temperature, patient fear or loss of a feeling of security (unfamiliar environment), and lack of exercise or mobility.33
Prevalence of Insomnia in Older Adults
Data on the prevalence of insomnia in adults come from scattered studies of community settings and LTC facilities. Estimates of prevalence range from 18% to 48%.34-42 Results from different studies are difficult to compare because of variability in data acquisition methodology and criteria used to define insomnia. Data from LTC settings may also be marred by underdiagnosis. Experience and drug utilization data suggest that there is a higher prevalence of insomnia in elderly patients in LTC facilities than is stated in the literature due to lack of identification or misdiagnosis.34 Older adults with insomnia may present with cognitive impairment and may be inappropriately identified as having dementia.
Prevalence of Insomnia in Community Settings
Figures on the prevalence of insomnia in adults living in community settings come from studies using telephone interviews of randomly selected individuals. According to a 1985 large-scale, community survey of noninstitutionalized American adults (aged 18 to 79 yr), the prevalence of insomnia increased from a low of 14% among 18- to 34-year-olds to 25% among 65- to 79-year-olds.34 After telephone interview surveys of representative samples of adults (aged > 18 yr) in France, Italy, Japan, and the United States, Leger and colleagues35 reported that 24% of respondents reported three symptoms of insomnia (ie, difficulty falling asleep, sleep maintenance problems, poor sleep) during the previous 12 months.
The 2003 National Sleep Foundation reported that among a random sample of 1508 community-dwelling patients aged 55 to 84 years living in the United States, 48% had 1 or more symptoms of insomnia at least a few nights a week, 18% had difficulty falling asleep, 33% reported waking “a lot” during the night, and 27% reported waking up not feeling refreshed.36
Prevalence of Insomnia in LTC Settings
To obtain data on the prevalence of insomnia in LTC settings, investigators have used a variety of methods such as chart reviews, observations, and interviews of patients who do not have cognitive difficulties. According to some estimates, 45% to 75% of elderly persons residing in LTC facilities have disturbed sleep.37 An observational study of 145 older patients (average age, 83 yr; range, 65-105 yr) living in 12 nursing homes in Massachusetts found that 65% had one or more sleep-related complaints.38 Interestingly, a Dutch study of 160 nondemented institutionalized patients reported an association between higher level of institutionalization and phase-advanced sleep/wake patterns, increased amounts of time spent in bed each day, and increased use of prescription sedative or hypnotic medications.39
A 1999 retrospective chart review of 600 patients (aged ≥65 yr) living in 12 nursing facilities in California, Ohio, and Virginia found that 19.2% of patients had a sleep disorder noted in the record, but fewer than 35% of these disorders were defined according to DSM-IV criteria.40 A study of 492 patients living in four New Hampshire LTC facilities found that 69% had excessive daytime sleeping and daytime in-bed time closely associated with daytime sleeping.41 Furthermore, of the 69%, 60% had disturbed nighttime sleep (defined as sleep < 80%, by wrist actigraphy), and nearly all had abnormal circadian rhythms of rest/activity.
A study of 198 randomly selected assisted living residents from 22 Maryland assisted-living facilities reported that 69% of the residents had sleep disturbances, 42% had insomnia, and 34.6% had excessive daytime sleepiness.42
Impact of Insomnia
The clinical relevance of insomnia is reflected by its significant impact on QOL as observed by measures of daytime functioning and health. Insomnia contributes to daytime sleepiness, irritability, restlessness, lethargy, listlessness, and apathy; increased risk of falls; and physical, emotional, and behavioral problems.43-49 Insomnia may also complicate treatment and recovery from medical conditions including heart disease and depression.37,50-52
To examine the risks and benefits of sedative and hypnotic use by older people, Glass and colleagues43 performed a meta-analysis evaluating randomized, controlled trials with sedative hypnotics for at least five consecutive nights in people with insomnia aged 60 years or older. They found that drug therapy improved sleep quality, decreased the number of sleep awakenings, and increased total sleep time. Sedative use compared to placebo resulted in an increased number of adverse cognitive events, increased number of adverse psychomotor events, and increased reports of daytime fatigue. The relationship between medications and increased risk of falls is uncertain. After excluding hospital-based case-control studies, epidemiological evidence largely from community settings suggests that BzRA use by older people is associated with a 50% or greater increased risk of hip fractures.44
According to a randomized, controlled, double-blind study in individuals aged 65 years or older taking psychotropic medications, withdrawal of these medications significantly reduced the risk of falling.45 Decreased dosage of BzRAs and antidepressants was associated with a 66% reduction in risk of falls.45 A 1999 systematic review and meta-analysis of observational studies reported an odds ratio of 1.48 (95% CI, 1.23-1.77) for BzRA use and the risk of falls in older adults (aged ≥60 yr), with no difference in risk between short- and long-acting medications.46 Even use of the nonbenzodiazepine hypnotic zolpidem appears to be associated with almost double the risk of hip fracture in older people (aged ≥65 yr).47
A study by Schneeweiss and Wang48 concluded that while claims data studies tend to overestimate the relationship between benzodiazepine use and the risk of hip fractures, after correcting for such bias the statistical significance of the association persisted. Avidan and colleagues49 performed a retrospective Minimum Data Set (MDS) assessment to examine the relationship between insomnia, hypnotic use, risk of falls, and hip fractures in 34,163 patients living in 437 Michigan nursing homes. These authors reported that 42.9% of patients were reported to have experienced a fall in the previous 6-month period, and 2.5% had a hip fracture. Moderate insomnia was reported in 5.5% of patients, severe insomnia in 0.81%, and hypnotic use in 2.6% of patients.
After adjustment for confounder variables, such as age and sex, insomnia at baseline predicted a 52% greater risk of future falls, whereas hypnotic use did not predict an increased fall risk.49 In addition, baseline hypnotic use, insomnia, and a combination of these two factors did not predict future hip fracture.49 These results suggest that in elderly nursing home patients, insomnia, rather than hypnotic use, is a strong predictor of risk for subsequent falls. Possible explanations for this finding are that insomnia may result in impaired psychomotor performance, excessive daytime sleepiness, and nighttime ambulation.
As previously mentioned, insomnia may be associated with certain comorbidities. According to the 2003 Sleep in America Poll,36 older adults diagnosed with hypertension, heart disease, arthritis, lung disease, depression, or memory problems were more likely to have a diagnosis of insomnia, sleep apnea, or restless legs syndrome as compared with older adults without these comorbid conditions.
Sleep disorders can also be pervasive in patients with chronic obstructive pulmonary disease (COPD) with significant consequences.50,51 For example, obstructive sleep apnea (OSA) exacerbates nocturnal hypoxemia in COPD, leading to clinical consequences (eg, neurophysiologic, cardiovascular, hematologic, possibly nocturnal death). Even in the absence of OSA, a single night’s sleep deprivation may impair pulmonary function in these patients.
Individual and societal consequences of insomnia are increased medical service use, chronic health problems, increased healthcare resource utilization, increased use of psychotropic drugs, poor health and medical conditions, cardiovascular disease, and musculoskeletal problems.52 In the nursing home setting, costs associated with insomnia include staff time due to increased comorbidities, corresponding increased use of medications, and the possibility of increased iatrogenic complications. The staff is also impacted by functional deficits caused by sleep disturbance, such as a need for assistance with ADLs due to drowsiness or late meal times to accommodate missing meals.
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Documentation Issues
Documentation gaps affect the proper and timely diagnosis and treatment of insomnia in LTC facility patients. Staff members need training to properly identify deviations from “normal” sleeping habits. Often there is inadequate reporting of symptoms and of the beneficial or adverse effects of medications used for insomnia. In addition, there is no specific guidance as to documentation and reporting. The accuracy of self-reported insomnia in LTC patients is affected by the patients’ cognitive and psychological status or functioning.
Regulatory Implications of Insomnia in Skilled Nursing
Facilities MDS Data
The Centers for Medicare and Medicaid Services (CMS) mandates compilation of MDS assessment within 14 days for a new admission to a Medicare- or Medicaid-certified LTC facility, at designated intervals during the facility stay, when there is a significant change in resident status, and annually. Thus, by themselves MDS data are not obtained at sufficient intervals to be useful in regularly monitoring a patient’s sleep habits to determine if there is a problem with insomnia. The MDS collects information on each patient’s characteristics, ADLs, medical needs, mental status, use of therapy, and other issues related to comprehensive planning for patient care.
Sleep-related elements in MDS 2.0 include53:
•Section AC.1.a–Stays up late at night (eg, after 9 PM)
•Section AC.1.b–Naps regularly during the day (at least 1 h)
•Section AC.1.n–Wakens to toilet all or most nights
•Section E.1.j & k–Sleep-cycle issues (ie, irregular, unusually timed, or reverse sleep cycle)
•Section N.1–Resident awake all or most of time (ie, naps no more than 1 h in morning, afternoon, evening)
•Section O.4.d–Number of days during last 7 days that resident has received hypnotic medications
Quality Indicators
Insomnia and related conditions may also affect the facility survey process. The MDS Quality Indicators (QIs) are 24 measures of quality of care used by surveyors to evaluate the level of care within a skilled nursing facility. Changes in QIs derived from the MDS in particular include sections
B: Cognitive Patterns,
E: Mood and Behavior Patterns,
F: Psychosocial Well-Being,
G: Physical Functioning, and
N: Activity Pursuit Patterns.53
QIs potentially affected by insomnia include falls, cognitive impairments, unnecessary antipsychotic use, depression without treatment, behavioral symptoms, new fractures, and little or no involvement with activities. Possible outcome indicators related to insomnia and its management include declines in complaints related to patient’s inability to sleep at night, prevalence of daytime sleepiness, use of sleep medications inappropriate in frail elderly patients, and use of hypnotic and sedative medications. Other possible outcomes include improvements in function, increased participation in ADLs, and increased participation in social and recreational activities and exercise programs.54
Process indicators, which are included in the preadmission assessment, show the sleep history and habits during the patient’s entire adult life, not just during the past year. Information obtained during preadmission assessment should be addressed upon admission and utilized at the initial care conference. This should be followed by documentation of sleep complaints and interventions in a patient’s individualized care plan, including implementation of environmental interventions to improve sleep quality.54
Nursing Facility Surveyor Guidelines: Tag F329—Unnecessary Drugs
As a general guideline, there are a number of questions that should be asked when evaluating the use of any medication in a nursing home (Figure 1).55 Revisions to the unnecessary medication Tag F329 that were implemented in December 2006 stress that facilities evaluate medications during a variety of situations, such as a new medication order, especially if used as an emergency measure, and a change in condition, decline in function, or new symptom or condition. Tag F329 requires that each resident’s medication regimen must be free from unnecessary medications, defined by any combination of the following characteristics: excessive dose (including duplicate therapy), excessive duration, without adequate monitoring and/or indications for its use, or in the presence of adverse consequences, which indicate that the dose should be reduced or discontinued.56
The intent of the revisions to Tag F329 is to improve medication management practices by promoting:
•Selection of medication(s) based on assessing relative benefits and risks to the individual patient
•Appropriate evaluation of signs and symptoms, in order to identify the underlying cause(s), including adverse drug consequences
•Appropriate medication doses and duration for treating the resident’s clinical conditions and underlying causes of symptoms
•Monitoring of medications for side effects and efficacy
•Nonpharmacologic interventions, where indicated
Another very important change in the updated Tag F329 relates to the policy on tapering sedatives/hypnotics, which include BzRAs, nonbenzodiazepines, melatonin receptor agonists, sedating antidepressants, and sedating antihistamines.56
The new guideline states that: “For as long as a resident remains on a sedative/hypnotic that is used routinely and beyond the manufacturer’s recommendations for duration of use, the facility should attempt to taper the medication quarterly unless clinically contraindicated. Clinically contraindicated means: •The continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder; or •The resident’s target symptoms returned or worsened after the most recent attempt at tapering the dose within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder.”
New tasks for the consultant pharmacists, medical directors, nurse practitioners, and nurses include assisting the facility in policy development for gradual dose reduction and assisting the facility and treating physician in determining objective and measurable goals of therapy (including global goals and individual goals). Providers can also provide input by creating a care plan comment to provide input on the efficacy and side-effect evaluation.56
Nursing Facility Surveyor Guidelines: Tag F428—Medication Regimen Review
The updated medication regimen review Tag F428 looks at medication-related problems (MRPs) that may include:
•Use of a medication without adequate indication for use
•Use of a medication without identifiable evidence that safer alternatives or more clinically appropriate medications have been considered
•Use of an appropriate medication that is not reaching treatment goals for reasons such as timing or techniques of administration, dosing intervals, etc
•Use of a medication in an excessive dose (including duplicate therapy) or for excessive duration
•Presence of an adverse consequence associated with medication(s)
•Use of a medication without adequate monitoring -Inadequate monitoring of response to med, or -Inadequate response to findings/results
•Presence of or risk for medication errors
•Presence of a clinical condition that might warrant initiation of medication
•Medication interaction—“Top 10 drug interactions in LTC”
The updated Tag F428 guideline asks the surveyor to determine if the treating physicians or staff noted and acted upon possible medication-related causes of recent or persistent changes in the resident’s condition, particularly in terms of typical geriatric syndromes.
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Identifying the Patient With Insomnia Signs and Symptoms
Understanding the definition of insomnia and its contributing factors is key to a comprehensive evaluation. The patient-caregiver interview is the best opportunity to determine if a patient may be suffering from insomnia. While available geriatric assessment tools created for research are not usually used in clinical practice, the following abbreviated 2- or 3-question test is a very viable alternative: (1) Do you have difficulty falling asleep, staying asleep, or wake up too early? (2) Are you excessively sleepy during the day? (3) Do you take naps? The American Medical Directors Association (AMDA) published a Clinical Practice Guideline on Sleep Disorders, which is a comprehensive step-wise approach to the recognition, assessment, treatment, and monitoring of sleep disorders.54
Highlights of this approach include:
•Evaluating the patient for sleep problems during assessment
•Defining the characteristics of the sleep disorder
•Assessing environmental, behavioral, and psychosocial factors, and medical conditions that may be contributing to the sleep disorder
•Considering the need for referral to a sleep specialist
•Implementing nonpharmacologic and/or pharmacologic therapy
•Monitoring effectiveness of the intervention and making modifications if appropriate
These guidelines assist the interdisciplinary team in selecting a course of action, including where actions should be taken and decisions should be made.54 The clinician needs to determine if there is a sleep disorder by discussing it with the patient and observers (eg, roommate, caregiver). One should look at daytime signs and symptoms such as abnormal behaviors, agitation in the morning, confusion, headaches, excessive sleepiness during daytime, inability to participate in activities, inability to participate in therapy, falls, accidents, functional decline, and new cognitive difficulties. Common sleep complaints in older adults include waking up too early, trouble falling asleep, daytime napping, insomnia, frequent nighttime waking, and waking not rested.30
Role of the Nursing Staff
The nursing staff is the best source to identify insomnia in patients of LTC facilities. The nursing staff should be trained to understand and properly evaluate all symptoms and responses to interventions. A key concern is the often limited communication between night and day staff, which may create gaps in the continuity of care and assessment. One option is a sleep log, which is a 24-hour, 5-day data collection device. It will reflect a resident’s behavior during both night and day.
In addition to finding out what they do at night, we need to know if during the day the resident is falling, taking long naps, is agitated, or is experiencing anything else that a sleepless night would cause. The log is to be completed by a certified nursing assistant (CNA) and/or nursing staff. In the facility, this could be addressed at a regularly scheduled direct care staff meeting.
Communication among staff is key—there is a dire need to get staff to “buy-in” so that they understand the value of hourly entries into a sleep log (see below) and that their input is part of the solution. Some institutions have had good success with QOL or behavior management committees that meet weekly and include the medical director, administrator, pharmacist, director of nursing, dietician, pastoral care representative, director of rehabilitation services, quality assurance coordinator, volunteer coordinator, activities representative, charge nurse, and the CNA of the “neighborhood”/unit to be evaluated. A sleep committee might include representation from pharmacy, advanced practice nurses (APNs), nursing, CNAs, housekeeping, and others as available.
Role of Other Key Members of the Healthcare Team
Various staff members possess different types of expertise that can be used individually and in collaboration with other members working as a team to optimize the patient’s care and quality of life. Primary care providers, therapists, social workers, pharmacists, and the medical director may be helpful in the detection and diagnosis of insomnia. Therapists work with patients who demonstrate variable functioning, and they can evaluate residents for sleepiness and poor attention during sessions. They can initiate a sleep log and communicate with the nursing staff.
Social workers, because of their relationship with patients and their families, often know baseline characteristics and concerns. They coordinate quarterly care conferences for all patients and are often responsible for memory testing, behavior documentation, and overall well-being. The pharmacist participates in interdisciplinary care management team meetings and works with other members of the team to evaluate any medications that may affect sleep, as well as all other medications used in the facility.
The medical director should be familiar with appropriate management of insomnia as well as facility-wide approaches for the general management of insomnia. The primary care provider should have a high index of suspicion for a sleep disorder, given its reported prevalence in the population. He or she should also address quality-of-life issues and communicate with other care providers.
What Methods and Tools Can Be Used?
Tools for sleep disorder assessment include the patient-caregiver interview, sleep logs and sleep rating sheets, polysomnography, pulse oximetry, and wrist actigraphy. Each of these methodologies has inherent advantages and disadvantages when applied to the LTC setting. The patient-caregiver interview is an easy, quick, and familiar way to obtain information on possible sleep-related problems experienced by a patient.
The disadvantage of this tool is that it relies on recall of sleep symptoms. The MDS may capture some relevant information about sleep quality (see above). The sleep log or sleep rating sheet is a useful means of obtaining objective information that has been used in selected settings (Figure 2). However, these logs also rely on recall of sleep symptoms and do not provide sleep-staging information. Furthermore, these logs are useful only for insomnia and do not capture daytime functioning. (The Eppworth Sleepiness scale is a self-rating test for daytime sleepiness.)
The institutional process used for sleep logs should allow the log to be initiated by any person involved in the patient’s care (eg, CNA, therapist, APN, physician) who thinks a patient is having problems with sleep. Polysomnography is the most reliable objective measure of sleep and has the advantage of providing sleep-staging and diagnostic information for most types of sleep disorder. However, it is expensive, intrusive, and difficult to obtain for LTC patients.
Polysomnography requires sleep technicians and a sleep clinician with expertise to interpret results, and is typically performed in a sleep laboratory. Pulse oximetry (overnight use) is less intrusive than polysomnography and allows direct monitoring for evidence of hypoxemia, which might indicate sleep apnea. Disadvantages include its expense, requirement for additional monitoring, and recording during the night. Wrist actigraphy is used to measure an individual’s day and nighttime movement in order to estimate sleep-wake patterns.57
Actigraphy is a method of activity and sleep study achieved by mounting a small unit on the wrist that continually records the movements it undergoes. When the data are later read to a computer, they can be analyzed and used in the study of circadian rhythm and sleep-wake patterns. Actigraphy has not traditionally been used in routine diagnosis of sleep disorders but is increasingly being employed in sleep clinics to replace full polysomnography. Its application in LTC is yet to be determined.
