Evaluating and Treating Insomnia in Institutional Settings
Christina S. McCrae, PhD, Assistant Professor, Center for Gerontological Studies, Institute on Aging, and Department of Psychology, University of Florida, Gainesville, FL, USA.
Candece Glauser, MA, Department of Psychology and Institute on Aging, University of Florida, Gainesville, FL, USA.
A variety of patient and environmental factors make nursing home residents particularly vulnerable to insomnia or poor sleep. Although precise estimates are not available, research suggests that up to 75% of institutionalized older adults suffer from disturbed sleep.1-3 Identifying the contributory factors and intervening to resolve or limit their impact on sleep is the key to effective management. Frequently, these factors can be difficult to control, and as a result, standard sleep evaluation and treatment practices may need to be modified for use in long-term care settings.
Evaluation
Insomnia may be present if an individual has more than 30 minutes of unwanted awake time on six or more days during a two-week period. Evaluation involves having patients record various aspects of their sleep habits, such as bed and wake times, in a sleep diary, daily for two weeks. Polysomnographic (PSG) evaluation is not necessary to diagnose insomnia; however, it may be necessary in some cases in order to rule out other sleep disorders such as sleep apnea. While this approach is feasible for reasonably healthy nursing home patients, persons with dementia or those who are extremely ill may not be able to complete a sleep diary, voice complaints or undergo a PSG. For such individuals, evaluation will depend on staff and family member reports of snoring, cessation of breathing during sleep, nighttime breathing difficulties or periodic limb movements (i.e., leg jerks) during the night.
Contributors and Treatment
Effective treatment involves identifying and targeting the contributory factors, including patient factors such as chronic pain or depression, and environmental factors such as nighttime noise (Table 1). Pharmacological and behavioural interventions, which are standard treatments for persons with insomnia, can also be used with residents of care facilities.
Patient Factors
Increasing age is associated with greater sleep fragmentation, decreased slow-wave (deep) sleep, susceptibility to external arousal and earlier bed and wake times.4
Mental and physical illnesses can disrupt sleep. For example, patients with chronic obstructive pulmonary disease often experience highly fragmented sleep due to impaired breathing and the resultant buildup of carbon dioxide.5
Chronic pain fragments sleep, changes conventional sleep architecture and is perhaps the most common medical cause of insomnia in elderly nursing home residents.5
Medications used to treat mental and physical illnesses may also impact sleep. For example, selective serotonin reuptake inhibitors, such as the antidepressant fluoxetine, can have a stimulating effect. In some cases, it may be possible to switch the patient to a less stimulating antidepressant (i.e., amitriptyline).
Polypharmacy is a concern because reported sleep quality decreases as the number of medications a person receives increases.6 Age-related changes in medication metabolism and absorption, combined with mental and physical illness, make the elderly particularly vulnerable to drug toxicity. Medication reviews, which focus on a reduction of the number of drugs taken and finding less sleep-disruptive medications, may prove helpful.
Adjustment reactions or bereavement are common in institutionalized patients. Frequently, the death of a spouse precipitates placement. In many cases, such sleep disruption is only temporary. However, bereavement, like depression, may create changes in sleep architecture, lower sleep efficiency and disrupt sleep continuity.7 Effective and supportive psychological treatment is especially important to prevent adjustment reactions or bereavement from developing into depression.
Dementia frequently disrupts sleep, and the severity of sleep disruption has been correlated with the severity of