Search

This article presents the key findings from an extensive research project aiming to identify the determinants of poor sleep in care homes. A mixed methods study was conducted in 10 care homes in South East England. This included 2-week daily diaries completed by 145 older residents and interviews with 50 care-home staff. This research demonstrated that the regular surveillance by qualified nurses and care assistants at night seriously impedes the quality of sleep experienced by older people living in care homes. However, nurses and social care workers have a duty of care, which would not be fulfilled if regular checks were not undertaken at night. There is a need for care-home staff to strike a balance between enabling older people living in care homes to have a good night's sleep and adhering to their own professional duty of care.

Objectives: To improve nighttime sleep in nursing home patients., Design: Controlled clinical trial., Setting: Eight community nursing homes enrolled two at a time., Participants: Of 1,077 patients assessed in the eight nursing homes, 638 (59%) were eligible, and consent was obtained for 273 (43% of those eligible). Of the 230 who underwent baseline assessments, 173 completed the immediate-intervention phase of the trial (77 in the intervention group and 96 in the control group). A total of 160 subjects completed the intervention (77 in the immediate-intervention group and 83 in the delayed-intervention phase)., Intervention: Trained research staff provided the intervention, which included daytime physical activity and attempts to keep subjects out of bed, evening bright light exposure, a consistent bedtime routine, nighttime care routines designed to minimize sleep disruption, and strategies to reduce nighttime noise. Subjects from one nursing home received the intervention (Group 1), whereas subjects in the second nursing home served as a control group (Group 2); then Group 2 received the intervention., Measurements: Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects. Secondary measures included assessments of mood and behavior using the Neuropsychiatric Inventory, the Geriatric Depression Scale, and behavioral observations., Results: There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial. In the 160 subjects who completed the intervention, there were no significant changes in any actigraphic measure of nighttime sleep, nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography., Conclusion: This multicomponent, nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients. Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible. Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials.

Objectives: The purpose of this study was to test whether an intervention combining increased daytime physical activity with improvement in the nighttime environment improves sleep and decreases agitation in nursing home residents., Design: A randomized trial., Setting: One community nursing home in the Los Angeles, California area., Participants: Twenty-nine incontinent residents (mean age 88.3 years, 90% female)., Intervention: Subjects were randomized to receive either (1) an intervention combining increased daytime physical activity (14 weeks in duration) plus a nighttime program (5 nights in duration) to decrease noise and sleep-disruptive nursing care practices (intervention group), or (2) the nighttime program alone (control group)., Measurements: Daytime physical activity monitors and structured physical function assessments; nighttime wrist activity monitors to estimate nighttime sleep; and timed daytime behavioral observations of sleep versus wakefulness, either in or out of bed, and agitation., Results: Physical function measures did not change significantly (MANOVA for repeated measures, group by time effect). Wrist actigraphy estimation of nighttime percent sleep (time asleep over time monitored in bed at night) increased in intervention subjects from 51.7% at baseline to 62.5% at follow-up compared with 67.0% at baseline to 66.3% at follow-up in controls (MANOVA, group by time, F = 4.42, P = .045, df = 27). At follow-up, intervention subjects averaged a 32% decrease in the percent of daytime observations in bed compared with baseline, with essentially no change in controls (MANOVA, group by time, F = 5.31, P = .029, df = 27). Seven of 15 intervention subjects had a decrease in observed agitation at follow-up, compared with baseline, versus only 1 of 14 controls with a decrease in observed agitation., Conclusions: This study provides preliminary evidence that an intervention combining increased physical activity with improvement in the nighttime nursing home environment improves sleep and decreases agitation in nursing home residents.

Objective: To describe sleep and body movement patterns in incontinent nursing home residents for the purpose of determining if the residents require nighttime changing and body repositioning on a 2-hour schedule., Design: Cross-sectional survey., Setting: Four nursing homes., Participants: 118 nursing home residents., Measurements: Over two nights, bedside monitoring equipment recorded wrist activity (as a proxy measure for sleep) and body movements of both the shoulder and hip areas in consecutive 2-minute intervals. Specific outcome measures were: (1) Average duration of a sleep episode, peak duration of a sleep episode, and percent of time in bed asleep. (2) The number of 2-minute intervals in which a large movement (45 degree turn) at the shoulder and hip was noted per hour of recording for each resident. (3) The number of resident-initiated, rather than staff-initiated, large movements at the shoulder and hip that occurred within the same 2-minute intervals., Results: There was large variability in all sleep measures; however, on average, residents slept 66% of the time they were in bed. The distribution of these measures suggests that sleep was punctuated with frequent nighttime awakenings. Thirty-three percent of the incontinent residents demonstrated very low levels of resident-initiated movement at the shoulder and hip. Sixty-six percent demonstrated at least one large movement at the shoulder and hip per hour during periods of sleep as well as during periods of wake., Conclusion: The majority of incontinent nursing home residents self-initiate sufficiently frequent movements at both the shoulder and hip so as not to be in need of frequent repositioning by nursing staff. Since the sleep of many of these residents is also characterized by frequent awakenings, incontinent nursing home residents may benefit from a schedule of nursing care at night that considers sleep of equal importance to incontinence care and body repositioning.

Objective: To evaluate the association between noise, light, nursing care practices, and nighttime awakenings in incontinent nursing home residents., Design: Cross-sectional survey., Setting: Four long-term care nursing facilities., Participants: One hundred eighteen incontinent nursing home residents., Measurements: Over two nights, bedside monitoring equipment recorded wrist activity, resident bed movements, and environmental noise and light changes in consecutive 2-minute intervals. Changes in sleep and bed movement were compared with changes in noise and light that occurred within the same or proximal 2-minute intervals. Noise and light changes in combination with large resident movement at the hip and shoulder were interpreted as related to incontinence care based on observational measures. Specific outcome measures were: (1) the number of noise and light changes as well as staff care practices that did not wake the resident during periods of consecutive sleep, ie, sleep lasting a minimum of 10 minutes; (2) the number of noise and light changes as well as staff care practices that occurred immediately before or during the 2-minute intervals during which a resident woke from a period of consecutive sleep; and (3) the number of such staff care practices that were related to incontinence care., Results: Noise and light changes associated with both general environmental events and more specific nurse care practices were associated with 50% of all waking episodes of 4 minutes or longer and 35% of all waking episodes of 2 minutes or shorter. The major sources of all noise were traced to nursing staff. Eighty-seven percent of all incontinence care practices were associated with episodes of waking., Conclusion: The data reported in this paper document that general environmental noise and incidents of nursing care practices, particularly those related to incontinence care, are responsible for a substantial amount of the sleep fragmentation that is common among nursing home residents.