Annals of Long Term Care

This review discusses options for nonpharmacologic management of insomnia in older adults. A proposed model provides insights into the multidimensional nature of insomnia as a geriatric syndrome and provides a framework for evaluation and treatment. Practical nonpharmacologic interventions (sleep hygiene, sleep restriction, stimulus control, relaxation techniques, cognitive interventions) have demonstrated effectiveness in older adults and may be considered as a component in a multifaceted approach to improve sleep quality. Interventions to help strengthen circadian rhythm regulation are also outlined. While the article discusses insomnia in the general elderly population, suggestions for special populations, such as individuals with cognitive impairment or those in long-term care, are also explored. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[8]:36-42)

The Magnitude of Sleep Disruption in Older Adults
Sleep disruption is a significant problem for older adults. Several changes in sleep architecture have been noted with age. The most prominent change in sleep for older adults is an increase in the number of nighttime awakenings.¹ Reductions in sleep efficiency (ratio of time in bed asleep to time in bed), total sleep time, and the amount of time spent in deep or slow-wave sleep are common. While a weakening of the suprachiasmatic nuclei (the brain’s biologic clock) may explain some of these changes in the context of normal aging, it is more likely that declines in sleep in an elderly individual are due to changes in health and well-being. Age, cognitive status, and medical burden appear to predict subsequent declines in sleep efficiency.² Sleep becomes increasingly disrupted with declines in physical health,³ and strong links have been found between anxiety4 and depression5 and disrupted sleep.

Getting a good night’s sleep for long-term care (LTC) residents proves to be more challenging than for community-based older adults. While 4% of community-based older adults meet the diagnostic criteria for insomnia, it is estimated that 6% of LTC residents meet the criteria, and 17% report at least one of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision criteria.⁶While insomnia is a significant problem in LTC, fewer than 25% of residents with insomnia receive treatment.⁷ Primary complaints include difficulty falling asleep and difficulty staying asleep, and studies of sleep in nursing homes (NHs) demonstrate very fragmented sleep.⁸ The result is that, despite residents spending more time in bed than community-based samples, sleep efficiency is considerably lower (48-72%).⁹

Sleep problems can be even more challenging for individuals with dementia. Some 19-54% of individuals with dementia experience problems with sleep, characterized by decreased total sleep time, less slow-wave and rapid eye movement (REM) sleep, and frequent nocturnal awakenings.^6,9 Sleep-related disorientation, referred to as confusional arousals, as well as agitation and wandering, may accompany nocturnal awakenings. Abnormal movements such as stereotypic repetitive flexion of the legs and/or dream enactment may be noted. Sleep disruption may be also due to damage to the neuronal pathways related to the suprachiasmatic nuclei. Medication used to treat dementia can contribute to sleep disruption: donepezil may increase REM sleep, decrease REM sleep latency, or increase nightmares, while galantamine may decrease REM sleep latency and slow-wave sleep. Comorbid illnesses and primary sleep disorders can also contribute significantly to sleep dysregulation.

One special population of older adults are spouses assuming the role of caregivers for an individual with dementia; they often work in an overburdened schedule, similar to a rotating shift worker but without much predictability.