Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents

Assessment of Sleep Quality and Effects of Relaxation Exercise on Sleep Quality in Patients Hospitalized in Internal Medicine Services in a University Hospital: The Effect of Relaxation Exercises in Patients Hospitalized

This study aims to assess sleep quality and determine the effects of relaxation exercise on sleep quality in patients hospitalized in internal medicine services. In total, 47 patients comprised the control group and did not engage in the exercise intervention--the progressive muscle relaxation exercise, whereas 235 patients were assigned to the intervention group (N = 282). In this study, Description Questionnaire Form and the Pittsburg Sleep Quality Index (PSQI) were used. Most patients (73.8%) had poor sleep quality. The mean pre- and postexercise PSQI scores of the patients in the interventional group were 8.7 ± 4.0 and 6.1 ± 3.3, respectively. The mean pre- and postexercise PSQI scores of the control patients were 6.6 ± 3.5 and 5.6 ± 2.7, respectively. According to this study, the exercises significantly enhanced the quality of sleep. Patients should be encouraged by nurses to perform relaxation exercises.

Person-Centered Dementia Care and Sleep in Assisted Living Residents With Dementia: A Pilot Study

The sleep of people with dementia living in long-term care is known to be disturbed. This pre-post controlled pilot study examined the effects of a person-centered dementia care intervention on sleep in assisted living residents with dementia. The three-month intervention included in-class staff training plus supervision and support in practice. The sleep-wake patterns were measured using actigraphy for three consecutive days at baseline and postintervention. Sixteen residents from the intervention and six from the control groups completed the study. The intervention group had significantly more nighttime sleep at posttest. After adjusting for baseline, the intervention group exhibited significantly less daytime sleep and more nighttime sleep. Person-centered dementia care may be effective for improving sleep of residents with dementia.

Sleep Variability Among Older Adults With Insomnia: Associations With Sleep Quality and Cardiometabolic Disease Risk

Sleep variability has been linked to poor subjective sleep quality, but few studies have investigated effects on physical health. In this study, we evaluated cross sectional associations and change over time in objective sleep variability of adults with insomnia and short sleep duration who were participating in a non-pharmacologic intervention study. Results indicated greater variability in objective sleep measures were associated with poorer subjective sleep quality (p < 0.05). Higher sleep duration variability was associated with higher HbA1c (p < 0.01) and sleep onset time variability was associated with higher BMI (p < 0.05). Sleep efficiency and WASO variability decreased with intervention (p < 0.05). These results indicate that objective sleep variability may be an important feature for the assessment of insomnia outcomes.

Association Between Social and Physical Activities and Insomnia Symptoms Among Community-Dwelling Older Adults

OBJECTIVE

To examine the association between organized social activity, walking exercise, and insomnia symptoms.

MATERIAL AND METHOD

Data for analysis are derived from the National Health Aging Trends Study (NHATS). At baseline, demographic characteristics, socioeconomic status, health-related behaviors, sleep-related problems, and health status were assessed using questionnaires.

RESULTS

Data for 7,162 community-dwelling older adults were available for analysis. Difficulty falling asleep, trouble staying asleep, and both insomnia symptoms were reported by 12%, 5%, and 11% of the participants, respectively. The proportion of participants who reported engaging in organized social activity, walking exercise, and both activities were 11%, 35%, and 26%, respectively. Participants who reported engaging in organized social activity and/or walking exercise were significantly less likely to report insomnia symptoms.

CONCLUSION

These results have important implications for future studies that plan to implement nonpharmacological interventions for management of insomnia among older adults.

Sleep quality in patients with chronic illness

AIMS AND OBJECTIVES

To explore sleep quality in patients with chronic illness in primary care.

BACKGROUND

Many people suffer from chronic illness with the numbers increasing. One common issue arises from problems that people have with their quality of sleep: a largely under-researched topic. This study exploring poor quality sleep allowed patients to describe their daily struggles with poor sleep in their own lives. This allowed the development of a deeper understanding of what it means to sleep poorly and find out how participants cope with not sleeping well.

DESIGN

A qualitative approach enabling a deep exploration of patient's experiences of sleep quality was used. Interviews were conducted with a purposive sample of nine participants from a primary care clinic. Analysis utilised an interpretative approach.

RESULTS

Data analysed produced four recurrent themes that were grouped into two categories. First, themes that identified the recognition by participants that 'something was wrong' were abrupt beginning and impact on their life. Second, themes that identified that the participants considered there was 'nothing wrong' were I am fine and I just carry on.

CONCLUSION

Data revealed that poor quality sleep can have a profound effect on quality of life. Participants lived without good quality sleep for years. They had come to accept two seemingly irreconcilable ideas that not being able to sleep is an enduring problem with a distinct starting point, and paradoxically, this is not a problem that deserves much professional attention.

RELEVANCE TO CLINICAL PRACTICE

Important original data were generated on the impact of poor quality sleep indicating that chronically disturbed sleep can increase the disease burden on patients with chronic illness. The results of this study suggest healthcare professionals need to understand how sleep quality issues impact on patient's experience of chronic illness. Data from this study will help nurses and other health professionals to deepen their understanding of the profound impact of poor quality sleep on patients with chronic illness. A programme of education highlighting the important role of sleep quality in chronic illness is suggested by the issues raised in this study. Nurses are ideally placed to assess sleep quality in patients and tailor intervention to positively affect the quality of life for this group.

Treatment of Sleep Disorders in Dementia

OPINION STATEMENT

Sleep and circadian disorders occur frequently in all types of dementia. Due to the multifactorial nature of sleep problems in dementia, we propose a structured approach to the evaluation and treatment of these patients. Primary sleep disorders such as obstructive sleep apnea should be treated first. Comorbid conditions and medications that impact sleep should be optimally managed to minimize negative effects on sleep. Patients and caregivers should maintain good sleep hygiene, and social and physical activity should be encouraged during the daytime. Given the generally benign nature of bright light therapy and melatonin, these treatments should be tried first. Pharmacological treatments should be added cautiously, due to the risk of cognitive side effects, sedation, and falls in the demented and older population. Regardless of treatment modality, it is essential to follow patients with dementia and sleep disorders closely, with serial monitoring of individual response to treatment.

Physical activity and behaviour in dementia

Physical activity can have a positive impact on cognition and well-being in older people. This article reviews and evaluates the effects of planned physical activity programmes on mood, sleep and functional ability in people with dementia. A total of 27 studies between 1974 and 2005 were found. Of these, four included participants living at home, two involved participants who were living either at home or in care homes and 21 included participants living solely in care homes. Since psychosocial intervention can reduce family caregiver burden, the break down of home-care and associated rates of institutionalization, the indirect effects of these physical activity programmes on the family caregiver are also explored. The scope for developing physical activity programmes for people with dementia in primary care using families and volunteers is discussed.

Environmental 24-hr Cycles Are Essential for Health

Circadian rhythms are deeply rooted in the biology of virtually all organisms. The pervasive use of artificial lighting in modern society disrupts circadian rhythms and can be detrimental to our health. To investigate the relationship between disrupting circadian rhythmicity and disease, we exposed mice to continuous light (LL) for 24 weeks and measured several major health parameters. Long-term neuronal recordings revealed that 24 weeks of LL reduced rhythmicity in the central circadian pacemaker of the suprachiasmatic nucleus (SCN) by 70%. Strikingly, LL exposure also reduced skeletal muscle function (forelimb grip strength, wire hanging duration, and grid hanging duration), caused trabecular bone deterioration, and induced a transient pro-inflammatory state. After the mice were returned to a standard light-dark cycle, the SCN neurons rapidly recovered their normal high-amplitude rhythm, and the aforementioned health parameters returned to normal. These findings strongly suggest that a disrupted circadian rhythm reversibly induces detrimental effects on multiple biological processes.

Subset of nursing diagnoses for the elderly in Primary Health Care

OBJECTIVE

To develop a subset of nursing diagnoses for the elderly followed in primary health care based on the bank of terms for clinical nursing practice with the elderly, in the International Classification for Nursing Practice (ICNP(r)) version 2013, and on the Model of Nursing Care.

METHOD

Descriptive study developed in sequential steps of construction and validation of the bank of terms, elaboration of the nursing diagnoses based on the guidelines of the International Council of Nurses and the bank of terms, and categorization of diagnostics according to the Care Model.

RESULTS

The total of 127 nursing diagnoses were elaborated from 359 validated terms, distributed according to the basic human needs.

CONCLUSION

It is expected that these diagnoses will form the basis for the planning of nursing care and use of a unified language for documentation of clinical nursing practice with the elderly in primary care.

OBJETIVO

Desenvolver um subconjunto de diagnósticos de enfermagem para idosos acompanhados na Atenção Primária à Saúde, com base no banco de termos para a prática clínica de enfermagem com idosos, na Classificação Internacional para a Prática de Enfermagem (CIPE(r)) Versão 2013 e no Modelo de Cuidados de Enfermagem.

MÉTODOS

Pesquisa descritiva, desenvolvida em etapas sequenciadas de construção e validação do banco de termos, elaboração dos enunciados de diagnósticos de enfermagem, com base nas diretrizes do Conselho Internacional de Enfermeiros e no banco de termos, e categorização dos diagnósticos segundo o Modelo de Cuidados.

RESULTADOS

A partir de 359 termos validados foram elaborados 127 enunciados de diagnósticos de enfermagem, distribuídos segundo as necessidades humanas fundamentais.

CONCLUSÃO

Acredita-se que esses enunciados servirão de base para o planejamento dos cuidados de enfermagem e utilização de uma linguagem unificada para a documentação da prática clínica de enfermagem com idosos na atenção primária.

Napping and Nighttime Sleep: Findings From an Occupation-Based Intervention

OBJECTIVE

To describe sleeping behaviors and trends over time among an ethnically diverse group of community-living older adults.

METHOD

A descriptive secondary data analysis of a subsample (n = 217) from the Lifestyle Redesign randomized controlled trial was done to explore baseline napping and sleeping patterns as well as 6-mo changes in these outcomes.

RESULTS

At baseline, the average time sleeping was 8.2 hr daily (standard deviation = 1.7). Among all participants, 29% reported daytime napping at baseline, of which 36% no longer napped at follow-up. Among participants who stopped napping, those who received an occupation-based intervention (n = 98) replaced napping time with nighttime sleep, and those not receiving an intervention (n = 119) experienced a net loss of total sleep (p < .05).

CONCLUSION

Among participants who stopped napping, the occupation-based intervention may be related to enhanced sleep. More research examining the role of occupation-based interventions in improving sleep is warranted.

Circadian Rhythm Sleep-Wake Disorders

The circadian system regulates the timing and expression of nearly all biological processes, most notably, the sleep-wake cycle, and disruption of this system can result in adverse effects on both physical and mental health. The circadian rhythm sleep-wake disorders (CRSWDs) consist of 5 disorders that are due primarily to pathology of the circadian clock or to a misalignment of the timing of the endogenous circadian rhythm with the environment. This article outlines the nature of these disorders, the association of many of these disorders with psychiatric illness, and available treatment options.

Clinical Practice Guideline for the Treatment of Intrinsic Circadian Rhythm Sleep-Wake Disorders: Advanced Sleep-Wake Phase Disorder (ASWPD), Delayed Sleep-Wake Phase Disorder (DSWPD), Non-24-Hour Sleep-Wake Rhythm Disorder (N24SWD), and Irregular Sleep-Wake Rhythm Disorder (ISWRD). An Update for 2015: An American Academy of Sleep Medicine Clinical Practice Guideline

A systematic literature review and meta-analyses (where appropriate) were performed and the GRADE approach was used to update the previous American Academy of Sleep Medicine Practice Parameters on the treatment of intrinsic circadian rhythm sleep-wake disorders. Available data allowed for positive endorsement (at a second-tier degree of confidence) of strategically timed melatonin (for the treatment of DSWPD, blind adults with N24SWD, and children/ adolescents with ISWRD and comorbid neurological disorders), and light therapy with or without accompanying behavioral interventions (adults with ASWPD, children/adolescents with DSWPD, and elderly with dementia). Recommendations against the use of melatonin and discrete sleep-promoting medications are provided for demented elderly patients, at a second- and first-tier degree of confidence, respectively. No recommendations were provided for remaining treatments/ populations, due to either insufficient or absent data. Areas where further research is needed are discussed.

Irregular Sleep-Wake Rhythm Disorder

Irregular sleep-wake rhythm disorder is a circadian rhythm disorder characterized by multiple bouts of sleep within a 24-hour period. Patients present with symptoms of insomnia, including difficulty either falling or staying asleep, and daytime excessive sleepiness. The disorder is seen in a variety of individuals, ranging from children with neurodevelopmental disorders, to patients with psychiatric disorders, and most commonly in older adults with neurodegenerative disorders. Treatment of irregular sleep-wake rhythm disorder requires a multimodal approach aimed at strengthening circadian synchronizing agents, such as daytime exposure to bright light, and structured social and physical activities. In addition, melatonin may be useful in some patients.

The social organization of a sedentary life for residents in long-term care

Worldwide, the literature reports that many residents in long-term care (LTC) homes are sedentary. In Canada, personal support workers (PSWs) provide most of the direct care in LTC homes and could play a key role in promoting activity for residents. The purpose of this institutional ethnographic study was to uncover the social organization of LTC work and to discover how this organization influenced the physical activity of residents. Data were collected in two LTC homes in Ontario, Canada through participant observations with PSWs and interviews with people within and external to the homes. Findings explicate the links between meals, lifts and transfers, and the LTC standards to reveal that physical activity is considered an add-on program in the purview of physiotherapists. Some of the LTC standards which are intended to product good outcomes for residents actually disrupt the work of PSWs making it difficult for them to respond to the physical activity needs of residents. This descriptive ethnographic account is an important first step in trying to find a solution to optimize real activities of daily living into life in LTC.

Identifying Feasible Physical Activity Programs for Long-Term Care Homes in the Ontario Context

Background

Structured exercise programs for frail institutionalized seniors have shown improvement in physical, functional, and psychological health of this population. However, the ‘feasibility’ of implementation of such programs in real settings is seldom discussed. The purpose of this systematic review was to gauge feasibility of exercise and falls prevention programs from the perspective of long-term care homes in Ontario, given the recent changes in funding for publically funded physiotherapy services.

Method

Six electronic databases were searched by two independent researchers for randomized controlled trials that targeted long-term care residents and included exercise as an independent component of the intervention.

Results

A total of 39 studies were included in this review. A majority of these interventions were led by physiotherapist(s), carried out three times per week for 30–45 minutes per session. However, a few group-based interventions that were led by long-term care staff, volunteers, or trained non-exercise specialists were identified that also required minimal equipment.

Conclusion

This systematic review has identified ‘feasible’ physical activity and falls prevention programs that required minimal investment in staff and equipment, and demonstrated positive outcomes. Implementation of such programs represents cost-effective means of providing long-term care residents with meaningful gains in physical, psychological, and social health.

The effects of physical activity on sleep: a meta-analytic review

A significant body of research has investigated the effects of physical activity on sleep, yet this research has not been systematically aggregated in over a decade. As a result, the magnitude and moderators of these effects are unclear. This meta-analytical review examines the effects of acute and regular exercise on sleep, incorporating a range of outcome and moderator variables. PubMed and PsycINFO were used to identify 66 studies for inclusion in the analysis that were published through May 2013. Analyses reveal that acute exercise has small beneficial effects on total sleep time, sleep onset latency, sleep efficiency, stage 1 sleep, and slow wave sleep, a moderate beneficial effect on wake time after sleep onset, and a small effect on rapid eye movement sleep. Regular exercise has small beneficial effects on total sleep time and sleep efficiency, small-to-medium beneficial effects on sleep onset latency, and moderate beneficial effects on sleep quality. Effects were moderated by sex, age, baseline physical activity level of participants, as well as exercise type, time of day, duration, and adherence. Significant moderation was not found for exercise intensity, aerobic/anaerobic classification, or publication date. Results were discussed with regards to future avenues of research and clinical application to the treatment of insomnia.

Buying time: a rationale for examining the use of circadian rhythm and sleep interventions to delay progression of mild cognitive impairment to Alzheimer's disease

As of 2010, the worldwide economic impact of dementia was estimated at $604 billion USD; and without discovery of a cure or effective interventions to delay disease progression, dementia's annual global economic impact is expected to surpass $1 trillion USD as early as 2030. Alzheimer's disease (AD) is the leading cause of dementia accounting for over 75% of all cases. Toxic accumulation of amyloid beta (Aβ), either by overproduction or some clearance failure, is thought to be an underlying mechanism of the neuronal cell death characteristic of AD-though this amyloid hypothesis has been increasingly challenged in recent years. A compelling alternative hypothesis points to chronic neuroinflammation as a common root in late-life degenerative diseases including AD. Apolipoprotein-E (APOE) genotype is the strongest genetic risk factor for AD: APOE-ε4 is proinflammatory and individuals with this genotype accumulate more Aβ, are at high risk of developing AD, and almost half of all AD patients have at least one ε4 allele. Recent studies suggest a bidirectional relationship exists between sleep and AD pathology. Sleep may play an important role in Aβ clearance, and getting good quality sleep vs. poor quality sleep might reduce the AD risk associated with neuroinflammation and the ε4 allele. Taken together, these findings are particularly important given the sleep disruptions commonly associated with AD and the increased burden disrupted sleep poses for AD caregivers. The current review aims to: (1) identify individuals at high risk for dementia who may benefit most from sleep interventions; (2) explore the role poor sleep quality plays in exacerbating AD type dementia; (3) examine the science of sleep interventions to date; and (4) provide a road map in pursuit of comprehensive sleep interventions, specifically targeted to promote cognitive function and delay progression of dementia.

Tailored lighting intervention improves measures of sleep, depression, and agitation in persons with Alzheimer's disease and related dementia living in long-term care facilities

Background

Light therapy has shown great promise as a nonpharmacological method to improve symptoms associated with Alzheimer’s disease and related dementias (ADRD), with preliminary studies demonstrating that appropriately timed light exposure can improve nighttime sleep efficiency, reduce nocturnal wandering, and alleviate evening agitation. Since the human circadian system is maximally sensitive to short-wavelength (blue) light, lower, more targeted lighting interventions for therapeutic purposes, can be used.

Methods

The present study investigated the effectiveness of a tailored lighting intervention for individuals with ADRD living in nursing homes. Low-level “bluish-white” lighting designed to deliver high circadian stimulation during the daytime was installed in 14 nursing home resident rooms for a period of 4 weeks. Light–dark and rest–activity patterns were collected using a Daysimeter. Sleep time and sleep efficiency measures were obtained using the rest–activity data. Measures of sleep quality, depression, and agitation were collected using standardized questionnaires, at baseline, at the end of the 4-week lighting intervention, and 4 weeks after the lighting intervention was removed.

Results

The lighting intervention significantly (P<0.05) decreased global sleep scores from the Pittsburgh Sleep Quality Index, and increased total sleep time and sleep efficiency. The lighting intervention also increased phasor magnitude, a measure of the 24-hour resonance between light–dark and rest–activity patterns, suggesting an increase in circadian entrainment. The lighting intervention significantly (P<0.05) reduced depression scores from the Cornell Scale for Depression in Dementia and agitation scores from the Cohen–Mansfield Agitation Inventory.

Conclusion

A lighting intervention, tailored to increase daytime circadian stimulation, can be used to increase sleep quality and improve behavior in patients with ADRD. The present field study, while promising for application, should be replicated using a larger sample size and perhaps using longer treatment duration.

[Profile of the elderly who naps]

This study aimed to characterize the elderly who naps according to sociodemographic characteristics and frailty. A descriptive, cross-sectional study part of the multicenter project Frailty in the Elderly Brazilians. We evaluated 1,866 elderly people using a sociodemographic questionnaire. The frailty was assessed using the phenotype proposed by Fried. The data were analyzed with descriptive statistics. The results showed that the profile of the elderly who naps consists predominantly of women, married, retired, pre-frail, with an average age of 73 years, four years of study, with monthly family income of 3.9 minimum salary, with 4,4 children who were living with them only. The elderly reported napping on average 5.9 days per week, lasting 53.5 minutes per nap. Knowing the profile of the elderly who naps contributes to health professionals in the development of actions in relation to sleep problems of the frail/pre-frail elderly, preventing, minimizing or solving these problems.

What is occupational therapy's role in addressing sleep problems among older adults?

Sleep problems, prevalent among older adults, are associated with poor outcomes and high health care costs. In 2008, rest and sleep became its own area of occupation in the American Occupational Therapy Association's Occupational Therapy Practice Framework. The current scoping review examined a broad context of sleep research to highlight efficacious interventions for older adults that fall within the occupational therapy scope of practice and present an agenda for research and practice. Four sleep intervention areas clearly aligned with the practice framework, including cognitive behavioral therapy for insomnia, physical activity, multicomponent interventions, and other interventions. Occupational therapy is primed to address sleep problems by targeting the context and environment, performance patterns, and limited engagement in evening activities that may contribute to poor sleep. Occupational therapy researchers and clinicians need to work collaboratively to establish the evidence base for occupation-centered sleep interventions to improve the health and quality of life of older adults.

Barriers to Physical Activity and Restorative Care for Residents in Long-Term Care: A Review of the Literature

Despite the benefits of physical activity, residents living in long-term care (LTC) are relatively sedentary. Designing successful physical activity and restorative care programs requires a good understanding of implementation barriers. A database search (2002–2013) yielded seven studies (nine articles) that met our inclusion criteria. We also reviewed 31 randomized controlled trials (RCTs) to determine if the authors explicitly discussed the barriers encountered while implementing their interventions. Eleven RCTs (13 articles) included a discussion of the barriers. Hence, a total of 18 studies (22 articles) were included in this review. Barriers occurred at resident (e.g., health status), environmental (e.g., lack of space for physical activity), and organizational (e.g., staffing and funding constraints) levels. These barriers intersect to adversely affect the physical activity of older people living in LTC. Future studies targeting physical activity interventions for residents living in LTC are needed to address these multiple levels of influence.

Daytime sleepiness: a risk factor for poor social engagement among the elderly

BACKGROUND

The aim of this study was to investigate the relationship between social engagement and daytime sleepiness among aged residents of a veterans' housing facility in Taiwan.

METHODS

A total of 597 men were enrolled in this cross-sectional study. Each subject was assessed with the Resident Assessment Instrument-Minimum Data Set, Geriatric Depression Scale, Pittsburgh Sleep Quality Index, and Mini-Mental State Examination. Social engagement was measured with the Index of Social Engagement (ISE), and daytime sleepiness was defined according to the relevant Pittsburgh Sleep Quality Index subcomponent. Subjects were divided into two groups according to their ISE levels. A multivariate logistic regression model was used to examine the association between ISE and other variables.

RESULTS

The sample's mean age was 80.8 ± 5.0 years (range: 65-99 years). Mean ISE score was 1.5 ± 1.3 (range 0-5), with 52% of participants reporting poor social engagement (ISE = 0-1). Mean Pittsburgh Sleep Quality Index global score was 5.6 ± 3.6 (range: 0-18), and 31% of participants reported daytime sleepiness. The analysis was adjusted for level of depression, cognitive impairment, dependence in activities of daily life, unsettled relationships, and illiteracy. After adjustment, daytime sleepiness was found to be independently associated with subjects' level of social engagement (odds ratio: 2.5; 95% confidence interval: 1.7-3.8; P < 0.001).

CONCLUSIONS

Daytime sleepiness and poor social engagement are common among aged residents of a veterans' housing facility. Subjects experiencing daytime sleepiness but not poor general sleep quality were at increased risk of poor social engagement. The clinical care of older residents must focus on improving daytime sleepiness to enhance their social engagement.

CONNECT for better fall prevention in nursing homes: results from a pilot intervention study

OBJECTIVES

To determine whether an intervention that improves nursing home (NH) staff connections, communication, and problem solving (CONNECT) would improve implementation of a falls reduction education program (FALLS).

DESIGN

Cluster randomized trial.

SETTING

Community (n=4) and Veterans Affairs (VA) NHs (n=4).

PARTICIPANTS

Staff in any role with resident contact (n=497).

INTERVENTION

NHs received FALLS alone (control) or CONNECT followed by FALLS (intervention), each delivered over 3 months. CONNECT used storytelling, relationship mapping, mentoring, self-monitoring, and feedback to help staff identify communication gaps and practice interaction strategies. FALLS included group training, modules, teleconferences, academic detailing, and audit and feedback.

MEASUREMENTS

NH staff completed surveys about interactions at baseline, 3 months (immediately after CONNECT or control period), and 6 months (immediately after FALLS). A random sample of resident charts was abstracted for fall risk reduction documentation (n=651). Change in facility fall rates was an exploratory outcome. Focus groups were conducted to explore changes in organizational learning.

RESULTS

Significant improvements in staff perceptions of communication quality, participation in decision-making, safety climate, caregiving quality, and use of local interaction strategies were observed in intervention community NHs (treatment-by-time effect P=.01) but not in VA NHs, where a ceiling effect was observed. Fall risk reduction documentation did not change significantly, and the direction of change in individual facilities did not relate to observed direction of change in fall rates. Fall rates did not change in control facilities (falls/bed per year: baseline, 2.61; after intervention, 2.64) but decreased by 12% in intervention facilities (falls/bed per year: baseline, 2.34; after intervention, 2.06); the effect of treatment on rate of change was 0.81 (95% confidence interval=0.55-1.20).

CONCLUSION

CONNECT has the potential to improve care delivery in NHs, but the trend toward improving fall rates requires confirmation in a larger ongoing study.

Light therapy and Alzheimer's disease and related dementia: past, present, and future

Sleep disturbances are common in persons with Alzheimer's disease or related dementia (ADRD), resulting in a negative impact on the daytime function of the affected person and on the wellbeing of caregivers. The sleep/wake pattern is directly driven by the timing signals generated by a circadian pacemaker, which may or may not be perfectly functioning in those with ADRD. A 24-hour light/dark pattern incident on the retina is the most efficacious stimulus for entraining the circadian system to the solar day. In fact, a carefully orchestrated light/dark pattern has been shown in several controlled studies of older populations, with and without ADRD, to be a powerful non-pharmacological tool to improve sleep efficiency and consolidation. Discussed here are research results from studies looking at the effectiveness of light therapy in improving sleep, depression, and agitation in older adults with ADRD. A 24-hour lighting scheme to increase circadian entrainment, improve visibility, and reduce the risk of falls in those with ADRD is proposed, and future research needs are discussed.

Senior Living Environments: Evidence-Based Lighting Design Strategies

OBJECTIVE:

To review from an architectural lighting perspective the effects of indoor lighting on the health and well-being of people in senior living environments.

BACKGROUND:

The role of circadian rhythms in people with chronic disorders continues to be a focus of laboratory research and clinical trials. Beneficial, evidence-based indoor lighting design strategies are being considered for senior living environments, particularly for residents who have limited access to natural bright light.

METHODS:

Articles published 2002–2012 reporting the results of prospective, randomized, controlled clinical trials (RCTs) were accessed using the U.S. National Library of Medicine PubMed site using the following search terms: “light, sleep, circadian, randomized, controlled, nursing home” and “light, sleep, circadian, randomized, controlled, elderly.”

RESULTS:

The search resulted in 48 citations, of which 18 meet our pre-search criteria. Data from these RCTs indicate options such as programmable, 24-hour lighting algorithms that may involve light intensity, lighting duration, spectra (wavelength) and lighting timing sequences

CONCLUSIONS:

Valid and actionable data are available about circadian rhythms, sleep, and human health and well-being that can inform the design of lighting for long-term care. Evidence-based architectural design of a 24-hour light/dark environment for residents may mitigate symptoms of circadian disruption; evidence-based management of darkness is as important as evidence-based management of light. Further research is needed into the long-term circadian health needs of night staff members in order to understand the effects of shift work while, at the same time providing the highest level of care.

Rest/activity rhythm is related to the coexistence of pain and sleep disturbance among advanced cancer patients with pain

PURPOSE

This study aimed to explore the relationships among pain, sleep disturbance, and circadian rhythms in advanced cancer patients.

METHODS

This cross-sectional study was conducted in 68 cancer patients from the oncology inpatient unit of a teaching hospital. Their demographic and medical characteristics, questionnaire surveys, including Brief Pain Inventory-Chinese version and Pittsburgh Sleep Quality Index Taiwanese version, and sleep logs and actigraphic recordings in consecutive 3 days and nights were collected and analyzed.

RESULTS

The mean (SD) scores for autocorrelation coefficient at 24 h (r24) and dichotomy index (I<O) were 0.19 (0.16) and 85.29 % (0.13 %), respectively, indicating dampened circadian rhythms in participants. The mean (SD) worst pain score was 5.47 (2.70). The sleep quality global score ranged 4 ∼ 19 with a mean (SD) of 11.19 (4.05). The worst pain levels, the Pittsburgh Sleep Quality Index (PSQI) global score, and most sleep parameters measured by actigraphy were significantly correlated with r24 and I<O. The worst pain score was significantly correlated with the PSQI global score (r = 0.69, p < 0.01). The Goodman version of the Sobel test further demonstrated that 45.77 % of the total effect was mediated by pain intensity (t = 2.76, p = 0.005). Pain was a complete mediator between circadian rhythms and sleep quality.

CONCLUSIONS

The rest/activity rhythm influences the coexisting pain and sleep disturbances. Pain functions as a complete mediator in their relationship. Interventions that improve rest/activity rhythms may improve the management of pain and sleep disturbances in cancer patients.

Dementia and sleep

Sleep evaluation can be essential in the treatment of dementia because sleep-related issues are common in dementia, often treatable, affect patient function, and are a major cause of caregiver distress. This article provides a practical approach to treatment of sleep in patients with dementia. Certain specific sleep disorders can be associated with certain underlying disorders and greater knowledge of these relationships is leading to more refined treatment approaches. Whether a sleep-related disorder such as obstructive sleep apnea, or limited sleep time, predisposes to the development of dementia is an active area of research.

The management of sleep and circadian disturbance in patients with dementia

Sleep and circadian disturbances are common among patients with dementia. Symptomatic manifestations vary according to dementia subtype, with one commonly shared pattern--the irregular sleep-wake rhythm (ISWR), a circadian disorder characterized by an absence of the sleepwake cycle’s circadian synchronization. Hypothesized mechanisms of circadian rhythm disturbance include suprachiasmatic nucleus (SCN) circadian pacemaker damage, pineal gland and melatonin secretion alterations, and reduced zeitbeigers and decreased input to the SCN. Management options include prescribed sleep/wake scheduling, light therapy, melatonin, physical and social activity, and mixed modality. The mixed-modality approach is the most effective method in treating ISWR. Pharmacologic interventions are controversial, with no evidence supporting their effectiveness while associated with multiple side effects. They should be used with caution and only be considered as short-term therapy. All treatment strategies should be individualized to achieve the best outcomes.

The effect of exercise on behavioral and psychological symptoms of dementia: towards a research agenda

BACKGROUND

Behavioral and psychological symptoms of dementia (BPSD) are common and are core symptoms of the condition. They cause considerable distress to the person with dementia and their carers and predict early institutionalization and death. Historically, these symptoms have been managed with anxiolytic and antipsychotic medication. Although potentially effective, such medication has been used too widely and is associated with serious adverse side-effects and increased mortality. Consequently, there is a need to evaluate non-pharmacological therapies for behavioral and psychological symptoms in this population. One such therapy is physical activity, which has widespread health benefits. The aim of this review is to summarize the current findings of the efficacy of physical activity on BPSD.

METHOD

Published articles were identified using electronic and manual searches. Rather than systematically aggregating data, this review adopted a rapid critical interpretive approach to synthesize the literature.

RESULTS

Exercise appears to be beneficial in reducing some BPSD, especially depressed mood, agitation, and wandering, and may also improve night-time sleep. Evidence of the efficacy of exercise on improving other symptoms such as anxiety, apathy, and repetitive behaviors is currently weak or lacking.

CONCLUSION

The beneficial effect of exercise type, its duration, and frequency is unclear although some studies suggest that walking for at least 30 minutes, several times a week, may enhance outcome. The methodological shortcomings of current work in this area are substantial. The research and clinical implications of current findings are discussed.

A systematic mapping review of randomized controlled trials (RCTs) in care homes

Background

A thorough understanding of the literature generated from research in care homes is required to support evidence-based commissioning and delivery of healthcare. So far this research has not been compiled or described. We set out to describe the extent of the evidence base derived from randomized controlled trials conducted in care homes.

Methods

A systematic mapping review was conducted of the randomized controlled trials (RCTs) conducted in care homes. Medline was searched for “Nursing Home”, “Residential Facilities” and “Homes for the Aged”; CINAHL for “nursing homes”, “residential facilities” and “skilled nursing facilities”; AMED for “Nursing homes”, “Long term care”, “Residential facilities” and “Randomized controlled trial”; and BNI for “Nursing Homes”, “Residential Care” and “Long-term care”. Articles were classified against a keywording strategy describing: year and country of publication; randomization, stratification and blinding methodology; target of intervention; intervention and control treatments; number of subjects and/or clusters; outcome measures; and results.

Results

3226 abstracts were identified and 291 articles reviewed in full. Most were recent (median age 6 years) and from the United States. A wide range of targets and interventions were identified. Studies were mostly functional (44 behaviour, 20 prescribing and 20 malnutrition studies) rather than disease-based. Over a quarter focussed on mental health.

Conclusions

This study is the first to collate data from all RCTs conducted in care homes and represents an important resource for those providing and commissioning healthcare for this sector. The evidence-base is rapidly developing. Several areas - influenza, falls, mobility, fractures, osteoporosis – are appropriate for systematic review. For other topics, researchers need to focus on outcome measures that can be compared and collated.

Environmental determinants of quality of life in nursing home residents with severe dementia

OBJECTIVES

To determine the relationship between quality of life (QOL) and environmental factors of temperature, noise, and lighting in nursing home residents with severe dementia.

DESIGN

Cross-sectional, observational, analytical.

SETTING

Eight public, long-term care nursing homes in the province of Girona, Spain.

PARTICIPANTS

Random sample of 160 nursing home residents with severe dementia.

MEASUREMENTS

Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were determined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a multifunction environment meter in a standardized manner.

RESULTS

Adjusted multivariate linear regression models demonstrated that environmental measures were independently associated with QOL and related factors. High temperature in the bedroom was associated with lower QOL (standardized β = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (β = 0.196), and low lighting levels in the bedroom were associated with number of signs of negative affective mood (β = -0.135).

CONCLUSION

The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individuals' QOL.

Department of Veterans Affairs Geriatric Research, Education and Clinical Centers: translating aging research into clinical geriatrics

Department of Veterans Affairs (VA) Geriatric Research, Education and Clinical Centers (GRECCs) originated in 1975 in response to the rapidly aging veteran population. Since its inception, the GRECC program has made major contributions to the advancement of aging research, geriatric training, and clinical care within and outside the VA. GRECCs were created to conduct translational research to enhance the clinical care of future aging generations. GRECC training programs also provide leadership in educating healthcare providers about the special needs of older persons. GRECC programs are also instrumental in establishing robust clinical geriatric and aging research programs at their affiliated university schools of medicine. This report identifies how the GRECC program has successfully adapted to changes that have occurred in VA since 1994, when the program's influence on U.S. geriatrics was last reported, focusing on its effect on advancing clinical geriatrics in the last 10 years. This evidence supports the conclusion that, after more than 30 years, the GRECC program remains a vibrant "jewel in the crown of the VA" and is poised to make contributions to aging research and clinical geriatrics well into the future.

Effectiveness of Physio Acoustic Sound (PAS) therapy in demented nursing home residents with nocturnal restlessness: study protocol for a randomized controlled trial

Background

Many older people with neuropsychiatric disorders such as Alzheimer's disease and frontotemporal dementia suffer from sleeping problems and often show nocturnal restlessness. Professionals and informal carers face considerable problems in solving these problems. Attempts to diminish these problems with medication in a safe and responsible manner have proven hardly effective or not effective at all. Therefore, nowadays the focus lies more on non-pharmacological solutions, for example by influencing environmental factors. There are indications that treatment with low-frequency acoustic vibrations, that is Physio Acoustic Sound (PAS) therapy, has a positive effect on sleeping problems. Therefore we study the effectiveness of PAS therapy in demented patients with nocturnal restlessness.

Methods

In a randomized clinical trial, 66 nursing home patients will be divided into two groups: an intervention group and a control group. For both groups nocturnal restlessness will be measured with actiwatches during a period of six weeks. In addition, a sleep diary will be filled in.

For the intervention group the baseline will be assessed, in the first two weeks, reflecting the existing situation regarding nocturnal restlessness. In the next two weeks, this group will sleep on a bed identical to their own, but with a mattress containing an in-built PAS device. As soon as the patient is lying in bed, the computer programme inducing the vibrations will be switched on for the duration of 30 min. In the last two weeks, the wash-out period, the measurements of the intervention group are continued, without the PAS intervention.

During the total study period, other relevant data of all the implied patients will be recorded systematically and continuously, for example patient characteristics (data from patient files), the type and seriousness of the dementia, occurrence of neuropsychiatric symptoms during the research period, and the occurrence of intermittent co-morbidity.

Discussion

If PAS therapy turns out to be effective, it can be of added value to the treatment of nocturnal restlessness in demented patients. Non-pharmacological PAS therapy is not only safe and patient-friendly, but it can also be widely used in a simple and relatively inexpensive way, both in institutions such as nursing homes and residential homes for the elderly, and at home. Ultimately, this may lead to a decrease in the frequent and still common use of psychotropic drugs. In addition, care needs of demented patients also may decrease as well as the number of preventable admissions to care institutions.

Trial registration

Netherlands Trial Register (NTR): NTR3242

Sleep and rest needs of seniors: a study grounded in the work of Henderson

OBJECTIVE: To identify the sleep/rest needs of an elderly population cared for by the Family Health Strategy, based on Virginia Henderson's theoretical framework. METHOD: This descriptive, quantitative study was conducted from May to June, 2011 through the application of a questionnaire to 52 seniors living in an area covered by a Primary Health Care (PHC) unit in Fortaleza, CE, Brazil. The data were analyzed using statistical software. RESULTS: the sleep disorders most frequently reported by the seniors were: sleeping less than four hours a night (84.6%), daytime sleepiness (71.2%), nighttime awakenings (71.2%), and the use of sleep medications (21.2%). Association was significant in relation to the variables: age (p=0.05), morbidities (p=0.02), smoking (p=0.01), and pain when moving (p=0.05). CONCLUSION: The sleep/rest needs of seniors were significantly associated with socio-economic factors and health conditions.

Poor self-reported sleep quality predicts mortality within one year of inpatient post-acute rehabilitation among older adults

STUDY OBJECTIVE

To evaluate the association between self-reported sleep quality among older adults during inpatient post-acute rehabilitation and one-year survival.

DESIGN

Prospective, observational cohort study.

SETTING

Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration).

PARTICIPANTS

Older patients (aged ≥ 65 years, n = 245) admitted for inpatient post-acute rehabilitation.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Within one year of post-acute rehabilitation, 57 participants (23%) were deceased. Cox proportional hazards models showed that worse Pittsburgh Sleep Quality Index (PSQI) total scores during the post-acute care stay were associated with increased mortality risk when controlling for amount of rehabilitation therapy received, comorbidities, and cognitive functioning (Hazard ratio [95% CI] = 1.11 [1.02-1.20]). Actigraphically estimated sleep was unrelated to mortality risk.

CONCLUSIONS

Poorer self-reported sleep quality, but not objectively estimated sleep parameters, during post-acute rehabilitation was associated with shorter survival among older adults. This suggests self-reported poor sleep may be an important and potentially modifiable risk factor for negative outcomes in these vulnerable older adults. Studies of interventions to improve sleep quality during inpatient rehabilitation should therefore be undertaken, and the long-term health benefits of improved sleep should be explored.

A critique of the evidence base for non-pharmacological sleep interventions for persons with dementia

Disordered sleep in persons with dementia is a contributing factor for a range of health problems. The evidence base for non-pharmacological interventions has not been evaluated and clearly presented in the literature. This paper provides a structured Critical Literature Review of the evidence for non-pharmacological interventions to reduce disordered sleep in persons with dementia. The systematic search retrieved 29 studies that were evaluated for methodological quality. The quality of evidence ranged from conclusive for light therapy and activity to inconclusive for most other interventions. There is a paucity of conclusive research for non-pharmacological sleep interventions for persons with dementia. Most of the evidence about effective interventions is anecdotal and untested. There is a need for rigorous scientific inquiry, coupled with tacit knowledge to build a strong evidence base on non-pharmacological interventions for disordered sleep for persons with dementia.

Therapeutic lighting design for the elderly: a review

AIMS

Research suggests that specialised lighting design is essential to cater for the elderly users of a building because of reduced visual performance with increased age. This review aims to document what is known of the physical and psychological aspects of lighting and their role in promoting a healthy and safe environment for the elderly.

METHODS

A methodical review was carried out of published literature on the physical and psychological impacts of light on the elderly. Design standards and guides from professional organizations were evaluated to identify synergies and gaps between the evidence base and current practice.

RESULTS

Lighting has been identified as a significant environmental attribute responsible for promoting physical and mental health of the elderly. The evidence related to visual performance was found to be robust. However, guides and standards appeared to have focused mostly on illumination requirements for specific tasks and have lacked detailed guidelines on vertical lighting and luminance design. This review has identified a growing body of evidence on the therapeutic benefits of lighting and its use in treating psychological disorders among the elderly. The experiments using light as a therapy have improved our understanding of the underlying principles, but the integration of therapeutic aspects of lighting in design practice and guidelines is lacking.

CONCLUSIONS

While design guidelines discuss the physical needs of lighting for the elderly fairly well, they lack incorporation of photobiological impacts. Despite positive outcomes from research, the implementation of therapeutic aspects of lighting in buildings is still debatable due to insufficient relevant investigations and robustness of their findings. Collaborations between designers and physicians can contribute in delivering customised lighting solutions by considering disease types and needs. Further investigation needs to be carried out for translating therapeutic benefits to photometric units to implement them in building lighting design.

Sleep disturbance in hospitalized recipients of stem cell transplantation

Disrupted sleep is considered a patient outcome sensitive to oncology nursing care and can lead to a variety of physical and psychologic dysfunctions, such as insomnia, chronic pain, respiratory distress, obesity, stress, and anxiety. Although sleep disturbances have been studied in recipients of hematopoietic stem cell transplantations (HSCTs), these studies have not examined the acute phase of transplantation. The current study aimed to identify the level of sleep disturbance in this patient population, identify factors contributing to decreased ability to sleep for hospitalized recipients of HSCT, and compare the differences in sleep disturbance between age, gender, type of transplantation, and initial stem cell transplantation versus readmission for transplantation-associated complications. Among the 69 patients studied, 26% reported clinical insomnia, as measured by the Insomnia Severity Index, and 74% had some degree of insomnia. Patient characteristics were not significantly associated with insomnia scores. Patients reported bathroom use as the most frequent reason for sleep disruption (85%). These findings suggest that sleep disturbances are common in hospitalized patients undergoing HSCT, and strategies to reduce disruptions are needed to improve patient outcomes.

Wrist actigraphy

To record sleep, actigraph devices are worn on the wrist and record movements that can be used to estimate sleep parameters with specialized algorithms in computer software programs. With the recent establishment of a Current Procedural Terminology code for wrist actigraphy, this technology is being used increasingly in clinical settings as actigraphy has the advantage of providing objective information on sleep habits in the patient's natural sleep environment. Actigraphy has been well validated for the estimation of nighttime sleep parameters across age groups, but the validity of the estimation of sleep-onset latency and daytime sleeping is limited. Clinical guidelines and research suggest that wrist actigraphy is particularly useful in the documentation of sleep patterns prior to a multiple sleep latency test, in the evaluation of circadian rhythm sleep disorders, to evaluate treatment outcomes, and as an adjunct to home monitoring of sleep-disordered breathing. Actigraphy has also been well studied in the evaluation of sleep in the context of depression and dementia. Although actigraphy should not be viewed as a substitute for clinical interviews, sleep diaries, or overnight polysomnography when indicated, it can provide useful information about sleep in the natural sleep environment and/or when extended monitoring is clinically indicated.

Automatic sleep/wake scoring from body motion in bed: validation of a newly developed sensor placed under a mattress

The purpose of this study was to formulate a "sleep/wake" scoring algorithm for processing activity measurements obtained using a newly developed nonwear actigraphy (NWA) device, and to test its validity. The NWA device has a highly sensitive pressure sensor and is placed under a mattress. It can continuously record the activity of a person lying on the mattress and identify an "in-bed/out-of-bed" state from the vibrations of the mattress. We formulated the sleep/wake scoring algorithm by using data obtained simultaneously by wrist actigraphy (Act) and the NWA device in 33 healthy participants. Agreement rate, sensitivity, and specificity with Act were 95.7%, 97.6%, and 75.8% (33 healthy people); the corresponding values were 85.9%, 89.1%, and 79.8% for 12 nursing home residents and 93.7%, 97.2%, and 60.8% for 60 nights for 6 healthy persons who slept 10 nights on their futons. Agreement rate, sensitivity, and specificity with polysomnography were in almost perfect agreement with Act (12 nights; 6 healthy persons who slept 2 nights). All our validation results indicate that the NWA device, placed under a mattress or a futon, can produce almost identical sleep/wake scores to Act. It is expected that the NWA device, a nonwear device for scoring sleep/wake and in-bed/out-of-bed, enables convenient long-term sleep-related evaluation in various fields, including hospital settings, home-care settings, and care facility settings such as nursing homes.

Treatment of sleep disturbance in Alzheimer's dementia

OBJECTIVE

To review the evidence-base behind current treatment options for sleep disturbance in Alzheimer's dementia.

DESIGN

A systematic review synthesized the qualitative and quantitative evidence on the treatment of sleep disturbance in Alzheimer's dementia. Studies with interventions targeting sleep disturbance in Alzheimer's dementia or other aspects of the neuropsychiatric symptoms, but which reported an effect on sleep, were included. The Oxford Center for Evidence-Based Medicine criteria was used in the evaluation and scoring of each study based on the quality of the evidence.

RESULTS

Thirty-eight studies were included. Majority of the studies enrolled participants with mild to moderate Alzheimer's dementia. Outcome measures included objective sleep assessments including polysomnography (PSG) or actigraphy, caregiver reports, sleep logs, and rating scales. The effectiveness of current treatments for sleep disturbance in Alzheimer's dementia is poor. Of the non-pharmacological treatments, bright light therapy (BLT) has the best results. The pharmacological agents produce inconsistent results and their use is further limited by their potential adverse effects.

CONCLUSION

Most current treatments targeting sleep disturbance in Alzheimer's dementia are ineffective. There is a need for further investigation of interventions for treating sleep disturbance in Alzheimer's dementia.

Factors that Influence Physical Activity in Long-term Care: Perspectives of Residents, Staff, and Significant Others

L’activité physique a des répercussions positives sur la santé des ainés. Toutefois, notre compréhension des facteurs qui influencent l’activité physique pour les résidents en soins de longue durée est limitée. Des résidents, des personnes significatives et des employés de neuf établissements de longue durée ont participé à des groupes de discussion (focus group). L’analyse de ces groupes de discussion révèle trois thèmes majeurs reflétant des facteurs qui semblent mitiger l’activité physique : 1) appui inadéquat pour l’activité physique; 2) routines institutionnelles omniprésentes; et 3) l’environnement physique. Tous les participants considèrent que l’activité physique est un facteur important pour préserver la santé. Des facteurs individuels, structuraux et environnementaux ont un impact sur la quantité et la qualité de l’activité physique accessible aux résidents. Ces résultats confirment le besoin de développer des stratégies pratiques et des moyens pour modifier les barrières et ancrer l’activité physique dans les soins de longue durée.