Sleep/awake status throughout the night and circadian motor activity patterns in older nursing-home residents with or without dementia, and older community-dwelling people without dementia

Nurses' attitudes, beliefs and knowledge of sleep health in residential aged care: An integrative literature review

AIM

To identify, synthesize and evaluate primary research on registered nurses' (RN) knowledge, attitudes and beliefs about sleep health and sleep health management of older adults living in residential aged care.

DESIGN

Integrative review.

DATA SOURCES

Medline, Embase and CINAHL databases from inception to September 2023.

REVIEW METHODS

Databases were searched using a combination of key words, subject heading terms. All abstracts and full-text articles were screened by two researchers. Qualitative synthesis of the included articles was conducted. Inductive content analysis was used to identify themes and analyse data.

RESULTS

A total of 923 abstracts were screened resulting in a final yield of 13 articles. Three themes were identified: (i) RN experience with sleep-disturbed residents, (ii) the emotional burden of sleep disturbances on RN and, (iii) organizational barriers to promoting resident's healthy sleep. Inappropriate administration of benzodiazepines and psychotropic drugs to manage residents' sleep disturbances was a major issue and lack of resources in residential aged care to facilitate sleep. There were concerns on nursing activity that disturbed residents' sleep and striking a balance between facilitating sleep and meeting managerial expectations was challenging.

CONCLUSION

This review identified that nurses' decision-making has an integral role in the management of sleep health in residents in aged care. Whilst evidence-based guidelines for managing sleep in residential aged care are available, there is a lack of translation to practice. Understanding RN perspectives is critical to improving sleep health models of care in residential aged care.

IMPACT

This review found that RN are attuned to the implications of sleep disturbance in residential aged care but are constrained by current sleep health models of care.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

Effect of an 18-Month Walking Intervention on the Rest-Activity Rhythm of Older Adults With Mild-Moderate Dementia

The objective of this 18-month walking intervention was to evaluate the effect on rest-activity rhythm (RAR) for older adults with mild-to-moderate dementia (65.8% female; aged M = 82.4 [SD = 6.5]). The intervention group (n = 44) was intended to walk 30 min, five times per week for 18 months. The control group (n = 35) received sedentary activities or usual care. RAR was measured at baseline to after 18 months and five times in between actigraphy outcome variables (interdaily stability, intradaily variability, relative amplitude, activity 10 most active hours, and activity 5 least active hours). Hierarchical mixed model analyses revealed no significant intervention effects (with or without baseline confounders as covariate) on RAR. However, participants in the intervention group were able to significantly increase their daily life activity (activity 10 most active hours) from the onset of the preceding measurement, b = 0.10, t(239.32) = 2.36, p = .019. More research is warranted to study the effect of regular walks on older persons with dementia whose RAR is worst at baseline.

Improving Sleep Using Mentored Behavioral and Environmental Restructuring (SLUMBER)

OBJECTIVES

To evaluate the impact of a mentoring program to encourage staff-delivered sleep-promoting strategies on sleep, function, depression, and anxiety among skilled nursing facility (SNF) residents.

DESIGN

Modified stepped-wedge unit-level intervention.

SETTING AND PARTICIPANTS

Seventy-two residents (mean age 75 ± 15 years; 61.5% female, 41% non-Hispanic white, 35% Black, 20% Hispanic, 3% Asian) of 2 New York City urban SNFs.

METHODS

Expert mentors provided SNF staff webinars, in-person workshops, and weekly sleep pearls via text messaging. Resident data were collected at baseline, post-intervention (V1), and 3-month follow-up (V2), including wrist actigraphy, resident behavioral observations, Pittsburgh Sleep Quality Index (PSQI), Patient Health Questionnaire-9 (PHQ-9) depression scale, Brief Anxiety and Depression Scale (BADS), Brief Cognitive Assessment Tool (BCAT), and select Minimum Data Set 3.0 (MDS 3.0) measures. Linear mixed models were fit for continuous outcomes and mixed-effects logistic models for binary outcomes. Outcomes were modeled as a function of time. Planned contrasts compared baseline to V1 and V2.

RESULTS

There was significant improvement in PSQI scores from baseline to V1 (P = .009), and from baseline to V2 (P = .008). Other significant changes between baseline and V1 included decreased depression (PHQ-9) (P = .028), increased daytime observed out of bed (P ≤ .001), and increased daytime observed being awake (P < .001). At V2 (vs baseline) being observed out of bed decreased (P < .001). Daytime sleeping by actigraphy increased from baseline to V1 (P = .004), but not V2. MDS 3.0 activities of daily living and pain showed improvements by the second quarter following implementation of SLUMBER (P's ≤ .034). There were no significant changes in BADS or BCAT between baseline and V1 or V2.

CONCLUSIONS AND IMPLICATIONS

SNF residents had improvements in sleep quality and depression with intervention, but improvements were not sustained at 3-month follow-up. The COVID-19 pandemic led to premature study termination, so full impacts remain unknown.

Aspects of Rest-Activity Rhythms Associated With Behavioral and Psychological Symptoms in Moderate and Severe Dementia: Results of a Cross-sectional Analysis

OBJECTIVE

Disturbances in rest-activity rhythms (RAR) are commonly observed in patients with dementia; however, the influence thereof on behavioral and psychological symptoms of dementia (BPSD) remains unexplored. This study aimed to determine whether there is an association between RAR and BPSD among patients with moderate and severe dementia.

METHODS

RAR analyses of 64 participants were performed using actigraphy. BPSD was assessed using the Neuropsychiatric Inventory-Nursing Home (NPI-NH) scale, and other clinical variables were assessed by the Mini-Mental State Examination, Cognitive Test for Severe Dementia, and Hyogo Activities of Daily Living Scale. Correlations among RAR, sleep time, and BPSD were analyzed. A stepwise multiple linear regression analysis was conducted to examine the association of RAR and sleep time with BPSD. The demographic variables were also adjusted. Variables were compared between two groups with aberrant and nonaberrant activity peak timing.

RESULTS

Correlation analysis showed that longer maximum durations of activity and shorter daytime sleep were associated with higher NPI-NH scores. Stepwise multiple linear regression analysis showed that maximum activity duration predicted the NPI-NH score after adjustment for the demographic variables. There was no significant difference in any variables between the groups with aberrant and nonaberrant activity peak timing.

CONCLUSION

RAR is associated with BPSD in moderate-to-severe dementia, which should be considered with regard to treatment.

Sleep Quality and Aging: A Systematic Review on Healthy Older People, Mild Cognitive Impairment and Alzheimer’s Disease

Aging is characterized by changes in the structure and quality of sleep. When the alterations in sleep become substantial, they can generate or accelerate cognitive decline, even in the absence of overt pathology. In fact, impaired sleep represents one of the earliest symptoms of Alzheimer’s disease (AD). This systematic review aimed to analyze the studies on sleep quality in aging, also considering mild cognitive impairment (MCI) and AD. The review process was conducted according to the PRISMA statement. A total of 71 studies were included, and the whole sample had a mean age that ranged from 58.3 to 93.7 years (62.8–93.7 healthy participants and 61.8–86.7 pathological populations). Of these selected studies, 33 adopt subjective measurements, 31 adopt objective measures, and 10 studies used both. Pathological aging showed a worse impoverishment of sleep than older adults, in both subjective and objective measurements. The most common aspect compromised in AD and MCI were REM sleep, sleep efficiency, sleep latency, and sleep duration. These results underline that sleep alterations are associated with cognitive impairment. In conclusion, the frequency and severity of sleep disturbance appear to follow the evolution of cognitive impairment. The overall results of objective measures seem more consistent than those highlighted by subjective measurements.

Use of the Xiaomi Mi Band for sleep monitoring and its influence on the daily life of older people living in a nursing home

Background: Lower quantity and poorer sleep quality are common in most older adults, especially for those who live in a nursing home. The use of wearable devices, which measure some parameters such as the sleep stages, could help to determine the influence of sleep quality in daily activity among nursing home residents. Therefore, this study aims to analyse the influence of sleep and its changes concerning the health status and daily activity of older people who lived in a nursing home, by monitoring the participants for a year with Xiaomi Mi Band 2. Methods: This is a longitudinal study set in a nursing home in [Details omitted for double-anonymized peer reviewed]. The Xiaomi Mi Band 2 will be used to measure biomedical parameters and different assessment tools will be administered to participants for evaluating their quality of life, sleep quality, cognitive state, and daily functioning. Results: A total of 21 nursing home residents participated in the study, with a mean age of 86.38 ± 9.26. The main outcomes were that sleep may influence daily activity, cognitive state, quality of life, and level of dependence in activities of daily life. Moreover, environmental factors and the passage of time could also impact sleep. Conclusions: Xiaomi Mi Band 2 could be an objective tool to assess the sleep of older adults and know its impact on some factors related to health status and quality of life of older nursing homes residents. Trial Registration: NCT04592796 (Registered 16 October 2020) Available on: https://clinicaltrials.gov/ct2/show/NCT04592796.

Do Daytime Activity, Mood and Unit Tumult Predict Nighttime Sleep Quality of Long-Term Care Residents?

Based on the premise that stressors can have a cumulative effect on people with dementia throughout the day that contributes to negative consequences later in the day, we examined if daytime activity, unit tumult, and mood were associated with sleep quality. A convenience sample of 53 long-term care (LTC) residents participated in this correlational study. Objective sleep quality was measured using actigraphy, and comorbid illness and level of dementia were control variables. Half of the sample had a sleep efficiency that was less than 80% and was awake for more than 90 min at night. Comorbid illness, negative mood at bedtime, and daytime activity level accounted for 26.1% of the variance in total sleep minutes. Census changes and the use of temporary agency staff were associated with poor sleep. Findings suggest daytime activity, mood at bedtime, and unit tumult should be considered when designing and testing interventions to improve sleep quality.

The Effect of Bright Light Treatment on Rest-Activity Rhythms in People with Dementia: A 24-Week Cluster Randomized Controlled Trial

Bright light treatment is an effective way to influence circadian rhythms in healthy adults, but previous research with dementia patients has yielded mixed results. The present study presents a primary outcome of the DEM.LIGHT trial, a 24-week randomized controlled trial conducted at nursing homes in Bergen, Norway, investigating the effects of a bright light intervention. The intervention consisted of ceiling-mounted LED panels providing varying illuminance and correlated color temperature throughout the day, with a peak of 1000 lx, 6000 K between 10 a.m. and 3 p.m. Activity was recorded using actigraphs at baseline and after 8, 16, and 24 weeks. Non-parametric indicators and extended cosine models were used to investigate rest-activity rhythms, and outcomes were analyzed with multi-level regression models. Sixty-one patients with severe dementia (median MMSE = 4) were included. After 16 weeks, the acrophase was advanced from baseline in the intervention group compared to the control group (B = -1.02, 95%; CI = -2.00, -0.05). There was no significant difference between the groups on any other rest-activity measures. When comparing parametric and non-parametric indicators of rest-activity rhythms, 25 out of 35 comparisons were significantly correlated. The present results indicate that ambient bright light treatment did not improve rest-activity rhythms for people with dementia.

Enhancing sleep quality for nursing home residents with dementia: a pragmatic randomized controlled trial of an evidence-based frontline huddling program

Background

Disturbed sleep places older adults at higher risk for frailty, morbidity, and even mortality. Yet, nursing home routines frequently disturb residents’ sleep through use of noise, light, or efforts to reduce incontinence. Nursing home residents with Alzheimer’s disease and or related dementias—almost two-thirds of long-stay nursing home residents—are likely to be particularly affected by sleep disturbance. Addressing these issues, this study protocol implements an evidence-based intervention to improve sleep: a nursing home frontline staff huddling program known as LOCK. The LOCK program is derived from evidence supporting strengths-based learning, systematic observation, relationship-based teamwork, and efficiency.

Methods

This study protocol outlines a NIH Stage III, real-world hybrid efficacy-effectiveness pragmatic trial of the LOCK sleep intervention. Over two phases, in a total of 27 non-VA nursing homes from 3 corporations, the study will (1) refine the LOCK program to focus on sleep for residents with dementia, (2) test the impact of the LOCK sleep intervention for nursing home residents with dementia, and (3) evaluate the intervention’s sustainability. Phase 1 (1 year; n = 3 nursing homes; 1 per corporation) will refine the intervention and train-the-trainer protocol and pilot-tests all study methods. Phase 2 (4 years; n = 24 nursing homes; 8 per corporation) will use the refined intervention to conduct a wedge-design randomized, controlled, clinical trial. Phase 2 results will measure the LOCK sleep intervention’s impact on sleep (primary outcome) and on psychotropic medication use, pain and analgesic medication use, and activities of daily living decline (secondary outcomes). Findings will point to inter-facility variation in the program’s implementation and sustainability.

Discussion

This is the first study to our knowledge that applies a dementia sleep intervention to systematically address known barriers to nursing home quality improvement efforts. This innovative study has future potential to address clinical issues beyond sleep (safety, infection control) and expand to other settings (assisted living, inpatient mental health). The study’s strong team, careful consideration of design challenges, and resulting rigorous, pragmatic approach will ensure success of this promising intervention for nursing home residents with dementia.

Trial registration

NCT04533815, ClinicalTrials.gov, August 20, 2020. 

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02189-8.

Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis

Study Objectives

Sleep disturbances are a feature in people living with dementia, including getting up during the night, difficulty falling asleep, and excessive daytime sleepiness and may precipitate a person with dementia moving into residential care. There are varying estimates of the frequency of sleep disturbances, and it is unknown whether they are a problem for the individual. We conducted the first systematic review and meta-analysis on the prevalence and associated factors of sleep disturbances in the care home population with dementia.

Methods

We searched Embase, MEDLINE, and PsycINFO (29/04/2019) for studies of the prevalence or associated factors of sleep disturbances in people with dementia living in care homes. We computed meta-analytical estimates of the prevalence of sleep disturbances and used meta-regression to investigate the effects of measurement methods, demographics, and study characteristics.

Results

We included 55 studies of 22,780 participants. The pooled prevalence on validated questionnaires of clinically significant sleep disturbances was 20% (95% confidence interval, CI 16% to 24%) and of any symptom of sleep disturbance was 38% (95% CI 33% to 44%). On actigraphy using a cutoff sleep efficiency of <85% prevalence was 70% (95% CI 55% to 85%). Staff distress, resident agitation, and prescription of psychotropic medications were associated with sleep disturbances. Studies with a higher percentage of males had a higher prevalence of sleep disturbance.

Conclusions

Clinically significant sleep disturbances are less common than those measured on actigraphy and are associated with residents and staff distress and the increased prescription of psychotropics. Actigraphy appears to offer no benefit over proxy reports in this population.

Meta-analysis of age and actigraphy assessed sleep characteristics across the lifespan

STUDY OBJECTIVES

Sleep quantity and continuity vary across the lifespan. Actigraphy is a reliable and widely-used behavioral measure of sleep in research and personal health monitoring. This meta-analysis provides a novel examination of whether age (in years) is associated with actigraphy-assessed sleep across the lifespan.

METHODS

A systematic search of PubMed, Embase.com, Cochrane CENTRAL, and PsycINFO using "actigraphy" and "sleep" terms provided 7,079 titles/abstracts; studies of individuals with known psychiatric or medical comorbidities were excluded. Ninety-one articles (N = 23,365) provided data for six meta-analyses examining sleep duration (k = 89), sleep efficiency (k = 58), bedtime (k = 19) and waketime (k = 9) for individuals ages 6-21, and bedtime (k = 7) and waketime (k = 7) for individuals ages 22 and older.

RESULTS

At older ages, sleep duration was shorter (r = -0.12) and sleep efficiency was lower (r = -0.05). Older age was associated with later bedtime (r = 0.37) and wake-up time (r = 0.24) from ages 6-21, whereas older age was associated with earlier bedtime (r = -0.66) and wake-up time (r = -0.59) for ages 22 and above. The strength of these associations was modified by study continent, but not by any other moderator.

CONCLUSIONS

Age was negatively associated with actigraphy-assessed sleep duration and efficiency, but the effects were small in magnitude. On the other hand, large associations were observed between age and sleep timing, despite a smaller literature and the absence of analyzable data for ages 30-60. Changes in sleep timing, rather than changes in sleep duration or continuity, may better characterize the effects of age on human sleep.

Impact of Disturbed Rest-activity Rhythms on Activities of Daily Living in Moderate and Severe Dementia Patients

PURPOSE

People with dementia exhibit disturbed rest-activity rhythms and extended sleep duration issues throughout their disease. Little is known about the effects of these issues on clinical problems for those with moderate and severe dementia. This cross-sectional study aimed to examine the associations of disturbed rest-activity rhythms and extended sleep duration with activities of daily living (ADL).

METHODS

Sleep parameters were measured using an actigraphy device. Cognitive function was assessed using the Mini-Mental State Examination and Cognitive Test for Severe Dementia, the Hyogo Activities of Daily Living Scale was used to assess ADL, and behavioral and psychological symptoms of dementia were assessed using the Neuropsychiatric Inventory-Nursing Home scale. Associations among rest-activity rhythms, sleep duration, and other clinical variables were analyzed with multiple linear regression. Clinical variables were compared between 2 groups categorized by onset timing of rest peak.

PATIENTS

Sixty-four participants with moderate and severe dementia were assessed.

RESULTS

In the correlation analysis, unstable daily rest-activity rhythm was associated with lower ADL. In the multiple linear regression analysis, low intradaily variability, and long daytime sleep duration were associated with low ADL. Aberrant rest peak timing showed lower ADL compared with nonaberrant timing.

CONCLUSIONS

Abnormal rest-activity rhythm and sleep duration in persons with moderate and severe dementia may affect ADL.

Factors that Influence Sleep among Residents in Long-Term Care Facilities

Long-term care residents often experience sleep disturbances as they are vulnerable to a variety of physical, psychosocial, and environmental factors that contribute to sleep disturbances. However, few studies have examined the combined impact of multiple factors on sleep among long-term care residents. This study aimed to identify the factors that influence sleep efficiency and sleep quality based on a modified senescent sleep model. A total of 125 residents were recruited from seven long-term care facilities in South Korea. Sleep patterns and sleep quality were collected using 3-day sleep logs and the Minimal Insomnia Screening Scale for Korean adults (KMISS), respectively. The mean sleep efficiency was 84.6% and the mean score on sleep quality was 15.25. A multiple linear regression analysis showed that greater dependence in activities of daily living (ADL), higher pain, and light at night were related to lower sleep efficiency. Higher pain and fatigue, less activity time, noise and light at night, and lower nighttime staffing levels were related to poorer sleep quality. This study highlights that psychosocial and environmental factors as well as physical factors could influence sleep for long-term care residents. Our findings could be foundational evidence for multi-faceted sleep intervention program development in long-term care settings.

The association between circadian rest-activity patterns and the behavioral and psychological symptoms depending on the cognitive status in Japanese nursing-home residents

BACKGROUND

Limited information is available on the relationship between sleep disturbances during nighttime and the behavioral and psychological symptoms of dementia in older nursing-home residents. However, a few reports on the association between the circadian rest-activity rhythm and the behavioral and psychological symptoms of dementia in older residents have been published. The main objective of the present study was to examine the association among the circadian rest-activity rhythm, behavioral and psychological symptoms, and the cognitive function status among older individuals living in facilities.

METHOD

The investigation was conducted from September 2017 to February 2018, and participants were recruited from five nursing homes in Akita prefecture, Japan, after obtaining patient agreement to participate in the study. To measure nonparametric circadian rest-activity parameters such as interdaily stability, intradaily variability, relative amplitude, mean of the least active 5-h period, and mean of the most active 10-h period, Actigraph devices were worn on the participants' nondominant wrists continuously for seven days. The score or classification of the cognitive status and the severity of the behavioral and psychological symptoms of dementia (BPSD) were assessed using the clinical dementia rating (CDR) and the dementia behavior disturbance scale (DBD), respectively. The binomial logistic regression model was applied to clarify which kinds of circadian rest-activity parameters predicted the cognitive status in nursing home residents as well as the BPSD outcome. A multi-level model was also used to examine the association between the nonparametric rest-activity parameters and the BPSD outcome explained by the cognitive status among older individuals in facilities.

RESULTS

Seventy-seven participants (49 residents with dementia, and 28 residents without dementia) were included in this study. According to the binomial logistic regression analysis after adjusting for covariates, the classification of the cognitive status for older residents was associated with the DBD score (odds ratio, 1.22; 95% confidence interval [CI], 1.08, 1.38; p < 0.001), the IS (odds ratio, 0.01; 95% CI, 0.00, 1.00; p = 0.05) and the L5 (odds ratio, 0.99; 95% CI, 0.99, 1.00; p = 0.05). The results of a multi-level model also indicated that the IV at individual-level was significantly associated with the DBD score for nursing home residents, with the CDR score at cluster-level as an explanatory variable. As well, a significant association between the RA at individual level and the DBD score was observed in a multi-level model explained by the CDR score at cluster-level.

CONCLUSION

Of these models, the multi-level model provided grounds for our proposal that the fragmentation or the amplitude of rest-activity parameters might be associated with the outcome of BPSD, considering the cognitive status of older individuals in different facilities. The findings offer practical insight into the prevention of BPSD and the improvement of rest-activity rhythms in rehabilitative care in nursing homes.

Sleep and Long-Term Care

Long-term care (LTC) involves a range of support and services for people with chronic illness and disabilities who can not perform activities of daily living independently. Poor sleep increases the risk of LTC placement, and sleep disturbance is extremely common among LTC residents. The identification and management of sleep disturbance in LTC residents is a vital, but perhaps underappreciated, aspect of offering high-quality care for this already compromised population. This review describes the nature and consequences of sleep disturbances in LTC, clinical assessment and management of sleep disturbances in LTC, and implications for future research and clinical practice.