SLEEP DISRUPTION IN OLDER ADULTS

A non-pharmacological multi-modal therapy to improve sleep and cognition and reduce mild cognitive impairment risk: Design and methodology of a randomized clinical trial

Aging populations are at increased risk of sleep deficiencies (e.g., insomnia) that are associated with a variety of chronic health risks, including Alzheimer's disease and related dementias (ADRD). Insomnia medications carry additional risk, including increased drowsiness and falls, as well as polypharmacy risks. The recommended first-line treatment for insomnia is cognitive behavioral therapy for insomnia (CBTi), but access is limited. Telehealth is one way to increase access, particularly for older adults, but to date telehealth has been typically limited to simple videoconferencing portals. While these portals have been shown to be non-inferior to in-person treatment, it is plausible that telehealth could be significantly improved. This work describes a protocol designed to evaluate whether a clinician-patient dashboard inclusive of several user-friendly features (e.g., patterns of sleep data from ambulatory devices, guided relaxation resources, and reminders to complete in-home CBTi practice) could improve CBTi outcomes for middle- to older-aged adults (N = 100). Participants were randomly assigned to one of three telehealth interventions delivered through 6-weekly sessions: (1) CBTi augmented with a clinician-patient dashboard, smartphone application, and integrated smart devices; (2) standard CBTi (i.e., active comparator); or (3) sleep hygiene education (i.e., active control). All participants were assessed at screening, pre-study evaluation, baseline, throughout treatment, and at 1-week post-treatment. The primary outcome is the Insomnia Severity Index. Secondary and exploratory outcomes span sleep diary, actiwatch and Apple watch assessed sleep parameters (e.g., efficiency, duration, timing, variability), psychosocial correlates (e.g., fatigue, depression, stress), cognitive performance, treatment adherence, and neurodegenerative and systemic inflammatory biomarkers.

Two-Hourly Repositioning for Prevention of Pressure Ulcers in the Elderly: Patient Safety or Elder Abuse?

For decades, aged care facility residents at risk of pressure ulcers (PUs) have been repositioned at two-hour intervals, twenty-four-hours-a-day, seven-days-a-week (24/7). Yet, PUs still develop. We used a cross-sectional survey of eighty randomly selected medical records of residents aged ≥ 65 years from eight Australian Residential Aged Care Facilities (RACFs) to determine the number of residents at risk of PUs, the use of two-hourly repositioning, and the presence of PUs in the last week of life. Despite 91 per cent (73/80) of residents identified as being at risk of PUs and repositioned two-hourly 24/7, 34 per cent (25/73) died with one or more PUs. Behaviours of concern were noted in 72 per cent (58/80) of residents of whom 38 per cent (22/58) were restrained. Dementia was diagnosed in 70 per cent (56/80) of residents. The prevalence of behaviours of concern displayed by residents with dementia was significantly greater than by residents without dementia (82 per cent v 50 per cent, p = 0.028). The rate of restraining residents with dementia was similar to the rate in residents without dementia. Two-hourly repositioning failed to prevent PUs in a third of at-risk residents and may breach the rights of all residents who were repositioned two-hourly. Repositioning and restraining may be unlawful. Rather than only repositioning residents two-hourly, we recommend every resident be provided with an alternating pressure air mattress.

Fatigue and acute coronary syndrome: a systematic review of contributing factors

Fatigue is a symptom of ACS, but it remains unclear who is at risk and what factors contribute to fatigue. The purpose of the systematic review was to identify factors that influence fatigue in patients with ACS. The review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Literature published from 1981 to 2017 was reviewed, and of 983 articles screened, 36 met inclusion criteria. Variables contributing to fatigue fell into 3 categories: demographic characteristics, clinical characteristics, and other factors. More fatigue was found in women than men, and significant differences in fatigue were identified by race. Additionally, sleep deprivation, depression, and anxiety were associated with higher levels of fatigue. The findings highlight the importance of demographic, clinical, and other factors' impact on fatigue in ACS patients. Fatigue is an important symptom in ACS and healthcare providers must recognize how patient variables affect symptom expression.

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 disorders and acute nocturnal delirium in the elderly: a comorbidity not to be overlooked

Delirium is a disturbance of consciousness and cognition that results in a confusional state. It tends to fluctuate in intensity and is often observed in older patients. Sleep is a window of vulnerability for the occurrence of delirium and sleep disorders can play a role in its appearance. In particular, delirious episodes have been associated with obstructive sleep apnoea syndrome, which is reported to be frequent in the elderly. Hereby, we present a case-report documenting the sudden onset of a confusional state triggered by obstructive sleep apnoea-induced arousal, together with a review of the literature on the topic. We emphasise that, among the many pathogenic factors implicated in delirium, it is worth considering the possible link between nocturnal delirium and the occurrence of impaired arousals. Indeed, the complex confusional manifestations of delirium could be due, in part, to persistence of dysfunctional sleep activity resulting in an inability to sustain full arousal during behavioural wakefulness. Arousals can be triggered by sleep disturbances or other medical conditions. Clinicians should be aware that older patients may present disordered sleep patterns, and make investigation of sleep patterns and disorders potentially affecting sleep continuity a key part of their clinical workup, especially in the presence of cognitive comorbidities. Correct diagnosis and optimal treatment of sleep disorders and disrupted sleep can have a significant impact in the elderly, improving sleep quality and reducing the occurrence of abnormal sleep-related behaviours.

Can a brief educational intervention improve sleep and anxiety outcomes for emergency orthopaedic surgical patients?

Abstract An educational intervention (EI) is useful in preparing patients for orthopaedic surgery. This quasi-experimental study examined the effect of a brief EI on pain level, anxiety, pain inference on sleep, and sleep satisfaction among Chinese patients undergoing emergency orthopaedic surgery. The intervention group received usual care plus 20-minute EI which comprised a combination of patient education and a breathing relaxation exercise (BRE) whereas the control group received usual care only. The outcomes were evaluated before the EI and at days 2, 4 and 7 post-surgery. One hundred and fifty two participants completed the study. The intervention group had significantly lower pain levels (Brief pain inventory), anxiety levels (The Chinese state Anxiety scale), and lower pain inference scores on mood and better sleep satisfaction. Therefore, a brief EI with a breathing relaxation exercise is a feasible and useful intervention that can improve post-operative outcomes in emergency orthopaedic surgery.

Longitudinal course of insomnia: age-related differences in subjective sleepiness and vigilance performance in a population-based sample

OBJECTIVE

The present study utilized a population-based sample investigating the following aims: (1) compare the longitudinal course of insomnia in middle-aged and older adults and (2) examine age-related differences on subjective complaint and objective performance in middle-aged and older adults based on the course of insomnia.

METHODS

1657 middle-aged adults (48.16% male, mean age=55.35±4.03years) and 405 older adults (48.40% male, mean age=70.13±3.88years) from the Korean Genome and Epidemiology Study (KoGES) were classified into 4 groups - no insomnia (NI), single episode insomnia (SEI), remitted persistent insomnia (PI-R), and ongoing persistent insomnia (PI-O) based on their course of insomnia over 5 time points spaced two years apart. Their performance on the psychomotor vigilance task (PVT) and subjective daytime sleepiness were compared across different insomnia groups, and the results were compared between middle-aged adults and older adults.

RESULTS

Analysis of covariance indicated that subjective daytime sleepiness was significantly different across the insomnia groups in middle-aged adults based on insomnia group (P=<.0001), but, did not affect objective vigilance performance. In contrast, older adults displayed significantly different PVT response time, but not daytime sleepiness, based on insomnia group (P=0.03).

CONCLUSION

Insomnia impacts psychomotor performance and subjective sleepiness differently, based on age group. There may be underlying processes associated with the aging that amplifies the impact of insomnia on vigilance performance, yet lessens perceived sleepiness in older adults.

The effects of sleep quality, physical activity, and environmental quality on the risk of falls in dementia

OBJECTIVES

This study aimed to identify the effects of sleep quality, physical activity, environmental quality, age, ethnicity, sex differences, marital status, and educational level on the risk of falls in the elderly individuals with dementia.

METHODOLOGY

Data were derived from a group of 1210 Malaysian elderly individuals who were noninstitutionalized and demented. The multiple logistic regression model was applied to estimate the risk of falls in respondents.

RESULTS

Approximately the prevalence of falls was 17% among the individuals. The results of multiple logistic regression analysis revealed that age (odds ratio [OR] = 1.03), ethnicity (OR = 1.76), sleep quality (OR = 1.46), and environmental quality (OR = 0.62) significantly affected the risk of falls in individuals (P < .05). Furthermore, sex differences, marital status, educational level, and physical activity were not significant predictors of falls in samples (P > .05).

CONCLUSION

It was found that age, ethnic non-Malay, and sleep disruption increased the risk of falls in respondents, but high environmental quality reduced the risk of falls.

The effects of social support and having a partner on sleep quality in dementia

OBJECTIVES

This study aimed to determine the effects of social support and having a partner on sleep quality in the elderly patients with dementia.

METHODOLOGY

This research was conducted on 1210 noninstitutionalized elderly Malaysian individuals with dementia. The effects of age, ethnicity, educational level, marital status, sex differences, social support, and having a partner on sleep quality were evaluated in the respondents. The multiple logistic regression analysis was used to predict the risk of sleep disturbances among the participants.

RESULTS

Approximately, 41% of the participants experienced sleep disruption. Further findings showed that ethnicity (odds ratio [OR] = 0.62), social support (OR = 1.35), marital status (OR = 2.21), educational level (OR = 0.65), and having a partner (OR = 0.45) significantly affected sleep quality (P < .05). Sex differences and age were unrelated predictors of sleep disturbances (P > .05).

CONCLUSION

It was concluded that social isolation and being single increased sleep disruption among respondents, but having a partner and ethnic non-Malay decreased the rate of sleep problems.

Pain and dementia: an overview of the literature

This paper discusses how pain and its undertreatment impacts upon older people with dementia. It outlines how the contributing factors to the underassessment of pain are numerous and includes dementia-related factors (such as loss of communication ability) and health professional-related factors (such as inappropriate or non-application of a pain-assessment tool and deficit knowledge regarding pain mechanisms and/or dementia). Pharmacological and non-pharmacological treatment options for pain are noted as important but are not the focus of this paper.

The influence of hearing impairment on sleep quality among workers exposed to harmful noise

OBJECTIVE

To assess connections between sleeping quality and hearing impairment due to prolonged exposure to industrial noise.

DESIGN

Observational cross-sectional study.

SETTING

Occupational clinic of the Clalit Health Services in Israel.

PARTICIPANTS

298 male volunteers occupationally exposed to harmful noise, who had an audiometric examination performed by an occupational nurse as a part of the national workers health supervision programs.

MEASUREMENTS AND RESULTS

The participants underwent an audiometric testing, and their sleep quality was measured by a validated Mini Sleep Questionnaire (MSQ). Participants with hearing loss greater than 25 dBA in the range of 1000-4000 Hz were defined as the research group (n = 99) and were compared to those with no hearing impairment (n = 199). Sleeping disorders were age related (30% higher MSQ score among workers above 50 years, P = 0.003). Tinnitus was the highest sleep disturbing factor, with 75% higher score among those affected, P = 0.001. In multiple linear regression analysis, tinnitus was the leading sleep-disturbing factor (regression coefficient B = 8.66, P < 0.001) followed by hearing impairment (regression coefficient B = 2.42, P = 0.084), adjusted for age (or years of exposure) and coffee drinking. A part of the MSQ, related to insomnia, was further evaluated using logistic regression models. Tinnitus was again the leading sleep disturbing factor [OR = 11.91; CI95% (1.56-91.2)], followed by hearing impairment [OR = 3.051; CI95% (1.18-7.86)].

CONCLUSION

Although tinnitus was the main sleep disrupting factor, hearing impairment among workers occupationally exposed to harmful noise, independently contributed to sleep impairment, especially to insomnia, regardless of age and years of exposure.

Coping with preclinical disability: older women's experiences of everyday activities

PURPOSE

The purpose of this paper is to describe coping practices used by older women during preclinical disability.

DESIGN

This paper was derived from qualitative data gathered during a larger multimethod longitudinal study. Twelve women (60 to 80 years of age) participated in baseline functional performance measures and then repeated in-depth interviews and participant observations over 18 months.

METHODS

A hermeneutic approach was used to interpret the in-depth interviews, participant observations, and field notes using three interrelated processes of thematic, exemplar, and identification of paradigm cases to identify coping practices.

FINDINGS

Women coped with functional decline, such as difficulty getting up from the floor, in many different ways. Coping practices were grouped into five themes: resist, adapt, substitute, endure, and eliminate.

CLINICAL RELEVANCE

These findings suggest that nurses need to realize outward appearances may mask the level of effort required for older women to complete daily activities.

Insomnia in elderly cancer survivors--a population-based controlled study of associations with lifestyle, morbidity, and psychosocial factors. Results from the Health Survey of North-Trøndelag County (HUNT-2). Insomnia in elderly cancer survivors

PURPOSE

To examine the associations among morbidity, lifestyle, psychosocial factors and insomnia symptoms in elderly (≥70 years) cancer survivors of the Health Survey of North-Trøndelag County (HUNT-2).

METHODS

Among 11,899 individuals aged≥70 years who participated in HUNT-2, 479 had been diagnosed with invasive primary cancer from 1-10 years previously. Each patient was randomly matched with three cancer-free controls (N=1,437). In this population-based cross-sectional survey, the sample consisted of 460 cancer survivors and 1,356 controls with complete dataset concerning insomnia symptoms. Data was collected by means of self-administered questionnaires, and descriptive statistics were used to analyse the data.

RESULTS

Survivors with insomnia symptoms (N=89, 19.3%, 95% CI 15.7-23.0%) evidenced a higher rate of musculo-skeletal diseases, increased gastro-intestinal symptoms, had fewer friends, and reported 'good health' less frequently than survivors without such symptoms (N=371). Survivors with insomnia symptoms reported more regular use of medication, problems with personal activities of daily living (P-ADL) and higher levels of anxiety and depression. When the survivors with insomnia were compared to 250 (18.4%, 95% CI 16.4-20.5%) controls with insomnia, the results were similar except for significantly more P-ADL problems among survivors. Five-step logistic regression analysis showed 16.6% explained variance where 'gastro-intestinal symptoms', 'daily use of medication' and 'anxiety' contributed significantly to insomnia symptoms.

CONCLUSIONS

Insomnia affects people physically, mentally and in their ability to perform ADL. Elderly cancer survivors with insomnia reported more physical and psychosocial problems compared to survivors without insomnia. Except for increased P-ADL problems, cancer survivors with insomnia reported similarly to cancer-free controls with insomnia.

Sleep disturbances in dementia

Approximately one quarter of adults with dementia experience sleep disturbances. The purpose of this article is to (a) describe and define sleep disturbances in individuals with dementia, (b) describe techniques to assess for sleep disturbances in individuals with dementia, and (c) provide nursing interventions to improve sleep in this patient population. Typical presentations of sleep disturbances in individuals with dementia are described, along with medications that may interfere with sleep. Suggestions for nursing measures that can be implemented to enhance sleep are also presented. Nurses have numerous nonpharmacological options to assist with the regulation of sleep-wake rhythms in individuals with dementia.

Daytime sleepiness in elderly Parkinson's disease patients and treatment with the psychostimulant modafinil: A preliminary study

BACKGROUND

Patients with Parkinson's disease (PD) or Parkinsonian syndromes often report excessive daytime sleepiness (EDS). The aim of this study was to evaluate the effects of the psychostimulant modafinil on elderly, institutionalized, severely impaired PD patients with EDS.

METHOD

A three-week open study on ten institutionalized PD patients scoring >10 points on the Epworth Sleepiness Scale (ESS) with modafinil eventually on 100 mg twice a day. Patients were assessed at the start, week 1, and week 3 with ESS, Clinical Global Impression (CGI) scale severity of PD and appetite.

RESULTS

Reduction of ESS score and PD severity over time were found as well as a significant increase in appetite and reduction in CGI score.

CONCLUSION

Modafinil 100 mg twice a day was safe and modestly effective for the treatment of EDS in elderly, institutionalized PD patients. Sustaining wakefulness throughout all stages of PD is crucial for participating in life, maintaining social life, and improving quality of life.

Challenges of depression and suicidal ideation associated with aging with HIV/AIDS: implications for social work

As the number of older adults with HIV/AIDS increases, new challenges are emerging that threaten their ability to age with this disease. Threats of particular concern are depression and suicidal ideation. Studies show that those aging with HIV/AIDS have a number of stressors that tax their coping mechanisms, increasing vulnerability to depression and suicidal ideation. These stressors can be categorized into three areas. First, there are psychosocial stressors that can contribute to depression. Second, there are health and biochemical stressors that can contribute to depression, as well as compromise cognitive abilities needed to adapt to such stressors. Third, cognitive stressors may create predispositions to depression. In particular, certain cognitive abilities needed to cope with depression and suicidal ideation may be compromised by aging with HIV/AIDS. A model of these stressors is provided for didactic purposes, as well as to suggest implications for social work practice and research.

Age-related reduction in daytime sleep propensity and nocturnal slow wave sleep

OBJECTIVE

To investigate whether age-related and experimental reductions in SWS and sleep continuity are associated with increased daytime sleep propensity.

METHODS

Assessment of daytime sleep propensity under baseline conditions and following experimental disruption of SWS. Healthy young (20-30 y, n = 44), middle-aged (40-55 y, n = 35) and older (66-83 y, n = 31) men and women, completed a 2-way parallel group study. After an 8-h baseline sleep episode, subjects were randomized to 2 nights with selective SWS disruption by acoustic stimuli, or without disruption, followed by 1 recovery night. Objective and subjective sleep propensity were assessed using the Multiple Sleep Latency Test (MSLT) and the Karolinska Sleepiness Scale (KSS).

FINDINGS

During baseline sleep, SWS decreased (P < 0.001) and the number of awakenings increased (P < 0.001) across the 3 age groups. During the baseline day, MSLT values increased across the three age groups (P < 0.0001) with mean values of 8.7 min (SD: 4.5), 11.7 (5.1) and 14.2 (4.1) in the young, middle-aged, and older adults, respectively. KSS values were 3.7 (1.0), 3.2 (0.9), and 3.4 (0.6) (age-group: P = 0.031). Two nights of SWS disruption led to a reduction in MSLT and increase in KSS in all 3 age groups (SWS disruption vs. control: P < 0.05 in all cases).

CONCLUSIONS

Healthy aging is associated with a reduction in daytime sleep propensity, sleep continuity, and SWS. In contrast, experimental disruption of SWS leads to an increase in daytime sleep propensity. The age-related decline in SWS and reduction in daytime sleep propensity may reflect a lessening in homeostatic sleep requirement. Healthy older adults without sleep disorders can expect to be less sleepy during the daytime than young adults.

Sleep in hospitalized medical patients, part 1: factors affecting sleep

BACKGROUND

Multiple factors lead to sleep disturbances in hospitalized medical patients. Inadequate sleep can lead to both psychological and physiological consequences.

METHODS

A PubMed search was conducted using the terms: ("sleep deprivation," "sleep," or "insomnia") and ("hospitalized," "inpatient," "critical illness," or "acute illness") to review the published data on the topic of sleep in hospitalized medical patients. The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search, including the terms "hospital noise," "hospital environment," "obstructive sleep apnea," and "heart failure."

RESULTS

Few articles specifically addressed the topic of sleep in hospitalized medical patients. Data were limited to observational studies that included outcomes such as sleep complaints and staff logs of wakefulness and sleep. In Part 1, we review normal sleep architecture, and discuss how major medical disorders, the hospital environment, and medications can disrupt sleep during hospitalization. In Part 2, we will propose an evaluation and treatment algorithm to optimize sleep in hospitalized medical patients.

CONCLUSIONS

Hospitalization may severely disrupt sleep, which can worsen pain, cardiorespiratory status, and the psychiatric health of acutely ill patients. Like vital signs, the patient sleep quality reveals much about patients' overall well-being, and should be a routine part of medical evaluation.