Problems with sleeping are prevalent among older adult patients in nursing homes and assisted living facilities and are a major cause of diminished quality of life. More than half of long-term care residents rely on prescription for at least one antihypnotic. Facility staff must help their residents improve or maintain good sleep hygiene, identify the issues causing lack of sleep, and prescribe the appropriate sleep medication to patients if needed.
It is well known that getting an adequate amount of sleep is necessary for maintaining normal function and quality of life. Studies have shown that sleep enables cerebrospinal fluid in the brain to bathe brain cells and wash away toxins–particularly, amyloid-beta protein. The benefits of amyloid-beta protein removal are diminished neurofibrillary tangle formation, lower blood-brain barrier damage and amyloid-beta deposition in plaques, protection of mitochondria from apoptosis, and a decrease in oxidative damage. Therefore, sleep allows the brain to be “washed,” cleaning the brain so that it can function optimally during waking hours.
Total duration of sleep tends to decrease with age. Due to being less frequently exposed to bright light, older adults experience disruption in their circadian rhythms, which is portrayed by a decrease in melatonin. The result of a lack of light exposure is phase advancement, in which older adults go to sleep earlier, but wake up earlier. These elderly people are at risk of increased mortality.
These sleep changes are exacerbated in residents of long-term care facilities. Daytime napping is more common with nighttime “sleep fragmentation.” Studies show that older adult residents commonly experience less than a continuous hour of sleep at any time. Those with dementia experience even worse effects due to these changes.
There are a variety of reasons, both extrinsic and intrinsic, why nursing home and assisted living facility residents could be experiencing sleep disturbances. Some environmental causes include nursing care interruptions, noise, and uncomfortable lighting in the evenings. Inadequate quality of light in nursing homes and lack of outside time (less than half an hour a day) are major factors. Spending long hours in bed, inactivity, and inadequate amount of physical activity are all important causes. These behaviors result in loss of muscle mass (sarcopenia) and frailty. Intrinsic factors include multiple medical illnesses and polypharmacy, depression, pain, and nocturia.
In order to treat insomnia (poor sleep) in long-term care residents, care facilities should give more opportunities to residents to be exposed to natural light during the day. Studies have shown that using low-level “blush-white” lighting during daytime hours increases total sleep duration and sleep efficiency, as well as decreases depression and agitation. Moreover, physical activity and social interaction promotes better sleep and less agitated behavior in patients. Exercise has also been shown to help residents in wheelchairs sleep longer, have better sleep efficiency, and diminished dysphoria. As regular physical activity has proven to have numerous other benefits, including improvement in cognitive and physical function, it should be a staple of care provided by long-term care facilities.