From the School of Aging Studies, University of South Florida, Tampa, FL (Dr. AA Gamaldo) and the Department of Neurology, Johns Hopkins Medicine, Baltimore, MD (Drs. Sloane, CE Gamaldo and Salas).
Abstract
Objective: To provide guidance on identifying and treating sleep disturbances commonly encountered in older nursing home residents.
Methods: Review of the literature in the context of 5 clinical cases.
Results: Sleep disturbances continue to be a growing global epidemic, and public health initiatives have been aimed at improving sleep health across all ages. In older adults, sleep disturbances are often associated with the development and/or worsening of health conditions. Common sleep disturbances observed in older nursing home residents include obstructive sleep apnea, restless legs syndrome/Willis-Ekbom disease, circadian rhythm sleep-wake disorders, insomnia, and parasomnias. The symptoms and recommended treatment plans vary across the sleep disturbances. For many sleep disturbances, modification of residents’ daily activities and/or nursing home environment can be helpful.
Conclusion: As the number of people residing in nursing homes increases, it is important for health care providers to be knowledgable about sleep disturbances in this population.
By 2030, almost 20% of the US population (approximately 72.1 million people) will be age 65 and older [1]. As many as 63% of older adults in the general population report sleep disturbances [2]. Specifically, older adults demonstrate difficulty with decreased total sleep duration, an increase in sleep fragmentation (ie, interruptions in nighttime sleep), and reduced total sleep time spent in rapid eye movement (REM) and slow wave sleep [3–5]. Poor sleep, either because of not getting enough sleep or having an undiagnosed and thus untreated sleep disorder, is associated with physical illness, impaired cognition, poor physical function, and mortality risk [6,7]. In fact, over 50% of individuals older than 65 years meet the diagnostic criteria for a sleep disorder, many of which are undiagnosed [6,7].
It is forecasted that we will see substantial increases in the rate of nursing home residence among the elderly [8]. The prevalence and severity of disturbed sleep is reportedly higher in NH residents [6,7]. Generally, NH residents tend to be on several medications for various medical disorders that may negatively impact sleep [7]. Reciprocally, sleep disruption may put NH residents at an increased risk for behavioral issues (eg, agitation) [9,10] as well as developing and/or exacerbating health conditions (eg, mood disorders, dementia, cardiovascular disease) [8]. Furthermore, NH residents exhibiting disturbed sleep, behavioral issues, and/or mood disorders are at an increased risk for being prescribed antipsychotic drugs [11], which are associated with adverse side effects and poorer quality of life [12]. Thus, the identification and management of sleep disturbances in the NH setting has become progressively more vital in efforts to optimize medical management of this population. This review identifies common sleep disturbances frequently underdiagnosed and undertreated among residents of NH facilities.
Case 1
A 73-year-old woman with a history of type 2 diabetes mellitus reports poor sleep quality with frequent awakenings during the night and excessive daytime sleepiness. She states that she can fall asleep within 5 minutes, but often is awoken throughout the night with a sensation of breathlessness. She has snored for many years, but the nursing staff at her NH facility has recently commented that her snoring has gone from intermittent to constant. She cannot remember the last time she has had restful sleep. She consumes 3 to 4 cups of caffeinated beverages daily to counter her sleepiness. She denies smoking or illicit drug or alcohol use. Her review of systems was notable for a 30-lb weight gain over the last year, and she reports increasing fatigue, irritability, and memory and concentration issues. Her current medication list includes metformin and amlodipine. Her examination is remarkable for a BMI of 31, large neck circumference (> 16), tonsillar enlargement, a crowded oropharynx, micrognathia, lungs clear to auscultation bilaterally, heart sounds of normal S1 and S2, and legs with trace pitting edema.
