Guide to Recognizing and Treating Sleep Disturbances in the Nursing Home

There are several types of CRSWDs, including delayed sleep-phase syndrome, advanced sleep-phase syndrome, irregular sleep-wake disorder, non–24-hour sleep-wake disorder, shift work sleep disorder, and jet lag sleep disorder. However, the most common type of CRSWDs observed in older adults is advanced sleep-phase syndrome [39]. Due to excessive sleepiness in the early evening, affected individuals may report a need to shift to earlier and earlier bedtimes (~6 to 7 pm) and wake times (~3 to 4 am) [36]. For older affected adults, this can cause distress and frustration, particularly if their sleep phase prevents them from participating in evening activities (eg, socializing with family/friends) [36].

In the assessment of patients with suspected CRSWDs, sleep diaries (self-reported or caregiver) daily account of sleep and wake times over at least 1 week) and actigraphy (wrist-worn accelerometer designed to measure activity and inactivity at night) can be used, particularly in older adults with dementia [40,41].

CRSWD treatment may include behavioral modifications and/or pharmacological intervention. Behavioral modifications can consist of chronotherapy, relaxation training, and/or bright light therapy. Chronotherapy involves making gradual shifts in an individual’s sleep time to meet his/her desired sleep schedule. Relaxation training involves implementing behaviors/activities that reduce tension and enhance the smooth transition into sleep. Bright light therapy involves exposure to an appropriate intensity and duration of light, which is an important environmental cue to help the synchrony of the sleep-wake cycle [7]. Previous studies have observed that NH residents are exposed to a restricted amount of bright light during the daytime [42,43], but higher levels of artificial light at night (eg, hallway lighting) [7]. NH residents’ exposure to artificial bright light during the daytime has not only improved the residents’ sleep [44–46], but also has improved their cognitive functioning and reduced their depressive symptoms [47]. Thus, steps towards targeted light exposure in sync with the typical sleep-wake cycle (eg, mandated time in well-lit rooms during the day and during meals) for NH residents, particularly those with CRSWDs, could prove to be beneficial across several social, behavioral and neurocognitive domains. Lastly, NH residents exposed to at least 30 minutes of outdoor daylight and at least 3 occasions of low intensity physical activities for 10 to 15 minutes daily can potentially improve sleep-wake patterns [48]. Thus, it may be beneficial to have an intervention that couples bright light exposure and physical activity in the NH setting.

Pharmacological interventions can also be implemented to improve older residents’ symptoms. However, the medications prescribed should be used with caution and should not be used as part of a long-term treatment plan. Melatonin is a commonly used herbal supplement that can assist advancing the timing of the circadian rhythms in the evening but can delay the circadian rhythms in the morning [49]. Several brands of this herbal supplement can be purchased over-the-counter and are not regulated by the FDA. Since the amount of melatonin used in the herbal supplement varies by brand, caution should be used when selecting a brand [50]. Two FDA-approved drugs (modafinil and armodafinil) are currently being used to reduce daytime sleepiness and improve vigilance amongst adults, but limited research has explored the effectiveness of these medication for older adults specifically suffering with CRSWDS [36,51,52]. Other stimulants (eg, caffeine, amphetamines, and nonamphetamine-derived medications) are also currently being used to reduce daytime sleepiness in patients with CRSWDS. Stimulant use, particularly caffeine consumption, has also been associated with better cognitive functioning in older adults [53]. However, stimulants should be taken with caution, particularly in older adults, because stimulant use has been associated with potentially serious and fatal health sequalae (eg, tachycardia, heart failure, irreversible heart damage and hypertension) [36,54].