When caring for residents with dementia, one quickly realizes that a common problem is sleep—too much or too little. If too little, not only is the resident not getting needed sleep, but the sleepless resident’s behaviors can disturb other residents. The vicious cycle of inadequate sleep impacts daytime events—residents are restless, irritable, agitated, and taking naps. As the lack of quality sleep accumulates, problems arise and residents take their frustrations out on each other or the staff.
Research shows sleep to be as important as food and water to long-term care residents’ well-being. In the State Operations Manual, Appendix PP (2017), CMS refers to quality of sleep over 30 times in multiple F-tags, such as those covering safe environment, dignity, comfort, home-like environment, and sound levels; adds emphasis on sleep quality to tags for behavioral health services and dementia care; and makes numerous references throughout to non-pharmacological interventions. These interventions add up to a sleep-hygiene program, which is defined by good sleep strategies.
Many residents’ sleep problems are related to intrinsic, extrinsic, institutional, and/or environmental factors; these factors can be minimized with culture-changing interventions.
Recall the sleep-wake cycle
A single cycle of sleep, consisting of four to five stages, lasts 90 to 110 minutes and repeats four to six times during the night. Sleep stages are divided into non-REM (Rapid Eye Movement) (stages one to four) and REM sleep (stage five). Stages one and two (lasting 5 to 15 minutes each) are called light sleep, as the individual drifts in and out of sleep several times and is easy to disturb and awaken. Stages three and four (5 to 15 minutes each) fall into the category of deep or “slow-wave” sleep. Stage five is called REM sleep.
For cognitively impaired residents, changes in sleep quality include increased nighttime awakening, more time in bed with less sleep, earlier sleep onset and awakening, increased time to fall asleep, decreased deep sleep, decreased REM sleep, and increased daytime napping. Additional comorbidities and/or medications lead to a formula for increased sensitivity to environmental distractions.
Utilize advances in care
Research and technology have introduced new information, tools, and solutions to reducing adverse events, increasing efficiency, and achieving positive resident outcomes. Using these, we can introduce effective, efficient, and safe sleep-hygiene programs.
For example, a turning and positioning study (Journal of American Geriatrics Society, October 2013) with 942 participants, aged 65 and older, with a Braden score of moderate to high risk for skin breakdown, and using high-density foam mattresses, found no difference in pressure ulcer incidence over three weeks among those turned at two-, three-, or four-hour intervals. Additionally, repositioning can be done using draw sheets for minimal disruption.
High-quality overnight incontinence products that wick moisture away and stay dry for six to eight hours can also reduce awakening. Other strategies to minimize nighttime toileting disruptions include encouraging residents to toilet as close to bedtime as possible and, for ambulatory residents, providing easy bathroom access by eliminating clutter and using nightlights.
Build mobility into daily routines
Residents who move more sleep better. Encouraging more movement encourages more restful sleep. Start with the following:
o Standing for a few extra seconds
o Walking a few additional steps
o Walking each day—if family members are capable and willing, encourage them, too, to get their loved one out for daily walks
o Decreased use of wheelchairs, instead adding seating for rest along hallways
o Seated exercise for non-ambulatory residents
o Fun with music and props
Choose the right bedtime snacks
Before bedtime, keep residents’ snacks light, and include “snooze food”: bananas, cherries, almonds, protein, milk, pineapple, peanut butter, chick peas, cheese and crackers, cereal and milk.
Be aware of pain
Residents with dementia often exhibit abnormal sleep patterns—daytime sleep and nighttime wakefulness. To improve sleep, consider unmet needs, especially pain. Sleep deprivation increases cortisol levels, increasing inflammation (pain). Sleep deprivation also increases anxiety levels. Pain increases when both sleep deprivation and anxiety are present. Consider using a pain assessment for advanced dementia, such as PAINAD (https://geriatricpain.org/assessment/cognitively-impaired/painad/pain-assessment-advanced-dementia-painad-tool). With the physician and pharmacist, review all medications and their impact on sleep and consider adjustments. Sleep medication is preferably avoided, due to the risk of poly-pharmacy. Try these ideas first:
o Maintain bright light during the day
o Encourage physical activity individualized for the resident’s tolerance
o Consider social and/or physical activities as tolerated
o Use music that matches the resident’s favorites
Provide sufficient daytime activity options