Guide to Recognizing and Treating Sleep Disturbances in the Nursing Home
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].
Case 3 Outcome
The patient was moved to a room with a window. An alarm clock was set for 7:30 in the morning and he was taken to breakfast, where he sat at a table near a window. Any time he appeared to be sleepy, he was encouraged to go for a walk or engage in other activities so daytime napping opportunities were limited. His environment was assessed for safety and bedrails were utilized to prevent falls.
Case 4
A 75-year-old woman with a history of anxiety and depression moved into the NH 4 months ago after suffering a stroke. She now reports difficulty falling asleep for many years, which has significantly worsened since moving to the NH. Currently, she has been getting only 3 to 4 hour of sleep per night. She reports mild but increasing daytime sleepiness and does not fall asleep until 1:00 am despite getting into bed at 10:30 pm. She occasionally reports arthritic pain that interferes with her sleep. The NH staff has mentioned that she will occasionally cry for her family when she appears to be asleep.
Case 4 Reflection: Insomnia
According to the International Classification of Sleep Disorders (ICSD-3) [39], insomnia is characterized as “a repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment.” Among the sleep disorders, insomnia is one of the most common sleep issues observed in sleep clinics [34]. Older adults with insomnia often have comorbid physical (eg, pulmonary disease, arthritis, chronic pain, cancer diabetes, Parkinson’s disease) and mental illness (eg, depression, panic disorder) [55]. Medications (eg, stimulants, respiratory medications, chemotherapy, decongestants, hormones, or psychotropics) may cause and exacerbate insomnia symptoms [55].
Since insomnia is a clinical diagnosis, there is no specific diagnostic tool or gold standard test to identify individuals suffering with insomnia. Insomnia screening usually involves a clinical interview, in which a health provider, preferably trained in sleep, conducts a physical examination and collects an in-depth history of a patients’ sleep problems [56]. Insomnia screening tools may also include having a patient complete a sleep diary or questionnaire, such as the insomnia severity index (ISI) [57] or Pittsburgh Sleep Quality Index (PSQI) [58].
Cognitive behavioral therapy for insomnia (CBT-I) and/or pharmacological intervention are typically used to treat insomnia in older adults. CBT-I is a combination of cognitive (eg, changing dysfunctional sleep attitudes/beliefs) and behavioral treatment (eg, adhering to a regular sleep schedule) [59]. CBT-I or a combination of CBT-I and pharmacological intervention is recommended as more effective long-term approach to insomnia treatment compared to pharmacological intervention alone [55]. CBT-I involves altering older adults’ misconceptions of their sleep and implementing behavioral techniques to their everyday life (eg, routine sleep-wake schedule, relaxation therapy). Several FDA-approved medications are available to treat insomnia; however, many commonly used medications to treat insomnia in older adults (ie, antihistamines, antidepressants, anticonvulsants, and anti-psychotics) pose more risks than benefits to their health and well-being [35,60–62]. Some of the more recent hypnotics (egm zolpidem, exzopiclone, and ramelteon) on the market have been shown to be safer and more effective pharmacological options [55]. In 2014, the FDA approved the first in class orexin receptor antagonist medication (suvorexant) to treat insomnia [63]. Unlike other medications to treat insomnia, suvorexant, via the blockade of the orexin neurotransmitter, effectively inhibits orexin (one of neurotransmitters involved in the activation pathways of the arousal system), so sleep can easily be induced and maintained [64, 65]. Furthermore, preliminary studies suggest that this medication may be associated with less severe side effects (ie, habituation) than the other approved medications on the market [64, 65]. In fact, in a recent clinical series that included both young and older insomnia patients, the most common adverse reaction to suvorexant was drowsiness [66].
Case 4 Outcome
The patient was initiated on basic CBT-I therapy strategies which included stimulus control therapy [67]; implementation of a consistent bedtime and awakening routine; reducing the use of TV, smart phone, or other electronic leisure devices 1 hour before bedtime; refraining from caffeine after lunchtime; improving the sleep environment; and relaxation techniques.
Case 5
The patient is a 65-year-old man diagnosed with Parkinson’s disease several years ago. Recently, he has often has been experiencing what appears to be very violent and terrifying dreams. While asleep, he often screams and shouts for help. In addition, he occasionally will punch, kick, and/or thrash around in bed at night, which the NH staff has noted as a concern for his safety.
