Nocturnal sleep disturbance is a common and disabling symptom in older adults who are cognitively impaired (Dowling, 1994; Reynolds, Hock, Stack, & Campbell, 1988). Their nocturnal sleep is light and inefficient, and they wake up often during the night (Bliwise, 1994; Schnelle, Ouslander, Simmons, Alessi, & Gravel, 1993). One study found that residents in a nursing home, 60% of whom had dementia, slept only 66% of nocturnal time in bed. When asleep, continuous sleep intervals averaged only 20 minutes (Schnelle, et al, 1993).
In addition to sleeping poorly at night, residents with cognitive impairment sleep more in the daytime than older adults who are healthy. One study found that some nursing home residents had similar activity levels both day and night (AncoliIsrael, Parker, Sinaee, Fell, & Kripke, 1991), and another showed 10% to 20% of their total 24-hour sleep time occurred during the daytime (Prinz et al., 1982). Multiple, short daytime napping episodes interfere with daytime activity and functioning (Ancoli-Israel, Parker, Sinaee, Fell, & Kripke, 1 991 ; Vinello, & Prinz, 1992), and perhaps nocturnal sleep. Furthermore, daytime disruptive behaviors such as pacing, hitting, and cursing, related significantly to sleep disturbance (Cohen-Mansfield, 1990; Rebok, Rovner, & Folstein, 1991).
Current interventions consist of pharmacological agents. Benzodiazepines, or antipsychotic medications, provide minimal efficacy in the presence of serious side effects, such as impairment of memory, cognition, coordination, and balance. Furthermore, tolerance develops and discontinuation may result in severe rebound insomnia (Feikey et al., 1995; Shorr & Robin, 1994; Bliwise, 1994).
Investigation into nonpharma,cologic interventions to improve sleep in this population is sparse. An urgent need exists for feasible, costeffective, nonpharmacologic interventions addressing the precipitating causes of sleep disturbance.
For some institutionalized elderly adults, living in a physically, cognitively, and emotionally understimulating setting may induce excessive napping during the day, disturbing circadian sleep-wake patterns (Ancoli-Israel et al., 1997b; Morewitz, 1988). Structured daytime activity may be an effective intervention for nocturnal sleep disturbance, but it has not been formally tested. Purposive physical, cognitive, and affective activities may help sustain daytime alertness and promote physiologic well-being. Concrete, reality-based activities may counter excessive napping by keeping residents with dementia involved in the world around them and helping them meet important psychological, physical, and social needs (Algose et al., 1997; Levy, 1986).
After baseline measures of sleep-wake patterns, the participants in this study received individualized activities for 14 days during peak napping periods. During the 10th, 12th, and 14th days of the intervention, the staff re-measured sleep-wake patterns. The researchers used actigraphy (Ambulatory Monitoring, Ardsley, NY), a device worn on the participant's wrist, to measure sleep-wake patterns.
The following questions were addressed in this study:
* What are the 24-hour sleep-wake patterns of nursing home residents who are cognitively impaired?
* What is the effect of an Individualized Activity Intervention (IAI) on nocturnal sleep in nursing home residents with cognitive impairment who demonstrate sleep disturbance?
ACTIVITY ASSESSMENT TOOL
The convenience sample consisted of seven male veterans residing on a locked, long-term dementia care unit in a veterans' affairs hospital. The participants underwent the Mini Mental State Examination (MMSE), a brief test measuring cognitive manifestations of mental function. This examination is widely used to track severity of dementia. Exclusion criteria follow:
* Physical disabilities severely limiting activity (e.g., bedfast).
* A chart diagnosis of untreated sleep apnea or periodic movements of sleep, because these disorders cause frequent awakenings and decreased sleep efficiency.
* Parkinson 's disease, because tremors interfere with actigraphy, the sleep measure used in this study.
Seven residents, five with vascular dementia and two with Alzheimer's disease, participated m the descriptive portion of the study. All of the residents were ambulatory without assistance, and none required physical restraints. Because of illness, one participant was unable to complete the IAI. Technical difficulties with one actigraph resulted in a loss of data on an additional participant. Thus, the final sample for the pilot was five residents, four with vascular dementia and one with Alzheimer's disease. There was one Black participant and four White participants, and the mean age was 76.2 years (SD = 7.98).
The research team screened for participants by asking the nursing staff to identify residents who had difficulty sleeping at night and napped during the daytime. The team then obtained informed consent from participants* next of kin. Participants wore an actigraph for 3 days during baseline and 3 days during intervention to measure their sleep-wake patterns. An actigraph is a watch-sized device worn on the wrist that senses and stores physical motion.
Based on the assumption that an individual tends to be less physically active asleep than awake, several algorithms have been developed to translate wrist activity measurements into estimates of sleep time (Chambers, 1994). Studies have demonstrated that minute-by-minute agreement between actigraphy and polysomnography, the gold standard for laboratory measurement of sleep, ranges from 85% to 95% (Ancoli-Israel, CIopton, Klauber, Fell, & Mason, 1997a; Sadeh, Sharkey, & Carskadon, 1994). To minimize within-participant variance and to increase sensitivity of the device, each individual wore the same actigraph for each measurement period (Sadeh et al.,1994).
Because the actigraph does not detect respiratory patterns, a trained observer completed a sleep observation checklist to screen participants for obstructive sleep apnea during one 8-hour night. Obstructive sleep apnea occurs when tissue such as the tongue or soft palate blocks the airway during sleep (Waite, 1998). The incidence of sleep apnea increases with advancing age and cognitive impairment and affects between 42% and 53% of elderly adults who are cognitively impaired (Hoch et al., 1 986; Hoch et al., 1 989).
After training, the observer determined the presence of sleep apnea aurally by observing snorting or gasping, and visually by paradoxical chest and abdominal motion. The observers made rounds every 15 minutes and noted apnea. Previous investigations using this technique report high correlation with objective measures (Carroll, Bliwise, & Dement, 1989).
The research team used a standard form to collect data on age, diagnosis, medications, continence, use of supportive or restraining devices, and mobility. Nursing staff provided hourly documentation of participant activities such as meals, games, music, pacing, exercise, and interaction with staff members. Staff also recorded interruptions to sleep for provision of care and recorded residents' bedtime and risetime.
Individualized AcUvHy Intervention
One of the investigators assessed the residents using an investigatordeveloped activity assessment patterned after the Farrington assessment (Buettner & Martin, 1995; Reynolds et al., 1995) and wrote a narrative prescription for IAI. This assessment provided the data for the investigator to individualize the activities to each participant's past interests and current capabilities. The instrument consisted of 113 items divided into domains of current cognitive, physical, communicative, sensory, and emotional status, as well as behavior problems and past interests.
Examples of items under the cognitive domain included the ability to follow a three-step command, identify colors, and recognize numbers (Table 1). The assessment involved interviews with family, nursing staff, and residents; observation of resident behavior; and chart review. In addition to prescribing the activities, the investigators prescribed the time for the project's nursing assistants to conduct the activities. They observed each resident's baseline actigraph data for peak napping intervals and prescribed activities to occur during that time. Each participant received from 1 to 2 hours of activities daily, occurring in 15- to 30-minute sessions.
The project's nursing assistants who were not employed in the setting implemented the prescribed IAI for 14 days. Table 2 is a list of activities prescribed, including those most effective in holding the participants' attention. The activities were derived from five modalities including verbal, visual, physical, tactile, and gustatory and olfactory. The following five areas of content were included:
* Expression of feelings.
* Expression of thoughts.
* Memory and recall.
The research assistants identified favored activities based on level of resident participation, amount of cueing required to maintain interest, and frequency of use.
Actigraphy provided the objective measure of sleep-wake patterns. The study measured the following sleep variables:
* Bedtime, The time the resident is put to bed for the evening. Residents do not always fall asleep immediately; therefore, the staff kept logs to verify bedtime.
* Risetime. The time the resident got out of bed to begin the day's activities.
* Minutes slept from bedtime to risetime. Tune in minutes the resident was asleep between bedtime and risetime.
* Percent nocturnal time asleep.
Percent nocturnal time asleep is determined by dividing the minutes slept from bedtime to risetime by the total time in bed.
* Minutes of daytime sleep. The amount of time the resident spent sleeping between risetime and bedtime.
The results indicate a positive effect of IAI on the nocturnal sleep patterns of older adults who are cognitively impaired. The overall sleep patterns of the older adults reflected more efficient nocturnal sleep with fewer minutes of daytime sleep.
EFFECT OF INDIVIDUALIZED ACTIVITY INTERVENTION ON SLEEP
Description of 24-Hour Sleep-Wake Patterns During Baseline
Staff put residents to bed for the night at times ranging from 6:30 p.m. to 10:00 p.m., and risetimes ranged from 5:30 a.m. to 7:30 a.m. The percent nocturnal time asleep ranged from 27% to 91% (mean = 55.96%) and minutes of daytime sleep ranged from 43 to 219 minutes (mean = 75.88). Variability in each participant's sleep pattern occurred during the 3 nights. For example, one resident slept 66% of the first 2 nights and only 0.08% of night 3. Additionally, the findings revealed that sleep was broken into fragments. Wakefulness occurred most often during meals, while napping occurred most often from 9:00 to 10:30 a.m. or from 1:00 to 3:00 p.m.
Hourly observations conducted around the clock by the nursing staff revealed that aimless wandering was the most frequent daytime activity of the residents. Residents wandered in the hallways in 163 of 768 observations (21%). Interruptions of nocturnal sleep for care occurred infrequently and most often consisted of toileting or incontinence care. Participants received a variety of medications that affect sleep, but only one routinely received a benzodiazepine at bedtime.
The Effect of Individualized Activity Intervention on Nocturnal Sleep
For each participant, for baseline and intervention, the investigators totaled the number of minutes slept each night and day and calculated two means. Table 3 displays baseline and intervention values for sleep measures and the MMSE scores of tbe sample. Project nursing assistants successfully engaged all participants in activities, and the percent of nocturnal time asleep improved by 6.8% (p < .01, 95% confidence interval = 2.58 to 9.90). Although daytime napping decreased in the entire sample, two of the patients actually had increased napping. Examination of the individual nights of data for these two participants revealed that improved sleep followed days when napping decreased.
To provide further insight into the intervention, a case study follows:
Patient A, a 79-year-old male veteran, had vascular dementia and a MMSE score of 18. During baseline, he wandered tbe hallway of the unit, watched some television, and napped in the dayroom. He frequently initiated interaction with the staff by asking for a cigarette. Although he remained in his bed at night, staff noted that he awakened easily. His baseline nocturnal acagraph data showed frequent awakenings and long periods of wakefulness.
The activity assessment detected that Patient A retained a high degree of manual dexterity and the ability to follow multi-step commands. His vision and hearing were within normal limits. He had worked as a dry cleaner, and his wife stated that he liked to play checkers. Based on his baseline actigraphy data, he napped most often after breakfast and lunch.
Based on this information, the investigator provided Patient A with wooden objects to sand and paint, capitalizing on his manual dexterity. He also enjoyed coloring. He categorized pieces of fabric and explained dry cleaning procedures for them. The team encouraged him to play checkers, and he became the unit champion, beating all other residents and several research assistants. The research staff scheduled Patient A's activities after breakfast and lunch, coinciding with peak napping periods noted on his baseline actigraph report. Project assistants provided additional activities as needed to further reduce the occurrence of daytime napping.
The research personnel noted an improvement in Patient A's affect and interaction with staff and a decrease in daytime sleepiness over the 2-week intervention period. Instead of constantly asking for a cigarette, he asked, "Do you have something I can do?" or "What can I do next?" In the morning when the research team arrived on the unit, Patient A waited for them at the door and greeted them with a smile.
Examination of Patient A's actigraph data, bedtimes, and risetimes, revealed that staff put him to bed at approximately 7:30 p.m. each evening, but he rarely fell asleep before midnight. Although his percent of nocturnal time asleep from bedtime to risetime improved by only 4.6%, percent time asleep from sleep onset until risetime improved by 21% (from 46% to 67%) during the activity intervention. These findings reflect a trend for Patient A to consolidate nocturnal sleep during the intervention.
This study supports findings of other investigators that nocturnal sleep is inefficient and frequent daytime napping occurs in nursing home residents who are cognitively impaired (Ancoli-Israel, Parker, Sinaee, Fell, &c Kripke, 1989; Bliwise, Bevier, Bliwise, Edgar, & Dement, 1990; Vitiello & Prinz, 1989). At baseline, nocturnal sleep time ranged from 27% to 81% of time in bed for this sample (mean = 47.5, SD = 22.7) with frequent nocturnal awakenings. Additionally, the mean minutes of daytime sleep for the seven participants in the descriptive group ranged from 38.66 minutes to 108 minutes.
Ancoli-Israel et al. (1989) reported in their observations of nursing home residents that between the hours of midnight and 6:00 a.m., 50% of patients were awake for more than 10 minutes per hour. Furthermore, Jacobs et al. (1989) reported that in 20 nursing home patients who underwent 24-hour sleep recordings, some sleep and some wake cycles occurred during every hour throughout the 24hour period.
When comparing the nocturnal sleep of the present study's participants to healthy elderly adults, the data reveal notable differences. The results reported by Hoch et al. (1994) in their study of 50 community dwelling, mentally-intact older adults differ in nocturnal minutes of sleep and percent of nocturnal sleep time, emphasizing the impact which dementia plays in sleep deterioration. In Hoch's group, the minutes spent asleep averaged 373 for residents younger than age 75 and 349 for residents older than age 75.
The present study's participants, with a mean age of 76.2, averaged only 327 minutes of nocturnal sleep at baseline. Additionally, the average percent of nocturnal sleep for Hoch's two groups were 83% and 78%, respectively. The present study's sample displayed an average percent nocturnal sleep of 47.5% at baseline.
One noteworthy descriptive finding of this study was the early time at which some residents went to bed. Schnelle et al. (1993) reponed their examination of four large long-term care facilities where staff placed residents in bed at approximately 6:00 p.m. and left them there for roughly 12 hours. This early bedtime potentially contributes to the light, poorly consolidated sleep frequently seen in elderly nursing home residents with cognitive impairment. Providing residents with an early evening activity intervention and delaying bedtime until between 9:00 and 10:00 p.m. may improve their nocturnal sleep.
The authors' conceptualization that excessive daytime napping interferes with nocturnal sleep and results from lack of meaningful daytime activity contrasts with other models such as the Progressively Lowered Stress Threshold model proposed by Hall and Buckwalter (1987). The authors' larger study may assist in understanding how these models complement one another.
Clinicians often use physical and chemical restraints to manage nocturnal wandering and other disruptive behavior in spite of their disadvantages (Hardin et al., 1993) and moderate effectiveness (Burgio, Scilley, Hardin, Hsu, & Yancey, 1996). The descriptive results in this study revealed that the participant receiving the greatest number of sleep-affecting medications (n - 4) had the least percent of nocturnal time asleep. A meta-analysis examining the effect of pharmacological therapy for patients with Alzheimer's disease found that only 20% of patients responded favorably to neuroleptics (Schneider, Pollock, & Lyness, 1990).
The benefits of developing interventions to increase nocturnal sleep may include the following:
* Decreased caregiver and resident stress.
* Increased quality of life for the resident because of a decrease in physical and pharmacological restraints (Allen, Seiler, Stahelin, & Spiegel, 1987; Gugel, 1988).
* Cost savings stemming from decreased injuries, property damage, staff -burnout, absenteeism, and turnover (Casciani, 1988; Christie & Ferguson, 1988; Hu, Huant, OC Cartwright, 1986).
* Decreased incidence of falls (Morgan, 1987)
Prior to the IAI, staff repeatedly noted residents to be wandering aimlessly or napping. The selection of a sample from a locked dementia unit may have contributed to the high prevalence of observed wanderings. This pilot study demonstrated that activities tailored to residents' interests and capitalizing on their remaining abilities improved nocturnal sleep and reduced daytime napping.
Additionally, although the authors did not measure psychological well-being, staff reported improvement in participant's affective states. This finding is of particular interest because nursing interventions that promote the psychological well-being of older adults who are cognitively impaired and support remaining physical abilities are scarce. A potential advantage of IAI is the use of specially trained nursing assistants to conduct the prescribed activities, providing a low-cost personnel source for a high yield program.
This pilot study had some minor limitations. One was the small sample studied. Small sample sizes magnify the effect of a deviate score. Increasing the number of participants would strengthen the findings and provide more support for clinicians to incorporate IAI in their practice. The second limitation was that all participants were men. Currently, the effect of dementia on the sleep of men as opposed to women is undifferentiated. Gender differences in the activity needs of individuals with dementia are unclear as well.
An additional limitation is the limited period of time over which activities occurred. Two of the participants began to sleep more at night in the last 3 days of the intervention period. It seems, therefore, that lengthening the activity intervention might provide an even greater improvement in nocturnal sleep. Finally, regardless of the activities, the additional attention received by the residents could have influenced their behavior.
Potential areas for further investigation include whether improvement in sleep-activity rhythms may decrease disruptive behaviors associated with sleep disturbances in cognitively impaired elderly adults. The comparison of mental status before and after the intervention period may help determine if IAI could be another factor in delaying cognitive deterioration. The authors are currently investigating the effect of a longer intervention period using a control group.
Activities offer a cost-effective, low-risk alternative to the current strategy of pharmacological intervention for sleep disturbance of elderly nursing home residents with cognitive impairment who exhibit excessive daytime sleepiness. The interventions described in this article provide a possible means to improve the quality of nocturnal sleep in this population.
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ACTIVITY ASSESSMENT TOOL
EFFECT OF INDIVIDUALIZED ACTIVITY INTERVENTION ON SLEEP