MDS Alert

Taking time to do this will help residents and staff rest easier.

Shakespeare may have been on to something when he said, "Sleep ... knits up the raveled sleep of care." Certainly, improving residents' sleep can improve care and reduce survey and litigation woes. How so? Insomnia leads to impaired cognition, increased depression and anxiety, social withdrawal, falls, medication use and dependency, increased mortality -- and survey citations for inappropriate hypnotic use, cautioned Daniel Bluestein, MD, MS, in a presentation on insomnia at the 2008 American Medical Directors Association meeting.

Assessment is the first step: Ask each resident or his responsible person at admission about the resident's sleep history and patterns. In collecting information to complete Section AC (customary routine), the resident may say he is used to staying up late at night or taking a nap at a certain time of day, notes Jennifer Gross, RN, BSN, a consultant with PointRight (formerly LTCQ) in Lexington, MA.

Tip: Use that information as part of the decision-making for assigning roommates, Gross suggests.

Also observe how residents seem to be sleeping at night. Ask them if they feel rested when they wake up. If not, what do they think is affecting their ability to sleep well? Correlate a resident's behavioral symptoms during the day to how the person sleeps that night and slept the night before, suggests Nathan Lake, RN, BSN, MHSA, a long-term care and MDS specialist in Seattle, WA.

If you determine that a resident appears to have sleep disturbances, look at these key areas to get to the root of the problem.

• Day-time naps. N1 (time awake in the morning, afternoon and evening) may give you a clue that a resident with insomnia sleeps a lot during the day, advises Gross. "That may be what he wants to do, but if he wants to sleep more and better at night, you might help him minimize his naps and participate more in an activity" in lieu of a nap, she adds.

Interesting findings: Researchers have linked a higher rate of daytime sleeping to less functional recovery among post-acute inpatient rehab patients with an average age of 80.6 years, according to a study reported in the Sept. 1 issue of the journal Sleep. (For more information, go to http://www.aasmnet.org/Articles.aspx?id=1043.)

• Psychosocial issues, lack of engagement (Sections N and F). Boredom, isolation, lack of stimulation, loneliness, social withdrawal and bereavement can lead to insomnia, cautioned Bluestein.

• Pain, shortness of breath (Section J). "A pain assessment may reveal causes of insomnia such as leg cramps or back pain," which could be alleviated, says Gross. Shortness of breath may be due to chronic lung disease or congestive heart failure, noted Bluestein.

• Mood or anxiety indicators (Section E). Insomnia is a "cardinal symptom of depression," Bluestein cautioned. Conversely, elderly people who are not sleeping well are at increased risk for developing depression, he added.

• Incontinence or nocturia Prostate disease or poorly regulated diabetes can cause nighttime voiding, noted Bluestein.

Does the person wake up due to incontinence or a need to use the bathroom? "You can care plan to restrict fluids near bedtime to reduce that issue," Gross says.

Good question: Are care-planned "check and change" or toileting routines interrupting the person's sleep? An incontinent resident could wear an extended-wear brief all night, if her skin isn't breaking down as a result, says Diana Waugh, RN, BSN, a consultant in Waterville, OH. And it may do more than allow the person to sleep. Studies show that when residents wear extended-wear briefs that allow them to sleep throughout the night, the residents' rate of falls go down, Waugh relays. In fact, Waugh recently gave a talk on this strategy, and a provider in the audience reported her facility was using the extended-wear briefs. The facility's fall rates were down -- and residents weren't experiencing skin issues, Waugh says.

• Medications. A pharmacy review may identify medications that are interfering with sleep. For example, look for those that have stimulant effects, such as albuterol, theophylline, decongestants, caffeine, nicotine, corticosteroids and amphetamines, advised Bluestein.

Diuretics administered near bedtime can also cause nighttime awakening when the person has to void.

Nursing home patients at particular risk for sleep apnea are those who stop breathing repeatedly during sleep, snort or gasp for breath at night -- and those with difficult-to-control hypertension, says Barbara Phillips, MD, MSPH, professor in the Division of Pulmonary, Critical Care and Sleep Medicine at the University of Kentucky College of Medicine.

"Nocturnal oximetry is a useful tool to rule in sleep apnea," she says. "Those who show cyclic hypoxemia only while sleeping are very likely to have sleep apnea," Phillips notes, although oximetry can't rule out sleep apnea. A resident with persistent signs of sleep apnea and normal pulse oximetry could have a sleep study to identify the condition. But "some people have tried empiric CPAP as a therapeutic trial" to see if it helps, Phillips says. "Potential benefits of identifying and treating sleep apnea in nursing home residents include reduced frequency of nocturia, improved cognition, and reduced cardiovascular morbidity and mortality."