How to manage a nursing home resident with insomnia?

Management of Insomnia in Nursing Home Residents

After a night of poor sleep, nursing home residents should receive a comprehensive assessment of underlying causes followed by targeted non-pharmacological interventions including increased daytime activity, bright light exposure, and environmental modifications to improve sleep quality and prevent negative health outcomes. 1

Assessment of Sleep Disturbances

• Sleep problems are extremely common in nursing home residents, with significant underreporting in standard documentation - likely affecting over 70% of residents 1
• Assessment should identify common causes of sleep disturbance:
  • Medical conditions: pain, paresthesias, nighttime cough, dyspnea, gastroesophageal reflux, and nocturia 1
  • Neurological disorders: dementia and Parkinson's disease (associated with circadian rhythm disturbances) 1
  • Medications: diuretics, stimulating agents (sympathomimetics, bronchodilators, stimulating antidepressants), anti-Parkinsonian agents, antihypertensives, and cholinesterase inhibitors taken near bedtime 1
  • Environmental factors: nighttime noise, light interruptions, limited daytime bright light exposure 1
  • Sleep disorders: sleep apnea (present in up to 50% of nursing home residents with dementia) 1

Immediate Interventions After a Night of Poor Sleep

1. Daytime Activity Modification

   • Avoid extended daytime napping which further disrupts the sleep-wake cycle 1, 2
   • Increase physical activity and social engagement during the day 2
   • Ensure resident spends time outdoors for natural light exposure 1

2. Environmental Modifications

   • Reduce nighttime noise and light interruptions 1
   • Coordinate care routines to minimize nighttime disruptions 1
   • Increase daytime bright light exposure to help regulate circadian rhythms 1

3. Address Underlying Medical Issues

   • Evaluate and treat pain, which is a common cause of sleep disturbance 1
   • Manage nocturia by timing diuretic administration appropriately 1
   • Review medication timing to avoid stimulating medications at night 1

Ongoing Management Strategies

• Non-pharmacological approaches should be first-line treatment 3, 2:

  • Regular physical activity programs 2
  • Mind-body practices (relaxation techniques, meditation) 2
  • Complementary therapies like acupressure have shown promising results 2
  • Multicomponent interventions addressing multiple factors simultaneously 2

• Medication Review:

  • Avoid long-acting benzodiazepines 4
  • Use hypnotics only for brief periods (2-3 weeks maximum) 4
  • Be cautious with psychotropic medications as they increase fall risk and may contribute to skin breakdown due to reduced nighttime movement 1
  • Consider timing adjustments of necessary medications to minimize sleep disruption 1

Important Considerations and Pitfalls

• Residents with poor sleep quality show significantly worse functional status, creating a cycle of decreased activity and worsening sleep 5
• Nursing home residents often need extended time in bed to achieve adequate sleep, with frequent awakenings (2-3 times per hour) 6
• Pharmacological interventions carry serious risks in this population, including increased falls, cognitive impairment, and daytime sedation 4
• Sleep apnea is frequently undiagnosed but highly prevalent in nursing home residents, particularly those with dementia 1
• Environmental factors in nursing homes (noise, light, care routines) are major contributors to sleep disruption but are modifiable 1

Follow-up and Monitoring

• Monitor for improvements in sleep quality and daytime functioning 5
• Assess for adverse effects of any interventions, particularly if medications are used 1
• Consider referral to sleep specialist for complex or treatment-resistant cases 1
• Regularly reassess sleep patterns as conditions may change over time 1