Sleep disturbance - National Association of State Veterans Homes

Sleep Disorders in State Vet Homes
How Interventions Drive Quality and
Optimize Resident Wellness
Melissa Napier, MS, BSN
Judy Borcherdt, BSN, RN, CWCMS
Charleston, SC
July 29th, 2014
So…Why are we here??
To learn the SIMPLE tools necessary for
your State Veteran Home to develop a
program for better sleep to improve
your veteran’s lives.
 Understand current Clinical Practice Guidelines and
Standards of Care for the evaluation, treatment,
intervention and documentation of sleep disorders in
LTC settings.
 Describe restful sleep physiology and the
pathophysiology related to sleep deprivation on acute
and chronic disease states, cognitive function and
quality of life measures
 Describe non-pharmacologic treatment strategies and
their positive effects on Patient Centered Care and
caregiver and resident satisfaction
 Evaluate how treatment interventions for disrupted
sleep can drive quality outcomes for facilities; and
physical, cognitive, and wellness outcomes for residents
 Most sleep disorders in the Long Term Care setting
are secondary to medical conditions or
environmental issues.
 We will NOT be discussing primary sleep disorders
including obstructive sleep apnea, restless-legsyndrome or periodic limb movement but will discuss
when to refer for evaluation.
 Understand current Clinical Practice Guidelines
and Standards of Care for the evaluation,
treatment, intervention and documentation of
sleep disorders in LTC settings.
Presented by Melissa Napier, MS. BSN.
National Guidelines
 AMDA The Society for Post-Acute and Long-Term
Care Medicine, affiliated with the American Medical
Association and the American Society of Internal
 Last updated 2005
 Available from
Sleep Disorders Definition
Difficulty in maintaining wakefulness during
the day OR abnormal behavior associated with
all of which are subjectively or
objectively distressing or harmful to the patient
or the patient’s roommate or sleep partner.
Most sleep disorders in LTC are secondary
to chronic disease states or environmental
factors and will be the focus of this presentation.
Classifications: Dyssomnias
 Insomnia:
 Difficulty falling or staying asleep or early awakening
 Non-restorative sleep resulting in impaired function:
cognitive, physical or social
 Often result of mood disorders or health issue
 Obstructive sleep apnea, restless leg syndrome, periodic
limb movements
 Hypersomnia:
 Increased sleepiness, usually during the day that causes
impairment of function
 Primary hypersomnia is rare in this population
 Parasomnias
 Disorders characterized by abnormal sleep-related
behaviors including: nightmares, sleep-terrors,
 Circadian Rhythm Sleep Disorders
 Twilight Psychosis or “Sundowning” is NOT a sleep
disorder but still requires identification and
Risk Factors: A Brief Overview
 Dementia, elderly
 Depression, bipolar disorder, other mental illnesses
 Inadequate
 Exposure to sunlight
 Family or social support
 Physical activity
 Multiple comorbidities especially COPD, CHF, arthritis
 Neurological disease
 New admit to LTC facility
 Medications
Signs and Symptoms that could
indicate a sleep disorder
 Nighttime Signs and Symptoms
 Noticeable snoring
 Apneic episodes and “arousal snort”
 Frequent awakenings
 Periodic, jerking limb movements
 Talking during sleep
 Wandering
Fun word of the day: somniloquy = sleep talking
Signs and Symptoms…….
 Daytime signs and symptoms
 Abnormal behavior in dementia patients such as
agitation, hostility, combativeness
 Complaints by roommate
 Early morning confusion, agitation, headache
 Falls, accidents, functional decline
 Impaired cognition
 Uncontrolled hypertension
 Decreased participation, food and fluid intake
Sleep problems in LTC settings
 VERY Common
 More time in bed-AWAKE: less time in REM sleep with
increased fragmentation
 Comorbidities and/or medications can increase sensitivity
to environmental distractions
 Increased interruptions, especially through the
 Increased risk for falling ( self toileting?)
 Elevated mortality risk
Evaluation, Assessment
 Obtain sleep history through the interview process,
utilize a sleep log
Determine the characteristics of sleep including
routines, quality, history that could indicate issues
Rule out external factors like diet, caffeine, exercise,
Assess impact and physical evaluation
Sleep observation
Review relevant medical conditions
If a primary sleep disorder is suspected: REFER
Treatment of Sleep Disorders
 IMPLEMENT non-pharmacologic interventions first
 Reconsider the need for medications that may be
interfering with sleep……….INITIATE facility wide
sleep program!!
 Treat the medical conditions that may be an
underlying cause
 MONITOR interventions and re-evaluate as necessary
 DOCUMENT per quality and survey standards
When to refer to a specialist:
 When Obstructive Sleep Apnea is suspected
 Daytime Symptoms
 Frequent accidents
 Morning headaches
 Excessive sleepiness
 Restless leg syndrome
 Periodic limb movements
Use clinical judgment and observation to determine if
diagnostic testing by a specialist is warranted.
To describe the physiology of restful sleep and the
pathophysiology related to sleep deprivation on acute and
chronic disease states, cognitive function and quality of
life measures.
Presented by: Judy Borcherdt, BSN, RN, CWCMS
Sleep defined…
 The natural state of rest during which your eyes are closed
and you become unconscious. (Merriam Dictionary)
 Sleep is a state that creates a heightened anabolic state,
accentuating growth and rejuvenation of all physiologic
systems. It is observed in all species of living creatures.
 A uniform block of time when we’re not awake
Sleep Defined… wonderful!
Like a baby
…never enough!
Sleep function
Sleep Cycle
Decrease in REM as we age
Circadian Rhythm
Here’s what we know…
 Sleep patterns began to drastically change during the Industrial
Revolution and the invention of the light bulb
 Most everything we know about sleep, we’ve learned in the past 25
 Tiny luminous rays from digital alarm clocks can be enough to disrupt
the sleep cycle even if you do not fully awaken. The light turns off a
“neural switch” in the brain, causing levels of a key sleep chemical to
decline rapidly.
 FYI- A well known Sleep expert, Dr. Mahowald suggests that anyone who needs an
alarm clock is by definition sleep deprived because “if the brain had received the
amount of sleep it wanted, you would have woken up before the alarm went off.”
Do we really know…
Just what is the impact of chronic sleep deprivation?
Sleep is a serious matter
 Sleep deprivation can have a disastrous effect,
ultimately leading to death.
 Seventeen hours of sustained wakefulness leads to a
decrease in performance equivalent to a blood
alcohol level of 0.05%.
 Major disasters attributed to human errors in which
sleep-deprivation played a role including the 1989
Exxon Oil Spill off Alaska
Sleep: a serious matter
 Well over 100,000 car accidents in North America occur every
year due to sleep deprivation—leading to 6000 deaths.
 Research conducted in 2012 showed:
 adults who regularly slept less than six hours each night were four
times more likely to suffer a stroke than were those who got plenty of
 A recent study of orthopedic surgical residents found that
residents were fatigued 48% of the time.
 Negatively effected performance 27% of the time
 Increased potential risk for medical errors by 22% (Arch. Surg. 2012;147)
Just what happens when we sleep?
 Biochemical:
 Hormone secretion
 Metabolic rate falls during REM sleep
 Energy is conserved
 Body temperature drops
 Protein synthesis and production of complex
molecules in the body increase
• Physiological:
• Restorative OR recovery phase
• Cell division more rapid during NREM
• Increase immune function
 Neurological:
 Development of brain cells and formation of new neurons
 Connections between brain cells during development
-Mood swings
Sleep should not decline as we age,
 Sleep patterns usually change as part of the normal aging
 Increased interruptions, especially through the night
 Many times takes longer to fall asleep
 Most sleep disruptions are related to physical or
psychological conditions and medications
 To bed earlier-arise earlier// changes in activity and/or
Sleep Duration and Cognition:
Preliminary Results
The Nurses’ Health Study
 Population: 15,263 woman, at least 70 years of age-study
sleep duration at mid-life/later life- free from stroke and
depression at the start.
 Women with sleep durations less than 6 hours a day or
more than 9 hours a day had worse average cognition at old
age compared to those with sleep durations of 7 hours a
(Presented by Dr.. Devore of the Harvard Nurse’s Health Study on, 2013)
Summary and duration and
cognition: preliminary results
 Women with sleep durations that change by 2 hours a day or more had
worse cognitive function than those with no change
 The findings support the following notion:
 Extreme sleep durations and changes in sleep duration over time may
contribute to cognitive decline and early Alzheimer’s changes in older
 Our findings suggest that getting an 'average' amount of sleep, seven
hours per day, may help maintain memory in later life and that clinical
interventions based on sleep therapy should be examined for the
prevention of cognitive impairment."
Elizabeth Devore, ScD –Brigham and Woman’s Hospital, Boston
Sleep and Dementia are
Diseases such as
Dementia/ Alzheimer’s can
significantly impact the
sleep cycle and trigger
declines in mental ability
“One of the unique challenges in researching sleep disturbance as a factor in
cognitive decline is: Once patients have developed AD, we do not know if
sleep disruption contributes to AD progression or if AD progression
contributes to sleep disruption.” (Mander BA. Disturbed sleep in preclinical cognitive impairment:
cause and effect? SLEEP 2013;36(9))
Sleep in dementia
 Almost ½ of all dementia patients have sleep disturbances
 Compared to older adults with normal cognition, adults with dementia
 Shorter sleep cycle with greater sleep fragmentation
 Less deep and REM sleep with reduced sleep efficiency
 More frequent nighttime awakening, wandering, and increased
daytime napping
 More difficulty falling asleep
(Feinburg et al., 1967: Moe et al., 1995; Prinz et al., 1982a, 1982b; Vitiello et al., 1990: Mortimore et al., 1992)
 Increased severity of dementia is associated with greater sleep
Sleep in dementia
 Sundowning: a state of confusion at the end of the day and into the
 Can cause a variety of behaviors, such as confusion, anxiety, aggression
or ignoring directions.
 Sundowning can also lead to pacing or wandering.
 Wandering and incontinence are the top two causes of
Institutionalization, because the family member has great difficultly
taking care of a patient who displays one characteristic or the other
(National Sleep Foundation)
Causes of sleep changes in Dementia
 The way that the brain controls sleep may be changed due to
the physical changes in the brain
 The person may have unmet needs or problems such as pain.
 It is also possible that their poor sleep may be linked to
breathing or other sleep related problems such as Obstructive
Sleep Apnea, Snoring or Periodic Limb Movements.
 Some medications may affect sleep (including pain relievers,
drugs to treat Dementia, Parkinson’s disease and
 To "get back to the basics" and describe nonpharmacologic Patient Centered Care interventions
and treatment strategies that caregivers can apply in
their facilities to improve QAPI and resident wellness
Presented by Melissa Napier, MS, BSN
Facility Readiness
 Staff Education
 Develop a “cross-pollinated team to evaluate issues
INCLUDING family and residents and caregivers to help
tailor person-centered care approach for EVERY resident
 Sleep disorders recognition and consequences
 Interventions to change the current “culture” of sleep
practices and routines in LTC facilities involve common sense.
 Environmental enhancements
 Individualized care planning
 Start with the sleep interview
 Interdisciplinary care management: TEAM effort!
Fayetteville, Arkansas SVH
Uninterrupted Sleep Program
Developed to promote person-centered
care and restorative sleep to all Veterans within
the Home. “Change will help restore dignity,
autonomy, privacy, choice, honor, trust and quality
of life to those we serve.” (Fayetteville Veterans
Home Policy)
Uninterrupted Sleep Program
 Sleep interview preferences incorporated into care
plan and re-evaluated as necessary
 Evaluate Incontinence
 For incontinence management, switched to
superabsorbent, longer wearing, brief/pull-on to
keep skin dry, improve skin integrity and
allow for longer periods of uninterrupted sleep
 Evaluate medical management where changes can
Sample Sleep Interview Questions
Do you have difficulties falling asleep or maintaining sleep?
Do you feel sleepy, tired or fatigued during the day?
What is your sleep schedule?
How many hours do you sleep at night?
How long does it take you to fall asleep
How many times do you wake up during a typical night?
Do you feel refreshed when you wake up?
Do you have loud snoring and do you stop breathing at night?
Are your legs restlessness, crawling or aching when trying to fall
 Do you repeatedly kick your legs during sleep?
 Do you act out your dreams?
Sleep in the Geriatric Patient Population p. 54 Table 1
Fayetteville: Standard of Care
 Keep lights to a minimum during checks.
 Use soft voices
 Decrease loud noises from any source i.e. promptly answer call lights
and alarms
 Don’t interrupt unless condition warrants.
Eliminate a “wake up list” altogether in an effort to support
the Veteran’s natural sleep pattern .
• AM medications: shift medication schedule for meds that can be
given anytime of day
• AM Blood Sugar: time based on individual needs
• Continental Breakfast: for early risers
• Eliminate universal, rigid morning routines
Fayetteville, Arkansas SVH
Uninterrupted Sleep Study
 Developed from observation of the following problems
 Anger and acting out issues
 Non-compliance with overall care and ADL’s
 Increase in negative psychiatric behaviors…leading to
 These behaviors caused an increase in:
 Anti-psychotic drug administration
 Transfers to acute care and psychiatric treatment facilities
 Negative side effects from the medications
Study Results: All related to
 Decrease in anti-psychotic med use
 Reduced admission rate to acute care and psychiatric facilities
 Decrease in anger issues
 Decrease in illness related to lack of sleep
 Increase in compliance with care including meals, ADL’s and
 Improvement in overall wellness of residents
(Jerry Poole, RN, Staff Development/Infection Prevention)
Fayetteville SVH Outcomes
 Longer periods of uninterrupted sleep.
 Staff have more time to do safety rounding during
the night and other meaningful and personal care.
 Staff/Veteran and family satisfaction.
 When asked if they have observed a change in
difficult behaviors……..
 To evaluate how treatment interventions for
disrupted sleep can drive QAPI (Quality Assurance
and Performance Improvement) outcomes for
facilities, and physical and cognitive wellness
outcomes in veterans.
Melissa Napier, MS, BSN
Quality Outcomes of Poor Sleep
 Patient dissatisfaction with sleep quality can significantly decrease overall
quality of life and perceived quality of residential care.
 Older, fatigued patients are more likely to:
 Have difficulty with ADL’s
 Experience confusion
 Be more challenging for caregivers
 Experience falls and injury
 Heal more slowly and have exacerbated acute and chronic illness
 Daytime sleepiness can also be dangerous. In a large study of older women
who self-reported the need for frequent napping during the day, poor sleep
was associated with a 30-40% increase in falls (Stone, et al. 2006).
Partnership to improve dementia care
 In 2012, CMS launched Partnership to Improve
Dementia Care in Nursing
 Partnership:
 Advancing Excellence in America’s Nursing Homes
 AHCA Quality Program and Quality Assurance
Performance Improvement (QAPI).
 Focus on person-centered care
 The reduction of unnecessary antipsychotic meds in
nursing homes and other care settings.
2012 QAPI Goal to Reduce
Antipsychotic Med Use
 (QAPI) standards from the Centers for Medicare and
Medicaid Services (CMS) to improve nursing home
 Part of CMS Partnership to Improve Dementia Care in
Nursing Homes.
 AHCA 2012 goal of 15% reduction in the off-label use of
antipsychotic drugs in skilled nursing centers
 Often used in patients with dementia that
become agitated or combative
 Sleep disturbance often a causative factor
QAPI 2012
 Ohio’s Long Term Care facilities,
for example, have decreased
the use of these medications
by 8.1% between 2011 and 2013
 Well on the way to the goal of a
15% reduction by March 2015.
 Increasing restful sleep can
reduce agitation and the need
for sedatives.
MDS and Sleep (MDS 3.0)
 Section D0200-A
 Trouble Falling or staying asleep or sleeping too much
 Section J0500-A
 How much of the time have you experienced pain or
hurting over the last day
 Section N0400-D
 Number of days during last 7 days that resident has
received hypnotic medication
Performance for facilities
and consumers
 State Veteran Home commitment to customer
service quality and a desire to improve
Consumer satisfaction
Meeting state survey standards
Participating in the Advancing Excellence in
America’s Nursing Homes Campaign.
Resident review compliance
Standard and Compliance Surveys
(Ohio LTC Quality Initiative
 Guidelines for the treatment of sleep disorders in LTC
and numerous available resources can help your facility
develop an effective program to improve veteran’s sleep.
 The relationship between sleep and aging is a bi-
directional one and is a hot topic of current research.
 Simple, non-pharmacologic interventions can help reset
circadian rhythms and optimize sleep efficiency.
 Improving sleep and establishing uninterrupted sleep
programs contribute to quality indicators AND resident
health and wellness.
Check the Back Table For:
Managing sleep disorders in the elderly
 The Nurse Practitioner
 By Judith Townsend-
Roccichelli, PhD, et al
 Excellent physiologic
overview of sleep disorders
with pharmacological and
Department of Veterans Affairs Evidence
Based synthesis program
 Published 2011 for VA
Veterans Health Admin.
Health Services R&D Service
 Practical, evidence-based
intervention programs to
improve behavioral outcomes
in the dementia population
Sleep and Dementia
 Published 2011
 A report on the evidence-base
for non-pharmacologic sleep
interventions for persons
with dementia
 Cary A. Brown, et. Al,
University of Alberta
Dementia and sleep
 Informative 2 page handout
for patients and caregivers
 Presented by the Sleep
Health Foundation
NIH Public Access Article
 Current Treatments for Sleep
Disturbances in Individuals
With Dementia (Deschenes,
C.L. MSN& McCurry, S. M., PhD
(Curr Psychiatry Rep.2009)
 Target audience is medical
professionals: evidence-based
 Society of the American
Medical Association for Post
Acute and Long Term Care
 Guidelines for the evaluation
and treatment of sleep
 $35 from website
Honoring our Veterans with
providing Excellent Care
Thank you!
To provide comments or ask further questions, please
contact us anytime……..
 Melissa Napier, MS, BSN
[email protected]
 Judy Borcherdt, RN, BSN
[email protected]

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