Strategies for improving residents' nighttime sleep: these researchers focused on methods that were common sense, but not commonplace. (Feature Article).

Research shows that the "rest home" is not, in fact, very restful. According to a National Institutes of Health consensus conference report, sleep disturbances affect more than 60% of long-term care residents. Recent studies have substantiated this report, concluding that while there is significant individual variability in sleep patterns among residents, sleep fragmentation is generally severe, with many residents awake for long periods at night and asleep for substantial parts of the day.

Several factors account for restless sleep among nursing home residents. Sleep-related respiratory disturbance, periodic leg movement, depression and circadian rhythm abnormalities are some of the medical conditions that are both prevalent among nursing home residents and known to adversely affect sleep. Behavioral factors potentially associated with poor nighttime sleep include low levels of daytime physical activity, excessive daytime napping and lengthy periods of time spent in bed.

In addition to medical and behavioral factors, environmental events can also disturb sleep in nursing homes. Nursing homes are 24-hour-day institutions, so even at night, doors slam, staff members converse, residents scream, carts creak and objects fall clattering to the floor. Resident care routines, particularly nighttime incontinence care activities, contribute to the problem.

Consider the results of a recent study we conducted in 10 nursing homes. Over two nights we measured sleep and bed mobility among 225 incontinent residents and monitored the environment to determine the association between noise, light and incontinence care practices and residents' sleep. We found that on average, 42% of waking episodes lasting four minutes or longer were associated with noise, light or incontinence care events. Twenty-two percent of the waking episodes were associated with noise alone, 10% with light or light plus noise and 10% with incontinence care routines. Seventy-six percent of all incontinence care practices resulted in awakenings.

With findings like these, we're not talking about an occasional poor night's sleep; these results suggest a chronic, ongoing problem. What happens when a person's sleep is disturbed night after night? It's no surprise: Chronic sleep disruption can cause anxiety, depression and other psychiatric complaints. It can also be associated with daytime sleepiness, agitation and other impairments in cognitive and physical functioning.

The good news is that relatively simple interventions can ameliorate environmental events that disturb sleep in the nursing home. Such interventions include individualizing nighttime incontinence care routines, implementing a noise abatement program and sensitizing staff to residents' sleep patterns, while educating them about the importance of uninterrupted sleep. In this article, we discuss methods for implementing each intervention. In considering them, however, take note: They're a package deal. In general, no single intervention in itself will yield significant results. A multifaceted approach is needed to enhance sleep in nursing homes.

Nighttime Incontinence Care Routines

Federal regulations require that nursing homes provide incontinence care around the clock to maintain residents' skin health and minimize the risk of pressure sore development. However, it is also consistent with federal regulations that this care be individualized, and we believe that this can be accomplished based at least partially on sleep patterns. Unfortunately, no matter how quiet and careful nursing staff are, it is nearly impossible to provide incontinence care without waking a sleeping resident. So our advice is, don't do it, unless it's absolutely necessary.

Here's our strategy: First, all incontinent residents should be assessed to determine their risk of developing skin problems. Perhaps the most complex aspect of the intervention, this step is absolutely critical to the success of the program. In assessing risk, nursing home staff should use objective data, such as the frequency of spontaneous body movements at night, as well as a subjective, clinical judgment of skin health to estimate a resident's need for repositioning and incontinence care. Based on the risk assessment, residents can be assigned to either a two-hour (high risk) or four-hour (low risk) incontinence care schedule.

To implement this schedule, incontinence rounds should be conducted hourly rather than every two hours (or every three or four hours, as happens in some facilities). Nurse aides should provide incontinence care only if the resident is observed to be awake during the hourly rounds. Residents assessed at low risk for skin problems should be allowed to sleep for as many as four consecutive hourly checks, but awakened on the fifth if asleep. Residents assessed at high risk for skin problems should be allowed to sleep for only two consecutive hourly checks and awakened on the third if asleep.

We tested this intervention with 92 residents in four nursing homes, coupling it with efforts to reduce noise and light intensity, and found that it significantly reduced awakenings caused by nighttime incontinence care. Moreover, there were no adverse changes in skin health or on most risk factors associated with skin health (e.g., exposure to moisture, body turns), although the long-term effects of the intervention still need to be evaluated.

The intervention also is no more labor-intensive to provide than usual care. Although nursing staff make more frequent incontinence care rounds as part of the intervention, each round takes less time to complete because not every incontinent resident receives care each time (i.e., whenever possible, sleeping residents are allowed to sleep through to the next round).

We strongly recommend this intervention as a means of reducing awakenings for nighttime incontinence care. For best results, however, it should be implemented in conjunction with a noise and light abatement program.

Noise and Light Abatement

Noise and light abatement programs can range from costly ventures involving major renovations to the physical facility to barebones interventions based primarily on common sense. While the former programs are likely to be more effective, we also believe they are less likely to be widely implemented because of their cost. For this reason, we present some practical noise and light abatement procedures that virtually every nursing home can implement easily.

To effectively reduce nighttime noise levels in nursing homes, you first need to identity the sources of such noises. In an analysis we conducted using data collected in four nursing homes, we found that 39% of changes in noise were staff initiated, with staff vocalizations (21%) being the most typical way staff made noise. The remaining 18% of "other" staff noises included door slams, noisy carts, objects being dropped and the like. Residents were the source of another 39% of recorded noises. Screaming was the most typical type of resident noise noted. We could not identify with certainty 22% of the noises recorded, although we suspect that the majority of these noises, most of which sounded like objects being dropped or hit together, were staff initiated.

In this study, we also identified changes in light intensity. Not surprisingly, most of these changes were associated with resident care activities, such as incontinence care. In other words, staff were turning on lights when providing care to residents.

Based on these findings, we developed the following common sense noise and light abatement procedures for nursing home staff:

* Fix squeaky carts and other equipment.

* Close doors to residents' rooms at night, if the residents sharing the room concur, both to significantly reduce bedside noise levels and to shut out ambient light from hallways.

* Ask residents who are watching television or listening to the radio to lower the volume at night, for example, after 9:00 p.m.

* Turn off radios and televisions no one is using.

* Do not use the intercom at night (e.g., after 9:00 p.m.) and speak in low tones of voice while in the hail or residents' rooms.

* Avoid turning on bright overhead lights. If possible, provide residents with small table lamps to use instead.

These procedures significantly reduced noise and light levels when we implemented them in a four-year study conducted in eight nursing homes. For example, among the four nursing homes to receive the intervention first, peak noises recorded above 50 decibels dropped from an average of 83 per night before the intervention to 58 per night during the intervention. Light changes were reduced from an average of four per night per resident to two per night.

Despite these reductions in noise and light, our intervention did not significantly improve sleep or reduce the percentage of awakenings associated with noise. Why didn't they? There are several possible explanations. Perhaps we didn't measure sleep with sufficient precision to detect intervention effects. Perhaps the fact that we did not control for medical factors limited the intervention's effectiveness. Perhaps our results would have been better had we addressed all behaviors associated with poor sleep, such as excessive daytime napping. And finally, perhaps, and indeed probably, our intervention did not reduce noise and light levels to low enough levels.

With this last explanation in mind, we are developing and plan to test cost-effective renovations to the physical environment that we hope will reduce noise and light to levels low enough to significantly improve sleep. In the meantime, we stand by the common sense noise and light abatement protocols we described above. They represent a practical starting point for nursing homes, and undoubtedly will be part of any new sleep interventions we test.

Staff Education

When we developed our noise and light abatement protocols, we anticipated that this practical approach to a complex problem would appeal to nursing home staff. It didn't. Instead it generated intense controversy among staff about whether and when residents' doors could be closed, televisions and radios could be turned off, and intercom use could be prohibited. So puzzled were we by this response that we surveyed staff in two of the participating facilities to assess their perceptions of the quality of sleep among residents. In general, they provided reasonable answers to our questions.

Ninety percent said that they believe nusrsing home residents sleep poorly. Eighty percent said that they believe noise contributes to sleep disturbances in nursing homes. About half said that both residents and staff contribute equally to disruptive noise in the nursing home, while 20% said that residents were the noisiest and 22% said that staff were.

In contrast to these responses is the behavior of nursing staff at night. In our sleep studies, for example, we found that incontinence care rounds were usually accompanied by increased light and noise; nursing staff generally talked in their normal conversational voices, pulled privacy curtains around beds and turned on room lights.

To encourage staff behavior that promotes rather than disrupts sleep among residents, we believe that an intensive staff training and feedback program must be part of any sleep intervention. This program should include an orientation to the intervention, with discussion about general issues concerning sleep. In particular, some commonly held but misguided assumptions about sleep in the nursing home should be addressed, for example, "Old people don't need much sleep" and, "Residents sleep a lot during the day, so they don't need as much sleep at night." Both these statements might hold true for many residents, but that's beside the point.

How so? Because the point of sleep interventions is to improve quality of sleep, not necessarily quantity of sleep (although that can be one aspect of quality). Patterns of sleep vary among individuals. One person might prefer eight hours of sleep while another is just fine with five hours. Some people awaken several times a night of their own accord; others routinely sleep through to morning. Recognizing this variability among individuals, an effective sleep intervention will try to minimize environmental events, especially noise and light changes, that can disrupt a resident's natural sleep pattern.

Another assumption that can undermine sleep interventions is that nighttime noise and light changes are acceptable in nursing homes. After all, one might argue, these facilities are health institutions, like hospitals, and anyone who has had a hospital stay knows how noisy they are at night. But nursing homes are not hospitals. Among their many differences, the average length of stay is considerably longer in the nursing home; indeed, for many long-stay residents, the nursing home is just what the name implies: home. For these residents, a noisy nighttime environment is not a short-term inconvenience resolved upon discharge; it's a chronic problem that can severely affect a person's mental and physical well-being.

Another problem that staff might need to address is their own need to stay awake at night. It's possible, even probable, that nighttime noise and light changes benefit staff working the graveyard shift, creating a more stimulating environment that helps workers stay awake. Nursing staff, thus, might speak in normal tones while changing incontinent residents in the wee hours because they desire stimulating conversational exchange. Discussing the possible conflicts between residents' need for sleep and staff's need to stay awake will help sensitize staff to their own behavior and pave the way for discussions about strategies for changing inappropriate behavior.

In addition to the orientation session, brief follow-up sessions should be held regularly--nightly, if possible--to reinforce the basic principles of the intervention and to present any feedback data that are being monitored as part of the intervention.

Summary

Even though sleep is an important quality-of-life consideration that can influence physical and mental well-being, the subject has been virtually ignored by most long-term care researchers and nursing home providers. The need for future research is no excuse, though, for present inaction. Our preliminary studies suggest that common sense interventions--including individualized nighttime care, noise and light abatement, and staff education--can improve the nighttime sleep environment for most nursing home residents. Together, they represent a good first step toward a good night's sleep.

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Anna N. Rahman, MSW, is senior writer, UCLA Multicampus Program in Geriatric Medicine and Gerontology. John F. Schnelle, PhD, is director, Borun Center for Gerontological Research, UCLA School of Medicine. For more information, call [phone].