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Facilitating Better Sleep — and How It Might Prevent Cognitive Decline

      Nonpharmacological approaches to insomnia require a high-priority, team approach in which staff and family are respectful of sleep and can help validate and facilitate sleep hygiene practices and environmental needs, long-term care providers told Caring for the Ages.
      “You can make a lot more headway if everyone around the individual is involved and is reminding them and validating some of the nonpharmacological interventions,” whether it’s the potential efficacy of a mild tea with calming herbs like valerian root and chamomile or the importance of turning off the TV earlier and adopting other nonstimulating bedtime routines, said Travis Neill, PA-C, MMS, who practices with Rocky Mountain Senior Care and serves as an assistant medical director for nursing homes in the Denver, CO, area.
      Mr. Neill believes sleep is an area in which he and his colleagues can make a significant difference for the health of long-term care residents — more so than nutrition and, to a large extent, exercise — and he has learned and practiced purposefully by reading articles, listening to podcasts, and working with residents and team members. He wrote a handout on sleep that he shares with residents, family members, and staff.
      He encourages staff to embrace residents’ naps but to help them limit the time spent napping, preferably to an hour a day. He also urges attention to more activity during the day, less lighting and noise in the evening and nighttime, and the identification of individual sleep-challenging patterns. For patients with dementia, “I do think it helps to walk with them more,” he notes. “Their body will naturally get more tired.”
      Insomnia describes difficulty falling or staying asleep at night despite adequate opportunity. Insomnia disorder is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (American Psychiatric Association, 2013) to describe a chronic condition with certain criteria that must be met, including an impact on daytime functioning. But identifying insomnia symptoms themselves should trigger further assessment, said Adam Spira, PhD, a sleep researcher and professor in the department of mental health at the Johns Hopkins Bloomberg School of Public Health.
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      Respect for sleep is vital in PALTC. Photo by Annie Spratt on Unsplash.

      How to Facilitate Sleep

      Bright light exposure early in the daytime “is probably one of the most important environmental cues for synchronizing our sleep-wake cycle and many physiological processes with cycles of light and dark. But it’s just as important to have a dark environment for sleeping,” said Dr. Spira, noting that the extent to which darkness can increase fall risk also needs to be considered.
      Hallway lights in skilled nursing facilities should be turned down at night, and both the time needed to wind down for sleep and the time for sleeping should be protected, said Ariel Cole, MD, FAAFP, CMD, director of the geriatrics fellowship program at AdventHealth Orlando in Florida, who also has a special interest in sleep.
      “Tasks [at some facilities] can get pushed to the night staff that don’t need to [be done] for any medical reason, like bathing and trimming fingernails,” she said. “And there’s still a routine among some nurses of treating the nursing home like a hospital and waking up residents for medications and vitals checks. This should be an exception ... there should be some flexibility on [every eight hours] orders, for instance.”
      Given the typical high staff turnover, “you have to have the conversation [with staff] again and again,” said Dr. Cole, who is also medical director for two nursing homes in Winter Park, FL, The Mayflower and The Gardens at DePugh. “We have to emphasize being respectful of sleep.”
      Regarding napping, she said, “residents are often bored. That’s a big motivator to sleep [during the day]. As facilities get back to more group activities and socialization, we need to ask, how do we entice this person to be active and engaged today?”
      Leading into sleep, mindful breathing and positive thinking, cooler temperatures, a light snack if hungry, and soothing music can be helpful, said Mr. Neill. For some people, so can white noise.
      Mr. Neill began advising the use of a small cup of calming tea after he observed the practice at a Green House home and saw some effect in his own patients. A partial placebo effect is “very powerful in my opinion when it comes to sleep,” he noted. “If we can get a few people who regularly interact with the resident to back up the value of our nonpharmacological interventions, they’ll work better.”
      For optimal sleep, whether one has insomnia or not, Mr. Neill often advises residents and their caregivers to avoid drinking fluids past 5:00 p.m. (except for a small cup of calming tea) to prevent getting up at night to urinate. “If you increase the amount of fluids you drink during the day [from about 1:00 to 5:00], you’ll urinate more in the hours right before bedtime, and you’ll still stay hydrated,” he said. “It is like you are training your bladder to urinate when it is full and while you are awake instead of when you are sleeping,” Mr. Neill wrote in his handout.
      Interventions for insomnia should come after a careful assessment of sleep habits and experiences and the possible effects of medical conditions and medications. “Let’s take a step back and ask, Are they in pain? Is heart failure [impacting their ability to] breathe well when they lay down?” Dr. Cole said.
      The value of probing a resident’s expectations for sleep is “underappreciated” in long-term care and geriatrics more broadly, Mr. Neill noted. “Some people think they should be sleeping for eight to nine hours at a stretch,” he said. “If they take a nap and sleep for six hours a night, I’ll say, ‘That’s good.’”

      Can Better Sleep Slow Cognitive Decline, Prevent Alzheimer’s Agitation?

      Indeed, with aging — and even more so with dementia — sleep duration shortens, and sleep becomes lighter and more fragmented. Less time is spent in slow-wave sleep — the deepest stage of sleep, which is believed to be the most important phase for memory formation and the restoration of body and mind, Dr. Spira said.
      Research suggests slow-wave sleep also protects against the aggregation of amyloid beta protein, a component of plaques in Alzheimer’s disease, by preventing buildup and/or by promoting clearance, he said. As a researcher, Dr. Spira thinks often about whether promoting better sleep and stable circadian rhythms in people who already have significant cognitive problems can help slow further decline.
      With Johns Hopkins colleagues Paul Rosenberg, MD, and Mark Wu, MD, PhD, Dr. Spira is currently studying the role of circadian rhythms and sleep disturbance in the promotion of agitation in Alzheimer’s disease. “We are investigating the possibility of a casual role,” Dr. Spira told Caring.
      Johns Hopkins investigators are also studying whether improving sleep with trazadone leads to better cognition and function in people with mild cognitive impairment and sleep complaints, and whether the treatment positively impacts hippocampal activation on functional magnetic resonance imaging measures. “Trazadone seems to promote slow-wave sleep,” is not habit forming, and “does not have as bad a side-effect profile, presumably, as other sedating medications,” Dr. Spira said.
      Overall, Dr. Spira and others emphasize that nonpharmacological interventions for insomnia should take precedence over medications. “One of the issues that has really come to the fore is that the medications used to treat insomnia are really problematic in [the nursing home] population,” he said.
      Christine Kilgore is a freelance writer based in Falls Church, VA.

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      In this episode, Dr. Karl Steinberg and Dr. Elizabeth Galik discuss our January-February issue, including the use of alcohol in long-term care communities, misconceptions about nurse practitioners and physician assistants in long-term care, dental hygiene in older adults, and how facilitating better sleep might help prevent cognitive decline.

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