Sleep disorders in the hospital

Sleep disorders are frequent and generally under-recognized in the hospital. Research has shown that patients tend to underestimate their total sleep time in hospitals, while nurses overestimate how long patients sleep.[33] Abnormalities in electroencephalogram patterns and plasma levels of melatonin have been observed among hospitalized patients. These alterations may occur during sepsis or inadequate light exposure, but the underlying mechanisms behind these observations are not completely understood.[34]

There are many potential factors leading to the increased prevalence of insomnia in hospitalized older adults. Acute pulmonary and cardiac diseases may interfere with the normal breathing cycle, generate dyspnea and cough, and lead to subsequent problems during sleep. Other symptoms that are also common in the hospital setting and may disrupt sleep are pain, delirium, and anxiety. Hospital-related environmental factors that interrupt sleep are noise, light, an unfamiliar bed, administration of medications, and the measurement of vital signs during the night. These disruptors are much more frequent in intensive care units.

The overall prevalence of sleep apnea in the hospital setting is unknown; however, in specific populations such as stroke patients it is as high as 60%.[35] Adverse outcomes are more frequent in patients with sleep apnea and include intra- and postoperative complications, prolonged length of stay, and possibly increased mortality.[36, 37] Screening questionnaires can be used to assess the risk of undiagnosed sleep apnea in hospitalized patients. Some recommendations for patients at risk are to reduce the doses of neuromuscular blockers, avoid opioids, assume a semi-upright sleeping position in bed, peripheral oxygen monitoring, oxygen supplementation, and the use of PAP therapy. Empirical evidence to support these strategies is limited. Those patients who have been previously prescribed PAP therapy should use it during the hospital stay.

Sleep disorders in the nursing home

Sleep disorders are more frequent in nursing home residents than in community-dwelling older people. Sleep/wake patterns are altered in most residents. A typical sleep presentation includes several episodes of napping during the day, coupled with fragmented sleep at night. Factors associated with these findings are older age and presence of medical and psychiatric diseases. Institutionalized older people present with a high prevalence of comorbidities and geriatric syndromes, such as frailty, depression, heart failure, urinary incontinence, and dementia. As in the hospital, environmental factors (e.g., lack of exposure to sunlight and physical activity, increased amount of time spent in bed during the day, and the use of medications with effects on the central nervous system) also contribute to the occurrence of sleep disorders. Some of the negative consequences ascribed to sleep disorders in this population are poorer self-rated quality of life, reduced involvement in social activities, and increased mortality.[38, 39]

A multidimensional intervention should be considered to treat sleep disorders in nursing homes. Nonpharmacological measures such as increased light exposure (e.g., bright light boxes) and physical activity participation may have modest benefit. Nighttime reductions in noise and light should be attempted. Adherence of nursing home staff to these recommendations can prove difficult. Cognitive behavioral strategies have been demonstrated to improve the subjective sleep quality of older adults in nursing homes.[40] Sedative hypnotic medications may have a small benefit in improving sleep of residents, but considering the side effects, risks, and complex metabolism of these drugs in frail older adults, they should be avoided if possible.[41]

Sleep disorders and dementia

Sleep disorders are frequent and have a great impact on patients with dementia. Sleep disorders are associated with loss of function, cognitive impairment, and an increased burden in caregivers.[42] Disturbed sleep is a frequently cited reason for institutionalization.

Sundowning is a particularly salient sleep-related disturbance in older adults with dementia. Sundowning is an altered behavioral state (e.g., delirium, anxiety, agitation, wandering) of a patient with dementia, in which the symptoms are characteristically more intense during the evening and at night. Biological and environmental factors have been suggested to explain this phenomenon. Conversely, some authors have proposed that sundowning is the result of more exhausted caregivers’ perceptions at the end of the day.[42]

In a patient with dementia, a comprehensive evaluation of not only the patient but also the environment should be performed to identify the potential causes of the sleep disorder. Special attention is necessary regarding the use of caffeine, alcohol, or any medication that may interfere with sleep. Common clinical findings in healthy older adults could be subtle or absent in patients with dementia. For example, delirium could be the only clinical manifestation of sleep apnea in dementia patients and should trigger further evaluation in patients with risk factors mentioned above. Pain and mood disorders could also be precipitating factors of the sleep disorder and may be more difficult to evaluate in patients with cognitive impairment.

Identifying and treating the underlying causal factors of the sleep disorder in conjunction with sleep-focused interventions could be effective in improving sleep patterns in older adults with dementia. Light exposure, physical exercise, stimulus control, sleep restriction, and behavioral activation/social activities should always be considered as first-line therapy. A recent meta-analysis of sleep medications for patients with Alzheimer’s disease reported that trazodone in low doses (50 mg) improves total nocturnal sleep time and sleep efficiency, whereas there was no benefit for melatonin or ramelteon. There is a lack of evidence for use of most sedative hypnotic drugs in patients with Alzheimer’s disease (e.g., benzodiazepines, nonbenzodiazepines hypnotics, other antidepressants, and antipsychotics agents).[43] Given the increased risk of falls and cognitive decline with benzodiazepines and increased mortality with antipsychotics agents in patients with dementia, a thoughtful risk/benefit evaluation should be performed and discussed with the patient and caregivers before considering these drugs.