Healthcare and Medicine Reference
nocturnal incontinence, falls, agitation, and wandering,
can benefit patients and their caregivers. Appropriate and
judicious pharmacologic implementation, albeit still
limited by lack of trials of newer sedative-hypnotic medica-
tions, may be warranted in some cases. Treatments for
sleep apnea should also be considered; poor adherence
should never be assumed, especially in the presence of an
engaged spouse or caregiver. Furthermore, introduction of
knowledge at the institutional or staffing level regarding
not only specific sleep disorders (sleep apnea, RLS) but
also basic sleep hygiene and principles of nonpharmaco-
logic management of inadequate nocturnal sleep, can
enhance health and quality of life. Rudimentary under-
standings of basic principles of chronobiology should also
be sought. The sleep and well-being of the institutional-
ized dementia patient should not be considered beyond the
range of care of the sleep medicine specialist.
8. Cohen-Mansfield J. Temporal patterns of agitation in dementia. Am
J Geriatr Psychiatry 2007;15:395-405.
9. McCann JJ, Gilley DW, Bienias JL, et al. Temporal patterns of
negative and positive behavior among nursing home residents with
Alzheimer's disease. Psychol Aging 2004;19:336-345.
10. Seiler WO, Stahelin HB. Pressure ulcers. In: Evans JG, Williams
TF, Beattie BL, et al. Oxford textbook of geriatric medicine. 2nd
ed. Oxford UK: Oxford University Press; 2000. p 103-111.
11. Schnelle JF, Ouslander JG, Simmons SF, et al. Nighttime sleep and
bed mobility among incontinent nursing home residents. J Am
Geriatr Soc 1993;41:903-909.
12. Bliwise DL. Dementia. In: Kryger MH, Roth T, Dement WC,
editors. Principles and practice of sleep medicine. 3rd ed. Philadel-
phia: Saunders; 2000. p. 1058-1071.
13. Rao V, Spiro JR, Samus QM, et al. Insomnia and daytime sleepiness
in people with dementia residing in assisted living: findings from
the Maryland Assisted Living Study. Int J Geriatr Psychiatry
14. Martin JL, Webber AP, Alam T, et al. Daytime sleeping, sleep
disturbance, and circadian rhythms in the nursing home. Am J
Geriatr Psychiatry 2006;14:121-129.
15. Carvalho-Bos SS, Riemersma-van der Lek RF, Waterhouse J, et al.
Strong association of the rest-activity with well-being in demented
elderly women. Am J Geriatr Psychiatry 2007;15:92-100.
16. Lee JH, Bliwise DL, Ansari FP, et al. Daytime sleepiness and func-
tional impairment in Alzheimer's disease. Am J Geriatr Psychiatry
17. Endeshaw YW, Ouslander JG, Schnelle JF, et al. Polysomnographic
and clinical correlates of behaviorally observed daytime sleep in
nursing home residents. J Gerontol Med Sci 2007;62A:55-61.
18. Fetveit A, Bjorvatn B. Sleep duration during the 24-hour day is
associated with the severity of dementia in nursing home patients.
Int J Geriatr Psychiatry 2006;21:945-950.
19. Bliwise DL. Sleep and circadian rhythm disorders in aging and
dementia. In: Turek FW, Zee PC, editors. Regulation of sleep and
circadian rhythms. New York: Marcel Dekker; 1999. p. 487-525.
20. Fick DM, Cooper JW, Wade WE, et al. Updating the Beers criteria
for potentially inappropriate medication use in older adults. Arch
Intern Med 2003;163:2716-2724.
21. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other
adverse effects of diphenhydramine use in hospitalized older
patients. Arch Inter Med 2001;161:2091-2097.
22. Hshieh TT, Fong TG, Marcantonio ER, Inouye SK. Cholinergic
deficiency hypothesis in delirium: a synthesis of current evidence.
J Gerontol Med Sci 2008;63A:764-772.
23. Hosia-Randell HM, Muurinen SM, Pitkala KH. Exposure to poten-
tially inappropriate drugs and drug-drug interactions in elderly
nursing home residents in Helsinki, Finland: a cross-sectional study.
Drugs Aging 2008;25:683-692.
24. Glass J, Lanctot KL, Herrmann N, et al. Sedative hypnotics in older
people with insomnia: meta-analysis of risks and benefits. BMJ
25. Greco KE, Deaton C, Kutner M, et al. Psychoactive medications
and actigraphically scored sleep quality in frail nursing home
patients. J Am Med Dir Assoc 2004;5:223-227.
26. Rao V, Spiro JR, Samus QM, et al. Sleep disturbances in the elderly
residing in assisted living: findings from the Maryland Assisted
Living Study. Int J Geriatr Psychiatry 2005;20:956-966.
27. Avidan AY, Bries BE, James ML, et al. Insomnia and hypnotic use,
recorded in the Minimum Data Set as predictors of falls and hip
fractures in Michigan nursing homes. J Am Geriatr Soc 2005;53:
28. Wang PS, Bohn RL, Glynn RJ, et al. Zolpidem use and hip fractures
in older people. J Am Geriatr Soc 2001;49:1685-1690.
29. Schneeweiss S, Wang PS. Claims data studies of sedative-hypnotics
and hip fractures in older people: exploring residual confounding
using survey information. J Am Geriatr Soc 2005;53:948-954.
30. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among
elderly persons living in the community. N Engl J Med 1988;319:
31. Thapa PB, Gideon P, Fought RL, et al. Psychotropic drugs and the
risk of recurrent falls in ambulatory nursing home residents. Am J
32. Ensrud KE, Blackwell T, Mangione CM, et al. Central nervous
system active medications and risk fractures in older women. Arch
Intern Med 2003;163:949-957.
Patients residing in nursing homes can present with
many significant sleep-related problems that affect
the quality of life of those patients and those who
care for them. These issues should not be considered
beyond the range of care of the sleep medicine spe-
cialist. Consultative advice regarding appropriate
medication use, including drug interactions, may be
significant when issues arise involving falls, noctur-
nal agitation and wandering, and daytime sleepiness.
Sleep apnea and its treatment should not be consid-
ered beyond the realm of possibility for the nursing
home patient as long as expectations are clear and
warranted. The inevitable aging of the population
raises the likelihood that many sleep medicine spe-
cialists will be asked to provide input regarding sleep
in such patients.
The writing of this chapter is supported by the following
grants: NS-050595, AG-020269, and AG-025688.
1. Bliwise DL, Breus MJ. Insomnia in dementia and in residential care.
In: Lichstein K, Morin CM, editors. Treatment of late-life insom-
nia. Thousand Oaks, Calif: Sage Publications; 2000. p. 321-344.
2. Schnelle JF, Cruise PA, Alessi CA, et al. Sleep hygiene in physically
dependent nursing home residents: behavioral and environmental
implications. Sleep 1998;21:515-523.
3. Bates-Jensen BM, Schnelle JF, Alessi CA, et al. The effects of staff-
ing on in-bed times of nursing home residents. J Am Geriatr Soc
4. Cadogan MP, Edelen MO, Lorenz KA, et al. The relationship of
reported pain severity to perceived effect on function of nursing
home residents. J Gerontol Med Sci 2008;63A:969-973.
5. Sloane PD, Mitchell CM, Preisser JS, et al. Environmental corre-
lates of resident agitation in Alzheimer's disease special care units.
J Am Geriatr Soc 1998;46:862-869.
6. Cohen-Mansfield J, Werner, P, Freedman L. Sleep and agitation in
agitated nursing home residents: an observational study. Sleep
7. McCurry SM, Logsdon RG, Teri L, et al. Characteristics of sleep
disturbance in community-dwelling Alzheimer's disease patients.
J Geriatr Psychiatry Neurol 1999;12:53-59.