BACKGROUND/RATIONALE:
Sleep-activity rhythm disturbance is a prevalent, disabling symptom in cognitively-impaired (CI) elders. Their nocturnal sleep is light and inefficient with frequent awakenings. Multiple short daytime napping episodes interfere with daytime activity and functioning. Daytime disruptive behaviors, such as pacing, hitting, and cursing are related significantly to sleep-activity rhythm disturbance. Medical treatment for sleep and behavior disturbances with benzodiazepines or antipsychotic medications has proven minimally effective and has serious side effects such as impairments in cognition, memory, coordination, and balance, tolerance and severe rebound insomnia, and tardive dyskinesia.

OBJECTIVE(S):
The degree of daytime sleepiness in elders may reflect a reduction in the purposive physical, cognitive, and affective activities that previously sustained daytime alertness and promoted psychological well-being. For some institutionalized elders, living in a physically, cognitively, and emotionally understimulating setting may induce excessive napping during the day with a subsequent adverse impact on circadian sleep-wake patterns. Concrete, reality-based activities may counter napping by keeping residents with dementia involved in the world around them and helping them meet psychological, physical, and social needs. Our pilot study with five nursing home residents demonstrated that activities timed to occur during usual naptime and tailored to residents’ interests and their remaining abilities improved nocturnal sleep. Our other research has shown that engaging residents in meaningful activity improved their psychological well-being and decreased certain types of disruptive behaviors.

METHODS:
We tested the effect of an Individualized Activity Intervention timed to occur when the resident usually napped in the daytime on nocturnal sleep as measured by actigraphy in CI nursing home residents. Examples of individualized activities include objects for tactile and visual stimulation, arts and crafts, and games. We also tested the effect of the intervention on psychological well-being and disruptive behavior, and measured its cost. After the collection of baseline sleep, disruptive behavior, and psychological well-being data for five days, residents were randomly assigned to the Individualized Activity Intervention or to a usual care control condition for 21 days. On days 17-21, the research assistant repeated the outcome measures.

FINDINGS/RESULTS:
The final sample consisted of 139 residents from eight nursing homes. Mean percent nocturnal time asleep was 54.95 percent (sd = 20.96) while minutes of nighttime sleep ranged from 21 to 648 minutes (mean = 353.18 minutes). Over one third of the sample (N = 55) slept >7 hours at night, indicating that some residents sleep rather well in the nursing home. The project nursing assistants successfully engaged the residents in the Individualized Activity Intervention. When compared to the control group, daytime sleep significantly decreased (p = .001) in the experimental group, but there were no significant differences in nocturnal sleep. Because of the extended time participants were confined to bed (mean = 10.64 hours), the study inclusion criteria of <85 percent of the night asleep incorporated a number of residents who did not have disturbed sleep. Based on the assumption that the intervention was designed to improve nocturnal sleep in residents with sleep disturbance, we chose to analyze data from only those (n = 50) who slept 5½ or fewer hours at baseline. The results indicated that minutes of daytime sleep significantly decreased (p = .005) in the experimental group, while there was no change in the control group. There was a trend for minutes nighttime sleep to increase in the experimental group compared to the control group (p = .09). When compared to the control group, participants in the experimental group were awake less (p = .04), and fell asleep faster (p = .03).

IMPACT:
Sleep significantly improved in residents with disturbed sleep who received the Individualized Activity Intervention.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Richards KC, Beck C, Shue VM, O'Sullivan PS. Demographic and sleep characteristics in cognitively impaired nursing home residents with and without severe sleep/wake pattern inefficiency. Issues in Mental Health Nursing. 2005 Aug 1; 26(7):751-69. [view]
2. Kolanowski AM, Richards KC, Sullivan SC. Derivation of an intervention for need-driven behavior. Activity preferences of persons with dementia. Journal of gerontological nursing. 2002 Oct 1; 28(10):12-5. [view]
3. Richards KC, Lambert C, Beck CK. Deriving interventions for challenging behaviors from the need-driven dementia-compromised behavior model. Alzheimer's care today. 2000 Oct 15; 1(4):62-76. [view]
4. Richards KC, Beck C, O'Sullivan PS, Shue VM. Effect of individualized social activity on sleep in nursing home residents with dementia. Journal of the American Geriatrics Society. 2005 Sep 1; 53(9):1510-7. [view]
5. Richards KC, Sullivan SC, Phillips RL, Beck CK, Overton-McCoy AL. The effect of individualized activities on the sleep of nursing home residents who are cognitively impaired: a pilot study. Journal of gerontological nursing. 2001 Sep 1; 27(9):30-7. [view]

Conference Presentations

1. Richards KC, Beck CK, Davila D, Bliwise DL. Effect of individualized social activities on sleep in dementia. Paper presented at: Associated Professional Sleep Societies Annual Meeting (SLEEP); 2001 Jun 19; Chicago, IL. [view]
2. Richards KC, Beck CK. Social activities to engage nursing home residents. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2001 Nov 16; Chicago, IL. [view]

DRA: Aging, Older Veterans' Health and Care
DRE: Treatment - Observational
Keywords: Dementia, Long-term care, Nursing
MeSH Terms: Sleep Disorders, Nursing, Dementia, Health Services, Long-Term Care