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IIR 04-321 – HSR&D Study

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IIR 04-321
Non-Pharmacological Interventions on Sleep in Post-Acute Rehabilitation
Cathy A Alessi MD
VA Greater Los Angeles Healthcare System, Sepulveda, CA
Sepulveda, CA
Funding Period: July 2006 - September 2010

BACKGROUND/RATIONALE:
The focus of post-acute rehabilitation among older adults is to restore physical functioning after an acute illness or injury. In a prospective cohort study (VA HSR&D IIR 01-053, PI: Alessi) to investigate sleep disturbance among older people undergoing post-acute rehabilitation, we found that sleep impairment (particularly excessive daytime sleeping) during the rehabilitation stay was associated with less functional recovery for up to six months follow-up. We also identified potentially modifiable environmental factors that may contribute to sleep disruption in the in-patient rehabilitation setting.

OBJECTIVE(S):
The purpose of this randomized controlled trial was to test whether a multicomponent, nonpharmacological intervention improves abnormal sleep/wake patterns, functional recovery, and quality of life in older adults undergoing inpatient post-acute rehabilitation. The long-term objective was to identify ways to improve care for older people undergoing post-acute rehabilitation in order to improve their well-being, function and quality of life.

METHODS:
The project was conducted on two VA post-acute rehabilitation wards. Older patients (>60 years), who were previously community-dwelling, were enrolled on admission to the post-acute rehabilitation ward. Eligible participants were randomized to receive the intervention, or a social attention/memory enhancement educational program as a control condition. The intervention combined: 1) environmental interventions (efforts to increase daytime bright light exposure, decrease daytime in-bed time, and provide a structured bedtime routine), and 2) elements of cognitive-behavioral strategies for insomnia treatment (combining aspects of stimulus control, sleep restriction, sleep hygiene, and cognitive therapy). Outcome data were collected at baseline, post-treatment (in the rehabilitation unit), and at three and six months post-discharge. The main outcome measures included sleep/wake patterns (sleep questionnaires and wrist actigraphy), functional status, and self-reported quality of life. Data were analyzed for all randomized participants in an intention-to-treat analysis.

FINDINGS/RESULTS:
219 participants were randomized (110 intervention; 109 controls). Randomized participants had a mean age of 72 years, 96% were male and 55% were non-Hispanic white. There were no significant time-by-treatment group interactions for the main outcome measures at any time points (i.e., baseline to post-treatment, or baseline to three and six months post-discharge). These findings suggest that the intervention was not effective in improving sleep quality, functional recovery or quality of life compared to the control condition. However, compared to controls, there was a significant decline in the percent of intervention participants who met diagnostic criteria for insomnia at 3-months follow-up.

IMPACT:
This multicomponent, nonpharmacological intervention which combined behavioral patient education and environmental strategies aimed at improving sleep was not adequate to improve sleep disturbance in these frail, older adults undergoing inpatient post-acute rehabilitation. The decrease in insomnia in the intervention group at 3-months follow-up suggests the intervention might be best suited for those with more significant sleep disturbance, but requires further study. Further work is needed to identify the most potent methods to improve sleep and important quality of life outcomes in this setting.

PUBLICATIONS:

Journal Articles

  1. Dzierzewski JM, Song Y, Fung CH, Rodriguez JC, Jouldjian S, Alessi CA, Breen EC, Irwin MR, Martin JL. Self-reported sleep duration mitigates the association between inflammation and cognitive functioning in hospitalized older men. Frontiers in psychology. 2015 Jul 21; 6:1004.
  2. Martin JL, Dzierzewski JM, Mitchell M, Fung CH, Jouldjian S, Alessi CA. Patterns of sleep quality during and after postacute rehabilitation in older adults: a latent class analysis approach. Journal of Sleep Research. 2013 Dec 1; 22(6):640-7.
  3. Martin JL, Jouldjian S, Mitchell MN, Josephson KR, Alessi CA. A longitudinal study of poor sleep after inpatient post-acute rehabilitation: the role of depression and pre-illness sleep quality. The American journal of geriatric psychiatry : official journal of the American Association for Geriatric Psychiatry. 2012 Jun 1; 20(6):477-84.
  4. Skibitsky M, Edelen MO, Martin JL, Harker J, Alessi C, Saliba D. Can standardized sleep questionnaires be used to identify excessive daytime sleeping in older post-acute rehabilitation patients? Journal of The American Medical Directors Association. 2012 Feb 1; 13(2):127-35.
Conference Presentations

  1. Alessi CA, Martin JL, Webber AP, Alam T, Josephson KR, Harker JO. Sleep disturbance and functional recovery among older people undergoing post-acute rehabilitation. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.
  2. Martin JL, Webber AP, Alam T, Josephson KR, Harker JO, Alessi CA. Daytime sleeping is associated with receiving less therapy among older rehabilitation therapy patients. Paper presented at: VA HSR&D National Meeting; 2006 Feb 1; Arlington, VA.


DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: none
Keywords: Complementary and Alternative Practices, Patient outcomes, Quality of life, Sleep disorders, Symptom Management
MeSH Terms: none

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