Jane was used to getting up at 6 a.m. daily to get ready for work. In order to get a good night’s sleep she was in bed by 10 p.m. She continued with this schedule until she retired. Upon retirement, she would go to bed and wake up at times that were convenient for her. However, she started having difficulty falling asleep at nights, and either slept late into the morning or felt sleepy during the day. She really wanted to have good sleep quality again.
After discussing the situation with her primary care provider, she was referred to cognitive behavioral therapy for insomnia. During the sessions, she was taught techniques that focused on monitoring her bedtime routine, having consistent bed and wake times, and sleep hygiene techniques. She was also encouraged to exercise daily. Over a period of three months, which included six visits, her sleep improved and at the end of that time, she reported better sleep quality, took a shorter time to fall asleep at the beginning of the night, and experienced significantly less daytime sleepiness.
Sleep is a period of inactivity and restoration of mental and physical function. A complete sleep cycle lasts between 70 to 120 minutes with between four to six cycles nightly. Each sleep cycle includes alternations between non-rapid eye movement (non-REM) and rapid eye movement (REM) sleep. Sleep has multiple functions. It serves to integrate new memories with existing knowledge and restore brain chemistry to a normal balance.
Cognitive impairment can result in day-night sleep pattern reversals, frequent nighttime awakenings, and increases in daytime sleepiness and napping.
Adults between ages 18 and 64 years should get an average of 7 to 9 hours of sleep each night, and the recommendation for adults older than age 65 is 7 to 8 hours nightly. However, more than a third of adults do not get at least 7 hours nightly and adults older than age 65 tend to have earlier bedtimes and wake times, longer times awake after sleep onset and more nightly awakenings than younger adults.
Factors Affecting Sleep
Sleep also changes with cognitive impairment due to multiple reasons including damage to the neuronal pathways that initiate and maintain sleep, changes in the circadian “pacemaker” located in the suprachiasmatic nucleus of the hypothalamus, and/or changes in the brainstem regions and pathways that regulate sleep-wake cycles. This results in day-night sleep pattern reversals, frequent nighttime awakenings, and increases in daytime sleepiness and napping.
When people living with cognitive impairment experience these sleep changes, it often impacts their care partners’ sleep. As a result, care partners report poor sleep quality, long duration to fall asleep and being awake nightly, multiple nightly awakenings and inconsistent sleep-wake times. These can in turn impact their psychological and physical health. Caregivers with poor sleep have reported greater burden, increased depression, and poorer cognitive function. Caregivers with poor sleep are also more likely to place persons living with dementia into residential care communities.
Other factors also affect sleep, including environmental, behavioral, demographic and medical. Environmental factors include temperature extremes, light, uncomfortable sleep surface or position, excess environmental noise; behavioral factors including caffeine, tobacco or alcohol use, irregular sleep schedules, napping, and shift work; and medical factors including certain types of medications, sleep disorders, and psychiatric conditions. Having experienced or experiencing major stressors (e.g., death of a loved one, divorce, major illness) also increase the risk for poor sleep.
Diagnosing Sleep Issues
To diagnose a sleep problem, healthcare providers will perform subjective and objective assessments. Subjectively, the provider will ask patients to complete a sleep history that asks for a description of one’s sleep pattern, sleep quality, daytime sleepiness, and daytime functioning. They may also ask patients about sleep hygiene practices (e.g., exercise before bed and caffeine intake), the sleep environment (e.g., noise, light) and general emotional and physical challenges. In addition, patients may complete sleep diaries or sleep specific questionnaires. Some providers may compare subjective diary reports with readings from devices worn on the wrist that measure motion.
‘Caregivers with poor sleep are also more likely to place persons living with dementia into residential care communities.’
Based on the subjective responses, a primary care provider may initially manage the sleep problem; however, most will refer the patients to a healthcare provider who specializes in sleep medicine. This provider may then order a polysomnography to further diagnose the sleep disorder. Polysomnography can be done at home or in a sleep laboratory. It involves electroencephalography, which measures electrical brain activity, electromyography, which records electrical activity from muscle movement, electrooculography, which records eye movements, electrocardiography, which measures heart rate and detects cardiac rhythm, pulse oximetry, which measures arterial oxygen saturation, and breathing movements.
Good Sleep Hygiene
Based on the assessments, a provider will then diagnose the sleep disorder. Once there’s a diagnosis, the provider may choose to manage it using medications, behavioral techniques and/or both. Regardless of the diagnosis, generally people can practice good sleep hygiene—maintaining a regular sleep schedule (including on weekends), practicing a relaxing bedtime ritual, which may include deep breathing, progressive muscle exercises and guided imagery, keeping the bedroom quiet, dark and at a cool, comfortable temperature, sleeping on a comfortable mattress and pillow, turning off electronics before going to bed, limiting caffeine intake after lunchtime, not eating a heavy meal or drinking alcohol within two hours of bedtime, and exercising regularly but not within two hours of bedtime.
The general recommendation for exercise is 150 minutes per week of moderate-intensity activity or 75 minutes weekly of vigorous-intensity activity in addition to two days per week of strength training activities. Anyone starting a new exercise routine or increasing the intensity of exercising should discuss these potential changes in activity with their healthcare provider and/or use an accredited professional to provide guidance regarding exercises based on ability.
As it pertains to medications used to treat sleep disorders, some may be cautioned for use in older adults due to their side effects and their increased risk for greater negative outcomes like falls. It is important to discuss potential side effects with the healthcare provider and how to identify and manage them. These medications also should be checked with medications the individual is taking to ensure they are not interacting with one another.
Sleep disturbances and disorders are prevalent in the population. To identify and manage them, it is critical to consult a healthcare provider who will diagnose and develop a collaborative plan of care for the specific sleep disorder. However, an individual can practice healthy sleep habits prior to diagnosis. After a diagnosis, following the prescribed plan of care after discussing potential medication side effects with the healthcare provider, for the best outcome.
Glenna S. Brewster Glasgow, PhD, RN, FNP-BC, is an assistant professor at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta, Ga.
