No large-scale epidemiological studies have been conducted to examine the prevalence of primary sleep disorders in long-term care facilities. One could assume, however, that sleep disorders that increase in prevalence with advancing age are at least as common among patients in long-term care facilities as in older adults in community settings (e.g., sleep disordered breathing (SDB), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), REM sleep behavior disorder (RBD)). In addition, these sleep disorders are even more common among individuals with certain dementing illnesses than among older adults without dementia (see ). The absence of true prevalence information in the long-term care setting is, in part, due to the difficulty in conducting polysomnographic sleep recordings with long-term care residents, especially among individuals with dementia or extreme frailty.
Sleep disorders to consider in dementing illnesses.
Sleep disordered breathing (SDB) is a condition in which airflow during respiration is interrupted. This can occur because the airway collapses during sleep or because central nervous system signaling is impaired. These respiratory events can involve a complete cessation of airflow (apnea) or a partial reduction in airflow (hypopnea). Events are considered clinically significant when they last at least 10 seconds and occur 15 or more times per hour of sleep. This can lead to decreased oxygen saturation and interruption of nighttime sleep. Both of these can contribute to negative consequences such as increased risk for cardio- and cerebrovascular disease, cognitive difficulties, depression, and impaired performance. Depending upon the precise criteria used, ½ to ¾ of long-term care residents have at least mild SDB. In the long-term care setting, research shows that SDB has been associated with cognitive impairment, agitated behaviors and increased mortality risk.8,9
SDB is generally treated with continuous positive airway pressure (CPAP). This treatment is not curative; however, it is highly effective in reducing the number of respiratory events. CPAP involves wearing a mask over the nose, which is connected via a hose to a machine that generates positive air pressure. This pressure acts as a splint to hold the airway open. While CPAP has not been evaluated for use with long-term care residents, recent findings suggest that Alzheimer’s disease patients living at home with a caregiver have the same level of compliance with CPAP as general sleep disorders clinic patients.10
Anecdotally, we have observed some residents of nursing homes who used CPAP prior to institutionalization who choose to continue to use CPAP while in the nursing home. This suggests that CPAP should still be considered the treatment of choice among individuals in the long-term care setting who suffer from SDB, and residing in long-term care should not by itself preclude treatment of SDB.11
Restless legs syndrome (RLS) is a disorder in which an individual experiences an uncomfortable sensation in the legs while at rest. This discomfort, often difficult to describe, is relieved with movement of the legs. RLS symptoms often grow worse late in the day and can lead to difficulties falling asleep. RLS increases in prevalence with age, and individuals with RLS sometimes report that their symptoms grow worse as they get older. This condition has not been studied in long-term care; however, it may be a possible cause of motor restlessness and perhaps wandering among residents with RLS and dementia.
Periodic limb movement disorder (PLMD) is a related condition in which the legs jerk or kick during sleep. These movements can lead to fragmentation of nighttime sleep, which can contribute to daytime sleepiness. Treatments for both RLS and PLMD are pharmacological and typically involve the use of dopaminergic agents. There are two FDA approved agents for the treatment of RLS: ropinerole (Requip) and pramipexole (Mirapex). These agents have not been studied in the long-term care setting.
REM sleep behavior disorder (RBD) is a condition in which the central nervous system mechanisms that cause muscle paralysis during REM sleep cease to function properly and the sleeper “acts out” dreams. In the long-term care setting, this condition has not been studied; however, RBD is most common among older men and among individuals with certain dementing illnesses (see ). The main concern associated with RBD is patient safety. Individuals can fall out of bed or engage in dangerous behavior during the night as a result of acting out dream-related behaviors while asleep. The treatment of choice for RBD is clonazepam (Klonopin), which is effective in about 90% of patients. Treatment also involves securing the sleep environment to insure safety.
To date, no studies have systematically examined treatment of SDB, RLS, PLMD or RBD in long-term care residents, and the safety and efficacy of these treatment, particularly among residents with severe dementia is unknown. In general, treatment of primary sleep disorders in long-term care residents should closely parallel the treatment of frail older adults in the community. The risk/benefit ratio of each treatment should be considered. Key foci of treatment should be improvements in functional status, cognition and/or quality of life. Clearly, further research on the treatment of primary sleep disorders in long-term care is needed.