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Nonpharmacologic Steps to Improve Sleep in Older Adults

Am Fam Physician. 1998 Nov 15;58(8):1842-1843.

Elderly persons are susceptible to sleep disturbances during hospitalization because of age-related changes in sleep patterns, environmental disruptions, pain and anxiety. Sedative-hypnotic medications commonly used to treat these sleep problems are associated with adverse effects such as delirium, falls and respiratory depression. McDowell and colleagues conducted this prospective study to determine whether a nonpharmacologic approach to treating sleep disturbances in elderly hospitalized patients is feasible and effective.

Patients who were at least 70 years old were included in the study if they spoke English and either requested a sleep medication or complained of difficulty in getting to sleep on at least one night during hospitalization.

The hospital nursing staff received education about the nonpharmacologic sleep protocol (see the accompanying table). If the patient refused the protocol or was still awake one hour after an intervention, the usual care was offered, including a sedative-hypnotic (defined as any benzodiazepine, minor tranquilizer or sedative antihistamine), if ordered. General sleep hygiene measures (such as avoiding caffeine in the evening) were followed. Quality of sleep was assessed by daily patient interview. Patients were asked to rate their overall sleep of the night before as “poor,” “fair” or “good.” Records were reviewed to determine the number of patients receiving sedative hypnotic medications and the level of adherence to the sleep protocol.

Nonpharmacologic Sleep Protocol*

Part 1. Back rub: a five-minute back massage consisting of slow, rhythmic stroking on both sides of the spinous processes from the crown of the head to the sacral area, with patient in side-lying position.

Part 2. Warm drink: patient's choice of herbal tea or milk.

Part 3. Relaxation tapes: classical music or nature sounds played on either a headset or bedside cassette tape player.


*—Nurse allows one hour to assess for effectiveness. If, ineffective, proceed to usual care.

Reprinted with permission from McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc 1998;46:701.

Nonpharmacologic Sleep Protocol*

View Table

Nonpharmacologic Sleep Protocol*

Part 1. Back rub: a five-minute back massage consisting of slow, rhythmic stroking on both sides of the spinous processes from the crown of the head to the sacral area, with patient in side-lying position.

Part 2. Warm drink: patient's choice of herbal tea or milk.

Part 3. Relaxation tapes: classical music or nature sounds played on either a headset or bedside cassette tape player.


*—Nurse allows one hour to assess for effectiveness. If, ineffective, proceed to usual care.

Reprinted with permission from McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc 1998;46:701.

A total of 111 patients were enrolled in the study. The sleep protocol was used for a total of 539 patient-days. At least one part of the nonpharmacologic sleep protocol was adhered to 74 percent of the time. The back-rub portion of the protocol had the highest adherence rate at 52 percent, with warm drink adherence at 49 percent and use of relaxation tapes at 36 percent. Patients were most likely to refuse the relaxation tapes (48 percent) and least likely to refuse the back rub (30 percent). The quality of sleep improved as the number of portions of the sleep protocol increased. One half of the patients reported “good” sleep when they received all three portions of the protocol versus about one quarter who reported “good” sleep when they received only one or two parts of the protocol. There was a significant reduction in the number of sedative hypnotic medications used after the non-pharmacologic protocol was put into place, compared with pre-protocol use of these medications (31 percent of patients received medications at least once during the study period compared with 54 percent of patients during the pre-study period).

The authors conclude that the use of simple nonpharmacologic interventions (specifically, back rub, warm drink and relaxation tapes) can improve sleep and reduce the use of sedative-hypnotic drugs in hospitalized elderly patients.

McDowell JA, et al. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. June 1998;46:700–5.


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