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Am Fam Physician. 2000;61(1):200

Sleep impairment among nursing home residents is highly common. A variety of factors contribute to sleep impairment in these settings, including nursing care practices, environmental noise and spending large amounts of time sleeping during the day. Disturbed sleep may then lead to problems during the day, such as increased agitation. Alessi and colleagues conducted a randomized trial to determine if nighttime sleep could be improved with a program of increased physical activity, decreased nighttime noise and decreased activity on the part of the nursing staff.

Nursing home patients with urinary incontinence were included in the study if they did not demonstrate severe physical aggression, were not comatose and had a life expectancy of at least three months. Residents were randomized to receive daytime physical activity plus the nighttime environmental program (intervention group) or only the nighttime environmental changes (control group). The physical activity intervention included up to four sessions per day, five days per week, of structured arm and leg exercises. After 14 weeks on this exercise program, the nighttime intervention was added for five days. The nighttime intervention reduced light, noise and nursing practices (such as incontinence care) that interfered with sleep. Staff kept patients' room doors closed when possible, turned off televisions that were not in use and timed incontinence care to occur when residents were awake when possible.

During hourly rounds, the patient was assessed as being asleep or awake. If asleep, the patient was not toileted or changed. If awake, the staff offered to change or toilet the patient. If a patient was asleep on four successive hourly rounds, he or she was awakened and toileted or changed. Outcomes measured included duration of nighttime sleep as measured by wrist actigraphy, daytime behavioral assessment and level of agitation. Nighttime noise and light levels were also measured at baseline and after the study. There was a significant decrease in light and noise in the nighttime program.

There were 15 patients in the intervention group and 14 patients in the control group. There were no significant differences among the groups at baseline. The intervention group had a significantly increased percentage of sleep compared with the control group. In the intervention group, maximum duration and average duration of sleep increased by 39 and 45 percent, respectively, although these figures were not statistically significant. Of the intervention group patients who had agitated behaviors at baseline, 47 percent no longer had such behaviors at follow-up. In the control group, 64 percent of patients had an increase in agitation after the study.

The authors conclude that simple interventions can improve nighttime sleep and subsequently decrease daytime agitation. Specifically, increasing physical activity and decreasing the intrusiveness of the nursing home environment at night can improve those factors in nursing home residents who are incontinent.

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