Sleep Disorders in State Vet Homes How Interventions Drive Quality and Optimize Resident Wellness

1. Sleep Disorders in State Vet HomesHow Interventions Drive Quality and Optimize Resident Wellness Melissa Napier, MS, BSN Judy Borcherdt, BSN, RN, CWCMS NASVH Charleston, SC July 29th, 2014

2. So…Why are we here?? To learn the SIMPLE tools necessary for your State Veteran Home to develop a program for better sleep to improve your veteran’s lives.

3. Objectives • Understand current Clinical Practice Guidelines and Standards of Care for the evaluation, treatment, intervention and documentation of sleep disorders in LTC settings. • Describe restful sleep physiology and the pathophysiology related to sleep deprivation on acute and chronic disease states, cognitive function and quality of life measures • Describe non-pharmacologic treatment strategies and their positive effects on Patient Centered Care and caregiver and resident satisfaction • Evaluate how treatment interventions for disrupted sleep can drive quality outcomes for facilities; and physical, cognitive, and wellness outcomes for residents

4. Introduction • Most sleep disorders in the Long Term Care setting are secondary to medical conditions or environmental issues. • We will NOT be discussing primary sleep disorders including obstructive sleep apnea, restless-leg-syndrome or periodic limb movement but will discuss when to refer for evaluation.

5. Objective • Understand current Clinical Practice Guidelines and Standards of Care for the evaluation, treatment, intervention and documentation of sleep disorders in LTC settings. Presented by Melissa Napier, MS. BSN.

6. National Guidelines • AMDA The Society for Post-Acute and Long-Term Care Medicine, affiliated with the American Medical Association and the American Society of Internal Medicine. • Last updated 2005 • Available from www.adma.com

7. Sleep Disorders Definition Difficulty in maintaining wakefulness during the day OR abnormal behavior associated with sleep all of which are subjectively or objectively distressing or harmful to the patient or the patient’s roommate or sleep partner. Most sleep disorders in LTC are secondary to chronic disease states or environmental factors and will be the focus of this presentation.

8. Classifications: Dyssomnias • Insomnia: • Difficulty falling or staying asleep or early awakening • Non-restorative sleep resulting in impaired function: cognitive, physical or social • Often result of mood disorders or health issue • Obstructive sleep apnea, restless leg syndrome, periodic limb movements • Hypersomnia: • Increased sleepiness, usually during the day that causes impairment of function • Primary hypersomnia is rare in this population

9. Classifications • Parasomnias • Disorders characterized by abnormal sleep-related behaviors including:nightmares, sleep-terrors, sleepwalking • Circadian Rhythm Sleep Disorders • Twilight Psychosis or “Sundowning” is NOT a sleep disorder but still requires identification and intervention

10. Risk Factors: A Brief Overview • Dementia, elderly • Depression, bipolar disorder, other mental illnesses • Inadequate • Exposure to sunlight • Family or social support • Physical activity • Multiple comorbidities especially COPD, CHF, arthritis • Neurological disease • New admit to LTC facility • Medications

11. Signs and Symptoms that could indicate a sleep disorder • Nighttime Signs and Symptoms • Noticeable snoring • Apneic episodes and “arousal snort” • Frequent awakenings • Periodic, jerking limb movements • Talking during sleep • Wandering Fun word of the day: somniloquy = sleep talking

12. Signs and Symptoms……. • Daytime signs and symptoms • Abnormal behavior in dementia patients such as agitation, hostility, combativeness • Complaints by roommate • Early morning confusion, agitation, headache • Falls, accidents, functional decline • Impaired cognition • Uncontrolled hypertension • Decreased participation, food and fluid intake

13. Sleep problems in LTC settings • VERY Common • More time in bed-AWAKE: less time in REM sleep with increased fragmentation • Comorbidities and/or medications can increase sensitivity to environmental distractions • Increased interruptions, especially through the night • Increased risk for falling ( self toileting?) • Elevated mortality risk

14. Evaluation, Assessment • Obtain sleep history through the interview process, utilize a sleep log • Determine the characteristics of sleep including routines, quality, history that could indicate issues • Rule out external factors like diet, caffeine, exercise, stress • Assess impact and physical evaluation • Sleep observation • Review relevant medical conditions • If a primary sleep disorder is suspected: REFER

15. Treatment of Sleep Disorders • IMPLEMENT non-pharmacologic interventions first • Reconsider the need for medications that may be interfering with sleep……….INITIATE facility wide sleep program!! • Treat the medical conditions that may be an underlying cause • MONITORinterventions and re-evaluate as necessary • DOCUMENT per quality and survey standards

16. When to refer to a specialist: • When Obstructive Sleep Apnea is suspected • Daytime Symptoms • Frequent accidents • Morning headaches • Excessive sleepiness • Restless leg syndrome • Periodic limb movements Use clinical judgment and observation to determine if diagnostic testing by a specialist is warranted.

17. Objective To describe the physiology of restful sleep and the pathophysiology related to sleep deprivation on acute and chronic disease states, cognitive function and quality of life measures. Presented by: Judy Borcherdt, BSN, RN, CWCMS

18. Sleep defined… • The natural state of rest during which your eyes are closed and you become unconscious. (Merriam Dictionary) • Sleep is a state that creates a heightened anabolic state, accentuating growth and rejuvenation of all physiologic systems. It is observed in all species of living creatures. • A uniform block of time when we’re not awake

19. Sleep Defined… wonderful! Like a baby

20. …never enough!

21. …frustrating!

22. Sleep function

23. Sleep Cycle REM-sleep

24. Decrease in REM as we age

25. Circadian Rhythm

26. Here’s what we know… • Sleep patterns began to drastically change during the Industrial Revolution and the invention of the light bulb • Most everything we know about sleep, we’ve learned in the past 25 years • Tiny luminous rays from digital alarm clocks can be enough to disrupt the sleep cycle even if you do not fully awaken. The light turns off a “neural switch” in the brain, causing levels of a key sleep chemical to decline rapidly. • FYI- A well known Sleep expert, Dr. Mahowald suggests that anyone who needs an alarm clock is by definition sleep deprived because “if the brain had received the amount of sleep it wanted, you would have woken up before the alarm went off.”

27. Do we really know… Just what is the impact of chronic sleep deprivation? OH MY!!

28. Sleepis a serious matter • Sleep deprivation can have a disastrous effect, ultimately leading to death. • Seventeen hours of sustained wakefulness leads to a decrease in performance equivalent to a blood alcohol level of 0.05%. • Major disasters attributed to human errors in which sleep-deprivation played a role including the1989 Exxon Oil Spill off Alaska

29. Sleep: a serious matter • Well over 100,000 car accidents in North America occur every year due to sleep deprivation—leading to 6000 deaths. • Research conducted in 2012 showed: • adults who regularly slept less than six hours each night were four times more likely to suffer a stroke than were those who got plenty of sleep. • A recent study of orthopedic surgical residents found that residents were fatigued 48% of the time. • Negatively effected performance 27% of the time • Increased potential risk for medical errors by 22% (Arch. Surg. 2012;147)

30. Just what happens when we sleep? • Biochemical: • Hormone secretion • Metabolic rate falls during REM sleep • Energy is conserved • Body temperature drops • Protein synthesis and production of complex molecules in the body increase

31. Cont. • Physiological: • Restorative OR recovery phase • Cell division more rapid during NREM • Increase immune function • Neurological: • Development of brain cells and formation of new neurons • Connections between brain cells during development

32. -Mood swings -Depression

33. Sleep should not decline as we age, however… • Sleep patterns usually change as part of the normal aging process • Increased interruptions, especially through the night • Many times takes longer to fall asleep • Most sleep disruptions are related to physical or psychological conditions and medications • To bed earlier-arise earlier// changes in activity and/or schedule

35. Sleep Duration and Cognition: Preliminary Results The Nurses’ Health Study • Population: 15,263 woman, at least 70 years of age-study sleep duration at mid-life/later life- free from stroke and depression at the start. • Women with sleep durations less than 6 hours a day or more than 9 hours a day had worse average cognition at old age compared to those with sleep durations of 7 hours a day. (Presented by Dr.. Devore of the Harvard Nurse’s Health Study on www.alz.org, 2013)

36. Summary and duration and cognition: preliminary results • Women with sleep durations that change by 2 hours a day or more had worse cognitive function than those with no change • The findings support the following notion: • Extreme sleep durations and changes in sleep duration over time may contribute to cognitive decline and early Alzheimer’s changes in older adults. • Our findings suggest that getting an 'average' amount of sleep, seven hours per day, may help maintain memory in later life and that clinical interventions based on sleep therapy should be examined for the prevention of cognitive impairment." Elizabeth Devore, ScD –Brigham and Woman’s Hospital, Boston

37. Sleep and Dementia are Bi-Directional Diseases such as Dementia/ Alzheimer’s can significantly impact the sleep cycle and trigger declines in mental ability SLEEP “One of the unique challenges in researching sleep disturbance as a factor in cognitive decline is: Once patients have developed AD, we do not know if sleep disruption contributes to AD progression or if AD progression contributes to sleep disruption.” (Mander BA. Disturbed sleep in preclinical cognitive impairment: cause and effect? SLEEP 2013;36(9))

38. Sleep in dementia • Almost ½ of all dementia patients have sleep disturbances • Compared to older adults with normal cognition, adults with dementia have: • Shorter sleep cycle with greater sleep fragmentation • Less deep and REM sleep with reduced sleep efficiency • More frequent nighttime awakening, wandering, and increased daytime napping • More difficulty falling asleep (Feinburg et al., 1967: Moe et al., 1995; Prinz et al., 1982a, 1982b; Vitiello et al., 1990: Mortimore et al., 1992) • Increased severity of dementia is associated with greater sleep fragmentation

39. Sleep in dementia • Sundowning: a state of confusion at the end of the day and into the night. • Can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions. • Sundowning can also lead to pacing or wandering. • Wandering and incontinence are the top two causes of Institutionalization, because the family member has great difficultly taking care of a patient who displays one characteristic or the other (National Sleep Foundation)

40. Causes of sleep changes in Dementia • The way that the brain controls sleep may be changeddue to the physical changes in the brain • The person may have unmet needs or problems such as pain. • It is also possible that their poor sleep may be linked to breathing or other sleep related problems such as Obstructive Sleep Apnea, Snoring or Periodic Limb Movements. • Some medications may affect sleep (including pain relievers, drugs to treat Dementia, Parkinson’s disease and antidepressants.

41. Objective • To "get back to the basics" and describe non-pharmacologic Patient Centered Care interventions and treatment strategies that caregivers can apply in their facilities to improve QAPI and resident wellness outcomes. Presented by Melissa Napier, MS, BSN

43. Facility Readiness • Staff Education • Develop a “cross-pollinated team to evaluate issues INCLUDINGfamily and residents and caregivers to help tailor person-centered care approach for EVERY resident • Sleep disorders recognition and consequences • Interventions to change the current “culture” of sleep practices and routines in LTC facilities involve common sense. • Environmental enhancements • Individualized care planning • Start with the sleep interview • Interdisciplinary care management: TEAM effort!

44. Fayetteville, Arkansas SVHUninterrupted Sleep Program Developed to promote person-centered care and restorative sleep to all Veterans within the Home. “Change will help restore dignity, autonomy, privacy, choice, honor, trust and quality of life to those we serve.” (Fayetteville Veterans Home Policy)

45. Uninterrupted Sleep Program Process • Sleep interview preferences incorporated into care plan and re-evaluated as necessary • Evaluate Incontinence • For incontinence management, switched to superabsorbent, longer wearing, brief/pull-on to keep skin dry, improve skin integrity and allow for longer periods of uninterrupted sleep • Evaluate medical management where changes can occur

46. Sample Sleep Interview Questions Do you have difficulties falling asleep or maintaining sleep? Do you feel sleepy, tired or fatigued during the day? What is your sleep schedule? How many hours do you sleep at night? How long does it take you to fall asleep How many times do you wake up during a typical night? Do you feel refreshed when you wake up? Do you have loud snoring and do you stop breathing at night? Are your legs restlessness, crawling or aching when trying to fall asleep? Do you repeatedly kick your legs during sleep? Do you act out your dreams? Sleep in the Geriatric Patient Population p. 54 Table 1

47. Fayetteville: Standard of Care • Keep lights to a minimum during checks. • Use soft voices • Decrease loud noises from any source i.e. promptly answer call lights and alarms • Don’t interrupt unless condition warrants. Eliminate a “wake up list” altogether in an effort to support the Veteran’s natural sleep pattern . • AM medications: shift medication schedule for meds that can be given anytime of day • AM Blood Sugar: time based on individual needs • Continental Breakfast: for early risers • Eliminate universal, rigid morning routines

48. Fayetteville, Arkansas SVHUninterrupted Sleep Study • Developed from observation of the following problems • Anger and acting out issues • Non-compliance with overall care and ADL’s • Increase in negative psychiatric behaviors…leading to • These behaviors caused an increase in: • Anti-psychotic drug administration • Transfers to acute care and psychiatric treatment facilities • Negative side effects from the medications

49. Study Results: All related to quality……………….. • Decrease in anti-psychotic med use • Reduced admission rate to acute care and psychiatric facilities • Decrease in anger issues • Decrease in illness related to lack of sleep • Increase in compliance with care including meals, ADL’s and PT/OT • Improvement in overall wellness of residents (Jerry Poole, RN, Staff Development/Infection Prevention)

50. Fayetteville SVH Outcomes • Longer periods of uninterrupted sleep. • Staff have more time to do safety rounding during the nightand other meaningful and personal care. • Staff/Veteran and family satisfaction. • When asked if they have observed a change in difficult behaviors……..