Sleep problems are a common issue for older adults and can lead to fatigue and sleepiness during the day, mood changes, difficulties with concentration, injuries, and an increased risk of illness such as high blood pressure, heart disease, and diabetes. Additionally, for up to 70% of caregivers, sleep issues play a major role in the decision to institutionalize the adult in their care (American Geriatrics Society [AGS], 2017).

Signs of sleep issues include daytime sleepiness, trouble falling asleep at night, waking up too early in the morning, not feeling rested in the morning, and difficulty concentrating. Ask the patient or caregiver to complete a sleep diary that includes: 1) when the patient goes to bed and wakes up, 2) the length of time it takes to fall asleep, 3) hours of sleep, 4) how often the patient wakes up at night and for how long, 5) any symptoms that occurred during the night, 6) how much the patient napped during the day, and 7) how rested they feel in the morning.

Common sleep disturbances that older adults suffer from include obstructive sleep apnea (OSA) restless leg syndrome, and rapid eye movement sleep behavior disorder (RBD) (Suzuki et al., 2017). Obstructive sleep apnea is characterized by a disruption of breathing during sleep, often with snoring and pauses in breathing. Patients with OSA may also have morning headaches, and urinary incontinence. Restless leg syndrome is a disorder characterized by an urge to move the legs and abnormal leg sensations. This is typically worse at night and is relieved by movement (walking or stretching). Iron levels should be checked and iron replacement therapy should be initiated when ferritin levels are below 50 ug/L (even without iron deficiency anemia).

Patients with RBD will enact dreams (including talking, shouting, punching, and kicking) due to not undergoing normal skeletal muscle atonia during sleep, and may have nightmares of being chased or attacked by unfamiliar people or animals. Remove potentially dangerous objects from the bedroom and placing the mattress on the floor. Melatonin at bedtime may be a potential therapy option for RBD.

Not all patients will have a formal sleep disturbance diagnosis, but may still have difficulty with their sleep. Other factors that can affect sleep are depression, anxiety, stress, smoking, caffeine intake, napping during the day, alcohol use, heart failure, prostate enlargement, pain, side effects of medications, chronic use of sedatives, dementia, delirium, noise, and the need to void during the night.

Educate the patient/caregiver to keep the same sleep and wake times and routines every day (no more than 7 to 8 hours in bed nightly), encourage daily exercise (but not within 3 hours of bedtime), get plenty of bright light during the day, and avoid napping. At bedtime, patients should avoid caffeine, alcohol, and tobacco, take a warm bath about 90 minutes before getting into bed, use a fan or white noise machine to help block external noise, use the bed solely for sleep, and do not go to bed unless sleepy. If the patient cannot sleep after 20 minutes, they should go to another room, keep lights dim, and read or listen to music for 30 minutes before trying to sleep again (AGS, 2017).

Clearly, sleep disturbances can cause significant issues for older adults. Home healthcare clinicians play an important role in the assessment of sleep issues, as well as working with the healthcare team to manage these conditions. Additionally, all patients can benefit from sleep hygiene measures and education to improve sleep and patient outcomes.

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