It is 4 AM and I can hear my 100-year-old father shuffling about in his room. Soon comes the knock on our bedroom door and my husband and I sit up only to see my father, dressed in suit, tie, and loafers. "When is the car coming to take us to church?" he asks anxiously. "Church?" I respond incredulously. "Yes, church-for my wedding. I do not want to be late. When is the car coming?" After 15 minutes of difficult negotiation, struggling to apply rationality where I know it will never work, my dad is back in bed. An hour later, there is a repeat episode. By 5:30 AM, I am exhausted but I cannot get back to sleep. I dress, have breakfast, and leave for work early. My dad sleeps until 10 AM that morning!! I arrive home from work at 6:30 PM. I am dreading another disrupted night. Sleep disturbances are one of the major downsides of family caregiving.
After several weeks of wedding episodes, the awakenings shift to 2:30 AM, with a new theme. Dressed in work clothes, my father would knock on our door and announce that he was off to work to snuff out the gas lamps in the alleys of South Philadelphia, his first job when he was 10 years old. The 4 AM awakenings were also work related-being on time to take the night shift bus into Center City. My dad was a bus driver for 40 years, and he often worked the late swing shift. After 2 months of rude awakenings, despite the turn-taking system that my husband and I worked out, we were both exhausted and the nighttime episodes continued on, 4 to 5 times per week.
After medical consultation, a low-dose, atypical antipsychotic drug was prescribed for bedtime. "It should calm down the brain, but at this age, there are never guarantees. If this does not work, we'll try something else." I was grateful for the physician's honesty about "no guarantees." In fact, there is so little data about what works with the very old because not that many people reach into their ninth decade and beyond. However, over 85s is a fast-growing segment of the population who will continue to present with problems similar to my dad's.
The new medication worked for 3 nights, and then my dad became uncharacteristically aggressive, banging his cane on the floor and pacing. He grew increasingly suspicious of me and resorted to cursing and name-calling, behavior that I had never previously seen. This was not my dad-I immediately stopped the medication and tried the over-the-counter antihistamine. I also consulted with a psychopharmacologist researcher, who said, "Antihistamine might work for awhile, but its tends to cause confusion in the elderly. Good luck and keep trying." Soon the effects of low-dose antihistamine began to dissipate and the sleep disruptions accelerated. In desperation, we considered placing my father in a dementia unit-so alien to our family values.
After a particularly difficult episode and with my dad back to bed, I stood in the middle of his room and looked at the clock through tear-filled eyes-4:30 AM the large, red, digital numbers screamed at me. I ripped the clock's wire from the socket, wrapped it around the clock, and hid it away in my closet. The removal of the clock brought the end of sleep disruptions for my father. That was 6 weeks ago, and we are all in much better spirits.
It is likely that when my father awoke periodically, the big, red, digital numbers on the clock triggered memory floods of events associated with the times-2:30 AM time to put the gaslights out; 4:00 AM, time to work the late swing shift; 5:30 AM, time to get ready for the wedding day, for the trip to church. I remembered all of those holistic nursing theories about person environment interaction, but when push came to shove, I called for a sleeping pill first.
I am learning so much about the needs of the very old, since I have 2 of them in my home, my 100-year-old father and my 98-year-old mother-in-law. I am also learning anew that simple solutions are often most effective. In this case, out of desperation and exhaustion, I found a simple solution to prevent sleep disruption-hiding in plain view in the digital clock.
Gloria F. Donnelly, PhD, RN, FAAN
Editor-in-Chief