​

Staff practices that interrupt resident sleep often fall into the category of, “We’ve always done it this way,” or misinterpreted as being required in the regulations. Sleep disruption is known to interfere with residents’ physical, emotional, and mental well-being, yet the practices are so ingrained in the system that staff do not think twice about why they do so.

The need for sleep has long been recognized as important to health, but recent research has linked a lack of adequate sleep to the development and worsening of dementia, diabetes, and cardiovascular disease. Similarly, fragmented or inadequate sleep is associated with depression, anxiety, agitation, and aggression.

For the population in skilled nursing care and assisted living, these physical and cognitive conditions resulting from sleep disruption may lead to medication use and risks associated with the medications themselves and polypharmacy.

Many sedative hypnotic medications that aid in sleep have side effects that have placed them on the AGS Beers Criteria to be used with caution in older adults. Similarly, psychotropic medication to address behavioral concerns that may in fact be related to sleep inadequacy and not psychosis places older residents at higher risk for falls and mortality.

Some changes in sleep can occur with normal aging. Others are associated with neurologic conditions like Parkinson’s disease and various forms of dementia that can impact sleep through disordered breathing, restless leg syndrome, and REM (rapid eye movement) sleep behavior disorders. Effective sleep cycles can be disrupted by these internal issues, so minimizing external disruptions is even more essential.

For well over a decade, studies of hospitals and skilled nursing centers have demonstrated that noise and staff practices impact sleep quality and quantity for patients and residents. Each of these are distinct from a traditional home environment due to the nature of multiple people living near each other and having caregivers working near them. 

Noise is a key factor in sleep disruption. While the physical design of many nursing centers with tile floors, central nursing stations, and shared rooms increases the risk of excessive noise levels, one of the key factors in increased noise levels is staff conversations. Particularly during the prime sleeping hours, staff need to be conscious that their work area is where people are sleeping, and conversations need to be kept to a minimum and occur away from sleeping areas.

Other residents who may be experiencing altered sleep/wake cycles, and who are up most of the night, should be provided engagement activities in an area where their noise is least likely to disrupt other residents.

Other factors that can add to the noise pollution include squeaky carts (linen, medication, housekeeping) and alarms, as well as televisions and music that can permeate from lounges and resident rooms. The World Health Organization recommends that sound levels in hospitals (and by extension nursing centers) should not exceed 30 to 40 decibels at night, yet most findings exceed this both at baseline and with spikes throughout the night.

This is easily measured with low to no cost “smart” phone apps. Have staff take turns sitting in various areas of the facility with decibel-measuring devices at various times of the day to get a good understanding of just how noisy the workplace, and the residents’ home, really is.

Beyond the noise of conversations, many staff practices are known to interfere with resident sleep. Witness the resident who is awakened for a sleep medication! But most staff practices were implemented for improved care: repositioning residents every two hours, waking people to go check for incontinence, “body” checks for people who may be at risk of elopement.

Many of these were created decades ago when equipment and products were not as advanced as they are today. For example, no one wants residents with incontinence to be exposed to wet surfaces and irritation. Products today are significantly better than existed 30 years ago when the practice of checking every two hours originated. 

Consider working with the product vendor for their help to individually assess residents’ needs, particularly those with the most challenging problems. Developing teams of staff to assess how fluids are distributed across the day, what is a resident’s typical voiding pattern, and then trying to gradually increase time between awakening to be sure skin integrity is sustained, can lead to less forced awakenings each night.

Other ideas that can be implemented include reviewing all medications delivered between certain hours (an example may be 10:00 p.m. and 7:00 a.m.). Does it truly have to be administered during that time period? Involve the physician and pharmacy and discuss this medication schedule with the family in relation to the value of sleep. Any medication during the nighttime hours should be reviewed and only used as a last resort, with the recognition of the negative impact it could have on sleep. 

Support the certified nurse assistant staff to be flexible in their morning assignments, encouraging residents to sleep until a natural awakening. Meet with outside vendors such as lab technicians to schedule blood work for a morning time that will not wake the resident (and potentially any roommates), at least on any kind of routine basis. Review the care tasks assigned to the overnight shift for relevance and interruption. For example, take a critical eye to common practices of refilling linens and ice water during the night.

Assessing each individual’s unique needs is the standard set by the Centers for Medicare & Medicaid Services as part of the Requirements of Participation. One method of identifying sleep efficacy is the use of Actigraphy, a wearable bracelet that records sleep/wake patterns over 24 hours.

As technology improves, this becomes an even more cost-effective way to see if changes in facility noise levels and staff practices have improved resident sleep. Other subjective methods can include measuring daytime sleepiness/wakefulness, changes in day/nighttime sleep patterns, and behavioral expressions of anxiety and agitation.

Changing practices that have been ingrained for years is difficult but not impossible. Focusing change efforts on a single unit and specific residents may be a key to getting staff to re-evaluate their practices.

Find the staff members who are resident advocates, who other staff look to for advice and guidance, and ask them to help lead the effort. Celebrate small changes to help focus on success. Most of all, help the residents to experience a higher level of well-being with better sleep practices. 

Free Noise Level Apps Available for Download