• American Medical Directors Association (AMDA). Sleep disorders. Columbia (MD): American Medical Directors Association (AMDA); 2006. 38 p. [48 references]

This is the current release of the guideline.

Sleep disorders in the long-term care setting that are secondary to chronic medical conditions or environmental issues, including insomnia, hypersomnia, and parasomnias

Note: The management of primary sleep disorders (e.g., central or obstructive sleep apnea, restless legs syndrome, periodic limb movement during sleep) in the long-term care setting is beyond the scope of this guideline.

Diagnosis
Evaluation
Management
Prevention
Treatment

Family Practice
Geriatrics
Internal Medicine
Sleep Medicine

Advanced Practice Nurses
Allied Health Personnel
Nurses
Pharmacists
Physician Assistants
Physicians
Social Workers

• To improve the quality of care delivered to patients in long-term care settings
• To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing, assessing, treating, and monitoring patients with sleep disorders

Elderly individuals and/or residents of long-term care facilities with sleep disorders

Recognition/Assessment

1. Obtaining medical and sleep history and evaluate signs and symptoms
2. Assessing risk factors for sleep disorder
3. Offering interim measures such as environmental adjustments and individualized comfort measures while assessment proceeds
4. Determining characteristics and possible causes of sleep disorder
5. Collecting information and making direct observations pertinent to the patient's sleep disorder
6. Assessing environmental, behavioral, and psychosocial factors that may be contributing to sleep disorders
7. Assessing medical conditions and medications that may be contributing to sleep disorder
8. Specialist evaluation, if indicated

Management/Treatment

1. Implementing nonpharmacologic interventions
2. Reconsidering medications that may be interfering with sleep
3. Treating the medical condition that is the underlying cause of sleep disorder
4. Prescribing medication in combination with nonpharmacologic therapy

Monitoring

1. Monitor the effectiveness of interventions
2. Maintaining or modifying interventions according to the patient's response to treatment
3. Monitoring the facility's management of sleep disorders

• Signs and symptoms indicating the presence of a sleep disorder
• Use of medications
• Quality of life
• Side effects of sleep medications

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

This guideline was developed by an interdisciplinary workgroup, using a process that combined evidence and consensus-based approaches. Workgroups include practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group works to make a concise, usable guideline that is tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations are based on the expert opinion of practitioners in the field.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Guideline revisions are completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporates information published in peer-reviewed journals after the original guidelines appeared, as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

The type of evidence supporting the recommendations is not specifically stated.

The guideline was developed by an interdisciplinary work group using a process that combined evidence- and consensus-based thinking.

Outcomes that may be expected from implementation of this clinical practice guideline include:

• Better awareness and understanding of sleep disorders among patients and caregivers
• Decreased long-term use of pharmacologic agents to promote sleep
• Decreased use of pharmacologic sleep agents that may be inappropriate in a frail, elderly population
• Greater acceptance of individualized scheduling (i.e., enabling patients to get up, go to bed, and eat meals at times of their choosing rather than at institutionally established times)
• Reduction in the frequency of daytime drowsiness, increased levels of participation in activities, improved social interaction, and enhanced quality of life for patients with sleep difficulties
• Improved physical and cognitive function and fewer falls
• Reduction in nighttime disruptive behavior caused by noise or bright lights
• Reduction in distressed daytime behavior in patients with dementia
• Decline in geriatric psychiatry referrals for evaluation of behavioral problems related to sleep disorders
• Increased participation in rehabilitation programs and better rehabilitation outcomes
• Increased job satisfaction among caregivers

Adverse Effects of Medications

• The most frequent adverse effect of eszopiclone is an unpleasant taste.
• Continuous use of benzodiazepine hypnotic agents should be discouraged in the long-term care setting because of the risk of side effects, physiological tolerance, and adverse effects on discontinuation. Adverse events such as memory impairment, falls, excessive daytime sleepiness, and accidents occur more often at higher doses and with the use of long-acting agents. In addition, prolonged use of long-acting benzodiazepines can lead to cognitive impairment, incoordination, and worsening of depression. These agents are associated with anterograde amnesia, rebound insomnia, and residual daytime sedation, especially at high doses. These adverse effects generally appear to be worse in the elderly.
• Side effects of tricyclic antidepressants include anticholinergic effects and various degrees of suppression of rapid eye movement (REM) sleep.
• Potential side effects of trazodone include induction of cardiac arrhythmias (in patients with heart disease) and orthostatic hypotension.
• All antidepressants have potentially significant adverse effects, raising concerns about the risk-benefit ratio.
• Patients with renal and hepatic insufficiency may be at greater risk for side effects from sedatives.
• In patients with underlying obstructive sleep apnea, hypnotics can produce further nocturnal hypoxemia.
• The anticholinergic and sedative side effects of tricyclic antidepressants and antihistamines can increase cognitive deficits.
• Antipsychotic medications can cause orthostatic hypotension, possibly increasing the risk of falls.

Patients with severe liver disease should not take ramelteon.

• This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association and the American Health Care Association, their heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.
• The utilization of the American Medical Director Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and care-givers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG
2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes
3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable
   • Identify individual responsible for each step of the CPG
   • Identify support systems that impact the direct care
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG
4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement
   • Evaluate the predefined performance measures and obtain and provide feedback

Getting Better
Living with Illness

Effectiveness

• American Medical Directors Association (AMDA). Sleep disorders. Columbia (MD): American Medical Directors Association (AMDA); 2006. 38 p. [48 references]

Not applicable: The guideline was not adapted from another source.

2006

American Medical Directors Association - Professional Association

Organizational participants included:

• American Association of Homes and Services for the Aging
• American College of Health Care Administrators
• American Geriatrics Society
• American Health Care Association
• American Society of Consultant Pharmacists
• National Association of Directors of Nursing Administration in Long-Term Care
• National Association of Geriatric Nursing Assistants
• National Conference of Gerontological Nurse Practitioners

Funding was supported by the following: Bristol-Myers Squibb Company, Eisai Inc., Forest Laboratories, Janssen, Mallinckrodt Pharmaceuticals, Novartis, Pfizer Inc., Sanofi-Aventis, Sepracor Inc., Wyeth

Steering Committee

Committee Members: Marjorie Berleth, MSHA, RNC, FADONA; Lisa Cantrell, RN, C; Charles Cefalu, MD, MS; Sandra Fitzler, RN; Joseph Gruber, RPh, FASCP, CGP; Susan M. Levy, MD, CMD; Harlan Martin, RPh., CCP, FASCP; Evvie F. Munley; Jonathan Musher, MD, CMD; Mary Tellis-Nayak RN, MSN; Barbara Resnick, PhD, CRNP; William Simonson, PharmD., FASCP

Not stated

This is the current release of the guideline.

None available

This summary was completed by ECRI on June 23, 2006. This summary was updated by ECRI Institute on April 30, 2007, following the FDA advisory on Sedative-hypnotic drug products. This summary was updated by ECRI Institute on November 9, 2007, following the U.S. Food and Drug Administration advisory on Antidepressant drugs.

This NGC summary is based on the original guideline, which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information, contact AMDA at (410) 740-9743.