Sleep Disturbance and Outcomes Rehabilitation in the Nursing Home
Cathy A. Alessi MD
VA Greater Los Angeles HCS, Sepulveda
Sepulveda, CA
Funding Period: January 2002 - September 2005

BACKGROUND/RATIONALE:
Previous research has shown that sleep disturbance is common among long-stay, nonrehabilitative nursing home residents and the nursing home environment contributes to poor sleep. Moreover, nursing home residents with more impaired sleep have worse functional status. While VA and non-VA nursing homes are increasingly being used to provide rehabilitation for older veterans recovering from recent illness or injury, little research has addressed how sleep disturbance among this group of nursing home residents may influence successful rehabilitation and other important clinical outcomes.

OBJECTIVE(S):
The primary purpose of this project is to identify factors that affect sleep in rehabilitative nursing home residents, and to determine whether sleep impairment is associated with the process of their rehabilitation and important clinical outcomes.

METHODS:
This is a prospective, cohort study of older people admitted for post-acute rehabilitation to VA and community sites. Residents are enrolled when admitted to the facility for rehabilitation, and followed prospectively for 9 months. Data collected at baseline includes medical data and demographics, comorbidity, functional status, physical function and subjective (i.e., questionnaire) and objective (i.e., wrist actigraphy) measures of sleep. Baseline ambulatory sleep monitoring is performed, and participants are monitored for falls during their stay. Functional status and physical function measure are repeated at discharge. In addition, follow up assessments are performed at two months, six months and nine months from admission to the post-acute rehabiliation site. These follow up assessments include questionnaire and wrist actigraphy sleep measures, functional status, physical function, living location, survival status and health care utilization (i.e., emergency room visits and hospitalizations).

FINDINGS/RESULTS:
A total of 245 participants have been enrolled into the study from one community (n=158) and 2 VA post-acute rehabiliation units (n=87). The mean age for these participants is 81 years, 62% are male, and 80% non-Hispanic white. Average length of stay in the post-acute rehabilitation setting was 21 days, and the majority (84%) of participants were discharged to community settings. Based on wrist actigraphy (and behavioral observation data), participants slept 16.4% of daytime hours (8am to 8pm) and had a nightime percent sleep (time asleep over time monitored between 10pm and 6am) of only 52.2%. More daytime sleeping was associated with attenuated functional recovery between admission and discharge (measured by improvement in the motor component of the Functional Independence Measure (FIM); r= - .252, p<.001), and with less total functional improvement from admission to the 2-month follow-up visit (r= -.261, p=.001). When MMSE score was included in statistical models, these relationships remained statistically significant.

IMPACT:
Results of this study may lead to a randomized controlled trial to test interventions to improve aspects of quality of care related to environmental, staff and patient factors that impact sleep.

PUBLICATIONS:

Journal Articles

1. Alessi CA, Martin JL, Webber AP, Alam T, Littner MR, Harker JO, Josephson KR. More daytime sleeping predicts less functional recovery among older people undergoing inpatient post-acute rehabilitation. Sleep. 2008; 31(9): 1291-300.
2. Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, Boehlecke B, Brown TM, Coleman J, Friedman L, Kapen S, Kapur VK, Kramer M, Lee-Chiong T, Owens J, Pancer JP, Swick TJ, Wise MS. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006; 29(3): 375-80.
3. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. 2006; 29(2): 240-3.
4. Webber AP, Martin JL, Harker JO, Josephson KR, Rubenstein LZ, Alessi CA. Depression in older patients admitted for postacute nursing home rehabilitation. Journal of The American Geriatrics Society. 2005; 53(6): 1017-22.
5. Alessi CA, Martin JL, Webber AP, Cynthia Kim E, Harker JO, Josephson KR. Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents. Journal of The American Geriatrics Society. 2005; 53(5): 803-10.
6. Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman J, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Loube DL, Owens J, Pancer JP, Wise M. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005; 28(4): 499-521.
7. Ancoli-Israel S, Cole R, Alessi C, Chambers M, Moorcroft W, Pollak CP. The role of actigraphy in the study of sleep and circadian rhythms. Sleep. 2003; 26(3): 342-92.
8. Littner M, Alessi C. Obstructive sleep apnea: asleep in our consciousness no more. Chest. 2002; 121(6): 1729-30.

DRA: Aging and Age-Related Changes, Health Services and Systems
DRE: Quality of Care, Rehabilitation
Keywords: Long-term care, Patient outcomes, Sleep disorders
MeSH Terms: none