Dr. El

Despite the fact that my search for column inspiration took place at 3 a.m., I chose the topic of sleep deprivation because residents regularly tell me about their own sleep disturbances. They also discuss their pain.

Though their aches often keep them up at night, a January 2019 article in the New York Times, “Why It Hurts to Lose Sleep,” suggests that there’s a more complicated relationship between sleep and pain.

Author Benedict Carey described research finding “that a single night of sleep deprivation reduced a person’s pain threshold by more than 15 percent.” In addition, “small deviations in the average amount of sleep from one day to another predicted the level of overall pain felt the next day.” Staying up all night — which has been known to happen in the long-term care setting — increased pain sensitivity by 15% to 30%.

This interaction between sleep and physical discomfort is particularly relevant to those of us working in eldercare. Increased use of pain medications not only raises pharmacy costs, but can lead to a host of other problems, including constipation, daytime drowsiness, increased fall risk, the possibility of addiction, medication interactions, breathing problems and more. Each of these complications can, in turn, lead to further difficulties.

Perhaps the silver lining in these significant complications will be that more attention is paid to sleep disturbances in long-term care.

I suspect that the shift-based nature of nursing care makes it easier to discount this issue. If an elder with disrupted sleep were at home keeping their caregivers awake, it would be a major problem for the family. In the nursing home, the nighttime care providers are already up, the daytime workers arrive to work rested and the administrative staff members aren’t around to directly observe the effects of unsettled sleep. It’s the residents who must contend with the mid-night disruptions of their peers.

One loud, agitated resident can awaken most of his or her neighbors. If, as this research suggests, all of those people feel discomfort more intently the next day, this could increase their requests for pain medications. Their fatigue might reduce their progress in rehab and increase their likelihood of irritability. This outbreak of insomnia, pain and aggravation should be attended to as much as scabies or lice.

While adequate pain medication is essential for restful slumber, the Times article suggests that we may be able reduce their need for meds by finding additional ways of improving sleep. The authors of the studies suggest that hospitals hand out earplugs and sleep masks like the airlines do.

I’ve written before about sleep disturbances. The sleep hygiene suggestions from that column bear repeating.

  • Set the expectation that employees are working in the residents’ homes and should be mindful of their slumber. This includes talking in calm, hushed tones and turning off unnecessary lights after nighttime care.
  • Limit fluids in the evening, provide toileting before bedtime and offer swift, calm and prepared mid-night care that increases the likelihood that residents can go back to sleep.
  • Communicate between shifts so that the elders who have gotten up earliest get to bed soonest if they desire.
  • Prioritize pain management, particularly if it’s interfering with sleep.
  • Refer residents experiencing sleep difficulty due to anxiety or depression to the consulting psychologist.
  • Attend to agitated residents immediately so that they don’t wake their neighbors.
  • Find peaceful nighttime pursuits for elders with dementia-related sleep disturbance such as magazines, drawing or music on headsets.
  • Replace noisy medical equipment such as oxygen machines with quieter models.
  • Select roommates with attention to sleep habits and nighttime needs.
  • Create a policy for quiet hours after, say, 10 p.m. and require low volumes or headsets for electronics after that.
  • Train teams to collaborate between shifts so that they identify and assist residents who are asleep during the day and up at night to re-establish regular sleep patterns.

As with many challenges in long-term care, one trouble often leads to another. This occurs not just in individuals but also in the impact that each resident has upon peers and staff. Attending to pain/sleep interactions can pay off not just in decreased pharmacy costs and reduced medication side effects of a single resident, it can also halt a unit-wide outbreak.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.