OLDER PEOPLE doi: 10.1111/j.1365-2702.2006.01385.

Effectiveness of sleep management strategies for residents of aged care

facilities: findings of a systematic review
Susan Koch BA (Educ Stud), PhD (La Trobe), RN, RCNT (Glasgow), Dip Prof Stud, MN (RMIT), FRCNA FAAG
Associate Professor, Gerontic Nursing Clinical School, La Trobe University, Bundoora, Australia

Emily Haesler BN, PGDip Adv Nurs (Gerontics)

Consultant Reviewer, Australian Centre for Evidence Based Aged Care (ACEBAC), Bundoora, Australia

Adriana Tiziani BSc, DipEd, RN, MEdSt, MRCNA

Research Officer, Australian Centre for Evidence Based Aged Care (ACEBAC), Bundoora, Australia

Jacinda Wilson BBehavSci, PGDip Rehab Stud

Research Officer, Gerontic Nursing Clinical School, La Trobe University, Bundoora, Australia

Submitted for publication: 12 November 2004

Accepted for publication: 6 July 2005

Correspondence: K O C H S , H A E S L E R E , T I Z I A N I A & W I L S O N J ( 2 0 0 6 ) Journal of Clinical Nur-

Susan Koch sing 15, 1267–1275
Gerontic Nursing Clinical School Effectiveness of sleep management strategies for residents of aged care facilities:
La Trobe University
findings of a systematic review
1231 Plenty Road
Aims and objectives. The objectives of this systematic review were to determine the
Bundoora 3083
Australia most effective tools for the assessment and diagnosis of sleep problems, as well as
Telephone: 61 3 9495 3209 identify the most effective strategies for the promotion of sleep within this popu-
E-mail: s.koch@latrobe.edu.au lation.
Background. Experiencing reduced sleep quality is often associated with normal
ageing, however this may be exacerbated for residents of aged care facilities.
External factors such as noise, light and night-time nursing may impact negatively
upon sleeping patterns.
Methods. Eleven electronic databases and the reference lists and bibliographies of
included studies were searched. Papers were grouped according to type of inter-
vention or assessment tool and presented in a narrative summary.
Conclusions. The review identified many interventions to promote sleep. Multidis-
ciplinary strategies such as combining a reduction in environmental noise, reduction
of night-time nursing care and promotion of daytime activity, are likely to be most
effective for promoting sleep in the population of interest. The use of sedating
medications is cautioned, as their long-term efficacy in promoting sleep is ques-
tionable. Wrist actigraphy was found to be the most accurate objective sleep
assessment tool.
Relevance to clinical practice. Lack of sleep, disturbed sleep and the overuse of
medications especially sedations reduce the quality of life for older people. Effective,
safe sleep interventions should be promoted and practised by nurses.

Key words: nursing, older people, sleep assessment, sleep promotion

 2006 Blackwell Publishing Ltd 1267

S Koch et al.
Introduction
As people age, there are often substantial changes to their
sleeping patterns. Older people experience a reduction in time
spent in the stages of the sleep cycle associated with deeper
sleep (stages 3 and 4) and an increase in time spent in the
lightest stages of the sleep cycle (stages 1 and 2), from which
they can be easily aroused. As such, older adults are prone to
increased night awakening and sleep fragmentation, fre-
quently feeling unrested on awakening and an inclination to
nap during the day. Early morning awakening, decreased
ability to maintain sleep and increased time taken to fall
asleep are all considered typical of age-related changes to
sleep patterns (Ancoli-Israel et al. 1989, Shelton & Hocking
1997, Beck-Little & Weinrich 1998, Ersser et al. 1999,
Humm 2001).
For people living in residential aged care facilities, natural
changes to sleep patterns can be exacerbated by environmen-
tal elements. Surveys of cognitively intact older residents have
found these factors to include increased light and noise
exposure and disruption to sleep by staff and other residents
(Ancoli-Israel et al. 1989, Middelkoop et al. 1995, Gentili
et al. 1997, Ersser et al. 1999). Furthermore, the routines
adhered to in aged care facilities frequently mean residents
spend much time in bed during the day, which is known to
interfere with circadian rhythms. Ancoli-Israel et al. (1989)
and Ancoli-Israel (1997) found that nursing home residents
were awake for at least 14 minutes in every hour of the night
and spent up to 17 hours per day in bed to achieve only
eight hours total sleep time.
Despite sleep disturbances being a prevalent problem,
research conducted by Cramer et al. (1999) suggested that
documentation of sleep issues in nursing homes is poor. Their
retrospective records analysis found documentation of early
awakening in only 2Æ3% of records, despite being a com-
monly reported characteristic of sleep disorders in older
adults (Fainstein et al. 1997, Shelton & Hocking 1997,
Humm 2001). Only 33% of the records included a descrip-
tion of resident’s sleep disturbance characteristics, with the
most frequently documented observations being difficulty
initiating sleep (61%), frequent wakening (36%) and beha-
vioural changes arising from lack of sleep such as agitation
(27%). Given 87% of the study population had a diagnosis
commonly known to impact on sleep, such as dementia,
arthritis and depression, Cramer et al. (1999) suggested that
the incidence of sleep disorders was under-documented.
The use of hypnotics and sedatives to manage sleep
complaints in nursing homes is reportedly high. It is estima-
ted that 25–53% of residents take short-acting hypnotics or
long-acting benzodiazepines to manage sleeping difficulties
1268  2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1267–1275
(Seppala et al. 1993, Monane et al. 1996, Cramer et al.
1999). However, long-term use of these medications has been
shown to be counter-productive. Older adults using hypnot-
ics may experience decreased total sleep time, an increase in
early morning awakening, an increase in daytime lethargy
and report reduced sleep quality (Seppala et al. 1993,
Monane et al. 1996). This suggests that medications are an
inappropriate long-term intervention for management of
sleep disturbances in this population and that alternate
interventions should be investigated.
Aims
Given the prevalence of sleep disturbance problems experi-
enced by older adults in aged care facilities and the
importance of good quality sleep to overall physical and
psychological well-being, it is an imperative that the most
effective sleep assessment, diagnosis and management strat-
egies be implemented in aged care facilities. This review
sought to establish the best available evidence in relation to
the assessment and promotion of sleep in residents of high-
level aged care facilities. Specifically it addressed:
1. What are the most effective measures to assess and diag-
nose sleep disturbances in older adults residing in high-
level care?
2. What are the most effective interventions for promotion of
sleep in older adults residing in high-level aged care set-
tings?
Methods
An expert panel was established to guide the systematic
review process. An initial limited literature search of
CINAHL and Medline was conducted to identify relevant
key words contained in the title, abstract and subject
descriptions. Additional search terms were identified by the
expert panel. A more extensive search was then conducted
using the following databases for the years 1993–2003:
AgeLine, APAIS Health, CINAHL, Cochrane Library, Cur-
rent Contents, Dissertation Abstracts International, Embase,
Medline, Proquest, PsycINFO and Science Citations Index.
Searches were limited to published and unpublished literature
in the English language. In the third phase of the review,
reference lists and bibliographies of the articles retrieved were
searched and additional papers were identified for inclusion
based on their titles. The primary search terms were:
• Advanced sleep phase disorder;
• Aromatherapy/mass;
• Age/therapy;
• Benzodiazepines;
Older people Effectiveness of sleep management strategies

• Elderly/aged/older adults; depending on whether the study was a randomized-controlled

• Hypnotics/sedatives; trial (RCT), non-RCT or a diagnostic study. Where disag-
• Insomnia/fatigue/tiredness; reement arose between reviewers, a third reviewer considered
• Minerals/herbs; whether the article should be included.
• Nursing home/long-term care facility;
• Obstructive sleep apnoea;
Data collection
• Periodic limb movement;
• Phototherapy/light therapy; A data extraction tool was developed to extract both
• Research/RCT; qualitative and quantitative data that related to the outcome
• Sleep/sleep disorders; measures of interest in this review. Data were extracted by
• Sleep assessment tools/diagnosis; two independent reviewers to enhance accuracy.
• Sleep hygiene;
• Sundowning.
Data analysis/synthesis

No research studies with comparable populations were

Participants
The review considered studies that included adults aged
65 years and older residing in high-level aged care facilities.
High-level care was defined as nursing home care, or 24-hour
care in a geriatric facility.
identified. As such, meta-analysis was not appropriate.
Findings of included papers were presented in a narrative
summary outlining research methods, findings and limita-
tions to studies. Data generated from observational and
descriptive studies were summarized through identification of
significant factors or themes (Table 1).

Types of interventions and instruments

The instruments of interest were those designed for the
assessment, measurement and/or diagnosis of the older
adult’s sleep pattern. Interventions of interest were those
designed to have an impact upon an individual’s sleep, the
review included, but was not limited to, consideration of:
• Alternative therapies including massage, aromatherapy and
medicinal herbs;
• Behavioural or cognitive interventions;
• Biochemical interventions to promote sleep such as herbs
and minerals;
• Environmental interventions to promote sleep;
• Pharmacological interventions including use of hypnotics;
• Related nocturnal interventions such as continence care.
Outcome measures
Results
Using the outlined search strategy, 114 papers were identified
for retrieval. Of these, 41 were included in discussions of
results. Studies were categorized according to the level of
evidence they offer (Quality of Care and Health Outcomes
Committee 1995).
Only one study was identified that addressed the issue of
the diagnosis of sleep disorders in the population of interest.
Cramer et al. (1999) used the Diagnostic and Statistics
Manual of Mental Disorders, Version 4 (DSM-IV American
Psychiatric Association) criteria, however, they did not
discuss the validity and reliability of the tool in this
population. Other studies referred to participants having
been diagnosed with a sleep disorder, however, they did not
disclose the tool used to make the diagnosis.

Outcome measures included subjective and objective indica- Table 1 Classification of included studies, based on type of research
tors of improved sleep quality such as improved daytime and level of evidence assigned
functioning, improved night-time sleep, reduction of drug use Number of Level of
and increased satisfaction with sleep. Instruments that were Type of research papers evidence
reviewed were those designed to diagnose and assess sleep in
Randomized-controlled trial 8 Level II
older people residing in high-level aged care settings. Non-randomized-controlled trial 3 Level III.1
Cohort studies 15 Level III.2
Times series trial 5 Level III.3
Critical appraisal Case report 3 Level IV
Descriptive study 5 Level IV
Two reviewers independently determined if the retrieved
Opinion paper 2 Level IV
articles met the stated inclusion criteria using three tools

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S Koch et al.
Assessment of sleep disturbance
Four techniques identified for assessing sleep disturbance in the
population of interest were polysomnography (PSG), wrist
actigraphy, behavioural observation and subjective sleep
assessment. According to Ancoli-Israel et al. (1989), PSG is
the ‘traditional gold standard’ (p. 24) in sleep assessment.
However in this systematic review, wrist actigraphy was found
to represent the most accurate objective sleep assessment tool.
PSG involves wiring subjects with electroencephalogram,
electrooculogram and electromyogram electrodes, to record
readings of brain and muscle activity. In a wrist actigraphy
assessment, a monitoring device containing an accelerometer
that measures intensity and frequency of body movement, is
worn on the subject’s non-dominant wrist. Activity is measured
in one- to five-second intervals and data are analysed to determine
sleep–wake cycles (Ancoli-Israel et al. 1997, Fetveit & Bjorvatn
2002). Some wrist actigraphy devices have the added benefit of
recording noise and light levels, enabling the opportunity to
concurrently assess sleep patterns and the sleep environment
objectively (Schnelle et al. 1993a,b, 1998a,b, 1999, Cruise
et al. 1998, Ouslander et al. 1998, Alessi et al. 1999).
Whilst behavioural observation of sleep is commonly used,
there a number of potential threats to the validity of this
technique. One is the absence of specific tools for recording
behavioural observations of sleep in residents of aged care
facilities. A second threat to validity is the frequency with
which observations are made. Many cohort studies report
that the sleep of older nursing home residents is regularly
interrupted and the evidence suggests that one to two hourly
observations by nursing staff are inaccurate in capturing these
night awakenings (Ancoli-Israel et al. 1997, 2002, Beck-Little
& Weinrich 1998, Ersser et al. 1999, Alessi et al. 2000,
Fetveit & Bjorvatn 2002, Gasio et al. 2003). Some research
however suggests that behavioural observation may be
effective when observations are conducted on a more
frequent basis (Alessi et al. 1995, 2000, Ancoli-Israel et al.
1997, Schnelle et al. 1998b).
The validity of subjective reports of sleep, which involve
resident interviews or reports, is also questionable, partic-
ularly for residents with cognitive impairment. Furthermore,
whilst two subjective sleep assessment tools were identified,
the Subjective Evaluation of Sleep Tool and the Pittsburgh
Sleep Quality Index, neither tool has been validated for use
with residents of aged care facilities.
Strategies for sleep promotion
The review identified a number of sleep promotion strategies
including those that addressed: disturbance to the nursing
1270  2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1267–1275
home environment, night-time nursing care, physical activity,
structured activities, resident decision-making, aromather-
apy, valerian preparations, light therapy, melatonin prepara-
tions, multidisciplinary regimes and traditional sedative
medication.
The impact of the nursing home environment on sleep
featured in many of the papers identified. The primary causes
of both difficulty in establishing and sustaining sleep were
identified as light, noise and disruption from roommates
(Ancoli-Israel et al. 1989, Schnelle et al. 1993a,b, 1999,
Ersser et al. 1999, Humm 2001). Specific sources of noise
and light include noise from residents (21%), staff talking
(26%), alarms/bells/phones (11%), equipment (21%) and
televisions (19%) and one study found that in 75% of
nursing homes, hall lighting was not reduced at night
(Schnelle et al. 1993a).
Interventions aimed at reducing noise levels however
found that noise abatement interventions were ineffective
in promoting sleep when used in isolation. Schnelle et al.
(1999) trialed their noise abatement programme using a
randomized controlled design. Despite staff significantly
reducing noise levels, no concurrent significant reduction in
resident awakenings was observed. Alessi et al. (1999) also
found that noise abatement interventions are ineffective in
promoting sleep when used independent of other sleep
promotion strategies.
The effect of using multiple interventions to promote
sleep was investigated by two trials. Nasseh et al. (2002)
combined five interventions in their non-RCT, promotion of
time out of bed, low intensity exercise programme, evening
bright light therapy, night-time noise abatement and a non-
disruptive night-time care routine. As the paper was a
preliminary report on the study, full details were not
accessible to analyse critically. The findings presented
suggested that multidisciplinary interventions are effective
in decreasing daytime sleep, however, the impact on night-
time sleep and overall well-being was not reported. Alessi
et al. (1999) investigated the effect of combining physical
exercise interventions and night-time environment and care
modification, using an RCT. The intervention group
(n ¼ 15) received both the exercise intervention and the
environmental and care modifications, whilst the control
group received only the environmental and care modifica-
tions. Residents in the intervention group exhibited a
significant increase in night-time sleep. However, despite a
less disruptive environment achieved by reducing noise and
light and minimization of nocturnal nursing care, the
control group did not show a corresponding improvement
in their sleep. This finding was in accordance with previous
research conducted by these researchers (Alessi et al. 1995),
Older people
which found neither intervention to be effective when
applied in isolation.
Another source of disruption in the residential aged care
facility environment may be staff providing nocturnal care.
Cruise et al. (1998) found 76% of direct resident care
episodes led to the resident awakening and Schnelle et al.
(1993a) reported that 85% of resident awakenings were
related to environmental changes associated with nocturnal
nursing care. Several papers reported findings that suggest a
balance can be found between promoting resident sleep,
whilst not compromising incontinence and pressure ulcer
care. Schnelle et al. (1993a,b) concluded that night-time care
routines can be individualized, so that consideration is made
of the resident’s mobility and skin integrity risk. O’Rourke
et al.’s (2001) study was supportive of this, their quasi-
experiment conducted with 18 residents over a 15-day period
suggested that incontinence and pressure ulcer care regimes
designed to minimize disruption to the resident can have a
positive effect on sleep, whilst not having a negative on skin
condition.
Only two studies relating to the effect of physical activity
on sleep in high-level residents were identified and findings
were contradictory. Alessi et al. (1995) instigated two
physical activity programmes, Functional Incidental Training
and Row Walk Wheel, in seven nursing homes. Residents in
the intervention group (n ¼ 33) were randomized to one of
the programmes. The control group (n ¼ 32) received normal
care during the intervention period of nine weeks. Analysis of
data by blinded research staff failed to show any significant
changes in any sleep characteristics (total time sleeping,
percentage of night spent sleeping, average duration and
average peak duration of a sleep episode).
Namazi et al. (1995) conducted a non-RCT with older
high-level care residents with a diagnosis of dementia (mean
MMSE score 12–13). Eleven residents participated in a 40-
minute exercise programme seven days per week for the four-
week intervention period. The control group (n ¼ 11) par-
ticipated in social activities held at the same time. Nursing
staff were blinded to the study objectives and collected data
on participant’s sleep–wake cycles. Significant improvements
were noted in resident’s sleep, with ratings of ‘sleeping
soundly’ increasing from 63% to 73% (P < 0Æ01) in the
intervention group and ‘restless’ ratings decreasing from 14%
to 8% (P < 0Æ01). No significant differences were noted in
the control group. Given the small number of studies
identified and the fact that their findings were contradictory,
no recommendations about physical exercise and sleep were
able to be made from this review.
The findings of one study suggest that providing residents
with activities during the day may reduce excessive daytime
 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1267–1275
Effectiveness of sleep management strategies
sleep and improve night-time sleep. Richards et al. (2001)
hypothesized that participating in structured daytime activity
may assist minimize daytime napping and in turn, promote
nocturnal sleep. A small sample of five nursing home
residents with dementia participated in the uncontrolled
quasi-experiment. Following identification of each resident’s
peak napping period by wrist actigraphy, individualized
programmes were developed that incorporated physical,
cognitive and affective activities, to decrease napping at these
times. Findings were positive, 60% of participants experi-
enced decreased daytime napping (79Æ7 minutes compared
with 105Æ9 minutes). However, no control was used for the
possible impact of social interaction with staff on results, and
all participants were male.
Matthews et al. (1996) hypothesized that routinized care
leads to perceived loss of control and diminished quality of
life, which contribute to poor sleep quality. In their 16-week
cohort study, data were collected for 33 residents (aged over
65 years) of a high-level dementia care ward. Whilst the focus
of the study was on interventions for agitation, outcome
measures included daytime napping and disturbance to night-
time sleep. Residents were given choices concerning getting
up and going to bed, timing of hygiene interventions and
activity and meal times. No significant changes were reported
for night-time sleep ratings, and although there was a
significant increase in daytime sleep from baseline, this was
not sustained.
Three studies were identified that investigated the efficacy
of aromatherapy in promoting sleep in the population of
interest. Cannard (1995) conducted a cohort study which
suggested that the use of essential oils promoted sleep in older
adults in extended care. However, findings were confounded
by the fact that those residents for whom being exposed to
vaporized essential oils was not enough to promote sleep
received the oils via a five-minute massage, suggesting it was
the route of administration rather than simply the oils, that
ultimately promoted sleep. Hudson (1995) also conducted a
cohort study to test her hypothesis that lavender essential oil
provides therapeutic benefits to sleep in older adults. Nine
older residents in a long-term care ward were recruited for
the two-week trial. During the first week, participants
received a nightly administration of one drop of Lavandula
angustifolia on their pillow. No treatment was given in the
second week and post-treatment data was collected. Whilst
Hudson reported improvements in the sleep of eight of the
nine participants, the study design and data collection
methods decreased the confidence in study findings.
Wolfe and Herzberg (1996) provided a brief outline of the
findings from their eight-week trial on the effect of essential
oils in promoting sleep. Participants were two randomly
1271
S Koch et al.
selected older residents with dementia, who received a week
each of lavender (Lavandula officales) and roman chamomile
(Anthemis nobilis) and then a blend of both essential oils.
Administration was two drops on bedding 15 minutes before
bedtime. Observations of sleep and night time behaviour
were conducted by qualified nurses every 30 minutes.
Improvement in sleep was reported for one participant,
particularly when roman chamomile was used. For the
second participant, improvements were also reported. Whist
the findings appear promising, the potential residual effects of
essential oils on sleep following treatment were not consid-
ered. Combined with the small sample size and minimal data
presented, findings must be considered with caution.
Valerian extract originates from the plant Radix Valerinae
offcinalis L. and is purported to have sedative effects (Schulz
et al. 1994). Only one study was identified that investigated
the use of valerian in promoting sleep in the population of
interest. Using a RCT, Schulz et al. investigated the effect of
valerian extract on both subjective and objective measures
of sleep, in a group of 14 female nursing home residents.
The residents had a history of poor sleep, with no organic
or psychiatric diagnosis for sleep difficulty, however, their
overall health was not outlined in the paper. The treatment
group (n ¼ 8) received 405 mg valerian extract, three times a
day, whilst the control group received a placebo. The results
indicate some promising effects of valerian on non-REM
sleep of older female residents, however these changes were
not associated with increased resident satisfaction with sleep.
Four RCTs and three studies offering lower levels of
evidence investigating the effect of various light therapies on
the sleep–wake cycles of nursing home residents with
dementia were identified for inclusion in this review. A
number of discussion points arose from the available litera-
ture on light therapy. These will be discussed in turn:
• Illumination levels;
• Type of light therapy administration and duration of ses-
sions;
• Timing of light therapy administration;
• Duration of therapy;
• Type and level of dementia.
Illumination levels
A wide range in illumination levels used in the studies was
noted. Participants in different studies were exposed to light
intensities of 2500 lux (Rheaume et al. 1998, Ancoli-Israel
et al. 2002), 4000 lux (Koyama et al. 1999), 5000–8000 lux
(Mishima et al. 1998) and 10 000 lux (Lyketsos et al. 1999).
However no study was identified that specifically investigated
the effectiveness of various bright light intensities on the
sleep–wake patterns of the population of interest.
1272  2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1267–1275
Type of light therapy administration and duration of sessions
Studies also differed with respect to the type of light therapy
administration technique used and the duration of the ther-
apy sessions. Whilst Ancoli-Israel et al. (2002) and Mishima
et al. (1998) both used light boxes (different makes) over
two-hour therapy sessions, Koyama et al. (1999) and Oku-
moto et al. (1998) subjected their participants to desktop
light sources for one- to two-hour periods. Another variation
noted was a study by Lyketsos et al. (1999), who ran one-
hour therapy sessions where participants were exposed to a
full spectrum lamp. Participants were encouraged every
15 minutes to look at the light source. In Ito et al.’s (2001)
quasi-experiment, subjects received bright light therapy over
two-hour sessions daily for eight weeks, and those in the
intervention group also received vitamin B12 dosages. De-
spite the researcher’s conclusion that vitamin B12 enhanced
the effect of bright light therapy, the lack of baseline findings
and data for control participants, and brief reporting of the
study decrease confidence in results.
A common experience reported amongst researchers of
bright light therapy was difficulty maintaining compliance
of the participants. However, even providing residents with
the freedom to move whilst receiving bright light therapy
may not alleviate this problem. Participants in a study
conducted by Rheaume et al. (1998) were able to engage in
regular recreational and relaxation activities whilst in a
bright light therapy room. Lighting was provided at
2500 lux intensity and situated at eye level. Although
exposure to light therapy in this manner may suggest
increased participant compliance, it was noted that one
participant spent the majority of the therapy administration
sleeping. This raises the need for constant staff supervision
during therapy sessions. Another disadvantage with using
light therapy to promote sleep in the population of interest
is that residents may experience an increase in agitation
(Lyketsos et al. 1999).
Gasio et al. (2003) investigated an alternative to bright
light therapy, the effect of dawn–dusk simulation illumin-
ation patterns. Residents were exposed to gradual light
transitions that replicated natural outdoor light changes,
delivered by a simulator connected to over-bed lamps, whilst
residents were in bed.
Timing of light therapy administration
The time of day that residents are exposed to light therapy
may impact upon their circadian rhythms. Shochat et al.
(2000) reported that residents who received the majority of
their exposure to light earlier in the day, had an earlier
activity acrophase. Ancoli-Israel et al. (2002) however noted
that morning bright light therapy resulted in significant delay
Older people
in activity acrophase. Gasio et al. (2003) observed phase-
advancing in participants receiving dawn–dusk simulation
therapy and assumed that the dusk simulation had the pri-
mary effect. Clearly the evidence concerning the effect of time
of day light therapy is given on circadian rhythms is con-
flicting.
Duration of therapy
Studies varied regarding the duration of bright light therapy
programmes that residents were exposed to. Programmes
ranged from three days (Shochat et al. 2000), 10 days (An-
coli-Israel et al. 2002), 2 weeks (Mishima et al. 1998) and
three weeks (Gasio et al. 2003) in duration.
Type and level of dementia
Another variation between identified studies was the level
and/or type of cognitive impairment participants had. All of
the studies identified that investigated bright light therapy
were conducted with participants with dementia, however
the type and severity of dementia varied between studies. At
least one study reported a difference in the effects of exposure
to light therapy, between participants with different types of
dementia. Mishima et al. (1998) found residents with vas-
cular dementia displayed a significant decrease in night-time
activity (P < 0Æ02) as a result of exposure to morning bright
light therapy, whereas there was no improvement in the sleep
of residents with Alzheimer’s disease. Ancoli-Israel et al.
(2002) found no significant responses to bright light therapy
in their study, and suggested this may be because of the
number of residents in their sample with ‘severe dementia’
(mean MMSE 12Æ8 ± 8Æ8). Conversely, Lyketsos et al.
(1999) reported improvements in sleep in a population with a
mean MMSE score (6Æ4 ± 6Æ8).
Two studies were identified which investigated the effect of
exogenous melatonin on sleep disturbance in high-level care
populations. Cohen-Mansfield et al.’s (2000) study, a time
series design, evaluated the effect of melatonin on the
sundowning symptoms of agitation and sleep disruption.
Baseline recording was conducted for a week, followed by a
three-week intervention period. Some residents began on a
titrated amount of melatonin in the first intervention week
and by the second week, all residents were receiving 3 mg of
melatonin orally, one hour before retiring to bed. No
significant differences between baseline recordings and the
final week of intervention were noted in the resident’s night-
time sleep. However, the researchers reported significant
improvements in the resident’s daytime sleep patterns, with a
decrease in ratings of daytime drowsiness (P ¼ 0Æ008),
decrease in frequency of daytime napping (P ¼ 0Æ001) and
a decrease in length of naps (P ¼ 0Æ002).
 2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 1267–1275
Effectiveness of sleep management strategies
It is possible that had Cohen-Mansfield et al.’s study been
continued for a longer period, positive effects to resident
night-time sleep may have been experienced. For residents
with concurrent sleep disturbance and depression, Fainstein
et al. (1997) reported improvements in night-time awakening
frequency (P < 0Æ05) and an increase in subjective rating of
sleep quality (P < 0Æ02), however these improvements did
not reach significance until day 19 of the 21-day trial period.
Fainstein et al. (1997) recruited two study groups of interest
to the current review: institutionalized residents with sleep
disturbance and depression (n ¼ 9) and institutionalized
residents with sleep disturbance and dementia (n ¼ 10).
Sleep logs maintained by residents and/or their primary carer
and structured interviews were used to collect data about the
resident’s bedtime, number of night awakenings and general
sleep patterns. Subjective measures of sleep quality and
daytime alertness were gathered using a visual analogue scale.
During the intervention period, all residents received 3 mg of
melatonin orally daily, 30 minutes before retiring to bed. No
improvements in night-time sleep variables or daytime
alertness were reported for the group with dementia. The
improvement in sleep for residents with depression at day 19
suggests that melatonin therapy may not have an immediate
effect and studies should be conducted over longer time
frames.
Interestingly, few studies were identified that investigated
the effectiveness of sedatives and hypnotics as management
for sleep disturbances in the population of interest. Alessi
et al. (1995) recruited 176 nursing home residents to
investigate the relationship between psychotropic medication
use and both sleep quantity and night-time bed mobility. No
significant differences in night or day sleep were found
between those residents receiving psychotropics (n ¼ 62) and
those who did not (n ¼ 114), or in average sleep duration or
average peak sleep duration. In their study involving residents
from 12 nursing homes, Monane et al. (1996) did not find
support for medications (specifically long-term use of sedat-
ive-hypnotics, neuroleptics and/or antidepressants) as pro-
moting sleep in this population. Shelton and Hocking (1997)
focussed on a specific non-benzodiazepine hypnotic, zolpi-
dem titrate and suggested that it is effective in promoting
sleep in cognitively impaired nursing home residents. How-
ever, as their conclusion was based on anecdotal evidence
(two case studies), further research is warranted to substan-
tiate this claim.
Discussion
This systematic review is instrumental in delineating areas
where further research is needed, regarding the diagnosis of
1273
S Koch et al.
sleep disturbance and promotion of sleep in older adults
residing in high-level care. The review was unable to provide
any recommendations on the most effective tools for the
diagnosis of sleep disturbances in older adults residing in
high-level care. In terms of promoting sleep, the review was
unable to make recommendations regarding the efficacy of
exercise, daytime activity, aromatherapy and melatonin in
aiding sleep in the population of interest. Further research
into these areas is clearly warranted.
It was noted that few studies investigated resident
satisfaction with sleep. Whist objective variables such as
amount of time spent sleeping and the number of night
awakenings were investigated in studies, it is not clear
whether improvement in these outcomes translated to
increased resident satisfaction with sleep. Resident satisfac-
tion is increasingly being recognized as worthy of study,
with some studies already focussing on resident satisfaction
with pain management (Casarett et al. 2002) and incontin-
ence and mobility care (Simmons & Schnelle 1999). As
such, it makes sense that resident satisfaction with sleep
should also be considered.
Conclusion
Staff working in residential aged care facilities need to
consider strategies to promote sleep in older residents. Using
a combination of interventions to promote sleep appears to
be a promising strategy, a finding that is supported by
informed opinion (e.g. Schnelle et al. 1998a, Camilleri &
Barrett 2000).
Contributions
Study design: SK; data analysis: EH, AT and manuscript
preparation: JW, EH, SK.
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