Some members of the interdisciplinary team discussed how they address insomnia in the elderly population. As the authors point out (see story above), insomnia is chronic and prevalent among the elderly. In fact, insomnia is so prevalent it is considered a normal sleep pattern in the elderly. Further, a disordered sleep-wake cycle can be characteristic of advanced dementia. Hypnotic drugs showed statistical benefit but not meaningful clinical benefit in a recent meta-analysis (Br. Med. J. 2005;331:1169–73). In addition, these drugs are associated with daytime sedation, headache, nightmares, and gastrointestinal symptoms. They also are associated with cognitive impairment and falls (odds ratio of 1.54 in an unpublished 2002 A.S.C.P. abstract), especially in nursing home residents. Thus, nonpharmacologic treatments are of interest. A recent study of nonpharmacologic, cognitive behavior therapy in nondemented subjects showed objective polysomnographic improvement in stage 3 and 4 slow-wave sleep (JAMA 2006;295:2851–8). But the intervention required weekly training sessions over 6 weeks, which is not always a practical possibility. This pilot study from the University of Pittsburgh indicates promise for much briefer training in “sleep restriction”—45-minute initial session plus 30-minute follow-up after 2 weeks. However, the study relied on self-reports and sleep diaries, and involved a follow-up of only 6 weeks. Whether benefits could be objectively demonstrated by polysomnography and whether they would persist beyond the 6-week observation period remains to be studied. Likewise, whether benefits could be replicated in a nursing home setting—with more prevalent dementia, comorbidities, disruptive nocturnal milieu, and institutional barriers—should be investigated, not simply assumed. Meanwhile, quiet activities for night-owl residents seems like a good idea either way. A few years ago at the Good Samaritan Center, we formed a Sleep Study Committee, which came up with several good ideas. One major accomplishment was the “sleep log” (see chart, right). It is a user-friendly data collection tool intended to report the resident's activity every hour. After we used the log for no more than 7 days (we found better staff compliance using it for 3 to 5 days), it was discussed at our weekly meeting with our medical director, DON, social worker, dietician, chaplain, activities coordinator, nurse, CNA, pharmacist, QI nurse, and rehab coordinator. We discussed the activity pattern as reflected by the log. We even reviewed the log the next week if there were issues that required follow-up. Some outcomes include finding that changing a morning medication to bedtime helped the resident sleep at night and stay awake during the day. We also have encouraged residents to stay up a little longer and discouraged spending excessive time in bed when not sleeping. We have found since adopting the culture change philosophy and letting our residents sleep as late as they want, many slept better at night and several were less agitated and more alert during the day. In 2004, I served as a panel member in the AMDA Clinical Practice Guideline study for sleep disorders. We found combining educational, behavioral, and cognitive approaches with drug therapy may reduce the utilization of sleep medications. In a study conducted in an institutionalized setting, residents with insomnia were offered nonpharmacologic therapies such as a 5-minute back rub; a warm, noncaffeinated beverage; or the opportunity to listen to a relaxing audiotape. A sleep medication was given if the resident had not fallen asleep within an hour of administration of the nonpharmacologic therapy. This intervention resulted in a 23% reduction in the administration of sedatives and hypnotic medications. There is clinical evidence that certain medications can cause insomnia. It's common for elderly patients to be on 7 or more medications per month. As the number of medications per patient increases, the likelihood of related insomnia also increases. Some of the most common medications that can disturb the normal sleep patterns are anticonvulsants, beta-adrenergic blockers, thyroid hormone preparations, corticosteroids, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, methyldopa, theopylline, caffeine, methylphenidate, estrogen, and some chemotherapeutic agents. The list of medications that can cause some type of insomnia is extensive. Therefore, it is crucial that current prescriptions are evaluated before an intervention (pharmacologic or behaviorial) is initiated for treatment of insomnia.