It is widely known that increasing age is associated with progressive deterioration in the structure, 24-hour distribution, and quality of sleep (Dement and Vaughan 2000).  Difficulty falling asleep, staying asleep, early awakening and an increase in daytime sleep have all been shown to have a higher prevalence within the older population (Ancoli-Israel et al. 2008; McCrae et al. 2006). Among older people, untreated chronic sleep disturbance degrades quality of later life, inhibits recovery (Ersser et al, 1999) and rehabilitation (Stepanski et al, 2003) following illness, and is an independent risk factor for falls and depression (Leger 1994). 

Given the lack of research concerning the correlates, meanings and management of sleep disturbances in the older population, the SomnIA (Sleep in Ageing) project aimed to undertake a range of studies relating to understanding poor sleep in later life. SomnIA is a four year NDA Collaborative Research Project which comprises eight workpackages aimed at (a) understanding poor sleep in later life in the community and in care homes, (b) devising interventions to help with poor sleep in the community and in care homes, and (c) dissemination through academic and practitioner conferences and workshops, briefing papers and journal articles, and through the creation of a module on ‘Sleep problems in Later Life’ for the Healthtalkonline website (www.healthtalkonline.org).  A figure illustrating the SomnIA workpackage interlinkages is given below.

Figure 1:  SomnIA (Sleep in Ageing) workpackage interlinkages

his article presents key findings from two elements of the SomnIA research project, ‘Poor Sleep among Community Dwelling Older People’ (Workpackage 2) and ‘Determinants of Poor Quality Sleep in Care Homes’ (Workpackage 3).

Poor sleep among community dwelling older people (Workpackage 2)
The primary focus of this part of the SomnIA research was to explore the perspectives and opinions of older men and women with poor sleep who are living in their own homes.   The aims were:

• to provide a detailed understanding of older people's experiences of poor sleep, sleep needs, perceptions of causes of poor sleep quality, strategies used to improve sleep, and attitudes to sleeping medication;  and
• to find out whether aspects of daily living (for example, light exposure, activities, food and drink consumption and social networks) are associated with poor sleep among older people.  

Data collection
Data collection was undertaken in two phases:

• Phase 1 comprised the sending of a self-completion questionnaire to 2400 people, equally divided by gender and age group (65-74 and 75+), via ten GP practices in the Thames Valley area.  The questionnaire contained the Pittsburgh Sleep Quality Index (PSQI) and socio-demographic variables. 
• From those who returned the questionnaire (n=1158) and who indicated their willingness to take part in further studies, 62 men and women with a score of >5 on the PSQI (an indicator of clinically poor sleep) agreed to take part in the next phase of data collection.
• Phase 2 comprised in-depth interviews in respondents’ own homes.  Those who agreed to have extracts of their interviews made available on the healthtalkonline website (www.healthtalkonline.org) were videoed, all other interviews were audio recorded.
• Following the interview, 61 men and women and 15 partners kept a two week audio diary of their sleep patterns.
• They also wore an actiwatch for two weeks (device to detect movement and light) and completed two weeks of sleep, activity and food consumption diaries.

Key findings
When talking to men and women living in their own homes about their poor sleep it was found that they expected their sleep to deteriorate as they aged, and this expectation influenced whether they would seek professional medical help for their poor sleep.  Additionally, there were also many different social factors that influenced how they slept, and how they managed their poor sleep.   Such factors included caring for partners during times of ill health (Arber and Venn, in press), worries and concerns for family, and future concerns about health and financial security.  Three of the key findings are presented here:

1.         Retirement brought opportunities for daytime sleep, but napping was often met with mixed feelings of guilt for wasting time, alongside pleasure at being able to have more energy to do things during the day or evening.  Sleeping during the day was either accepted or resisted, and the rationale for this dichotomous attitude was the desire to be productive and active in later life. Therefore those who resisted daytime sleep did so because it was felt to be a sign of laziness, whereas those who accepted daytime sleep did so because it gave them energy to undertake their daily activities. (Venn and Arber, forthcoming).

2.         Older people often get up in the night to go to the toilet, sometimes several times a night.  This, along with sleeping during the day, was regarded as ‘normal’ in later life, so that they were unlikely to seek medical help, but tried out a range of strategies instead.  These strategies ranged from going to the toilet in the night when they woke up ‘just in case’, rather than out of need;  going to the toilet several times before finally settling down to sleep, and severely restricting fluid intake during the day.

3.         An additional reason for not wanting to visit the doctor for problems sleeping was a concern that sleeping medication would be prescribed. Sleeping tablets, it was believed, would make them feel drowsy during the day and therefore unable to be in control of their daily lives and routines. Women, more than men, tended to explore alternative treatments and remedies for poor sleep, such as over the counter remedies and herbal medicines.

Determinants of poor quality sleep in care homes (Workpackage 3)
The aim of this aspect of the SomnIA research was to provide an insight into how organisational routines and structures of care homes influence residents' sleep, and to identify the determinants of poor quality sleep in care homes.

Data Collection
Ten care homes in the South-East of England participated in the study. The care homes comprised eight nursing homes and two residential care homes. Three homes were owned by a local authority, five by larger care home chains, one was an independent business and one was run by a charity. 145 residents completed one or more of the following:

• Wearing actiwatches (small activity monitors) to record levels of movement for 14 days
• Daily sleep and activity diaries over 14 consecutive days
• The Pittsburg Sleep Quality Index– a self-report sleep quality scale
• General information such as age, gender, amount of support required from care staff, medication and continence care.

In addition, 38 residents from 4 care homes participated in interviews and over 50 care staff across the 10 homes were also interviewed, as were each of the 10 managers. Over 300 hours of observations were also undertaken by researchers which covered the full 24 hours in each care home, with a focus on daytime activities, bedtimes and getting up times.

Key findings
Sleep in a residential care setting needs to be viewed as part of the full 24 hour time period as many residents may fall asleep during the day.  Both the physical and social environment of a care home can impact on a residents’ experience of sleep.  This is combined with individual factors, such as disability, pain, continence and cognition that not only may affect sleep, but also the experience of time spent awake during the night. 

There needs to be raised awareness of the fundamental importance of sleep for older people living in care homes and recognition by care providers of their role in helping residents achieve good sleep quality.  Improvements could be made to social care policy, regulations, care home culture and staff training by adopting the view of care homes as 24 hour care environments and giving equal importance to both day and night-time staffing and care practices.

Time spent in bed and time spent in bed awake.
By analysing the sleep diary data from 125 residents, it was found that the mean time residents spent in bed at night was 10 hours 50 minutes.  Longer hours in bed did not relate to more time spent actually asleep and a high proportion of residents reported spending a number of hours in bed awake each night.  The bedtimes and getting up times for those residents most dependent on staff for support were influenced by staffing levels and shift changes. Staffing levels and shift patterns often did not allow staff to give all residents choice over when they went to bed and got up, so residents compromised to fit in with the care home routine (Luff et al. forthcoming).

Findings have also highlighted how aspects of pain/discomfort, physical disability and continence issues impact on how residents in a care home experience sleep and the night-time. From a resident’s perspective, findings also identify the lack of resources and strategies available to residents to help themselves cope with sleep disruption or wakeful periods in bed, something which is being further addressed in workpackage 7.

Night-time care.
Care practices and routines undertaken at night can significantly impact on sleep quality.  These are linked to issues of monitoring the well-being of residents and risk reduction.  Staff balance resident choice against the care practices required of staff and the needs of the care home, but residents’ sleep is not always prioritised.  For example, regular staff checks are conducted to see if the resident is safe, in distress or needs continence care.  The regularity of these checks and whether they involve waking residents is not currently well balanced against the importance of residents' sleep. 

Living in a care home influences rest/wake patterns of older people.
By comparing the actigraphy from older people living in care homes with that of older people who were self-reported ‘poor sleepers’ living in their own homes, it was found that care home residents had a more fragmented rest/wake pattern, that is, residents were generally more active in the night-time hours and less active in the daytime hours than those in their own home. This is indicative of broken sleep and daytime inactivity or napping. The analysis took into account the health, dependency, continence and age of care home residents.
This finding is important as it suggests that certain aspects of living in a care home relate to residents having broken night-times, which is not only due to their age and frailty (Meadows et al, 2010).

Final project conference
As part of its dissemination plans, key findings from all the SomnIA workpackages will be presented at a day conference ‘Sleep, Well-being and Active Ageing: New Evidence for Policy and Practice’ to be held on 28 October 2010 at Church House Conference Centre, Westminster, London SW1P 3NZ The conference aims to 

• Place 'sleep quality' at the heart of the health, well-being and active ageing agenda
• Influence policy and practice in relation to sleep and night-time care in care homes
• Raise awareness of the importance of the lighting environment for sleep and well-being
• Improve policy and practice in relation to the management of insomnia in primary care
• Demonstrate how a range of novel sensor devices can improve sleep at home and in care homes

For further information, and to book a place, please visit the SomnIA website: http://www.somnia.surrey.ac.uk/conferences.html.

Acknowledgements
The SomnIA (Sleep in Aging) research was funded by the New Dynamics of Aging initiative, a multidisciplinary research programme supported by AHRC, BBSRC, EPSRC, ESRC and MRC (RES-339-25-0009). The authors gratefully acknowledge this support, and the support of colleagues in the SomnIA project.

References

Ancoli-Israel, S., Ayalon, L., and Salzman, C. (2008) Sleep in the elderly: normal variations and common sleep disorders. Harvard Review Psychiatry, 16, 5, 279-86. 

Arber, S. and Venn, S.  (in press) ‘Caregiving at night: Understanding the impact on carers’ sleep’, Journal of Aging Studies.

Dement, W. and Vaughan, C. 2000. The Promise of Sleep, Pan: London.

Ersser, S., Wiles, A., Taylor, H., Wade, S., Walsh, R., Bentley, T. (1999) The sleep of older people in hospital and nursing homes, Journal of Clinical Nursing, 8, 360-368.

Leger, D., Scheuermaier, K., Philip, P., Paillard, M., Guilleminault, C. (2001) Evaluation of quality of life in severe and mild insomniacs compared with good sleepers, Psychosomatic Medicine, 63, 49-55.

Luff, R., Ellmers, T., Eyers, I., Young, E., Arber, S.  (forthcoming) ‘Time spent in bed at night by care homes residents.’  Ageing and Society.

Meadows, R., Luff, R., Eyers, I., Venn, S., Cope, E. and Arber, S. (2010) ‘An actigraphic study comparing community dwelling poor sleepers with non-demented care home residents’, Chronobiology International, 27, 4, 1-13.

McCrae C.S., Rowe, M.A., Dautovich, N.D., Lichstein, K.L., Durrence, H.H., Riedel, B.W., et al. (2006) Sleep hygiene practices in two community dwelling samples of older adults. Sleep, 29, 1551–60.

Stepanski E., Rybarczyk B., Lopez M., Stevens, S. (2003) Assessment and treatment of sleep disorders in older adults: A review for rehabilitation psychologists, Rehabilitation Psychology, 48, 23-36.

Venn, S. and Arber, S. (Forthcoming) Daytime sleep and active ageing in later life.  Ageing and Society.

Contact:  Sue Venn, s.venn@surrey.ac.uk, 01483 689292