PowerPoint Presentation

Sleep Disorders in State Vet HomesHow Interventions Drive Quality and Optimize Resident WellnessMelissa Napier, MS, BSN Judy Borcherdt, BSN, RN, CWCMS

NASVH Charleston, SCJuly 29th, 20141NASVH 2014SoWhy are we here??To learn the SIMPLE tools necessary for your State Veteran Home to develop a program for better sleep to improve your veterans lives.

2 Introduction before bullets for objectives.

Unravel and explain the changes to current diagnostic criteria; ho9w that looks now and how it will look 10 years from nowGood sleep, bad sleep, sleep changes in dementiaWhat can we do? What a SVH in Fayetteville Arkansas didAll about outcomes right? Lets talk quality, surveys, outcomes2NASVH 2014ObjectivesUnderstand current Clinical Practice Guidelines and Standards of Care for the evaluation, treatment, intervention and documentation of sleep disorders in LTC settings.

Describe restful sleep physiology and the pathophysiology related to sleep deprivation on acute and chronic disease states, cognitive function and quality of life measures

Describe non-pharmacologic treatment strategies and their positive effects on Patient Centered Care and caregiver and resident satisfaction

Evaluate how treatment interventions for disrupted sleep can drive quality outcomes for facilities; and physical, cognitive, and wellness outcomes for residents

3 Introduction before bullets for objectives.

Unravel and explain the changes to current diagnostic criteria; ho9w that looks now and how it will look 10 years from nowGood sleep, bad sleep, sleep changes in dementiaWhat can we do? What a SVH in Fayetteville Arkansas didAll about outcomes right? Lets talk quality, surveys, outcomes3NASVH 2014Introduction Most sleep disorders in the Long Term Care setting are secondary to medical conditions or environmental issues.

We will NOT be discussing primary sleep disorders including obstructive sleep apnea, restless-leg-syndrome or periodic limb movement but will discuss when to refer for evaluation.4NASVH 2014ObjectiveUnderstand current Clinical Practice Guidelines and Standards of Care for the evaluation, treatment, intervention and documentation of sleep disorders in LTC settings.

Presented by Melissa Napier, MS. BSN.5NASVH 2014National GuidelinesAMDA The Society for Post-Acute and Long-Term Care Medicine, affiliated with the American Medical Association and the American Society of Internal Medicine.Last updated 2005Available from www.adma.com6NASVH 2014Sleep Disorders DefinitionDifficulty in maintaining wakefulness during the day OR abnormal behavior associated with sleep all of which are subjectively or objectively distressing or harmful to the patient or the patients roommate or sleep partner.

Most sleep disorders in LTC are secondary to chronic disease states or environmental factors and will be the focus of this presentation.

7NASVH 2014Classifications: DyssomniasInsomnia:Difficulty falling or staying asleep or early awakeningNon-restorative sleep resulting in impaired function: cognitive, physical or socialOften result of mood disorders or health issueObstructive sleep apnea, restless leg syndrome, periodic limb movementsHypersomnia:Increased sleepiness, usually during the day that causes impairment of functionPrimary hypersomnia is rare in this populationSleep too much or sleep too little8NASVH 2014ClassificationsParasomniasDisorders characterized by abnormal sleep-related behaviors including: nightmares, sleep-terrors, sleepwalkingCircadian Rhythm Sleep Disorders

Twilight Psychosis or Sundowning is NOT a sleep disorder but still requires identification and interventionWont be discussing Parasomnias 9NASVH 2014Risk Factors: A Brief OverviewDementia, elderlyDepression, bipolar disorder, other mental illnessesInadequateExposure to sunlightFamily or social supportPhysical activityMultiple comorbidities especially COPD, CHF, arthritisNeurological diseaseNew admit to LTC facilityMedicationsSigns and Symptoms that could indicate a sleep disorder

Nighttime Signs and SymptomsNoticeable snoringApneic episodes and arousal snortFrequent awakeningsPeriodic, jerking limb movements Talking during sleepWandering

Fun word of the day: somniloquy = sleep talkingLimb movements while asleep or in bed awakeSleep talking: formerly known as somniloquy: maybe sign of stress, depression, fever, sleep-deprivation and can occur with other sleep disorders like REM disorders, or night terrors. Also can be benign.NASVH 201411Signs and Symptoms.Daytime signs and symptomsAbnormal behavior in dementia patients such as agitation, hostility, combativeness Complaints by roommateEarly morning confusion, agitation, headacheFalls, accidents, functional declineImpaired cognitionUncontrolled hypertensionDecreased participation, food and fluid intakeSleep problems in LTC settingsVERY Common

More time in bed-AWAKE: less time in REM sleep with increased fragmentation

Comorbidities and/or medications can increase sensitivity to environmental distractions

Increased interruptions, especially through the night

Increased risk for falling ( self toileting?)

Elevated mortality risk

13Evaluation, AssessmentObtain sleep history through the interview process, utilize a sleep log Determine the characteristics of sleep including routines, quality, history that could indicate issuesRule out external factors like diet, caffeine, exercise, stressAssess impact and physical evaluationSleep observation Review relevant medical conditionsIf a primary sleep disorder is suspected: REFER

External factors include activity, diet, stress, meds, caffeineNASVH 201414Treatment of Sleep DisordersIMPLEMENT non-pharmacologic interventions firstReconsider the need for medications that may be interfering with sleep.INITIATE facility wide sleep program!!Treat the medical conditions that may be an underlying causeMONITOR interventions and re-evaluate as necessaryDOCUMENT per quality and survey standards

15NASVH 2014When to refer to a specialist:When Obstructive Sleep Apnea is suspectedDaytime SymptomsFrequent accidentsMorning headachesExcessive sleepinessRestless leg syndromePeriodic limb movements

Use clinical judgment and observation to determine if diagnostic testing by a specialist is warranted.RLS: NASVH 201416ObjectiveTo describe the physiology of restful sleep and the pathophysiology related to sleep deprivation on acute and chronic disease states, cognitive function and quality of life measures.

Presented by: Judy Borcherdt, BSN, RN, CWCMS 17NASVH 2014Sleep definedThe natural state of rest during which your eyes are closed and you become unconscious. (Merriam Dictionary)

Sleep is a state that creates a heightened anabolic state, accentuating growth and rejuvenation of all physiologic systems. It is observed in all species of living creatures.

A uniform block of time when were not awake

18How many of you slept for at least 7 hour last night? If not.

Think about how you would define sleep???

We may all define sleep differentlyI like the 2nd description as its very simple

Lastscientificone that most of us would have come up with18Sleep and Dementia Leading Age 2014 Session D5Sleep Defined wonderful!19

Like a baby

Take a look at these pictures that may best describe sleep for you.!!19Sleep and Dementia Leading Age 2014 Session D520

never enough!Sleep and Dementia Leading Age 2014 Session D520frustrating!

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Sleep function22

Sleep Cycle23

REM-sleep

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Decrease in REM as we ageAs you can see in this graphThe % of REM sleep decreases as we age.

Infants spend most of their sleep cycle in REM and elderly only about 12-15%Sleep and Dementia Leading Age 2014 Session D524Circadian Rhythm

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Circadian Rhythm:. Latin word- circa- meaning around AND diem meaning day!IS A NATURAL 24 hour CLOCK OF SIGNALING WHEN OUR BODY SHOULD BE AWAKE AND WHEN WE SHOULD BE ASLEEP. IT NATURALLY KICKS INTO RYTHYM. Its influenced by the amount of light entering the eyes, which triggers cells in the brain to produce more or less melatonin (causes drowsiness)

-Circadian Rhythms can influence sleep wake cycles, hormone release, body temp and other important bodily functions. As we age-

DISTURBANCES IN CYCLE WITH NORMAL AGING AND THE PHYSIOLOGICAL EFFECTS OF THE DISEASE.There is a progressive deterioration of circadian rhythms with aging. changes in the sleep wake cycle manifested by reductions in sleep quality and impairment in cognitive performance [1, 2]. exaggeration of age-related changes is seen in Alzheimers Disease (AD) affecting as many as a quarter of patients during some stage of their illness.

As well review in later in the presentation: In LTC facilities-sleep disturbances accompanied by sleepiness during the daytime hours.Sleep disturbances related to negative health outcomes, including risk for falling, and elevated mortality riskResidents are commonly asleep intermittently at all hours of the day, even during mealtime periodsSleep fragmentation both nighttime and daytimeincontinence and other personal care, lights etc

25Sleep and Dementia Leading Age 2014 Session D5Heres what we knowSleep patterns began to drastically change during the Industrial Revolution and the invention of the light bulb

Most everything we know about sleep, weve learned in the past 25 years

Tiny luminous rays from digital alarm clocks can be enough to disrupt the sleep cycle even if you do not fully awaken. The light turns off a neural switch in the brain, causing levels of a key sleep chemical to decline rapidly. FYI- A well known Sleep expert, Dr. Mahowald suggests that anyone who needs an alarm clock is by definition sleep deprived because if the brain had received the amount of sleep it wanted, you would have woken up before the alarm went off.

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Bullet #1- we know that in the 1800s, people actually used to sleep in 2 phases (they would go to bed for a couple hours then awake for a few hours, then back to sleep)

33% of those who drink 4 or more caffeinated beverages daily are designated at risk for sleep apnea

Sleep and Dementia Leading Age 2014 Session D526Do we really knowJust what is the impact of chronic sleep deprivation?

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OH MY!!Weve learned that sleep plays a significant role in our health, but do we really understand the impact?? Lets take a look27Sleep and Dementia Leading Age 2014 Session D5Sleep is a serious matterSleep deprivation can have a disastrous effect, ultimately leading to death.

Seventeen hours of sustained wakefulness leads to a decrease in performance equivalent to a blood alcohol level of 0.05%.

Major disasters attributed to human errors in which sleep-deprivation played a role including the 1989 Exxon Oil Spill off Alaska28The Challenger space shuttle disasterThe Chernobyl nuclear accident 1999, American Airlines Flight 1420 overshot the runway at Little Rock National Airport, killing 11

28Sleep and Dementia Leading Age 2014 Session D5Sleep: a serious matterWell over 100,000 car accidents in North America occur every year due to sleep deprivationleading to 6000 deaths.

Research conducted in 2012 showed: adults who regularly slept less than six hours each night were four times more likely to suffer a stroke than were those who got plenty of sleep.

A recent study of orthopedic surgical residents found that residents were fatigued 48% of the time. Negatively effected performance 27% of the timeIncreased potential risk for medical errors by 22% (Arch. Surg. 2012;147)

29I WANT YOU TO REALLY THINK ABOUT THESE STATS THE NEXT TIME YOU ARE BEHIND THE WHEEL WITH LITTLE SLEEP

READ after 1st bullet---32 million people (17%), said they have fallen asleep at the wheel

RESEARCHADULTS WHO REGULARLY GET LESS THAN 6HRS OF SLEEP-MORE LIKELY TO SUFFER STROKE

ORTHO STUDYINCREASES POTENTIAL RISK FOR MEDICAL ERROR-BY 22% WOW!

Recent book_ Essentialism by Greg McKeown- chapter on sleep: Protecting the Assetyourself!! If protecting or asset is so essential- why do we give up sleep so easily???

Sleep continues to be a serious matter more so as we age!

MYTH- we dont need as much sleep29Sleep and Dementia Leading Age 2014 Session D5Just what happens when we sleep?Biochemical:Hormone secretion

Metabolic rate falls during REM sleepEnergy is conserved Body temperature drops

Protein synthesis and production of complex molecules in the body increase

30Cont.Physiological:Restorative OR recovery phase

Cell division more rapid during NREM

Increase immune function

Neurological:Development of brain cells and formation of new neurons

Connections between brain cells during development

31Physiological:Restorative OR recovery phase-40 per cent of the usual blood flow to the brain is diverted to the muscles to restore energy

OVER 100,000 BILLION OF CELLS RESTORE THEMSELVES IN THEIR 7 YEAR CYCLES. WOUNDS HEAL- WHITE CORPUSCLES SURROUND BACTERIACELL DIVISION MORE RAPID DURING NREM

Increase immune function- CORTICOSTEROIDS BUILD UP OUR RESISTANCE TO INFECTIONS AND TIREDNESSimmune system's increased production of certain proteins during sleep, as the levels of certain agents which fight disease rise during sleep and drop when we are awake.

Sleep and Dementia Leading Age 2014 Session D531

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-Mood swings-Depression

Lets TAKE NOTICE TO COGNITIVE IMPAIRMENT/ CONCENTRATION/ MOOD SWINGS/ IRRITABILITY/ DEPRESSION/ AND

What about wounds that the elderly acquire while in a hospital or LTC facilityour bodies need to repair, new cells need to be generated etc

Dr. Michael Twery, sleep specialist at National Institute of Health says that sleep affects almost every tissue in our bodies.

Risk of Cancer may also be elevated in people who fail to get enough sleep.

In woman, low melatonin levels may be linked to breast cancer.

Decrease production of cytokines, cellular hormones that help to fight infections

Sleep and Dementia Leading Age 2014 Session D532Sleep should not decline as we age, howeverSleep patterns usually change as part of the normal aging process

Increased interruptions, especially through the night

Many times takes longer to fall asleep

Most sleep disruptions are related to physical or psychological conditions and medications

To bed earlier-arise earlier// changes in activity and/or schedule3334

Lets take a look at a snap shot of those areas that effect the sleep cycle as we ageSleep and Dementia Leading Age 2014 Session D534Sleep Duration and Cognition: Preliminary ResultsThe Nurses Health Study

Population: 15,263 woman, at least 70 years of age-study sleep duration at mid-life/later life- free from stroke and depression at the start.

Women with sleep durations less than 6 hours a day or more than 9 hours a day had worse average cognition at old age compared to those with sleep durations of 7 hours a day.

(Presented by Dr.. Devore of the Harvard Nurses Health Study on www.alz.org, 2013)

35Women with sleep durations that change by 2 hours a day or more had worse cognitive function than those with no change

The findings support the following notion: Extreme sleep durations and changes in sleep duration over time may contribute to cognitive decline and early Alzheimers changes in older adults.

Our findings suggest that getting an 'average' amount of sleep, seven hours per day, may help maintain memory in later life and that clinical interventions based on sleep therapy should be examined for the prevention of cognitive impairment."

Elizabeth Devore, ScD Brigham and Womans Hospital, Boston

36Summary and duration and cognition: preliminary resultsSleep and Dementia are Bi-Directional37

SLEEP

Diseases such as Dementia/ Alzheimers can significantly impact the sleep cycle and trigger declines in mental ability One of the unique challenges in researching sleep disturbance as a factor in cognitive decline is: Once patients have developed AD, we do not know if sleep disruption contributes to AD progression or if AD progression contributes to sleep disruption. (Mander BA. Disturbed sleep in preclinical cognitive impairment: cause and effect? SLEEP 2013;36(9))

Sleep in dementia

Almost of all dementia patients have sleep disturbances

Compared to older adults with normal cognition, adults with dementia have:Shorter sleep cycle with greater sleep fragmentationLess deep and REM sleep with reduced sleep efficiencyMore frequent nighttime awakening, wandering, and increased daytime napping More difficulty falling asleep (Feinburg et al., 1967: Moe et al., 1995; Prinz et al., 1982a, 1982b; Vitiello et al., 1990: Mortimore et al., 1992)

Increased severity of dementia is associated with greater sleep fragmentation

38Greater sleep disturbances may predict more rapid cognitive decline.

Greater dementia severity is associated with greater sleep fragmentation

Sleep and Dementia Leading Age 2014 Session D538Sleep in dementiaSundowning: a state of confusion at the end of the day and into the night. Can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering.

Wandering and incontinence are the top two causes of Institutionalization, because the family member has great difficultly taking care of a patient who displays one characteristic or the other (National Sleep Foundation)

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Sundowning refers to a state of confusion at the end of the day and into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering.39Sleep and Dementia Leading Age 2014 Session D5Causes of sleep changes in DementiaThe way that the brain controls sleep may be changed due to the physical changes in the brain

The person may have unmet needs or problems such as pain.

It is also possible that their poor sleep may be linked to breathing or other sleep related problems such as Obstructive Sleep Apnea, Snoring or Periodic Limb Movements.

Some medications may affect sleep (including pain relievers, drugs to treat Dementia, Parkinsons disease and antidepressants.40Sleep and Dementia Leading Age 2014 Session D540Objective To "get back to the basics" and describe non-pharmacologic Patient Centered Care interventions and treatment strategies that caregivers can apply in their facilities to improve QAPI and resident wellness outcomes.

Presented by Melissa Napier, MS, BSN41Back to the basis. How does all of this affect PATIENTS/RESIDENTS THAT WE CARE FOR41NASVH 2014

4242NASVH 2014Facility ReadinessStaff EducationDevelop a cross-pollinated team to evaluate issues INCLUDING family and residents and caregivers to help tailor person-centered care approach for EVERY residentSleep disorders recognition and consequences Interventions to change the current culture of sleep practices and routines in LTC facilities involve common sense.

Environmental enhancementsIndividualized care planningStart with the sleep interviewInterdisciplinary care management: TEAM effort!

Fayetteville, Arkansas SVHUninterrupted Sleep ProgramDeveloped to promote person-centered care and restorative sleep to all Veterans within the Home. Change will help restore dignity, autonomy, privacy, choice, honor, trust and quality of life to those we serve. (Fayetteville Veterans Home Policy)

44Introduce the folks in Arkansas and acknowledge them for this great programSleep interview: what are their preferences /previous routines related to nighttime sleep and nap periods, with preferences incorporated into care plan and re-evaluated as necessaryEvaluate Incontinence3 subgroups of residents related to incontinenceambulatory and can self-toilet during the nightincontinent and can reposition themselvesincontinent but unable to reposition without assistance.

44NASVH 2014 Uninterrupted Sleep ProgramProcessSleep interview preferences incorporated into care plan and re-evaluated as necessary

Evaluate IncontinenceFor incontinence management, switched to superabsorbent, longer wearing, brief/pull-on to keep skin dry, improve skin integrity and allow for longer periods of uninterrupted sleep

Evaluate medical management where changes can occur

45Introduce the folks in Arkansas and acknowledge them for this great programSleep interview: what are their preferences /previous routines related to nighttime sleep and nap periods, with preferences incorporated into care plan and re-evaluated as necessaryEvaluate Incontinence3 subgroups of residents related to incontinenceambulatory and can self-toilet during the nightincontinent and can reposition themselvesincontinent but unable to reposition without assistance.

45NASVH 2014Sample Sleep Interview QuestionsDo you have difficulties falling asleep or maintaining sleep?Do you feel sleepy, tired or fatigued during the day?What is your sleep schedule?How many hours do you sleep at night?How long does it take you to fall asleep How many times do you wake up during a typical night?Do you feel refreshed when you wake up?Do you have loud snoring and do you stop breathing at night?Are your legs restlessness, crawling or aching when trying to fall asleep?Do you repeatedly kick your legs during sleep?Do you act out your dreams?

Sleep in the Geriatric Patient Population p. 54 Table 1Many of these questions are directly related to physiological disorders that can be disrupting sleep46NASVH 2014 Fayetteville: Standard of Care Keep lights to a minimum during checks.Use soft voicesDecrease loud noises from any source i.e. promptly answer call lights and alarmsDont interrupt unless condition warrants.

Eliminate a wake up list altogether in an effort to support the Veterans natural sleep pattern .AM medications: shift medication schedule for meds that can be given anytime of dayAM Blood Sugar: time based on individual needsContinental Breakfast: for early risersEliminate universal, rigid morning routines

47. Assist each Veteran in a non-hurried fashion at the time of arising each morning47NASVH 2014Fayetteville, Arkansas SVHUninterrupted Sleep Study Developed from observation of the following problemsAnger and acting out issuesNon-compliance with overall care and ADLsIncrease in negative psychiatric behaviorsleading to

These behaviors caused an increase in:Anti-psychotic drug administrationTransfers to acute care and psychiatric treatment facilitiesNegative side effects from the medications48Introduce why we have this protocol to discuss and thank the folks in Arkansas for caring enough to develop it and put it into practice48NASVH 2014Study Results: All related to quality..Decrease in anti-psychotic med useReduced admission rate to acute care and psychiatric facilitiesDecrease in anger issuesDecrease in illness related to lack of sleep

Increase in compliance with care including meals, ADLs and PT/OTImprovement in overall wellness of residents

(Jerry Poole, RN, Staff Development/Infection Prevention)49 49NASVH 2014Fayetteville SVH OutcomesLonger periods of uninterrupted sleep.

Staff have more time to do safety rounding during the night and other meaningful and personal care.

Staff/Veteran and family satisfaction.

When asked if they have observed a change in difficult behaviors..

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Comment about behavior50NASVH 2014ObjectiveTo evaluate how treatment interventions for disrupted sleep can drive QAPI (Quality Assurance and Performance Improvement) outcomes for facilities, and physical and cognitive wellness outcomes in veterans.

Melissa Napier, MS, BSN

51Add two rafting slides. Its all about outcomes51NASVH 2014Quality Outcomes of Poor SleepPatient dissatisfaction with sleep quality can significantly decrease overall quality of life and perceived quality of residential care.

Older, fatigued patients are more likely to: Have difficulty with ADLs Experience confusionBe more challenging for caregiversExperience falls and injuryHeal more slowly and have exacerbated acute and chronic illness Daytime sleepiness can also be dangerous. In a large study of older women who self-reported the need for frequent napping during the day, poor sleep was associated with a 30-40% increase in falls (Stone, et al. 2006). 52Find remainder of citation and bullet info. Last bullets will be from trials. POOR SLEEP = INCREASE IN CHRONIC AND ACUTE DISEASES, HOSPITAL ADMISSIONS FOR HEART FAILUREPOOR HEALING, INCREASE IN PAIN, HYPERTENSION, DIABETES AND THE LIST GOES ON AND ON

What does this mean? Decreased quality of life and increased healthcare $$$$$52NASVH 2014Partnership to improve dementia careIn 2012, CMS launched Partnership to Improve Dementia Care in Nursing Partnership:Advancing Excellence in Americas Nursing Homes CampaignAHCA Quality Program and Quality Assurance Performance Improvement (QAPI).

Focus on person-centered care The reduction of unnecessary antipsychotic meds in nursing homes and other care settings.

53In 2012, CMS launched Partnership to Improve Dementia Care in Nursing Homes to promote comprehensive dementia care and therapeutic interventions for nursing home residents with dementia-related behaviors. AHCA Quality Program and Quality Assurance Performance Improvement (QAPI). Programs for un-interrupted sleep fall into place with a person-centered care approach.

53NASVH 20142012 QAPI Goal to Reduce Antipsychotic Med Use(QAPI) standards from the Centers for Medicare and Medicaid Services (CMS) to improve nursing home safety.

Part of CMS Partnership to Improve Dementia Care in Nursing Homes.

AHCA 2012 goal of 15% reduction in the off-label use of antipsychotic drugs in skilled nursing centersOften used in patients with dementia that become agitated or combative Sleep disturbance often a causative factor

54 What is the clinical importance of sleepfor mood, cognitive function, DEPRESSION,distressed behaviors, falls, appetite, healing?

54NASVH 2014QAPI 2012Ohios Long Term Care facilities, for example, have decreased the use of these medications by 8.1% between 2011 and 2013

Well on the way to the goal of a 15% reduction by March 2015. Increasing restful sleep can reduce agitation and the need for sedatives.

55Bullet on QAPI actual title of initiative then bullet the remainder of the infoThis slide should go after Alzheimer's/dementia differentiation slides55NASVH 2014MDS and Sleep (MDS 3.0)Section D0200-ATrouble Falling or staying asleep or sleeping too much

Section J0500-AHow much of the time have you experienced pain or hurting over the last day

Section N0400-DNumber of days during last 7 days that resident has received hypnotic medication56NASVH 2014Performance for facilities and consumers

State Veteran Home commitment to customer service quality and a desire to improve performance:Consumer satisfactionMeeting state survey standards Participating in the Advancing Excellence in Americas Nursing Homes Campaign. Resident review complianceStandard and Compliance Surveys (Ohio LTC Quality Initiative ohio.gov)

5757NASVH 2014Summary

Guidelines for the treatment of sleep disorders in LTC and numerous available resources can help your facility develop an effective program to improve veterans sleep.

The relationship between sleep and aging is a bi-directional one and is a hot topic of current research.

Simple, non-pharmacologic interventions can help reset circadian rhythms and optimize sleep efficiency.

Improving sleep and establishing uninterrupted sleep programs contribute to quality indicators AND resident health and wellness. 5858NASVH 2014Available ResourcesCheck the Back Table For: 5959NASVH 2014Managing sleep disorders in the elderlywww.tnpj.comThe Nurse Practitioner By Judith Townsend-Roccichelli, PhD, et alExcellent physiologic overview of sleep disorders with pharmacological and non-pharmacologic interventions.

6060NASVH 2014Department of Veterans Affairs Evidence Based synthesis programwww.ncbi.nlm.nih.govPublished 2011 for VA Veterans Health Admin. Health Services R&D Service

Practical, evidence-based intervention programs to improve behavioral outcomes in the dementia population

6161NASVH 2014Sleep and Dementiawww.dementiaknowledgebroker.caPublished 2011A report on the evidence-base for non-pharmacologic sleep interventions for persons with dementiaCary A. Brown, et. Al, University of Alberta

6262NASVH 2014Dementia and sleepwww.sleephelthfoundation.orgInformative 2 page handout for patients and caregivers

Presented by the Sleep Health Foundation

6363NASVH 2014NIH Public Access Articlewww.ncbi.nlm.nih.gov Current Treatments for Sleep Disturbances in Individuals With Dementia (Deschenes, C.L. MSN& McCurry, S. M., PhD (Curr Psychiatry Rep.2009)Target audience is medical professionals: evidence-based discussion.

6464NASVH 2014 www.amda.comSociety of the American Medical Association for Post Acute and Long Term Care Medicine.Guidelines for the evaluation and treatment of sleep disorders.$35 from website65

65NASVH 2014Honoring our Veterans with providing Excellent Care66

Thank you!To provide comments or ask further questions, please contact us anytime..

Melissa Napier, MS, BSN mnapier@pbenet.com

Judy Borcherdt, RN, BSN jborcherdt@pbenet.com

6767NASVH 2014