DOI: 10.1111/j.1741-6612.2007.00260.x Australasian Journal on Ageing, Vol 26 No 4 December 2007, 201–204 201 © 2007 The Authors Journal compilation © 2007 ACOTA Blackwell Publishing Asia Innovations in Aged Care Assessment of insomnia in high level residential aged care facility residents Samuel C Scherer, Jeanette Rule, Melanie Fischer, Elizabeth Jacobs, Lois Dobson, Heather de la Rue, Michael Browning and Josephine Duffus Royal Freemasons’ Homes of Victoria, Melbourne, Victoria, Australia Stephen J Gibson National Ageing Research Institute, Melbourne, Victoria, Australia Peteris Darzins Monash University, Melbourne, Victoria, Australia Insomnia is common in nursing home settings but assessment and management of sleep disturbance is often suboptimal. New assessment procedures that target potentially remediable clinical causes of insomnia were implemented and evaluated at two high level residential aged care Facilities (HLRACFs) (formerly called nursing homes), in Melbourne, Australia. Fifty-eight of 147 residents (39%) who complained of insomnia, or were nominated by nursing staff as having disturbed sleep, and had confirmation of sleep disturbance on overnight sleep log, were provided with a structured assessment protocol. A multidisciplinary team then considered the causes of each resident’s insomnia. A potentially remediable medical or psychiatric cause was identified in 66% of residents with insomnia. More than one such factor was identified in 34%. Pain was a likely factor in 39%. Depression was a likely factor in 30%. Insomnia, depression and pain were significantly correlated. Key words: assessment, insomnia, nursing home, sleep disturbance. Introduction Two-thirds of nursing home residents are dissatisfied with their sleep [1], and insomnia has important adverse consequences [2], but there are few if any clearly effective approaches to the management of insomnia in the nursing home population [3]. Although insomnia becomes more common with age, epidemi- ological data do not support a model of insomnia caused by the ageing process per se [4], and clinicians may be inappro- priately attributing sleep disturbance to ageing, rather than age-related illnesses commonly seen in nursing home populations [5]. Aim To develop and evaluate new procedures that can target potenti- ally remediable clinical causes of insomnia in high level residential aged care facilities (HLRACFs) (formerly called nursing homes). Method New assessment and management procedures for residents with insomnia were introduced at two HLRACFs (75 and 72 beds, respectively) in Melbourne, Australia, between August 2005 and January 2006. The initiative was a quality of care innovation and evaluation, rather than research, and was approved as such by members of the Research and Ethics Committee of the Freemasons’ Hospital, Melbourne. Whole- of-facility sleep hygiene and staff and resident education initiatives were also introduced, but this report is confined to the new clinical assessment procedures that were employed. Resi- dents and their representatives and doctors received written information about the introduction of the new procedures. Cognitively able residents who expressed dissatisfaction with their sleep, as well as residents with dementia who displayed recurrent disturbed nocturnal behaviours, had their age, sex, Mini-Mental State Examination (MMSE), medical history and current medications recorded and were given the following structured assessment: 1 An hourly sleep log was recorded by nursing staff from 19.00 hours to 08.00 hours on a convenient night. Timed behavioural observations of whether residents are asleep or awake have previously been shown to have method- ological validity in the nursing home setting [6]. The sleep log proforma also prompted staff to record residents’ comments and behaviours, responses to care routines and any signs of primary sleep disorders. 2 Cognitively able residents completed the Sleep Impairment Index (SII): a self-rating scale with seven questions about sleep, which provides a quantitative index of insomnia severity. The SII has been validated in older people in com- munity settings [7]. 3 Residents unable to provide a valid self-report had the Nighttime Behaviour Scale (NBS) – a subscale within the Neuropsychiatric Inventory (NPI) – completed by nursing staff [8]. The NPI NBS has eight questions about night-time sleep problems and behaviours of residents. A calculation of the product of the NBS frequency and severity scores has previously demonstrated concurrent validity with an independent Sleep Questionnaire [9]. 4 The Brief Pain Inventory (BPI) [10] is a validated multi- dimensional instrument which was employed in a modified Correspondence to: Dr Samuel Scherer, Royal Freemasons’ Homes of Victoria. Email: sams@freemasons.net.au Alternate correspondent: Ms Jeanette Rule, Royal Freemasons’ Homes of Victoria. Email: jrule@freemasons.net.au