The relationship between falls and sleep
Sleep deficiency increases older adults’ risk of falls (St George et al 2009; Stone et al 2008; Stone, Ensrud &Ancoli-Israel 2008; Teo et al 2006) and, as a result of many physiological, socio-cultural and environmental aspects of aging, is very common (Tractenberg, et al 2003; Wolkove et al 2007). Sleep deficiency in older adults contributes to depression, social isolation, reduced strength and postural stability, diminished insight about risk behaviors, and decreased concentration and problem solving; all of these, in turn, increase the likelihood of falls. This reciprocal relationship between sleep and risk for falls offers an opportunity to decrease older adults’ likelihood of falling by addressing their sleep deficiency. However, it appears that few falls risk assessment tools include any questions to identify potential modifiable sleep problems (Brown et al 2014). Additionally, we know that sleep problems for many older adults, and particularly those persons with dementia (Brown et al 2014) are under-assessed and therefore, undertreated. This means that reversible sleep-related risk factors for older adults’ likelihood of falling go unaddressed.
To learn more about the science behind sleep and risk of falling click on these links:
1) http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2869.2010.00867.x/pdf Mesa et al (2011) Self-reported sleep duration and falls in older adults. Journal of Sleep Research, Volume 20, Issue 1pt1, pages 21–27
2) Falls, sleep and older women. http://www.medicalnewstoday.com/articles/120575.php
3) Hill et al (2006) Sleep disturbances and falls in older adults J Gerontol A Biol Sci Med Sci (2007) 62 (1): 62-66. http://biomedgerontology.oxfordjournals.org/content/62/1/62.short
*Where can I get more information about sleep?
1) The Canadian Sleep Society has brochures on sleep and sleep apnea you can download for free http://css-scs.ca/menu/education-and-information/brochures. As well they provide a 78 page booklet with detailed information about how we sleep, what interferes with sleep and how we can improve our sleep http://css-scs.ca/images/brochures/Insomnia_Adult_Child.pdf. The Canadian Sleep Society also provides more detailed scientific reviews in their series “Insomnia Rounds” http://css-scs.ca/menu/education-and-information/insomnia-rounds one of which is specific to Sleep and Older Adults http://css-scs.ca/downloadfolder/150-004_Eng.pdf .
2) A team of researchers lead by Dr Cary Brown at the University of Alberta created a website to help family members and healthcare providers to understand sleep problems in persons with dementia http://www.sleep-dementia-resources.info/ . The website contains audio visual clips, reports and a section of evidence based, non-medication approaches to help improve sleep of persons with dementia.
3) American Psychological Association- Older Adults and Insomnia Guidelines http://www.apa.org/pi/aging/resources/guides/insomnia.aspx
* What specific factors about sleep increase the risk of falls?
- Napping (St George, Ret al. 2009)
- Short nighttime sleep duration and increased sleep fragmentation (Stone, et al 2008)
- Nocturia (Teo, et al. 2006)
*Why is daylight so important when someone has sleep problems? Basically daylight (bright light at the blue end of the spectrum) helps regulate the hormones that tell our bodies to sleep or be alert. Too much bright light at night tells the body to stay awake – not what we want at all! For more details about the role light plays in sleep clink on this website- https://www.youtube.com/watch?v=OHnGbTk9qOM.
* What evidence based non-medication interventions are recommended to help improve sleep? A recent review of the evidence found that there was sufficient evidence to use light, activity and passive body warming. That is not to say that other interventions would not work but they have not been well tested yet. The best place to start is making that the bedroom is dark, quiet and cool. For details about this see the Sleep and Dementia Resources website http://www.sleep-dementia-resources.info/
*How can I assess for sleep problems? Assessment of sleep deficiency in older adults requires a team effort- the patient, family and healthcare providers can all play a role. The best place to start is with a sleep diary http://www.helpguide.org/life/pdfs/sleep_diary.pdf so you and the patient can track changes and patterns. There are also a number of standardized self-report tools that can help you gain a better understanding of what type of sleep problems your patient is having. The Pittsburg Sleep quality Index is perhaps the most widely used http://www.aurora.edu/documents/wellness/toolbox/assessment.pdf .
Even collecting some basic information about whether the person feels they sleep well, if they feel rested and if the snore can help the healthcare team determine if a referral to a more specialized service is required.
Unfortunately few of the standardized falls risk assessment tools include basic sleep screening questions. However you can add these questions for yourself and lobby falls’ risk assessment teams and policy developers to incorporate sleep screening into their best-practice guidelines.
Brown, C., et al., Healthcare Providers’ Knowledge of Disordered Sleep, Sleep Assessment Tools, and Nonpharmacological Sleep Interventions for Persons Living with Dementia: A National Survey. Sleep Disorders, 2014. 2014(Article ID 286274): p. 1-9.
St George, R.J., et al., Sleep Quality and Falls in Older People Living in Self- and Assisted-Care Villages. Gerontology, 2009. 55(2): p. 162-168.
Stone, K.L., et al., Actigraphy-measured sleep characteristics and risk of falls in older women. Arch Intern Med, 2008. 168(16): p. 1768-75.
Stone, K.L., K.E. Ensrud, and S. Ancoli-Israel, Sleep, insomnia and falls in elderly patients. Sleep Med, 2008. 9 Suppl 1: p. S18-22.
Teo, J.S., et al., Do sleep problems or urinary incontinence predict falls in elderly women? Aust J Physiother, 2006. 52(1): p. 19-24.
Tractenberg, R.E., et al., The Sleep Disorders Inventory: an instrument for studies of sleep disturbance in persons with Alzheimer’s disease. J Sleep Res, 2003. 12(4): p. 331-7.
Wolkove, N., et al., Sleep and aging: 2. Management of sleep disorders in older people. CMAJ, 2007. 176(10): p. 1449-54.