A need for comprehensive care planning for excessive daytime sleepiness symptoms in older adults who receive long-term services and support

Excessive daytime sleepiness, sleep disturbance, and circadian rhythm disruptions are extremely common among older adults in both the general population and in long-term care facilities. Approximately, 20%–30% of older adults experience excessive daytime sleepiness (Ohayon, 2012; Young, 2004). Ohayon et al. (2012) identified several factors associated with daytime sleepiness in the general population, including being female, having cancer, heart disease, psychological disorders, and short sleep duration, as well as sleep disorders, such as sleep disordered breathing, restless leg syndrome, and insomnia. Daytime sleepiness is associated with a higher risk of developing dementia, cognitive dysfunction, and poor quality of life (Foley et al., 2001; Gooneratne et al., 2003; Jaussent et al., 2012; Webster et al., 2020). Older adults who require long-term services and support typically have chronic illnesses, disabilities, and difficulties performing activities of daily living independently, and importantly, an estimated up to 69% experience excessive daytime sleepiness (Brewster et al., 2019; Martin et al., 2006; Tan et al., 2015). Thus, it is important to understand excessive daytime sleepiness and the contributing factors to develop interventions for older adults who receive long-term services and support. Excessive daytime sleepiness is the increased propensity to sleep during the daytime including frequent napping or unintentional dozing. The concept includes three dimensions: perceived daytime sleepiness, propensity to fall asleep in active or less calming environments where falling asleep is inappropriate, and sleepiness where the propensity to fall asleep is acceptable (Kim and Young, 2005). The homeostatic and circadian process drives sleepiness and wakefulness and determines sleep and wake cycles. However, daytime sleepiness among older adults is a complex condition that is explained by multiple personal, age-related, medical, and environmental factors. Neurodegeneration of the suprachiasmatic nucleus in the hypothalamus from aging can lead to reduced circadian amplitude, and, in turn, reduce signals for wakefulness and sleeping (Dijk and von Schantz, 2005). Older adults have circadian phase advances that lead to the tendency to fall asleep earlier in the evening and wake up in the middle of the night or in the early morning (Dijk and von Schantz, 2005). Excessive daytime sleepinessmay also be symptomatic of an underlying chronic illness, psychological disorder, neurodegenerative condition, or sleep disorder (Zalai et al., 2017). Medications, such as psychiatric, cardiac, or pain medications may also increase sleepiness in the daytime. Long-term care environments may also interfere with sleep and wake cycles and increase excessive daytime sleepiness. Older people in nursing homes are often exposed to an extended time spent in bed, physical inactivity, disruptive nighttime experiences (e.g., noise, light, roommate-related issues, room checks or continence care, medication schedules). and poor sleep hygiene, all of which may contribute to excessive daytime sleepiness (Lorenz et al., 2011). Martin et al. (2006) found that long-term care residents spent nearly one-third of the day in their rooms, were nearly always in bed, and almost never went outdoors. They also found that residents who required more help with activities of daily livings were more likely to sleep excessively; residents who slept excessively were less engaged in activities; and those with weak rest–activity consistencies slept more during the day, slept less at night, and were less socially active during the day. Reduced daytime activities, lack of social engagement, and exposure to sleep-inducing situations such as watching TV may also play a role in increased daytime sleepiness. Thus, older adults in long-term care settings may have insufficient levels and types of environmental stimulation to remain alert compared to younger adults (Kim and Young, 2005). In brief, older adults who rely on long-term services and support may experience multiple agerelated, medical, and personal factors that place them at higher risk for daytime sleepiness. These factors may be further complicated by long-term care residential features that impact the person’s ability to both sleep well at night and remain active and engaged during the day. These features may also contribute to daytime sleepiness. Thus, it is International Psychogeriatrics (2020), 32:7, 799–801 © International Psychogeriatric Association 2020