More daytime sleeping predicts less functional recovery among older people undergoing inpatient post-acute rehabilitation.

STUDY OBJECTIVES: To study the association between sleep/wake patterns among older adults during inpatient post-acute rehabilitation and their immediate and long-term functional recovery DESIGN: Prospective, observational cohort study. SETTING: Two inpatient post-acute rehabilitation sites (one community and one Veterans Administration). PARTICIPANTS: Older patients (aged > or = 65 years, N = 245) admitted for inpatient post-acute rehabilitation. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Based on 7-day wrist actigraphy during the rehabilitation stay, mean nighttime percent sleep was only 52.2% and mean daytime percent sleep was 15.8% (16.3% based on structured behavioral observations). Using the Pittsburgh Sleep Quality Index (PSQI), participants reported their sleep was worse during rehabilitation compared to their premorbid sleep. Functional recovery between admission and discharge from rehabilitation (measured by the motor component of the Functional Independence Measure) was not significantly associated with reported sleep quality (PSQI scores) or actigraphically measured nighttime sleep. However, more daytime percent sleep (estimated by actigraphy and observations) during the rehabilitation stay was associated with less functional recovery from admission to discharge, even after adjusting for other significant predictors of functional recovery (mental status, hours of rehabilitation therapy received, rehospitalization, and reason for admission; adjusted R2= 0.267, P < 0.0001). More daytime sleeping during rehabilitation remained a significant predictor of less functional recovery in adjusted analyses at 3-month follow-up. CONCLUSIONS: Sleep disturbance is common among older people undergoing inpatient post-acute rehabilitation. These data suggest that more daytime sleeping during the rehabilitation stay is associated with less functional recovery for up to three months after admission for rehabilitation.

Sleep in assisted living facility residents versus home-dwelling older adults.

BACKGROUND: Sleep problems among assisted living facility (ALF) residents are not well understood, and sleep-related differences between ALF residents and home-dwelling older adults have not been examined. METHODS: We compared sleep patterns in 19 ALF residents to sleep patterns in 19 matched home-dwelling older people (age > or =65 years). All were participating in the follow-up portion of a longitudinal study of sleep and functional outcomes following post-acute rehabilitation. Sleep was assessed with the Pittsburgh Sleep Quality Index and 1 week of wrist actigraphy. RESULTS: By actigraphy, ALF residents awoke earlier in the morning and exhibited more nighttime awakenings compared to home-dwelling participants (06:50 hours +/- 1:29 hours vs 07:51 hours +/- 1:19 hours and 19.5 +/- 8.5 vs 12.9 +/- 11.4 awakenings, respectively). CONCLUSIONS: Larger studies are needed to confirm these initial findings that ALF residents have more disrupted sleep than do home-dwelling older persons, and to examine the functional and health consequences of poor sleep among ALF residents.

What is the proper use of hemoglobin A1c monitoring in the elderly?

Diabetes mellitus (DM) is a major health problem for the aging population. Glycemic control is fundamental to the management of diabetes, as glycemic levels are closely linked to development of diabetes-related complications. Measurement of the hemoglobin A1c (A1c) to assess chronic glycemic control is an integral component of diabetes care. Currently, there is no clear evidence that age alters the relationship between A1c and average blood glucose. The Diabetes Control and Complications trial and the United Kingdom Prospective Diabetes Study are the 2 main studies that have provided evidence leading to the widespread recommendation of A1c monitoring. The American Diabetes Association recommends achieving an A1c level of 7% or lower. However, older diabetics represent a heterogeneous population ranging from frail nursing home residents to active community-dwelling elderly with variable life expectancies. One needs to look at the individual in order to best balance risk versus benefit associated with tight glycemic control. Benefits of intensive therapy in an effort to lower A1c must always be weighed against the greater risk of disabling and unpredictable hypoglycemia, as the geriatric population is less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.

Daytime sleeping, sleep disturbance, and circadian rhythms in the nursing home.

OBJECTIVE: This study reports the frequency of abnormal daytime sleeping and identifies factors related to daytime sleeping, nighttime sleep disturbance, and circadian rhythm abnormalities among nursing home residents. METHODS: The authors conducted secondary analysis of data collected under usual care conditions within a nonpharmacologic sleep intervention trial. All residents from four Los Angeles nursing homes were screened for daytime sleeping (asleep>or=15% of observations, 9:00 am-5:00 pm). Consenting residents with daytime sleeping had two nights of wrist actigraphy to assess nighttime sleep disturbance (asleep<80%, 10:00 pm-6:00 am). Residents with nighttime sleep disturbance completed an additional 72-hour wrist actigraphy recording to assess circadian activity rhythms and light exposure. RESULTS: Sixty-nine percent of 492 observed residents had daytime sleeping, of whom 60% also had disturbed nighttime sleep. Sleep disturbance and daytime sleeping were rarely documented in medical records. Residents spent one-third of the day in their rooms, typically in bed, and were seldom outdoors or exposed to bright light. More time in bed and less social activity were significant predictors of daytime sleepiness. Ninety-seven percent of residents assessed had abnormal circadian rhythms. More daytime sleeping and less nighttime sleep were associated with weaker circadian activity rhythms. Later circadian rhythm acrophase (peak) was associated with more bright light exposure. CONCLUSION: Daytime sleepiness, nighttime sleep disturbance, and abnormal circadian rhythms were common in nursing home residents. Modifiable factors (e.g., time in bed) are associated with sleep/wake abnormalities. Mental health specialists should consider the complexity of factors causing sleep problems in nursing home residents.

What is the proper use of hemoglobin A1c monitoring in the elderly?

Diabetes mellitus (DM) is a major health problem for the aging population. Glycemic control is fundamental to the management of diabetes, as glycemic levels are closely linked to development of diabetes-related complications. Measurement of the hemoglobin A1c (A1c) to assess chronic glycemic control is an integral component of diabetes care. Currently, there is no clear evidence that age alters the relationship between A1c and average blood glucose. The Diabetes Control and Complications trial and the United Kingdom Prospective Diabetes Study are the 2 main studies that have provided evidence leading to the widespread recommendation of A1c monitoring. The American Diabetes Association recommends achieving an A1c level of 7% or lower. However, older diabetics represent a heterogeneous population ranging from frail nursing home residents to active community-dwelling elderly with variable life expectancies. One needs to look at the individual in order to best balance risk versus benefit associated with tight glycemic control. Benefits of intensive therapy in an effort to lower A1c must always be weighed against the greater risk of disabling and unpredictable hypoglycemia, as the geriatric population is less likely to benefit from reducing the risk of microvascular complications and more likely to suffer serious adverse effects from hypoglycemia.

Sleep-waking discharge patterns of neurons recorded in the rat perifornical lateral hypothalamic area.

The perifornical lateral hypothalamic area (PF-LHA) has been implicated in the control of several waking behaviours, including feeding, motor activity and arousal. Several cell types are located in the PF-LHA, including projection neurons that contain the hypocretin peptides (also known as orexins). Recent findings suggest that hypocretin neurons are involved in sleep-wake regulation. Loss of hypocretin neurons in the human disorder narcolepsy is associated with excessive somnolence, cataplexy and increased propensity for rapid eye movement (REM) sleep. However, the relationship of PF-LHA neuronal activity to different arousal states is unknown. We recorded neuronal activity in the PF-LHA of rats during natural sleep and waking. Neuronal discharge rates were calculated during active waking (waking accompanied by movement), quiet waking, non-REM sleep and REM sleep. Fifty-six of 106 neurons (53 %) were classified as wake/REM-related. These neurons exhibited peak discharge rates during waking and REM sleep and reduced discharge rates during non-REM sleep. Wake-related neurons (38 %) exhibited reduced discharge rates during both non-REM and REM sleep when compared to that during waking. Wake-related neurons exhibited significantly higher discharge rates during active waking than during quiet waking. The discharge of wake-related neurons was positively correlated with muscle activity across all sleep-waking states. Recording sites were located within the hypocretin-immunoreactive neuronal field of the PF-LHA. Although the neurotransmitter phenotype of recorded cells was not determined, the prevalence of neurons with wake-related discharge patterns is consistent with the hypothesis that the PF-LHA participates in the regulation of arousal, muscle activity and sleep-waking states.