Quieting Noisy Nursing Homes : Elderly: Study says disruptions are affecting residents’ sleep at four Valley sites. Researchers hope findings will encourage solutions.
Long after midnight, when most of his fellow UCLA medical professors are snugly in bed, John Schnelle pads through the halls of San Fernando Valley nursing homes, slipping into residents’ darkened rooms to see how well they’re sleeping.
Schnelle and a team of researchers are studying how noise, light and other disruptions caused by night work routines at nursing homes affect the sleep of their elderly occupants.
His conclusion: There’s quite a racket in nursing homes after sundown, and it’s keeping residents awake.
In a study of four Valley nursing homes, Schnelle found that occupants were subjected to a nightly cacophony of nurses gabbing, doors slamming and agitated patients shrieking. On average, residents were startled by 32 loud noises each night, he found.
“People are yelling at each other down the hall--'Bring me a Diet Coke!’ A loud cart is being rolled down the hall, someone’s using the intercom,” said Schnelle, director of UCLA’s Borun Center for Gerontological Research.
While such interruptions would be mere nuisance if they occurred only occasionally, they can have serious consequences for elderly people confined to nursing homes for months or years, he said. Long-term exposure to noise and light changes can produce symptoms of sleep deprivation such as depression, poor memory and a weakened immune system, he said.
Schnelle said many nursing-home nurses were trained in hospitals and are just as noisy and intrusive when making night rounds as their hospital counterparts--even to the point of waking people up to give them sleeping pills.
Schnelle’s $1-million study is a joint effort of UCLA and the Jewish Home for the Aging in Reseda, and is being financed by the National Institutes of Health. He is about halfway through the four-year research project.
Elderly people generally do not sleep as soundly as those in other age groups, and previous studies have shown nursing-home residents experience particularly fragmented sleep, often waking up repeatedly during the night.
To test how well his subjects are sleeping, Schnelle straps small, computerized monitors to their wrists. The devices record wrist movement, a measure of sleep. Other sensors are mounted near residents’ heads to gauge noise and light changes in their rooms.
When patients are asleep, Schnelle and his researchers often shadow nursing home staff members as they take vital signs, give medication, change incontinence diapers and turn patients to prevent bedsores. The object is to see how much such routines disturb residents, whose average age is 88.
In a pair of 1993 reports published in the Journal of the American Geriatrics Society, Schnelle said residents slept only two-thirds of the time they were in bed, awakening frequently. Half of their waking episodes of four minutes or longer were caused by caregivers creating noise and light changes on their rounds, according to the studies, which concluded that “the nursing home environment is not conducive to sleep.”
Schnelle, a behavioral psychologist who worked for years in nursing homes, said nurses typically make three or four rounds a night, at two-hour intervals. They enter rooms regardless of whether patients are asleep or awake, switching on lights and talking while repositioning residents or changing them if they’re wet.
On top of rounds, there is usually a shift change at 11 p.m., creating more commotion. Moreover, night workers often converse more loudly than day-shift employees to stay awake themselves, Schnelle said.
But Schnelle said his research shows that many residents frequently shift position in bed on their own power, and don’t need to be awakened for repositioning as much as occurs.
Dr. Joseph Ouslander, associate director of the Borun Center, said nursing aides also wake up residents often to go to the bathroom. But he said research indicates many elderly people won’t go at night, and that they should not be roused.
Schnelle said nursing-home employees are not being malicious in waking up elderly residents so much. Many residents require frequent help at night, either because they are so immobile in bed, are at serious risk of skin breaks or because they are severely incontinent and need changing.
But he said nursing staffs need to be less intrusive on their rounds.
One way, Schnelle said, would be to make rounds more often to check when residents are awake and then perform care routines, rather than operating on a fixed schedule that does not account for whether patients are awake or asleep.
Another: Just be quieter.
“We make a major effort to keep the staff quiet,” Schnelle said. “If there’s a lot of loud talk at the nurses’ station, we’ll shush [them]. If they’re using the intercom after 9 p.m., we’ll ask them not to do that.
“This might seem like common sense,” he said. “But the reality is, [nursing homes are] just like hospitals. The people who work in these places are not highly sensitive to sleep issues.”
But employees are not the only source of the late-night hubbub. Schnelle’s research indicates that 39% of loud noise at night is made by residents themselves, especially those with advanced Alzheimer’s disease who often scream spontaneously.
Pamela Parsons, administrator of the Sherman Oaks Convalescent Hospital, where Schnelle is conducting his current research, acknowledged that her night staff makes a certain amount of noise. But, she said, the hospital also has made significant efforts to keep things quiet.
Staff members have been trained to perform their work less intrusively, carpeting has replaced vinyl flooring and nurses often use flashlights when entering a room, rather than flip on the lights, Parsons said.
The hospital, she said, tries to put residents who need frequent nighttime care in the same room so that those who don’t need as much attention can sleep. The institution also has a “very vocal” residents’ council, whose members don’t hesitate to complain to staff members, she said.
But Schnelle said nursing-home dwellers are often very frail or suffer from Alzheimer’s or dementia and cannot speak up for themselves.
His researchers are working with an engineer to develop a sensor that could provide instant feedback if noise exceeds certain levels in residents’ rooms. The device, which would be mounted on a wall, would alert employees both at nursing stations and in the halls to be quieter.
Schnelle said researchers are now studying whether making nursing homes quieter at night actually improves residents’ health. They are tested for sleep deprivation by being taken into a quiet room during daytime to see how fast they fall asleep. Preliminary data indicates that those in quieter environments at night are less drowsy during the day, Schnelle said.
He said he hopes to translate the results of his study into manuals and software to help nursing-home staffs disturb their patients less during rounds.
“They are not insensitive, they are not beasts,” he said. “They just don’t know what to do.”