Use of sleep-promoting medications in nursing home residents: Risks versus benefits

Drugs and Aging

Volumn 23, Issue 4, 2006, Pages 271-287

  Conn, David K ^a,b   Madan, Robert ^a,b  

^a BAYCREST CENTRE FOR GERIATRIC CARE   (Canada)

^b UNIVERSITY OF TORONTO   (Canada)

Author keywords

[No Author keywords available]

Indexed keywords

ATYPICAL ANTIPSYCHOTIC AGENT; BENZODIAZEPINE; DIAZEPAM; ESZOPICLONE; HYPNOTIC AGENT; MELATONIN RECEPTOR; OXAZEPAM; PSYCHOTROPIC AGENT; RAMELTEON; TRAZODONE; UNCLASSIFIED DRUG; ZALEPLON; ZOLPIDEM; ZOPICLONE;

AGING; BEHAVIOR THERAPY; COGNITIVE DEFECT; COGNITIVE THERAPY; DEMENTIA; DEPRESSION; DRUG DEPENDENCE; DRUG TOLERANCE; ELDERLY CARE; ENVIRONMENT; FALLING; HEALTH SURVEY; HUMAN; HYGIENE; INSOMNIA; LEG DISEASE; LIMB MOVEMENT; MENTAL DISEASE; NOISE; NURSING HOME; PREVALENCE; PRIORITY JOURNAL; PSYCHOMOTOR DISORDER; PSYCHOSIS; REVIEW; SEDATION; SEX DIFFERENCE; SLEEP APNEA SYNDROME; SLEEP DISORDER; SLEEP INDUCTION;

AGED; DRUG UTILIZATION; ENVIRONMENT; HOMES FOR THE AGED; HUMANS; HYPNOTICS AND SEDATIVES; NURSING HOMES; PSYCHOTROPIC DRUGS; RISK ASSESSMENT; SLEEP DISORDERS; SLEEP INITIATION AND MAINTENANCE DISORDERS;

EID: 33744826261     PISSN: 1170229X     EISSN: 1170229X     Source Type: Journal    
DOI: 10.2165/00002512-200623040-00001     Document Type: Review

References (127)

1. National Institutes of Health. The treatment of sleep disorders of older people. NIH Consens Statement 1990 Mar 26-28; 8 (3): 1-22
2. Foley DJ, Monjan AA, Brown SL, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995; 18: 425-32
3. Foley DJ, Monjan A, Simonsick EM, et al. Incidence and remission of insomnia among elderly adults: an epidemiologic study of 6800 persons over three years. Sleep 1999; 22 (2): S366-72
4. Monane M. Insomnia in the elderly. J Clin Psychiatry 1992; 53 (6): 23-8
5. Ohayon MM, Carskadon MA, Guilleminault C, et al. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep 2004; 27 (7): 1238-9
6. Prinz PN, Vitello MV, Raskind MA, et al. Geriatric sleep disorders and aging. N Engl J Med 1990; 323 (8): 520-6
7. Folks DG, Fuller WC. Anxiety disorders and insomnia in geriatric patients. Psychiatr Clin North Am 1997; 20: 137-64
8. Wooten V. Sleep disorders in geriatric patients. Clin Geriatr Med 1992; 8 (2): 427-39
9. Ancoli-Israel S. Insomnia in the elderly: a review for the primary care practitioner. Sleep 2000; 23 (2): S23-30
10. Fitzpatrick MF, Engleman H, Whyte KF, et al. Morbidity in nocturnal asthma: sleep quality and daytime cognitive performance. Thorax 1991; 46: 569-73
11. Janson C, Gislason T, Boman G, et al. Sleep disturbances in patients with asthma. Respir Med 1990; 84: 37-42
12. Asplund R. Sleep and cardiac disease among the elderly. J Intern Med 1994; 236: 65-71
13. Woodward M. Insomnia in the elderly. Aust Fam Physician 1999; 28 (7): 653-7
14. Lees AJ, Blackburn NA, Campbell VL. The nighttime problems of Parkinson's disease. Clin Neuropharmacol 1988; 11: 512-9
15. Nausieda PA, Weiner WJ, Kaplan LR, et al. Sleep disruption in the course of chronic levodopa therapy; an early feature of levodopa psychosis. Clin Neuropharmacol 1982; 5 (2): 183-94
16. Partinen M. Sleep disorder related to Parkinson's disease. J Neurol 1997; 244 (1): S3-6
17. Mohsenin V, Valor R. Sleep apnea in patients with hemispheric stroke. Arch Phys Med Rehabil 1995; 76: 71-6
18. Ancoli-Israel S. All I want is a good night's sleep. Chicago (IL): Mosby-Year Book Inc., 1996
19. Brower KJ. Insomnia, alcoholism, and relapse. Sleep Med Rev 2003; 7 (6): 523-39
20. Vitiello MV. Sleep, alcohol, and alcohol abuse. Addict Biol 1997; 2: 151-8
21. Ancoli-Israel S. Epidemiology of sleep disorders. In: Roth T, Roehrs TA, editors. Clinics in geriatric medicine. Philadelphia (PA): WB Saunders, 1989: 347-62
22. Ancoli-Israel S, Kripke DF, Klauber MR, et al. Sleep disordered breathing in community-dwelling elderly. Sleep 1991; 14: 486-95
23. Ancoli-Israel S, Kripke DF, Klauber MR, et al. Periodic limb movements in sleep in community-dwelling elderly. Sleep 1991; 14: 496-500
24. Mayeux R, Sano M. Drug therapy: treatment of Alzheimer's disease. N Engl J Med 1999; 341 (22): 1670-9
25. Vitello MV, Bliwise DL, Prinz PN. Sleep in Alzheimer's disease and the sundown syndrome. Neurology 1992; 42 (6): 83-94
26. Little JT, Satlin A, Sunderland T, et al. Sundown syndrome in severely demented patients with probable Alzheimer's disease. J Geriatr Psychiatry Neurol 1995; 8: 103-6
27. Volicer L, Harper DG, Maning BC, et al. Sundowning and circadian rhythms in Alzheimer's disease. Am J Psychiatry 2001; 158 (5): 704-11
28. Stopa EG, Volicer L, Kuo-Leblanc V, et al. Pathological examination of the human suprachiasmatic nucleus in severe dementia. J Neuropathol Exp Neurol 1999; 58: 29-39
29. Chokroverty S. Sleep and degenerative neurologic disorder. Neurol Clin 1996; 14: 807-26
30. Ancoli-Israel S, Klauber MR, Butters N, et al. Dementia in institutionalized elderly: relation to sleep apnea. J Am Geriatr Soc 1991; 39 (3): 258-63
31. Gehrman PR, Martin JL, Shochat T, et al. Sleep-disordered breathing and agitation in institutionalized adults with Alzheimer disease. Am J Geriatr Psychiatry 2003; 11 (4): 426-33
32. Pollak CP, Perlick D. Sleep problems and institutionalization of the elderly. J Geriatr Psychiatry Neurol 1991; 4: 204-10
33. Schnelle JF, Ouslander JG, Simmons SF, et al. The nighttime environment, incontinence care, and sleep disruption in nursing homes. J Am Geriatr Soc 1993; 41: 910-4
34. Alessi CA, Schelle JF, McRae PG, et al. Does physical activity improve sleep in impaired nursing home residents? J Am Geriatr Soc 1995; 43: 1098-102
35. Ancoli-Israel S, Parker L, Sinaee R, et al. Sleep fragmentation in residents from a nursing home. J Gerontol 1989; 44: M18-21
36. Bliwise DL, Bevier WC, Bliwise NG, et al. Systematic 24-hour behavioral observations of sleep and wakefulness in a skilled-care nursing facility. Psychol Aging 1990; 5: 16-24
37. Pat-Horenczyk R, Klauber MR, Shochat T, et al. Hourly profiles of sleep and wakefulness in severely vesus mild-moderate demented nursing home patients. Aging (Milano) 1998; 10 (4): 308-15
38. Middlekoop HAM, Kerkhof GA, Smilde-Van Den Doel DA, et al. Sleep and ageing: the effect of institutionalization on subjective and objective characteristics of sleep. Age Ageing 1994; 23: 411-7
39. Cohen D, Eisdorfer C, Prinz P, et al. A. Sleep disturbances in the institutionalized aged. J Am Geriatr Soc 1983; 31: 79-82
40. Cruise PA, Schnelle JF, Alessi CA, et al. The nighttime environment and incontinence care practices in nursing homes. J Am Geriatr Soc 1998; 46: 181-6
41. Schnelle JF, Cruise PA, Alessi CA, et al. Sleep hygiene in physically dependent nursing home residents: behavioral and environmental intervention implications. Sleep 1998; 21: 515-23
42. Ancoli-Israel S, Kripke DF. Now I lay me down to sleep: the problem of sleep fragmentation in the elderly and demented residents of nursing homes. Bull Clin Neurosci 1989; 54: 127-32
43. Ancoli-Israel S, Jones DW, Hanger MA, et al. Sleep in the nursing home. In: Kuna ST, Suratt PM, Remmers JE, editors. Sleep and respiration in ageing adults. New York: Elsevier Press, 1991: 77-84
44. Ancoli-Israel S, Klauber MR, Jones DW, et al. Variations in circadian rhythms of activity, sleep and light exposure related to dementia in nursing-home patients. Sleep 1997; 20 (1): 18-23
45. Campbell SS, Kripke DF, Gillin JC, et al. Exposure to light in healthy elderly subjects and Alzheimer's patients. Physiol Behav 1988; 42: 141-4
46. Shochat T, Martin J, Marler M, et al. Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res 2000; 9: 373-9
47. Rovner BW, German PS, Broadhead J, et al. The prevalence and management of dementia and other psychiatric disorders in nursing homes. Int Psychogeriatr 1990; 2 (1): 13-24
48. Brodaty H, Draper B, Saab D, et al. Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001; 16 (5): 504-12
49. Katz IR, Lesher E, Kleban M, et al. Clinical features of depression in the nursing home. Int Psychogeriatr 1989; 1 (1): 5-15
50. Ames D. Epidemiological studies of depression among the elderly in residential and nursing homes. Int J Geriatr Psychiatry 1991; 6 (6): 347-54
51. Payne JL, Sheppard JM, Steinberg M, et al. Incidence, prevalence and outcomes of depression in residents of a long-term care facility with dementia. Int J Geriatr Psychiatry 2002; 17 (3): 247-53
52. Conn DK, Ferguson I, Mandelman K, et al. Psychotropic drug utilization in long-term care facilities for the elderly in Ontario, Canada. Int Psychogeriatr 1999; 11: 223-33
53. Nolan L, O'Malley K. The need for a more rational approach to drug prescribing for elderly people in nursing homes. Age Ageing 1989; 18: 52-6
54. Tyberg J, Gulmann NC. Use of psychopharmaceuticals in municipal nursing homes: a national survey. Ugeskr Laeger 1992; 154: 3126-9
55. Snowdon J, Vaughan R, Miller R, et al. Psychotropic drug use in Sydney nursing homes. Med J Aust 1995; 163: 70-2
56. Wancata J, Benda N, Meise U, et al. Psychotropic drug intake in residents newly admitted to nursing homes. Pharmacology 1997; 134: 115-20
57. Borson S, Doane K. The impact of OBRA-87 on psychotropic drug prescribing in skilled nursing facilities. Psychiatr Serv 1997; 48: 1289-96
58. Tobias DE, Pulliam CC. General and psychotherapeutic medication use in 878 nursing facilities: a 1997 national survey. Consult Pharm 1997; 12: 1401-8
59. Schmidt I, Claesson CB, Westerholm B, et al. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc 1998; 46: 77-82
60. Hosia-Randell H, Pitkälä K. Use of psychotropic drugs in elderly nursing home residents with and without dementia in Helsinki, Finland. Drugs Aging 2005; 22 (9): 793-800
61. Snowdon J. Mental health in nursing homes: perspectives on the use of medication. Drugs Aging 1993; 3: 122-30
62. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm 1990; 47: 533-43
63. Avorn J, Gurwitz JH. Drugs in the nursing home. Ann Intern Med 1995; 123: 195-204
64. Beers MH, Ouslander J, Rollinger I, et al. Explicit criteria for determining inappropriate medication use in nursing home residents. Arch Intern Med 1991; 151: 1825-32
65. Beers MH, Fingold SF, Ouslander JG, et al. Characteristics and quality of prescribing by doctors practicing in nursing homes. J Am Geriatr Soc 1993; 41: 802-7
66. Conn DK. Optimizing the use of psychotropic medications. In: Conn DK, Herrmann N, Kaye A, et al., editors. Practical psychiatry in the long term care facility: a handbook for staff. Toronto (ON): Hogrefe and Huber, 2001
67. Omnibus Budget Reconciliation Act of 1987: subtitle C. Nursing home reform: PL100-203. Washington, DC: National Coalition for Nursing Home Reform, 1987
68. Shorr RI, Gought RL, Ray WA. Changes in antipsychotic drug use in nursing home during implementation of the OBRA-87 regulation. JAMA 1994; 271: 358-63
69. Lantz M, Giambanco V, Buchalter EN. A ten-year review of the effect of OBRA-87 on psychotropic prescribing practices in an academic nursing home. Psychiatr Serv 1996; 47: 951-5
70. Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebo-controlled trials. JAMA 2005; 294 (15): 1934-43
71. Cramer GW, Chaponis RJ, Bauwens S, et al. Evaluation of sleep disorders in nursing facilities. Consult Pharm 1999; 14: 545-56.
72. Craig D, Passmore AP, Fullerton KJ, et al. Factors influencing prescription of CNS medications in different elderly populations. Pharmacoepidemiol Drug Saf 2003: 12: 383-7
73. Eide E, Schjott J. Assessing the effects of an intervention by a pharmacist on prescribing and administration of hypnotics in nursing homes. Pharm World Sci 2001; 23 (6): 227-31
74. Monane M, Glynn RJ, Avorn J. The impact of sedative-hypnotic use on sleep symptoms in elderly nursing home residents. Clin Pharmacol Ther 1996; 59 (1): 83-92
75. Seppala M, Rajala T, Sourander L. Subjective evaluation of sleep and the use of hypnotics in nursing homes. Aging (Milano) 1993; 5 (3): 199-205
76. Clapin-French E. Sleep patterns of aged persons in long-term care facilities. J Adv Nurs 1986; 11 (1): 57-66
77. Holmquist IB, Svenssou B, Hoglund P. Psychotropic drugs in nursing and old age homes: relationships between needs of care and mental health status. Eur J Clin Pharmacol 2003; 59: 669-76
78. Svarstad BL, Mount JK. Effects of residents' depression, sleep, and demand for medication on benzodiazepine use in nursing homes. Psychiatr Serv 2002; 53 (9): 1159-65
79. Martin J, Shochat T, Ancoli-Israel S. Assessment and treatment of sleep disturbances in older adults. Clin Psychol Rev 2000; 20 (6): 783-805
80. Chesson Jr AL, Anderson WM, Littner M, et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep 1999; 22 (8): 1128-33
81. Alessi CA, Yoon EJ, Schnelle JF, et al. A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc 1999; 47 (7): 784-91
82. Alessi CA, Martin JL, Webber AP, et al. Randomized, controlled trial of a nonpharmacological intervention to improve abnormal sleep/wake patterns in nursing home residents. J Am Geriatr Soc 2005; 53 (5): 803-10
83. Ancoli-Israel S, Gehrman P, Martin JL, et al. Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer's disease patients. Behav Sleep Med 2003; 1 (1): 22-36
84. Ancoli-Israel S, Martin JL, Kripke DF, et al. Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. J Am Geriatr Soc 2002; 50 (2): 282-9
85. Satlin A, Volicer L, Ross V, et al. Bright light treatment of behavioral and sleep disturbances in patients with Alzheimer's disease. Am J Psychiatry 1992; 149 (8): 1028-32
86. Morin CM, Colecchi C, Stone J, et al. Behavioral and pharmacological therapies for late-life insomnia: a randomized controlled trial. JAMA 1999; 281 (11): 991-9
87. Holbrook AM, Crowther R, Lotter A, et al. Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ 2000; 162 (2): 225-33
88. Avidan AY, Fries BE, James ML, et al. Insomnia and hypnotic use, recorded in the minimum data set, as predictors of falls and hip fractures in Michigan nursing homes. J Am Geriatr Soc 2005; 53 (6): 955-62
89. Meuleman JR, Nelson RC, Clark Jr RL. Evaluation of temazepam and diphenhydramine as hypnotics in a nursing home population. Drug Intell Clin Pharm 1987; 21 (9): 716-20
90. Agostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med 2001; 161: 2091-7
91. McLeod PJ, Huang AR, Tamblyn RM, et al. Defining inappropriate practices in prescribing for elderly people: a national consensus panel. CMAJ 1997; 156 (3): 385-91.
92. Ray WA, Thapa PB, Gideon P. Benzodiazepines and the risk of falls in nursing home residents. J Am Geriatr Soc 2000; 48 (6): 682-5
93. Landi F, Onder G, Cesari M, et al. Psychotropic medications and risk for falls among community-dwelling frail older people: an observational study. J Gerontol A Biol Sci Med Sci 2005; 60 (5): 622-6
94. National Institutes of Health. National Institutes of Health State of the Science Conference statement on manifestations and management of chronic insomnia in adults, 2005 Jun 13-15. Sleep 2005; 28 (9): 1049-57
95. Swift CG, Swift MR, Hamley J, et al. Side-effect 'tolerance' in elderly long-term recipients of benzodiazepine hypnotics. Age Ageing 1984; 13 (6): 335-43
96. Rothschild AJ. Disinhibition, amnestic reactions, and other adverse reactions secondary to triazolam: a review of the literature. J Clin Psychiatry 1992; 53 Suppl.: 69-79
97. Jenner P, Pratt JA, Marsden CD. Mechanism of action of clonazepam in myoclonus in relation to effects on GABA and 5-HT. Adv Neurol 1986; 43: 629-43
98. Mitler MM, Browman CP, Menn SJ, et al. Nocturnal myoclonus: treatment efficacy of clonazepam and temazepam. Sleep 1986; 9 (3): 385-92
99. Fulda S, Wetter TC. Dopamine agonists for the treatment of restless legs syndrome. Expert Opin Pharmacother 2005; 6 (15): 2655-66
100. Drover DR. Comparative pharmacokinetics and pharmacodynamics of short-acting hypnosedatives: zaleplon, zolpidem and zopiclone. Clin Pharmacokinet 2004; 43 (4): 227-38
101. Heydorn WE. Zaleplon: a review of a novel sedative hypnotic used in the treatment of insomnia. Expert Opin Investig Drugs 2000; 9 (4): 841-58
102. Ancoli-Israel S, Walsh JK, Mangano RM, et al. Zaleplon, a novel nonbenzodiazepine hypnotic, effectively treats insomnia in elderly patients without causing rebound effects. Prim Care Companion J Clin Psychiatry 1999; 1 (4): 114-20
103. Ancoli-Israel S, Richardson GS, Mangano RM, et al. Long-term use of sedative hypnotics in older patients with insomnia. Sleep Med 2005; 6 (2): 107-13
104. Terzano MG, Rossi M, Palomba V, et al. New drugs for insomnia: comparative tolerability of zopiclone, zolpidem and zaleplon. Drug Saf 2003; 26 (4): 261-82
105. Barbera J, Shapiro C. Benefit-risk assessment of zaleplon in the treatment of insomnia. Drug Saf 2005; 28 (4): 301-18
106. Scharf MB, Mayleben DW, Kaffeman M, et al. Dose response effects of zolpidem in normal geriatric subjects. J Clin Psychiatry 1991; 52 (2): 77-83
107. Roger M, Attali P, Coquelin JP. Multicenter, double-blind, controlled comparison of zolpidem and triazolam in elderly patients with insomnia. Clin Ther 1993; 15 (1): 127-36
108. Hemmeter U, Muller M, Bischof R, et al. Effect of zopiclone and temazepam on sleep EEG parameters, psychomotor and memory functions in healthy elderly volunteers. Psychopharmacology (Berl) 2000; 147 (4): 384-96
109. Copinschi G, Akseki E, Moreno-Reyes R, et al. Effects of bedtime administration of zolpidem on circadian and sleep-related hormonal profiles in normal women. Sleep 1995; 18 (6): 417-24
110. Montplaisir J, Hawa R, Moller H, et al. Zopiclone and zaleplon vs benzodiazepines in the treatment of insomnia: Canadian consensus statement. Hum Psychopharmacol 2003; 18 (1): 29-38
111. Tamminen T, Hansen PP. Chronic administration of zopiclone and nitrazepam in the treatment of insomnia. Sleep 1987; 10 Suppl. 1: 63-72
112. Pecknold J, Wilson R, le Morvan P. Long term efficacy and withdrawal of zopiclone: a sleep laboratory study. Int Clin Psychopharmacol 1990; 5 Suppl. 2: 57-67
113. Wortelboer U, Cohrs S, Rodenbeck A, et al. Tolerability of hypnosedatives in older patients. Drugs Aging 2002; 19 (7): 529-39
114. Allain H, Bentue-Ferrer D, Polard E, et al. Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly. Drugs Aging 2005; 22 (9): 749-65
115. Melton ST, Wood JM, Kirkwood CK. Eszopiclone for insomnia. Ann Pharmacother 2005; 39 (10): 1659-66
116. Scharf M, Erman M, Rosenberg R, et al. A 2-week efficacy and safety study of eszopiclone in elderly patients with primary insomnia. Sleep 2005; 28 (6): 720-7
117. Krystal AD, Walsh JK, Laska E, et al. Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia. Sleep 2003; 26: 793-9
118. Sadavoy J. Psychotropic drugs and the elderly: fast facts. New York: WW Norton and Company, 2004
119. Roth T, Stubbs C, Walsh JK. Ramelteon (TAK-375), a selective MT1/MT2-receptor agonist, reduces latency to persistent sleep in a model of transient insomnia related to a novel sleep environment. Sleep 2005; 28 (3): 303-7
120. Erman M, Seiden D, Zammit G, et al. An efficacy, safety, and dose-response study of ramelteon in patients with chronic primary insomnia. Sleep Med 2006; 7 (1): 17-24
121. Tobias DE, Sey M. General and psychotherapeutic medication use in 328 facilities: a year 2000 national survey. Consult Pharm 2001; 16 (1): 54-64
122. Kunik ME, Orengo CA, Molinari V, et al. Trazodone for sleep and agitation in a geropsychiatry inpatient unit. Nurs Home Med 1996; 4: 255-9
123. Mendelson WB. A review of the evidence for the efficacy and safety of trazodone in insomnia. J Clin Psychiatry 2005; 66 (4): 469-76
124. Winokur A, Sateia MJ, Hayes JB, et al. Acute effects of mirtazapine on sleep continuity and sleep architecture in depressed patients: a pilot study. Biol Psychiatry 2000 Jul 1; 48 (1): 75-8
125. Schittecatte M, Dumont F, Machowski R, et al. Effects of mirtazapine on sleep polygraphic variables in major depression. Neuropsychobiology 2002; 46 (4): 197-201
126. Roose SP, Nelson JC, Salzman C. Open-label study of mirtazapine orally disintegrating tablets in depressed patients in the nursing home. Curr Med Res Opin 2003; 19 (8): 737-46
127. Cohen-Mansfield J, Werner P, Freedman L. Sleep and agitation in agitated nursing home residents: an observational study. Sleep 1995; 18 (8): 674-80