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Table 3 Characteristics of Included Studies (except multi-component interventions; n = 43)

From: A systematic review of non-pharmacological interventions to improve nighttime sleep among residents of long-term care settings

First author, Year Design, Number of groups, and Study type Setting (number of facilities), Number of participants, Mean age, % male, and Inclusion/exclusion criteria Description of intervention Effect (positive, mixed, none, or negative), Measurement of sleep, Main finding(s)
Clinical care practices (n = 3)
Kim, 2016 [73] Quasi-experimental pre-post intervention with 3 groups (intervention, comparison with placebo of 36.5 ° C water and control) Nursing home (n = 1), N = 30, mean age 85.9, 20% men Adjust core body temperature: 30 min of warm (40 ° C) foot baths in the evening daily for 4 weeks None; Actigraphy; No significant differences in total sleep amount, efficiency, or latency among the 3 groups
O’Rourke, 2001 [25] Quasi-experimental pre-post intervention without comparison Assisted-living facility (n = 2), N = 18, mean age 84.5, 22% men, with incontinence Minimize clinical disruptions: 15 consecutive days alternating every 5 days between usual nighttime rounds and non-disruptive nighttime care Positive; 24-h monitoring at 30-min intervals; Significant improvement in total nighttime sleep by 30 min (p = 0.01)
Matthews, 1996 [41] Quasi-experimental pre-post intervention without comparison group Nursing home (n = 1), N = 33, mean age 84.2, 36.3% men, with dementia Individualize care: Four 4-week phases of changes in staff behavior from task-oriented to individualized (client-centered) care None; Sleep subscale of Dementia Mood Assessment Scale; Nighttime sleep did not change significantly
Mind-body practices (n = 3)
Chen, 2010 [22] Quasi-experimental pre-post intervention with comparison Assisted-living facility (n = 2), N = 55, mean age 75.4, 47.3% men Relaxation techniques: 70-min sessions of Silver Hatha Yoga (adapted for older population) 3 times per week for 6 months Positive; Pittsburgh Sleep Quality Index; Overall sleep quality significantly improved, and sleep disturbances and daytime dysfunction decreased significantly (p = 0.05)
Örsal, 2014 [58] Quasi-experimental pre-post intervention with comparison Nursing home (n = 1), N = 64, mean age 75.8, 57.8% men Relaxation techniques: Progressive muscle relaxation exercises each night between 9 pm and 12 MN (for a total of 30 min/week) each night × 7 days Positive; Pittsburgh Sleep Quality Index; Quality of sleep improved significantly (p = 0.000)
El Kady, 2012 [50] Quasi-experimental pre-post intervention without comparison Nursing home (n = 4), N = 210, mean age 72.2, 46.2% men, with sleep problems Cognitive-behavioral therapy: Four 30-min sessions of cognitive behavioral sleep therapy using sleep hygiene education and stimulus control techniques Positive; Pittsburgh Sleep Quality Index; Statistically higher improvement in sleep quality (percentage of poor sleepers decreased from 63.3 to 46.2%)
Social and physical stimulation (n = 11)
Kuck, 2014 [51] RCT clustered by nursing home Nursing home (n = 20), N = 85, mean age 83.9, 75.5% men, with sleep problems Combination (social/physical): 2 days per week of both two 45-min sessions of social activity and two sessions of physical exercise (balance & muscle strengthening) for 8 weeks Mixed Actigraphy & Insomnia Severity Index; No improvement by actigraphy measures in the intervention group but subjective sleep quality increased post intervention (p = 0.04)
Lorenz, 2012 [55] RCT, 4 groups (3 intervention and 1 control) Nursing home (n = 13), N = 193, mean age 81.4, 36% men Combination (social/physical): 3 intervention groups of exercise (3 days physical resistance training and 2 days walking per week), individualized social activity (1 h per day 5 days per week), or both for 7 weeks None; Polysomnography; No relationship between change in everyday function (from interventions) and change in sleep parameters
Richards, 2011 [26] RCT, 4 groups (3 intervention and 1 control) Nursing home (n = 10) and assisted-living centers (3), N = 165, mean age 81.8, 39.9% men Combination (social/physical): 3 intervention groups of exercise (3 days physical resistance training and 2 days walking per week), individualized social activity (1 h per day 5 days per week), or both for 7 weeks Positive; Polysomnography; Group receiving both treatments showed a significantly greater increase in total nocturnal sleep time and sleep efficiency over the control condition, but the exercise and social activity alone groups did not
Richards, 2001 [42] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 5, mean age 76.2, 100% men, with dementia Social and cognitive activity: 15–30 min of individualized activity for 1 to 2 h per day for 3 days Positive; Actigraphy; Percent of nocturnal time asleep significantly increased (p < 0.01)
Richards, 2005 [43] RCT Nursing home (n = 7), N = 139, mean age 79, 51.8% men, with dementia Social and cognitive activity: 1–2 h of individualized social activity for 21 days Mixed; Actigraphy; Significantly reduced minutes to sleep onset, significantly reduced minutes awake, and increased sleep among those with baseline poor sleep but not for total group; sleep efficiency not improved
Thodberg, 2015 [46] Quasi-experimental pre-post intervention (dog visit) with comparison (robot seal or toy cat) Nursing home (n = 4), N = 100, mean age 85.5, with dementia Social and cognitive activity: 10-min biweekly visits by an “animal” (dog, robot seal, or toy cat) for 6 weeks Mixed; Actigraphy; Sleep duration increased in the third week for the dog group compared to the robot seal or toy cat (p = 0.01); no effects were found in the sixth week or after the visit period had ended
Alessi, 1995 [33] Quasi-experimental pre-post intervention with comparison Nursing home (n = 7), N = 65, mean age 84.8, 85% men, with urinary incontinence or physically restrained Physical exercises: Exercises (transfers, walking, and rowing) performed every 2 h (8 am-4 pm) 5 days a week for 9 weeks None; Actigraphy; No significant improvement in nighttime or daytime sleep
Chen, 2015 [57] RCT (clustered by nursing home) Nursing home (n = 10), N = 127, mean age 79.2, 50.9% men, wheelchair bound Physical exercises: 40-min elastic-band exercises (in wheelchair) 3 times per week for 6 months Positive; Pittsburgh Sleep Quality Index; Intervention group had significantly longer sleep duration at 3 and 6 months and overall better sleep quality at 6 months
Eggermont, 2010 [67] RCT Nursing home (n = 19), N = 79, mean age 84.3, 20.3% men, with dementia Physical exercises: Five 30-min walking sessions per week for 6 weeks (total of 30 sessions) None; Actigraphy; No significant improvement in nighttime restlessness, sleep efficiency, number of waking bouts, or daytime activity
Taboonpong, 2010 [32] Quasi-experimental pre-post intervention with comparison Elderly residential center (n = 2), N = 50, 58% men Physical exercises: Tai Chi exercise at least 3 times a week for 22 min for 12 weeks Positive; Pittsburgh Sleep Quality Index; Significant improvement in sleep quality (p < 0.01)
Lee, 2008 [23] Quasi-experimental pre-post intervention without comparison Assisted-living facility (n = 1), N = 23, with dementia Physical activity: Indoor gardening twice daily for 4 weeks Positive; 24-h sleep diary; Significant improvement in wake after sleep onset, nocturnal sleep time, and sleep efficiency
Complementary health practices (n = 12)
Soden, 2004 [29] RCT (3 groups: aromatherapy and massage, massage, or control) Assisted-living facility (n = 3), N = 42, 24% men Combination (touch and aromatherapy): Massage with lavender oil and/or massage with inert oil, each for 30 min for four weeks Mixed; Verran and Snyder-Halpern Sleep Scale; Statistically significant improvement in the massage (p = 0.02) and combined massage (p = 0.03) groups but not for the aromatherapy and massage group only
Gehrman, 2009 [68] RCT Nursing home (n = 1), N = 41, mean age 82.9, 31.7% men; with dementia Oral supplement: Melatonin (8.5 mg immediate release and 1.5 mg sustained release) administered at 10 pm for 10 consecutive nights None; Actigraphy; No significant differences between the groups for nighttime or daytime sleep
Rondanelli, 2011 [28] RCT Assisted-living facility (n = 1), N = 43, mean age 78.3, with insomnia Oral supplement: Melatonin (5 mg) plus dietary supplement (magnesium 225 mg and zinc 11.25 mg) every day for 8 weeks Positive; Pittsburgh Sleep Quality Index; Significantly better sleep (p < 0.001)
Valtonen, 2005 [47] Quasi-experimental pre-post intervention with comparison, crossover design (3 groups: 2 intervention and 1 control) Nursing home (n = 2), N = 81, mean age 82.8, 21% men, mild cognitive impairment Oral supplement: 8 weeks of melatonin-rich (5–20 mg/day) milk then 8 weeks of normal milk (and conversely for the other intervention group) Mixed; Sleep questionnaire; In one intervention group, sleep quality, morning activity, and evening activity all increased significantly (p < 0.001) when milk was consumed in the evening
Braun, 1986 [62] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 6, mean age 85, 0% men Touch: 5 min of talking and 5 min of therapeutic touch 6 in. above the solar plexus Positive; Visser’s Sleep Quality Assessment; Improved sleep quality
Chen, 1999 [21] RCT Nursing home (n = 1), N = 84, mean age 79, 61.9% men Touch: 15 min of acupressure, consisting of 5 min of finger massage and 10 min of acupoint massage between 1 pm and 10 pm 5 days per week for 3 weeks Positive; Pittsburgh Sleep Quality Index; Significantly more positive sleep including quality, latency, duration, efficiency; reduced disturbances of sleep; and frequencies of nocturnal awakening and night wakeful time.
Harris, 2012 [69] RCT Nursing home (n = 4), N = 40, mean age 86, 22.5% men, with dementia Touch: 3-min slow-stroke back massage at bedtime for 2 nights None; Actigraphy; No significant increase in minutes of nighttime sleep
Nelson, 2010 [74] RCT Nursing home (n = 4), N = 28, mean age 69.5, 57.1% men Touch: 15-min massage to head, neck shoulders, and back between 8 pm and 10 pm every night and 7 days None; Observed 3 participants asleep following the intervention
Reza, 2010 [59] RCT (3 groups: intervention, sham, and control) Nursing home (n = 1), N = 77, mean age 75.2, 53.2% men Touch: 3 sessions of acupressure (hands, head, ears, and feet) per week for 4 weeks Positive; Pittsburgh Sleep Quality Index; Compared to controls, the acupressure group had significantly positive subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep sufficiency, and reduced sleep disturbance. No differences between the sham and control groups.
Simoncini, 2015 [60] Quasi-experimental pre-post intervention without comparison Nursing home (n = 2), N = 129, mean age 82.7 Touch: Daily acupressure of 8 h continuously on the HT7 acupoint with a patch device for 8 weeks Positive. Pittsburgh Sleep Quality Index; Significant improvement in ability to fall asleep and quality of sleep
Sun, 2010 [30] RCT Assisted-living facility (n = 2), N = 50, mean age 70.48, 64% men, with insomnia Touch: 5 s of acupressure on HT7 acupoint of both wrists followed by 1-s rest repeated for 5-min before bedtime for 5 weeks Positive; Athens Insomnia Scale-Taiwan Form; Significant improvement in sleep at 6 weeks post-intervention (p = 0.002)
Van Someren, 1998 [48] RCT Nursing home (n = 1), N = 14, mean age 84, 7.1% men, with early dementia Touch: TENS (transcutaneous electrical nerve stimulation) between the shoulder blades for 30 min per day between 4 pm and 6 pm, 5 days a week for 6 weeks Positive; Actigraphy; Post-treatment mean was significantly higher in the treatment group than both the pretreatment mean (p = 0.03) and the follow up mean (p = 0.03)
Environmental intervention (n = 14)
Ancuelle, 2015 [56] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 38, mean age 78.4, 44.7% men, with musculoskeletal pain Ergonomic adjustment: 4 weeks of medium-firm mattress use None. Pittsburg Sleep Quality Index and subsample with actigraphy. Sleep not significantly improved (p = 0.245).
Akyar, 2013 [49] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1): N = 24, mean age 80, 33.3% men, with poor sleep quality Increased light: 30 min of morning bright light (10,000 lx) for 30 days Positive; Pittsburg Sleep Quality Index; Immediately and 4 weeks post-intervention, there was significant improvement on all sleep outcomes (p < 0.001)
Ancoli-Israel, 2002 [36] RCT, 3 intervention groups (morning v. evening light) v. sleep restriction or comparison Nursing homes (n = 2), N = 77, mean age 85.7, 24.7% men with dementia Increased light: Bright light box (2500 lx) from 5:30 pm to 7:30 pm or 9:30 am to 11 am or daytime sleep restriction comparison with dim (50 lx) red light from 5:30 pm-7:30 pm for 10 days None; Actigraphy; No improvements in nighttime sleep or daytime alertness in any of the treatment groups. (Note: Daytime restriction is comparison group.)
Ancoli-Israel, 2003 [35] RCT, 3 groups (intervention of daytime or evening bright light with comparison of dim red light) Nursing home (n = 2), N = 92, mean age 82.3, 31.5% men, with late-stage Alzheimer’s disease Increased light: Either morning or evening bright light box (2500 lx) compared with morning dim (<  300 lx) red light for 10 days Mixed; Actigraphy; Duration of maximum sleep bout significantly increased from 64.9 min to 88.4 min in the morning and evening bright light group. However, there was no effect on total sleep time or on night or day wake time.
Burns, 2009 [37] RCT Nursing home (n = 2), N = 48, mean age 83.5, 33% male; with dementia & agitation Increased light: 2-h (10 am to 12 pm) bright light therapy (10,000 lx) for 2 weeks None; Actigraphy; Mean duration of nocturnal sleep improved but not significantly
Calkins, 2007 [38] RCT Nursing home (n = 3), N = 17, 11.8% men, with dementia Increased light: Outdoor daylight exposure for 30 min for 2 weeks None; Actigraphy and Pittsburgh Sleep Quality Index; No significant improvement in sleep
Castor, 1991 [63] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 12, mean age 70, 100% men Increased light: Twice daily exposure (1 h in morning and 1 h in afternoon) to sunlight for 1 week Positive; Nursing Assessment of Sleep; Significant improvement in uninterrupted sleep (p = 0.003) and mean sleep hours per 24 h (p = 0.052), as well as a decrease in night wake hours (p = 0.007)
Dowling, 2005 [40] RCT Assisted-living Facility (n = 2), N = 46, mean age 84, 22% men, with severe dementia Increased light: 1 h of bright morning light (9:30 am to 10:30 am; 2500 lx) 5 days per week for 10 weeks None; Actigraphy; No significant improvement in nighttime sleep efficiency, sleep time, wake time, or number of awakenings
Fetveit, 2003 [61] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 11, mean age 86.1, 9.1% men, with dementia Increased light: 2 h of morning (8 am to 11 am; 6000–8000 lx) bright light per day for 2 weeks Positive; Actigraphy; Waking time within nighttime sleep reduced by 2 h and sleep efficiency improved from 73 to 86%
Fetveit, 2004 [64] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 11, mean age 86.1, 9.1% men, with dementia Increased light: 2 h of bright morning light (6000–8000 lx) per day for 2 weeks Mixed; Actigraphy; Sleep efficiency remained higher than baseline for 4 weeks and sleep onset latency remained significantly reduced for 12 weeks
Figueiro, 2014 [53] Quasi-experimental pre-post intervention without comparison Nursing home (n = 1), N = 14, mean age 86.9, 37.7% men, with dementia Increased light: 4 weeks of blush-white lighting (luminaires) in residents’ rooms with timer (from waking until 6 pm) for 4 weeks Mixed; Daysimeter; Significant improvement in sleep efficiency (80 to 84%, p = 0.03) and sleep time (431 min to 460 min, p = 0.03) but not in sleep latency
Koyama, 1999 [71] Quasi-experimental pre-post intervention without comparison Nursing home (n = 2), N = 6, with dementia Increased light: 1 or 2 h of late morning bright light (4000 lx) None; sleep observation diary; Nighttime sleep maintained in 3 participants
Lyketsos, 1999 [24] RCT Assisted-living facility (n = 1), N = 8, mean age 80.8, 6.7% men, with dementia and agitated behaviors Increased light: 1 h of morning bright light (10,000 lx) therapy for 4 weeks Positive; sleep observation log, 8 pm-8 am; Statistically significant improvement in sleep duration from 6.4 h to 8.1 h (p < 0.05)
Wu, 2015 [31] Quasi-experimental pre-post intervention with comparison (clustered by unit) Assisted Living Facility (n = 1) N = 65, mean age 80, 57.1% men Increased light: 30 min of morning (9:30 am–10 am) bright light (10,000 lx) therapy 3 times per week for 4 weeks Mixed; sleep diary; Significant decrease in sleep disruptions in the experimental group from week 1 to week 4 (p = 0.02) but no significant difference between treatment and control groups
  1. RCT Randomized controlled trial