Sleep, 18(8):674-680
© 1995 American Sleep Disorders Association and Sleep Research Society
Aging and Sleep
Sleep and Agitation in Agitated Nursing Home
Residents: An Observational Study
*Jiska Cohen-Mansfield, tPerla Werner and :j:Laurence Freedman
*Research Institute of the Hebrew Home of Greater Washington. Rockville. Maryland. U.S.A. and
Department of Psychiatry. Georgetown University. Washington. D.C.. U.S.A.;
t Research Institute of the Hebrew Home of Greater Washington; and
'fBiometry Branch. Division of Cancer Prevention and Control.
National Cancer Institute
Summary: An observational study was conducted to describe the physical and social environment of sleep of 16
highly agitated and cognitively impaired nursing home residents, and the relationships between manifestations of
agitation and sleep. Results showed that nursing home residents were more likely to be observed asleep when alone,
in their own rooms, and between 9 p.m. and 5 a.m. Considerable amounts of sleep were also observed during the
day. Great individual variation was observed in the presence of sleep-related disorders, although a tendency was
observed for more fragmented sleep during the day hours. Almost all the agitated behaviors observed decreased
immediately after sleep. Similar to findings of objective studies. much individual variation was found in sleep
patterns and sleep pathology of cognitively impaired and highly agitated nursing home residents. Findings suggest
that agitation may be exacerbated by fatigue. Key Words: Sleep-Agitation-Nursing home residents-Dementia.
Sleep disturbances in the elderly have been linked
to cognitive impairment (1). Sleep disturbances of elderly persons with Alzheimer's disease include fragmented sleep with frequent awakenings, reduced stage
3 and rapid eye movement sleep, and no stage 4 sleep
(2-5).
In one study of sleep-disordered breathing, a significantly greater amount of sleep apnea occurred in elderly persons suffering from Alzheimer's disease than
in normal elderly persons, depressive elderly persons,
or those with mixed symptoms of cognitive impairment and depression (6). Other investigators have reported that patients with Alzheimer's disease did not
have significantly more apnea than normal elderly individuals (7,8). Many ofthese issues have been covered
in a recent and comprehensive review about sleep in
normal aging and dementia (9).
Generally, sleep patterns of healthy persons and those
suffering from dementing disorders have been meaAccepted for publication May 1995.
Address correspondence and reprint requests to Perla Werner,
M.A., Research Institute, Hebrew Home of Greater Washington,
6121 Montrose Road, Rockville, MD 20852, U.S.A.
sured in polysomnographic laboratories, using equipment for electrographic monitoring of respiration, electrocardiograms, and related muscle activity (2,6,1013). One drawback of these studies is that the effect of
sleeping in an unfamiliar setting and the presence of
electroencephalogram electrodes may cause changes in
sleep behavior (14). Young and Muir-Nash (15) have
suggested that examinations of sleep are more accurate
if done in a familiar place (i.e. where the individual
lives). Moreover, the use of polysomnographic methods may exacerbate confusion and agitation in demented elderly persons, rendering the test invalid.
Lately, several studies of sleep used systematic observations to address sleep disorders in the elderly population (16,17). However, most of these studies addressed only the issue of sleep/wake patterns (18,19),
and/or did not include residents who were confused or
agitated (20). Recently, one study documented the reliability, validity, and efficacy of an observational tool
in cognitively intact as well as cognitively impaired
nursing home residents (21).
In the present study, systematic observations were
used to describe the temporal, environmental and social conditions under which sleep typically occurs in
674
SLEEP AND AGITATION
nursing home residents suffering from severe cognitive
impairment and agitation. The data presented here are
part of a large data set that examined situational and
environmental correlates of agitation. The relationship
between sleep, sleep-related disorders and agitation is
the focus of the present study. Although several recent
studies addressed the issue of sleep disturbances in
nursing home residents, this study is the first to describe the physical and social environment of the agitated nursing home residents when asleep, as well as
the relationship with agitated behaviors using naturalistic observations.
METHODS
Study participants
iI
Sixteen residents of a 550-bed long-term care facility
were selected for study. All. the subjects were women.
The mean age was 85.9 years, with a range from 73 to
93 years. Length of stay in the nursing home ranged
from 1 year to 15 years.
The study participants were selected on the basis of
their high level of agitation and high cognitive impairment. The level of agitation was assessed via the
Cohen-Mansfield Agitation Inventory (22). Cognitive
impairment was assessed using the Brief Cognitive
Rating Scale (BCRS) (23). All residents received BCRS
scores above 5 (mean BCRS score = 5.7), where a score
of7 indicated total cognitive deterioration. Due to the
impaired cognitive functioning of these residents, informed consent was obtained from a close relative of
the resident.
Instrument
Data were collected via the Agitation Behavior Mapping Instrument (ABMI) (24) which is a multidimensional observational instrument that allows an observer to systematically record not only the agitated behaviors manifested by a resident but also aspects of
the resident's physical and social environment. For the
purposes of the present study, the following sections
of the ABMI were utilized: 1) the occurrence of sleep
and sleep pattern, 2) social environment, 3) location
and 4) manifestation of agitated behaviors.
The occurrence of sleep was defined as absence of
response to the environment and apparent state of sleep.
Discontinuity of sleep was defined as the number of
times the resident woke up-even briefly-during the
3-minute observation period; the loudness of breathing
was defined as low, medium or high; discontinuation
of breathing was defined as the number of times the
675
resident stopped breathing during the 3-minute observation period, and the occurrence of snoring was recorded even if it was not continuous during the entire
period. Other sleep-related items included in the ABMI
are myoclonic movements (i.e. the number of times
the resident was observed jerking her legs during the
observation period) and body restlessness (the number
of times the resident moved her arms or trunk during
an observation in which sleep was recorded). The interobserver agreement rate for the sleep variables on
the ABMI, calculated as exact agreement, averaged
92.9% (range 84.8-100%).
The following categories were included in the resident's social environment: the resident only, other residents, members of the staff (includes nursing staff and
housekeeping staff), other persons such as visitors and
volunteers and a combination of the above-mentioned
categories. The location section included places within
the building that the nursing home resident was most
likely to frequent, such as her own room, another resident's room, shower, the toilet, dining room, corridor, activity room and in or around the nurses' station.
The ABMI also included 20 agitated behaviors that
may be categorized as verbally nonaggressive (e.g.
strange noises, requests for attention), physically nonaggressive (e.g. pacing, strange movements, repetitious
mannerisms, picking at things) and aggressive (including behaviors such as biting, hitting and cursing). Each
manifestation of an agitated behavior was recorded as
a checkmark on the ABMI. When a behavior was manifested five or more times per observation period, a
value of "C" (i.e. constant) or a value of "E" (i.e.
extreme) was recorded for the behavior. Research assistants were later asked to operationalize the "C" and
"E" ratings by assigning the numerical average for each
behavior.
The interobserver agreement rates for the agitated
behaviors on the ABMI averaged 93% (24). Previous
research has indicated that agitated nursing home residents tend to manifest the following behaviors most
frequently: picking at or throwing things, repetitious
mannerisms, strange noises (includes screaming), constant requests for attention, strange movements and
pacing (24). Given their frequency, these behaviors
were the focus of the present study. In addition, aggressive behaviors (including biting, hitting and cursing) were examined because of their disruptive and
sometimes painful consequences. We also included a
composite score of total agitation derived for each resident as the weighted total number of agitated behaviors manifested by that resident. The weightings were
based on the disruptive effect of the agitated behaviors
manifested; that is, aggressive behaviors are maximally
disruptive whereas repetitious mannerisms are not
particularly disruptive to persons on the unit (24).
Sleep. Vol. lB. No. B. 1995
J. COHEN-MANSFIELD ET AL.
676
TABLE 1. Percentage oj 2-hour blocks spent asleep
Block
Time
Total number of
observations
I
2
3
4
5
6
7
8
9
10
II
12
7:01-9:00 a.m.
9:01-11:00 a.m.
11:01 a.m.-I:OO p.m.
1:01-3:00 p.m.
3:01-5:00 p.m.
5:01-7:00 p.m.
7:01-9:00 p.m.
9:01-11:00 p.m.
11:01 p.m.-I:OO a.m.
1:01-3:00 a.m.
3:01-5:00 a.m.
5:01-7:00 a.m.
1,316
1,326
914
1,117
1,149
1,027
1,117
755
1,399
1,298
828
913
Procedure
Over a 3-month period, 1,000 observations, on average, were obtained for each participant via the ABMI.
Observations of residents were scheduled using a stratified, random time-sampling method. Each observation lasted for three consecutive minutes per hour (only
one observation of each resident was scheduled per
hour); all hours of the 24-hour day were utilized. The
observations were performed by nonprofessional
trained research assistants. During each observation,
the research assistant recorded the number of times
that each resident manifested each of the individual
agitated behaviors. The research assistant also recorded observations concerning the observed sleep pattern,
as well as the resident's location and social environment.
Mean % spent
asleep
11.0
13.0
5.4
14.4
11.2
5.3
34.6
84.9
88.8
91.1
87.9
63.1
Range
Number of residents
awake at each observation within the block
0-38.0
~9.0
0-18.3
0-51.7
0-36.6
0-18.5
11.1-81.5
54.5-98.4
65.2-99.1
78.6-99.0
69.8-100.0
37.5-86.1
I
2
5
I
3
5
0
0
0
0
0
0
Although residents usually were alone when asleep
(between 54% and 99% of the observations), during
day and evening hours (i.e. from 7 a.m. to 9 p.m.) they
were with staff and other residents for 14% of the observations, with other residents for 11 % of the observations and with staff for 4% of the observations.
The relationship between sleep and physical location
also was examined. Regardless of the time of the day,
sleeping residents were mostly in their own rooms,
between 56% and 100% of the observations. However,
during the day and evening hours, residents were also
observed asleep in the dayroom (for 18% of the observations) and in the corridor (for 5% of the observations).
Description of pattern of sleep in
agitated nursing home residents
In addition to the description of the social and physical environment of the agitated nursing home resident
who is asleep, we studied the pattern of sleep of these
Description of the temporal, environmental
nursing home residents.
and social conditions of sleep in
Participants snored during 15% of the observations
agitated nursing home residents
when they were observed asleep. Great variability was
Following the study of Bliwise et al. (19), the day observed among the residents; whereas two residents
was divided into 12 2-hour periods. Nursing home were observed snoring during only 2% of the obserresidents were observed asleep to some extent at all vations, four were observed snoring during more than
the times. Sleep was more likely to be observed be- a quarter of the observations (range 26-43%). The obtween 9 p.m. and 5 a.m. During these 8 hours, residents servers recorded discontinuity of breathing in 6% of
were observed asleep during 88% of the observations. the observations. Individual variability was also obHowever, even during these four periods, only two served in the discontinuity of breathing; only one resresidents were observed asleep during the entire period ident was never observed having an episode of disover the 3-month observation period, whereas several continuity of breathing. For the remaining particiother residents were observed asleep for only 54% of pants, discontinuity of breathing was observed bethe observations. During the other 16 hours, residents tween 0.2% and 37% of the time they were asleep.
were observed asleep for an average of 20% of the Although the residents' sleep was interrupted during
observations.
only 3% of the observations (range between 0.9% and
RESULTS
Sleep, Vol. 18, No.8, 1995
:.
SLEEP AND AGITATION
TABLE 2. Average across participants ofpercentage ofeach
participant's observations asleep in which specific sleep patterns were observed
Sleep pattern
Average %
Range
Snoring
Discontinuity of breathing
Discontinuity of sleep
Body restlessness
Myoclonic movements
14.6
6.1
3.0
12.9
17.3
1.7-42.6
0-37.0
0.9-6.9
4.0-23.6
0.9-36.9
677
TABLE 4. Significance levels and means of sleep variables
during first (8 p.m.-l:30 a.m.) and second (1:31-7 a.m.) half
of the night
Snoring
Discontinuity of breathingb
Loudness of breathingc
Discontinuity of sleepb
Body restlessnessb
Myoclonic movements b
a
8 p.m.1:30 a.m.
1:317 a.m.
z value
0.18
0.07
1.48
O.OS
0.27
0.44
0.14
0.11
l.2S
0.04
0.22
0.29
-0.96
-1.07
-3.00d
-0.36
-1.14
-0.98
Presence or absence.
Number of times each one of the sleep characteristics was observed in a 3-minute observation.
, I = low; 2 = medium; 3 = high.
d p < 0.01.
a
7%), they moved during 13% of their observed sleep
(range 4-24%), and myoclonic movements were observed during 17% of the observations (range 0.9-37%).
Additionally, sleep variables observed during daytime (i.e. 7 a.m. through 8 p.m.) were compared with
sleep variables during nighttime (i.e. 8:0 1 p.m. through
6:59 a.m.) using the Wilcoxon matched-pairs signed
ranks test for two related samples. With the exception
of discontinuity of sleep, the participants presented
significantly more sleep-related disorders during the
nighttime than during the daytime.
Sleep variables observed during the first half of the
night (i.e. 8 p.m. through 1:30 a.m.) were compared
with sleep variables observed during the second half
of the night (i.e. 1:31 a.m. through 7 a.m.) using the
same analysis as described for comparing sleep variables during daytime and nighttime. Although in general, higher rates of sleep disorder variables were observed during the first half of the night, only loudness
of breathing reached statistical significance. When a
parametric test was applied to the same data, myoclonic movements also reached statistical significance at
the p < 0.05 level (data not shown).
b
The most frequently observed agitated behaviors when
the residents were asleep were strange noises (including
screaming) and repetitious mannerisms.
Pearson correlations were computed comparing the
seven variables of quality of sleep during nighttime (8
p.m.-7 a.m.) with the level of agitated behaviors (eight
variables) manifested during the following day (7:01
a.m.-7:59 p.m.) within participants. Seven of the 56
correlations were significant at the p < 0.05 level (only
three would be significant by chance). These analyses
revealed that pacing was negatively associated with
sleep variables reflecting sleep disorder breathing (i.e.
higher levels of snoring and discontinuity of breathing
were associated with less pacing; r = -0.15, p < 0.01,
and r = -0.10, p < 0.05, respectively). However, myoclonic movements were positively associated with
pacing (r = 0.16, p < 0.01). Constant requests for
attention were associated with myoclonic movements
(r = 0.22, p < 0.01), and strange movements were
associated with discontinuity of breathing, body restlessness
and myoclonic movements (r = 0.19 and 0.11,
The relationship between sleep and agitation
p < 0.01, and r = 0.09, p < 0.05, respectively). No
Nursing home residents manifested very low rates other statistically significant relationships were found.
of agitated behaviors during observed sleep periods.
The level of agitated behaviors manifested during
the 3-minute observations immediately before (i.e.
TABLE 3. Significance levels and means of sleep variables during the hour preceding) any observation in which
during daytime (7 a.m.-8 p.m.) and night time (8:01 p.m.- an occurrence of sleep was recorded and the level of
6:59 a.m.)
agitation during the 3-minute observations immediately after any occurrence of sleep (i.e. during the fol7 a.m.- 8:01 p.m.lowing
hour), was compared using the Wilcoxon
8 p.m. 6:S9 a.m.
z value
matched-pairs
signed ranks test for two related sam-2.38 b
O.OS
0.16
Snoringa
d
ples.
Data
for
this
test were the mean levels of agitation
-3.29
0.01
0.08
Discontinuity of breathing'
-2.12b
1.34
1.48
Loudness of breathinge
for
each
resident
prior
to and after sleep. Because pre-2.69 d
0.19
0.06
Discontinuity of sleep'
vious
findings
showed
that the manifestation of agi-2.9S d
O.IS
0.28
Body restlessness'
d
tated
behaviors
increases
when residents are physically
-3.46
0.17
0.39
Myoclonic movements
restrained
(25),
only
observations
during which the
a Presence or absence.
participants were not physically restrained were inb p < O.OS.
, Number of times each of the sleep characteristics was observed cluded.
in a 3-minute observation.
As can be seen in Table 5, with the exception of
d p < 0.01.
e I = low; 2 = medium; 3 = high.
strange movements, the level of agitation observed afC
Sleep, Vol. 18, No.8, 1995
J. COHEN-MANSFIELD ET AL.
678
TABLE 5. Significance levels and means of agitated behaviorsa immediately before and after sleep
Agitated behaviors
Before
sleep
After
sleep
z value
1.30
-0.67
1.39
Constant request for attention
-1.16
0.83
1.22
Pacing
-0.68
1.43
Repetitious mannerisms
1.66
-0.71
0.13
0.10
Strange movements
0.40
-2.59 b
0.79
Picking at things
-2.02'
0.41
0.65
Strange noises
-1.49
0.07
0.10
Agressive behaviors
9.03
-1.96'
12.36
Total score of agitation
a Mean frequency of behaviors during the 3-minute observations.
b p < 0.01.
'p < 0.05.
among residents with disturbed sleep than among residents without pathology. Pacing was not related to
sleep pathology other than myoclonic movements.
Strange movements, picking at things and strange noises were related to discontinuity of sleep, body restlessness and inefficiency of sleep, but not to snoring.
Body restlessness was consistently related to increases
in agitation.
DISCUSSION
The purpose of the present study was two-fold. The
first goal was to document the temporal, environmental and social conditions under which sleep occurs in
ter sleep was lower than before sleep for all the agitated severely demented, highly agitated nursing home resbehaviors. These differences were statistically signifi- idents. The second was to investigate whether or not
cant for picking at things, strange noises, and the total a relationship exists between the manifestation of agmean score of agitation.
itation and sleep attributes.
Additionally, the level of agitation when awake for
The results showed that nursing home residents were
residents suffering from sleep disturbances and those more likely to be observed asleep when alone, in their
without sleep disturbances was compared using t test. own rooms. These findings suggest that the environThe residents were divided into two groups: those suf- mental and social conditions of sleep of cognitively
fering from a specific sleep pathology and those without impaired and highly agitated residents are similar to
it. Because no clear rules for the definition of sleep those of normal elderly persons. Most of the participathology in this population exist in the literature, sleep pants were observed asleep between 9 p.m. and 5 a.m.
pathology was defined for this study as follows: a) sleep This finding confirms the results by Regestein and
efficiency during the nighttime ofless than 80% (seven Morris (17), who found that the time of day when the
residents), b) snoring during 10% or more of the ob- greatest number of their 16 nursing home participants
servations (eight residents), c) discontinuity of sleep were observed asleep was between 8 p.m. and 4 a.m.
during 3% or more of the observations (six residents), Bliwise et al. (26) also found sleep to occur most likely
d) body restlessness during 10% or more of the obser- between 7 p.m. and 5 a.m. in a group of 24 nursing
vations (nine residents) and e) myoclonic movements home residents. However, based on the present study,
during 15% or more of the observations (eight resi- considerable amounts of sleep were also observed durdents).
ing the day. The time of the day at which residents
Although no consistent pattern was found in the were observed to be awake more was between 11 a.m.
levels of agitated behaviors manifested by residents and 1 p.m. and between 5 p.m. and 7 p.m., periods
with any type of sleep pathology and those without that replicate the findings by Jacobs et al. (27) and
sleep pathology, several findings emerged from the data. Bliwise et al. (26), and may be related to the fact that
More constant requests for attention were observed these are meal times.
TABLE 6. Relationships among agitation and sleep pathology
Agitated behavior
Pathology
based on
sleep efficiency
Constant requests for attention
Pacing
Repetitious mannerisms
Strange movements
Picking at things
Strange noises
Agressive behaviors
a p < 0.01.
b P < 0.05.
d = decrease in the level of agitated behavior,
Sleep. Vol. lB. No. B. 1995
da
da
ia
ia
ia
ia
Pathology
based on
discontinuity
of sleep
da
da
ia
io
i"
Pathology
based on
snoring
ia
da
ia
do
da
d"
do
i = increase in the level of agitated behavior.
Pathology
based on
body restlessness
Pathology
based on
myoclonic
movements
ia
da
ia
ia
ia
i"
ja
ia
da
i"
d
ja
db
SLEEP AND AGITATION
Regarding the presence of sleep-related disorders,
our findings corroborate other studies that reported
considerable individual variation in the presence of
sleep disorders in cognitively impaired elderly persons
(18). The variation is specially marked for discontinuity of breathing and myoclonic movements. Although the presence of sleep-related disorders was
greater at nighttime compared with daytime hours, the
sleep of the participants was more fragmented during
the day hours, as indicated by the greater rate of discontinuity of sleep observed. Although it should be
noted that these observational findings were not validated by objective recordings in the present study, a
previous study (21) established the reliability and validity of observational measures for examining sleep
and sleep pathology in the nursing home population.
As to the second aim of this study, we found that,
with the exception of pacing and aggressive behaviors,
agitated behaviors also were observed when the resident was asleep, although at a very low level. This
finding, however, should be taken cautiously. As reported in another study of sleep in nursing home residents (28), cognitively impaired residents are characterized by restless sleep, with high rates of myoclonic
movements and general restlessness. Some of these
involuntary movements may be interpreted by the observer as the manifestation of strange movements or
repetitious mannerisms. Similarly, the relationship between pacing and myoclonic movements is interesting
because they both relate to leg movements.
A negative association was found between sleep disordered breathing variables and pacing. Nursing home
residents who have higher rates of sleep disorders at
night may feel too weak to pace during the following
day. This result fits with our previous findings relating
pacing to overall good health (29). Additionally, constant requests for attention were associated with myoclonic movements and discontinuity of breathing. Although the reasons for this association are unclear,
previous studies found similar relationships. Regestein
and Morris (17), in a study of 16 institutionalized demented women, found a relationship between demanding behaviors and lessened sleep, and CohenMansfield et al. (30), in a study of 408 nursing home
residents, found verbally agitated behaviors related to
poor quality of sleep. However, results of the present
study should be taken cautiously as they relate only to
16 highly agitated nursing home residents. It will be
important for future research to explore these relationships in other populations, such as demented nonagitated residents. Further studies also should evaluate
the potential role of pain and discomfort and their
relationship to sleep-related problems and agitation.
Findings of this study also show a modest but theoretically important confirmation of the hypothesis that
679
agitated behaviors may be exacerbated by fatigue. Six
of the agitated behaviors observed, as well as the total
score of agitated behaviors, decreased after a sleep
event. This trend was especially marked for picking at
things, strange noises (including screaming) and the
total mean score of agitation. This finding may have
clinical importance for the understanding and management of agitated behaviors, and further research
should be pursued in this direction.
Results of this study should, however, be taken cautiously. Because a stratified, random, time-sampling
method was used, results were derived from 3-minute
observations per hour. This method is especially problematic for nursing home residents who wake up frequentlyat night and doze intermittently during the day
(18). Although the generalizability and validity of our
study are limited by the small sample size and by the
methodology used, the findings have important implications for the understanding and treatment of severely cognitively impaired and agitated nursing home
residents.
Acknowledgements: The authors gratefully acknowledge
Dr. N. Freedman, Mr. Wassertzug, and Mr. F. Gertler for
assistance with part of the statistical analysis. This study was
supported by National Institute on Aging Grant #ROI
AG08675.
REFERENCES
1. Loewenstein RJ, Weingartner H, Gillin JC, Kaye W, Ebert M,
Mendelson WB. Disturbances of sleep and cogniti ve functioning
in patients with dementia. NeuroNol Aging 1982;3:371-7.
2. Allen SR, Stahelin HB, Seiler WO, Spiegel R. EEG and sleep
in aged hospitalized patients with senile dementia: 24-hour recordings. Experientia 1983;39:249-55
3. Prinz PN. REM sleep and senile dementia. J Am Geriatr Soc
1982;30:422.
4. Prinz PN, Vitaliano PP, Vitiello MV, et al. Sleep, EEG, and
mental function changes in senile dementia of the Alzheimer's
type. NeuroNol Aging 1982;3:361-70.
5. Vitiello MV, Prinz PN, Williams DE, Frommlet MS, Ries RK.
Sleep disturbances in patients with mild-stage Alzheimer's disease. J GerontoI1990;45:M131-8.
6. Hoch CC, Reynolds CF, Kupfer DJ, Houck PR, Berman SR,
Stack JA. Sleep-disordered breathing in normal and pathologic
aging. J Clin Psychiatry 1986;47:499-503.
7. Smallwood RG, Vitiello MV, Giblin EC, Prinz PN. Sleep apnea:
relationship to age, sex, and Alzheimer's dementia. Sleep 1983;
6:16-22.
8. Reynolds CF, Kupfer DJ, Taska LS, et al. Sleep apnea in Alzheimer's dementia: correlation with mental deterioration. J Clin
Psychiatry 1985;46:257-61.
9. Bliwise DL. Sleep in normal aging and dementia. Sleep 1993;
16:40-81.
10. Roehrs T, Zorick F, Sicklesteel J, Wittig R, Roth T. Age-related
sleep-wake disorder center. JAm Geriatr Soc 1983;31 :364-70.
II. Prinz PN, Peskind ER, Vitaliano PP, et al. Changes in the sleep
and waking EEG's of nondemented and demented elderly subjects. JAm Geriatr Soc 1982;30:86-93.
12. Reynolds CF, Kupfer DJ, Houck PR, et al. Reliable discrimination of elderly depressed and demented patients by electroencephalographic sleep data. Arch Gen Psychiatry 1988;45:25864.
Sleep, Vol. 18, No.8, 1995
680
J. COHEN-MANSFIELD ET AL.
13. Ancoli-Israel S, Parker L, Sinaee R, Fell RL, Kripke DF. Sleep
fragmentation in patients from a nursing home. J Gerontol1989;
44:MI8-21.
14. Kales A, Wilson T, Kales JD, et al. Measurements of all-night
sleep in normal elderly persons: effects of aging. J Am Geriatr
Soc 1967;15:405-14.
15. Young SH, Muir-Nash J. The effect of white noise in nocturnal
wandering in the elderly. Presented at meeting the challenge of
mental health care for the elderly, a workshop sponsored by the
Maryland Office of Aging, Baltimore, MD, November 1986.
16. Webb WB, Swinburne H. An observational study of sleep of
the aged. Percept Motor Skills 1971;32:895-8.
·17. Regestein QR, Morris J. Daily sleep patterns observed among
institutionalized elderly residents. JAm Geriatr Soc 1987;35:
767-72.
18. Bliwise DL, Carroll JS, Dement We. Predictors of observed
sleep/wakefulness in residents in long-term care. J Gerontol1990;
45:MI26-30.
19. Bliwise DL, Bevier WC, Bliwise NG, Dement WC. Systematic
behavioral observations of sleep/wakefulness in a skilled care
nursing home. Sleep Res 1990; 16.
20. Gress LD, Bahr RT, Hassanein RS. Nocturnal behavior ofselected institutionalized adults. J Gerontol Nursing 1981 ;7:86-
92.
21. Cohen-Mansfield J, Waldhorn R, Werner P, Billig N. The validation of sleep observations in a nursing home. Sleep 1990; 13:
512-25.
22. Cohen-Mansfield J, Marx MS, Rosenthal AS. A description of
agitation in a nursing home. J Gerontol Med Sci 1989;44:M7784.
Sleep, Vol. 18, No.8, 1995
23. Reisberg B, Schneck MK, Ferris SH, Schwartz GE, deLeon MJ.
The brief cognitive rating scale (BCRS): findings in primary
degenerative dementia (PDD). Psychopharmacol Bull 1983; 19:
47-50.
24. Cohen-Mansfield J, Werner P, Marx MS. An observational study
of agitation in agitated nursing home residents. Int Psychogeriatr
1989; I: 153-65.
25. Werner P, Cohen-Mansfield J, Braun J, Marx MS. Physical
restraints and agitation in nursing home residents. JAm Geriatr
Assoc 1989;37:1122-6.
26. Bliwise DL, Bevier WC, Bliwise NG, Edgar DM, Dement WC.
Systematic 24-hr behavioral observations of sleep and wakefulness in a skilled care nursing facility. Psychol Aging 1990;5:
16-24.
27. Jacobs D, Ancoli-Israel S, Parker L, Kripke DF. Twenty-four
hour sleep-wake patterns in a nursing home population. Psychol
Aging 1989;4:352-6.
28. Werner P, Cohen-Mansfield J, Waldhorn R, Billig N. Sleep pattern in demented and non-demented nursing home residents.
Monograph of the Research Institute of the Hebrew Home of
Greater Washington 1991;no. 68.
29. Cohen-Mansfield J, Werner P, Marx MS, Freedman L. Two
studies of pacing in the nursing home. J Gerontol1991 ;46:M7783.
30. Cohen-Mansfield J, Marx MS, Werner P. Agitation in elderly
persons: an integrative report of findings in a nursing home. Int
Psychogeriatr 1992;4:221-40.