Institutionalization of the elderly costs U.S. society over $40 billion a year and costs elders their autonomy. Admissions to long-term care institutions occur when families, most of which have striven to maintain the elder at home, find that they can no longer cope. Efforts to relieve families of the strain of caregiving have met with only partial success. Most effective would be the amelioration of the disorder(s) that make elders dependent on caregivers. Among the few disorders of the elderly that contribute to caregiver burden but can be successfully treated are disorders of sleep. Caregivers often cite nocturnal behaviors that disrupt their own sleep as leading causes of strain, and elders, complaints regarding sleep are important predictors of eventual institutionalization. This investigation will target elders receiving adult day care and others at high risk for institutionalization. Those residing with caregivers and reporting disruptive nocturnal behaviors will be interviewed at length regarding sleep and other risk factors for institutionalization. Their sleep as well as that of their caregivers will then be quantified by means of daily sleep logs and ambulatory monitoring of body movements, both for 9 days, followed by a diagnostic sleep recording performed in the home. Elders with 2 types of sleep maintenance insomnia will be randomly assigned to active treatment and control groups. Cases of insomnia associated with depression will be treated with nortriptyline; remaining cases associated with early timing of sleep and free of polygraphic sleep abnormalities will be treated in the evening with bright light. The interview, sleep logs and ambulatory monitoring will be repeated after treatment. Short and long-term measures of treatment outcome will include the quality of life of elders and caregivers, including caregiver burden and demoralization; doctor visits and short-stay hospital days; and length of time elders continue to live in the community before institutionalization finally becomes necessary.
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