Sleep in Hospitalised Patients

Original Editor - Vidya Acharya

Top Contributors - Vidya Acharya  

Introduction[edit | edit source]

Sleep is an essential daily requirement for the development and maintenance of mind and body. A good sleep quality consists of a sufficient amount of uninterrupted sleep, age-appropriate naps and a sleep schedule that fits with individual's natural biological rhythms. Proper sleep allows the body to engage in circadian rhythms that build-up of energy stores for metabolic processes, neuronal remodelling for synaptic function, memory consolidation, and the assimilation of complex motor systems. [1] [2]The sleep/wake cycle is necessary to replenish and heal the body to ensure that it can function properly. It helps repair and replenish cellular components necessary for biological functions that become depleted during wakeful hours.

Sleep Disruption in Hospitalised Patients[edit | edit source]

Sleep is crucial for the well-being of unwell individuals who are hospitalised. The hospital environment can be busy and noisy, which may put patients at risk for sleep deprivation. In the ICU, nursing procedures are carried out at least once every hour, leading to frequent interruptions and little opportunity to rest. Overloading patients with stimuli can have a negative impact on their well-being, especially those in critical care.[3]. Sleep deficiency is associated with health risks. Reports suggest that sleep disrupted in the hospital environment, which impacts the healing process. Changes in the normal sleep pattern have a negative impact on the medical conditions such as diabetes, obesity, and cardiovascular disease; alteration in behaviour resulting in confusion, delirium and a decline in working memory; cognitive performance; mental health and recovery of the hospitalised individuals. .[4][5][6] Frequent interruptions leave little time for rest. Stimuli overload has been documented in numerous studies as detrimental to the well-being of all patients, particularly critical care patients (

Sleep wake dysfunction[edit | edit source]

The sleep deficit manifests in a variety of sleep and circadian functions: sleep duration, timing, architecture, continuity, and regularity; internal and external circadian alignment; circadian amplitude; self-perception of sleep; quality of wakefulness; and daytime function[7] Lack of sleep could lead to the development of a transient or chronic sleep wake disorder which could be because of a reduced number of hours of sleep, poor quality sleep, or inappropriate timing or stabilisation between wake and sleep. This is also called sleep wake dysfunction and that can contribute to the development and progression of co-morbid disease.[8]

Most common sleep wake dysfunction seen in hospitalized patients are insomnia, circadian rhythm disorders, sleep disordered breathing, restless leg syndrome and hypersomnia disorders. Pre-existing sleep wake dysfunctions, may become exacerbated by hospitalization and predisposing to the development of additional sleep dysfunctions.[8]

Factors Affecting Sleep in the Hospitals[edit | edit source]

Various factors[5] affect sleep in hospitalised patients lead to poor sleep quality. They include:

  • Intrinsic Factors [8]differ from patient to patient. They could be:
    • physical pain, discomfort
    • disease-related, i.e. primary medical illness, delirium, psychiatric co-morbidity (anxiety, depression, post-traumatic stress), disease severity, co-morbidities, pre-existing SD, and physical pain or discomfort
    • psychological factors (e.g. anxiety or stress or fatigue) and uncertainty experienced from having more complicated or undiagnosed diseases
    • medications
    • pre-existing sleep disorder
  • Extrinsic Factors[8] can be environmental related to:
    • care-related routines: doctor and nurse interruptions, hospital environment and round-the-clock activities on the ward, repetitive clinical interventions, such as testing, clinical examinations, and vitals, as well as medication administration
    • sound disturbances: environmental noise from equipment/alarms, medical staff, or hospital roommates,
    • light disturbances: bright lights, and irregular exposure to lighting. Light exposure can affect the patients’ circadian rhythm thereby causing sleep disturbances and poor sleep quality. Light suppresses the release of melatonin, a sleep-promoting substance produced from the pineal gland, controlled by the suprachiasmatic nuclei (SCN), the central circadian clock located in the hypothalamus[5].
    • windowless room or lack of stimulus from the outside world esp in the ICUs.[9]
    • an unfamiliar environment, being in different place
    • uncomfortable beds, hard pillows, and protective mattress cover[10]
    • cold temperature or hot temperature[5]
    • disturbance by visitors.[5]

Poor sleep quality and sleep deprivation affects the functioning of various organs, weakening immune system, increasing cardiovascular events, impairing cognitive function impairment, and increasing risk of falling and bone fracture in elderly. It is seen that sleep deprivation may impact recovery, prolong length of stay in the hospital, reduce subjective well-being, and result in poor patient perception of hospitalised care.[1]

Strategies to Improve Sleep Quality[edit | edit source]

The light-dark cycle provides the primary environmental signal for human circadian rhythm. As a result, both irregular light exposure and intense light exposure outside of normal circadian hours might cause circadian sleep disruption.[8] Strategies to improve environmental sound levels and light exposure can help improve sleep in hospitalised patients. Maintaining specific light intensities in rooms to help regulate patients’ circadian rhythms, installing sound-absorbing panels to reduce environmental noise,

Individualised patient care might have a significant influence in improving patients' sleep. It is important to assess the following[1]:

  • Whether the sleep is disturbed because of a room close to the nurse's station, or patient sharing a room with a restless fellow patient?
  • Are the nightly checkups necessary for a specific patient?
  • Could vital check-ups, iv fluid changes and medication rounds be postponed to the day shift instead of the night shift?
  • Or can vital signs be monitored remotely (and automatically with silent alarms) limiting the need for interventions in the room?
  • Are sleep disturbances are related to emotions like depression and anxiety?

Paying attention to all these aspects could ensure patients getting a quality sleep during the hospital stay. Patients' good quality of sleep can be ensured by providing comprehensive staff training. According to research, light exposure and pain were the prime factors associated with poor sleep quality [5]

Circadian Rhythm[edit | edit source]

Aligning circadian rhythm is essential step in optimizing sleep cycle in hospitalised patients. Controlling light exposure during day and night time along physical activity during the day could aid in enhancing sleep.

Light levels measured in lux units ranges anywhere from 32,000 to 60,000 lux on a bright and sunny day in the early spring. [11]Light levels in the ICU have been reported to be 30-164 lux during the day, 2.4-145 lux at night, and up to 10,000 lux while performing clinical procedures (e.g., central line insertion), which can certainly modulate the patient's circadian rhythm and disrupt sleep. According to a pilot study determining relation between sleep and light in hospitalized older adults, an average of 3 periods of elevated light levels (mean, 64 lux) lasting an average of 1.75 hours was reported each.[12]

Limiting Light Exposure

  • In patients undergoing frequent assessments, eye masks are found to be effective nonpharmacologic sleep-promoting adjuncts in the ICU.[13] .
  • Recommendations include light reduction measures such as dedicated "do not disturb" time to allow for a full 90-minute sleep cycle.

Regulating Light

  • Regulating the brightness of the room in the daytime according to the circadian rhythm.
  • Exposure to natural daylight, with adequately-sized and correctly-positioned windows should be considered for all hospitalized patients to align circadian clocks. [9]
  • For non-critical patients, roofs, areas with windows, terraces, or outdoor parking spaces may give advantages via natural light, fresh air, sunshine, and a view of the clear sky, therefore regulating circadian rhythm[14]


Physical Activity

  • Exercises has significant impact on the quality of sleep. Patients should be encouraged by the healthcare professionals to perform exercises. A study assessing the effects of relaxation exercise on sleep quality in patients hospitalized in internal medicine services found that Progressive Muscular Relaxation exercises enhanced sleep in these patients.[10]
  • There is evidence that regular physical activity improves sleep quality and symptoms related to sleep disorders[15]. Providing physical activities for the patients in the daytime may facilitate sleep [16]

Pain, Fear and Anxiety[edit | edit source]

Pain along with anxiety and fear are reported to be most frequently associated with poor sleep quality.[1]

  • Anticipating the care of symptoms and effective measures to relieve pain can promote sleep.
  • Care should be taken to provide a safe and peaceful environment. Encourage patients to discuss the matters that trouble them in order to allay fear and uncertainity.[16]
  • Music therapy might help reduce anxiety, stress and discomfort while improving sleep quality. A research discovered that earphone-delivered sleep-inducing music was more successful in enhancing the quality and amount of sleep in ICU patients who had undergone PTCA than just using ear plugs. Listening to sleep-inducing music using earphones or headphones helps to block out environmental noise while simultaneously producing soothing delta-waves, which improves the patient's sleep.[17]
  • Relaxation and imagery techniques, massage therapy, muscle relaxation, foot baths, and foot reflexology massage might help calming the anxiety and inducing sleep.[18]

Noise[edit | edit source]

Noise is being the most frequently reported cause of sleep disruption in the hospital [1] Medical devices, alarms, conversations among staff and visitors, activities at the nursing station, caregiving activities are relevant sources of noise in hospital wards and ICUs[19]. Research indicates that the patients reported conversation amongst the humans and television volumes to be most disruptive noises with some studies suggesting hospital noise generated by humans to be over 50%[20]. Polysomnographic studies suggest noise levels between 40 and 45 dB(A) have 10 to 20% probability of awakening, and noise over 50 dB(A) results in arousal. A pilot study in 48 hospitalized older adults (aged 70 years and above) monitoring the sleep and noise levels reported noisy surroundings with a median sound level of 49.65 dBA and shorterned sleep time with multiple awakenings.[12] Patients are unlikely to achieve the critical sleep stages (slow wave sleep and rapid eye movement) that are important for physiological healing and psychological wellbeing with such noise levels[20]. According to WHO guidelines, the sound in the hospital should not exceed 35 dB for the rooms in which patients are treated or observed.[21] The US Environmental Protection Agency (EPA) proposes hospital noise levels should not exceed 45 dBA (day) and 35 dBA (night).[19]


Sound reduction strategies to allow a full 90-minute sleep cycle[12]. Efforts to reduce sounds:

  • Clustering clinical procedures would facilitate patients' ability to sleep: allocating time, scheduling and reconfiguration of clinical procedures or care activities and procedures such as daily radiological and pathological investigations.[6]
  • Human noise can be regulated through behavioral interventions.[19] by increasing staff awareness about the potentially negative impact of noise on patients. Educating staff about the importance of sleep.[22]Answering patient call quietly and admitting new patients quietly.[16]
  • Use of noise monitoring equipment to alert staff to any increase in noise volume.[3]Muting alarm notification in a stable patient during napping.
  • Earplugs are effective in improving sleep quality in ICU patients who undergo frequent assessments.[13]
  • Offering relaxation music through headphones could be helpful in lowering anxiety, stress, and thereby improving sleep quality and quantity. [17]

Pharmacological Intervention[edit | edit source]

Pharmacological management is considered if no improvement is seen with non-pharmacological strategies. Use of melatonin could be considered to improve sleep as circadian rhythm abnormalities seen in ICU patients are associated with reduced melatonin levels. [23]

Role of Multidisciplinary Team[edit | edit source]

Sleep-promoting activities must be multimodal, with the goal of reestablishing and sustaining day/night or circadian rhythms. A multidimensional approach must be utilized for improving the sleep quality. Identifying, controlling, and avoiding sleep disruptions should be implemented as an intervention strategy in the daily routines of hospitalized patients to enhance sleep quality. After improving sleep hygiene and eliminating possible disruptions, individualized and/or multi-component activities could be implemented. It is crucial that the entire treatment process must be coordinated with the demands of the circadian rhythm.[23] It is necessary to provide consultation services aiming at increasing sleep quality of the patients and also ensuring the accessibility of these services. [10]

Summary[edit | edit source]

Sleep-promoting Interventions

  • Daytime interventions: Like raising window blinds, preventing excessive napping, encouraging mobilization, and minimizing pre-bedtime caffeine in order to promote normal circadian rhythms.[24]
  • Nighttime interventions included dimming lights, regulating room temperature, turning off televisions, administering pain relief, grouping care activities, quieting alarms, and using eye masks to minimize sleep disruptions.[24]

The video discusses how sleep is impacted in hospitals and suggests ways to reduce sleep interruption:

[25]

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Burger P, Van den Ende ES, Lukman W, Burchell GL, Steur LM, Merten H, Nanayakkara PW, Gemke RJ. Sleep in hospitalized pediatric and adult patients–A systematic review and meta-analysis. Sleep Medicine: X. 2022 Dec 1;4:100059.
  2. ↑ Reddy S, Reddy V, Sharma S. Physiology, circadian rhythm.
  3. ↑ 3.0 3.1 Dennis CM, Lee R, Woodard EK, Szalaj JJ, Walker CA. Benefits of quiet time for neuro-intensive care patients. Journal of Neuroscience Nursing. 2010 Aug 1;42(4):217-24.
  4. ↑ Brinkman JE, Reddy V, Sharma S. Physiology of sleep.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 Kulpatcharapong S, Chewcharat P, Ruxrungtham K, Gonlachanvit S, Patcharatrakul T, Chaitusaney B, Muntham D, Reutrakul S, Chirakalwasan N. Sleep quality of hospitalized patients, contributing factors, and prevalence of associated disorders. Sleep disorders. 2020 Jan 20;2020.
  6. ↑ 6.0 6.1 Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. “They can rest at home”: an observational study of patients’ quality of sleep in an Australian hospital. BMC health services research. 2018 Dec;18:1-9.
  7. ↑ Knauert MP, Ayas NT, Bosma KJ, Drouot X, Heavner MS, Owens RL, Watson PL, Wilcox ME, Anderson BJ, Cordoza ML, Devlin JW. Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement. American journal of respiratory and critical care medicine. 2023 Apr 1;207(7):e49-68.
  8. ↑ 8.0 8.1 8.2 8.3 8.4 Morse AM, Bender E. Sleep in hospitalized patients. Clocks & sleep. 2019 Feb 25;1(1):151-65.
  9. ↑ 9.0 9.1 Keep P, James J, Inman M. Windows in the intensive therapy unit. Anaesthesia. 1980 Mar;35(3):257-62.
  10. ↑ 10.0 10.1 10.2 Alparslan GB, Orsal Ö, Unsal A. Assessment of sleep quality and effects of relaxation exercise on sleep quality in patients hospitalized in internal medicine services in a university hospital: The effect of relaxation exercises in patients hospitalized. Holistic Nursing Practice. 2016 May 1;30(3):155-65.
  11. ↑ Telias I, Wilcox ME. Sleep and circadian rhythm in critical illness. Annual Update in Intensive Care and Emergency Medicine 2019. 2019:651-64.
  12. ↑ 12.0 12.1 12.2 Missildine K, Bergstrom N, Meininger J, Richards K, Foreman MD. Sleep in hospitalized elders: a pilot study. Geriatric nursing. 2010 Jul 1;31(4):263-71.
  13. ↑ 13.0 13.1 Obanor OO, McBroom MM, Elia JM, Ahmed F, Sasaki JD, Murphy KM, Chalk S, Menard GA, Pratt NV, Venkatachalam AM, Romito BT. The impact of earplugs and eye masks on sleep quality in surgical ICU patients at risk for frequent awakenings. Critical care medicine. 2021 Sep 1;49(9):e822-32.
  14. ↑ Igeño-Cano JC. Benefits of walks in the outdoor gardens of the hospital in critically ill patients, relatives and professionals.# healingwalks. Medicina Intensiva. 2019 Nov 2;44(7):446-8.
  15. ↑ Alnawwar MA, Alraddadi MI, Algethmi RA, Salem GA, Salem MA, Alharbi AA. The effect of physical activity on sleep quality and sleep disorder: a systematic review. Cureus. 2023 Aug 16;15(8).
  16. ↑ 16.0 16.1 16.2 Ritmala‐Castren M, Salanterä S, Holm A, Heino M, Lundgrén‐Laine H, Koivunen M. Sleep improvement intervention and its effect on patients’ sleep on the ward. Journal of clinical nursing. 2022 Jan;31(1-2):275-82.
  17. ↑ 17.0 17.1 Ryu MJ, Park JS, Park H. Effect of sleep‐inducing music on sleep in persons with percutaneous transluminal coronary angiography in the cardiac care unit. Journal of clinical nursing. 2012 Mar;21(5‐6):728-35.
  18. ↑ Ashghab, A., Vahedian-Azimi, A., Vafadar, Z. et al. Nursing Interventions to Improve the Sleep Quality of Hospitalized Patients: A Systematic Review and Meta-analysis. Intensive Care Res (2024). https://doi.org/10.1007/s44231-024-00056-9
  19. ↑ 19.0 19.1 19.2 Nyembwe JP, Ogundiran JO, Gameiro da Silva M, Albino Vieira Simões N. Evaluation of noise level in intensive care units of hospitals and noise mitigation strategies, case study: democratic Republic of Congo. Buildings. 2023 Jan 18;13(2):278.
  20. ↑ 20.0 20.1 Delaney LJ, Currie MJ, Huang HC, Lopez V, Van Haren F. “They can rest at home”: an observational study of patients’ quality of sleep in an Australian hospital. BMC health services research. 2018 Dec;18:1-9.
  21. ↑ Berglund BL. Guidelines for community noise. Geneva: World Health Organization; 1999.
  22. ↑ Konkani A, Oakley B, Penprase B. Reducing hospital ICU noise: a behavior-based approach. Journal of healthcare engineering. 2014 Feb;5:229-46.
  23. ↑ 23.0 23.1 Nilius G, Richter M, Schroeder M. Updated perspectives on the management of sleep disorders in the intensive care unit. Nature and Science of Sleep. 2021 Jun 9:751-62.
  24. ↑ 24.0 24.1 Kamdar BB, King LM, Collop NA, Sakamuri S, Colantuoni E, Neufeld KJ, Bienvenu OJ, Rowden AM, Touradji P, Brower RG, Needham DM. The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU. Critical care medicine. 2013 Mar;41(3):800.
  25. ↑ Health care Triage Sleeping in a Hospital is Just Awful Available from https://www.youtube.com/watch?v=vFclKfulL3w, Accessed on 15/3/24
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