Sleep in Hospitalised Patients

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Top Contributors - Vidya Acharya  

Introduction

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. 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

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.. 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. . 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

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 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.

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.

Factors Affecting Sleep in the Hospitals

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

• Intrinsic Factors 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
  • medications
  • pre-existing sleep disorder
• Extrinsic Factors 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.
  • an unfamiliar environment, being in different place
  • cold temperature or hot temperature
  • disturbance by visitors.

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.

Strategies to Improve Sleep Quality

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. 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:

• 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

Circadian Rhythm

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. 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.

• Regulating the brightness of the room in the daytime according to the circadian rhythm.

• Provide activities for the patients in the daytime

Light

In patients undergoing frequent assessments, eye masks are found to be effective nonpharmacologic sleep-promoting adjuncts in the ICU.

Pain, Fear and Anxiety

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

• 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.

• 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.
• Relaxation and imagery techniques, massage therapy, muscle relaxation, foot baths, and foot reflexology massage might help calming the anxiety and inducing sleep.

Noise

Noise is being the most frequently reported cause of sleep disruption in the hospital 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. Research indicates 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%. 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. 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. According to WHO guidelines, the sound in the hospital should not exceed 35 dB for the rooms in which patients are treated or observed. The US Environmental Protection Agency (EPA) proposes hospital noise levels should not exceed 45 dBA (day) and 35 dBA (night).

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.
• Human noise can be regulated through behavioral interventions. by increasing staff awareness about the potentially negative impact of noise on patients. Educating staff about the importance of sleep.Answering patient call quietly and admitting new patients quietly.
• Use of noise monitoring equipment to alert staff to any increase in noise volume.Muting alarm notification in a stable patient during napping.
• Earplugs are effective in improving sleep quality in ICU patients who undergo frequent assessments.
• Offering relaxation music through headphones could be helpful in lowering anxiety, stress, and thereby improving sleep quality and quantity.

Pharmacological Intervention

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.

Role of Multidisciplinary Team

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, implement individual and multi-component activities. It is crucial that the entire treatment process must be coordinated with the demands of the circadian rhythm.

Summary

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.

• 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.

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