Sleep in Hospitalised Patients

Original Editor - User Name

Top Contributors - Vidya Acharya and Kim Jackson  

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. Hospitalised patients are at risk for sleep disturbance. Sleep deficiency is associated with health risks. Reports suggest that sleep is 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. .

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, 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.

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

Noise is being the most frequently reported cause of sleep disruption in the hospital Efforts should be made to reduce sounds. Alarm notification can be turned to silent mode in a stable patient during napping. 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) proposed that the noise levels in hospitals should not exceed 45 dBA (day) and 35 dBA (night).

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.
• Studies have shown an increased outdoor time and increased physical activity had a positive impact on sleep time, sleep quality in healthy adults and students.

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