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of various organs. Patients also undergo necessary procedures which are usually
performed at the bedside if feasible given the critical condition of the patients. All
these above-mentioned interventions can cause significant disturbances in patients’
sleep.
242 P. P. Vaishnav et al.
Grooming of the Patient
Hospitalized p
atients need to be assisted with activities of daily living including
bathing, feeding, and grooming and most of these interventions are performed
during the hospitalization by nurses or nursing assistants. For some of the patients
these activities could come in the way of their sleep causing sleep disturbances.
Mechanical Ventilation
Both invasive and noninvasive ventilation (NIV) modes of mechanical ventilation
can affect a patient’s sleep. Regardless of certain limitations arising from a high
variance in underlying diseases, patient groups, and types of ventilation (endotra-
cheal tube, tracheostomy, mask), there are many hints that the mode of ventilation
will also influence sleep quality and quantity (Chang et al.
2020).
Mechanical ventilation can disrupt sleep due to a mismatch between patient
demand and ventilator supply (inadequate support leading to dyspnea or excessive
support leading to apnea) (Chang et al.
2020). Major causes of sleep disturbance
associated with mechanical ventilation include patient – ventilator asynchronies, cen-
tral apneas due to overventilation, and inadequate ventilatory support due to
improper settings or air leaks leading to increased respiratory effort (Chang et al.
2020).
Studies by Parthasarathy and Tobin (2002) and Toublanc et al. (2007) found that
pressure support ventilation (PSV) led to episodic hyperventilation with resulting
decreased partial pressure of carbon dioxide, causing apneic events in comparison to
assist control ventilation (ACV ). However, work by Cabello and colleagues showed
no differences in sleep architecture between non-sedated ICU patients on clinically
adjusted PSV, automatically adjusted PSV, or ACV. The authors, therefore,
suggested that it is not PSV itself that causes sleep disruption but the specific
ventilator settings: They used lower levels of pressure support, standard minute
ventilation, and tidal volume across all modes to better mimic physiological condi-
tions (Cabello et al. 2008).
Other studies looking at proportional assist ventilation in which pressure is
applied in proportion to the patient’s inspiratory effort and neurally adjusted venti-
latory assist in which pressure is applied in proportion to the electrical activity of the
patient’s diaphragm also find improved sleep quality. Thus, evidence from multiple
studies indicates that patient–ventilator mismat ch, rather than any given ventilator
mode, is most responsible for sleep disruption (Chang et al.
2020).
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15 Sleep Disturbances in Hospitalized and Intensive Care Unit Patients 243
Noninvasive Ventilation
Patients with hypercapnic respiratory failure requiring >24 h of noninvasive venti-
lation (NIV) exhibit marked sleep disturbances as assessed by PSG. Sleep alterations
including circadian sleep cycle disruption and shorter REM sleep time were associ-
ated with subsequent delirium and late NIV failure (Pulak and Jensen
2016).
15.9.3 Patient Specific Factors
15.9.3.1 Pain
Pain could be either related to illness severity or on its own is associated with poor
sleep and increased arousal due to discomfort. Pain causing loss of sleep may trigger
an unfortunate feedback loop in which the lack of sleep leads to hyperalgesia, which
in turn inhibits adequate rest (Chang et al.
2020).
The most common patient-reported physiological factor is pain and breathing
difficulty in those reporting poor sleep as stated in a systematic review of patient-
reported studies by K. Honnarmand et al. (2020).
Bed Rest and Physical Activity
Daytime physical activity improves nighttime sleep and supports the maintenance of
a healthy circadian rhythm. Therefore, reduced physical activity due to limited
opportunities to engage in exercise or outdoor activities might result in impaired
sleep and circadian disruption during hospitalization. This in turn may decrease
daytime physical activity due to a lack of motivation (Tan et al.
2019). Another
common behavior among inpatients is napping. A daytime nap may compensate in
part for less sleep at night and promote recovery from acute illness. However,
excessive napping might be a marker of other pathology, including undiagnosed
sleep disorders (Tan et al.
2019).
15.9.3.2 Anxiety and Fear
The ability to sleep is most affected by fear-related factors. A strong sense of
powerlessness and helplessness related to their critical clinical condition leads to
sleeping difficulties. Some of the patients are afraid to sleep due to recurring
nightmares, which leads to constant tiredness and anxiety. The death of a fellow
patient staying in the same ward also contributes to feelings of insecurity, causing
patients to experience sleeping difficulties. In an ICU setting where death is not
uncommon, patients were too frightened to go to sleep. Another factor that
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contributed to lack of sleep was loneliness, longing for family, and lack of commu-
nication with them (Lewandowska et al. 2020).
244 P. P. Vaishnav et al.
15.10 Sleep Measurement in Critically Ill Patients
Sleep is a multidimensional construct, composed of dimensions such as total sleep
time, percent of sleep stages, frequency of awakenings or arousals, expectations,
global perceptions, sleep movements, tiredness upon awakening, daytime energy
levels, and functional impairments. Although there are vario us methods of measure-
ment of sleep in ICU patients, they do not all measure the same dimensions, and we
do not expect them to demonstrate 100% agreement (Medrzycka-Dabrowska et al.
2018). Below is a brief description of the different types of measurem ents that exist.
15.10.1 Polysomnography
Polysomnography is the gold standard test and a comprehensive method for sleep
assessment. Such an examination includes electroencephalography (EEG), electro-
oculography (EOG), subcutaneous electromyography (EMG), electrocardiography
(ECG), monitoring of thorax movements, and pulse oximetry. In an ICU setting, the
course of polysomnographic examination is additionally hampered by the presence
of several sensors monitoring basic vital functions, which are attached to the
patient’s body (Medrzycka-Dabrowska et al. 2018).
15.10.2 Bispectral Index
The bispectral index (BIS) is used to minimize the amount of equipment required to
perform EEG. BIS is calculated by the multiple analysis of the native EEG wave-
form, including power spectroscop y analysis, bispectral analysis, and timing analy-
sis of the suppression to stimulus index. A BIS value ranges from 0 (no EEG signal)
to one hundred, the higher numbers indicating awakeness, and a score one hundred
indicates a clinically fully awake patient. BIS may potentially assess the depth of
sleep, yet it is not a standard method for assessing sleep in the ICU setting (Kamdar
et al. 2012a).
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15 Sleep Disturbances in Hospitalized and Intensive Care Unit Patients 245
15.10.3 Actigraphy
Actigraphy is one of the methods for sleep assessment commonly referred to in the
literature. It is a continuous method for registering a patient’s activity during the day
and night using a special device called an actigraph (usually lasting several days).
Technically, the device comes in the form of a watch. It is placed on the patient’s
wrist, which enables researchers to evaluate the patient’s wakefulness based on their
movements. Once the subject is asleep the device detects no movement at all (Pulak
and Jensen
2016). Actigraphy allows the calculation of total and average sleep
duration, sleep onset latency (the length of time that it takes to fall asleep), the
number of awakenings during sleep, the number of naps during the day, and the
amount of active and non-active time during the day (Medrzycka-Dabrowska et al.
2018).
15.10.4 Patient Assessment
Subjective methods make it possible to assess sleep in ICU patients. One such
method is the RCSQ (Richards-Campbell Sleep Questionnaire). This five-item
scale evaluates the patient’s perception of their depth of sleep, sleep onset latency,
sleep duration, sleep onset latency after awakening, and overall sleep quality.
Patients who can maintain logical communication mark their score on a scale of
0–10 (Medrzycka-Dabrowska et al. 2018).
15.10.5 Nurse Assessment
This is a subjective method where nurses may assess a patient’s sleep by direct
observation, as well as by using scales and questionnaires. Recent studies proved
that direct observation by nurses may be insufficiently accurate for an evaluation of
the amount of sleep and for identifying sleep disorders (Bourne et al.
2007). Results
of a study published in 2012, which compared a patient’s self-assessed sleep and an
assessment performed by the nurse taking care of the patient during a particular shift
using the RCSQ questionnaire, showed that nurses tend to overestimate the score
(Kamdar et al.
2012b). Due to the nature of the constant care that nurses provide to
patients, they should take sleep and rest into consideration in the process of taking
care of the patient (Medrzycka-Dabrowska et al. 2018) (Table 15.1).
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Advantages Disadvantages
(continued)
246 P. P. Vaishnav et al.
Table 15.1 Methods of sleep assessment (Medrzycka-Dabrowska et al. 2018)
Sleep assessment
method
Nature and
reliability
Clinical
application
Polysomnography Gold standard
Inter-rater reliabil-
ity in critical care,
kappa = 0.79–0.83
Monitors the
amount and
quality of sleep.
Distinguishes
particular sleep
stages
Continuous
attendance of a
technician is
needed during
monitoring to
obtain adequate
results. Partially
subjective
assessment dur-
ing the first
stage of sleep.
The amount of
equipment
hampers sleep
in non-sedated
patients. Cost-
expensive in the
ICU setting. A
patient’s critical
condition may
result in EEG
disturbances
Not performed
in routine clin-
ical sleep
assessment
BIS All patients with
BIS values below
80 were asleep
BIS sensor eas-
ily applied. The
entire equip-
ment to measure
BIS is easy to
use. Inexpen-
sive examina-
tion. Outcome is
readily available
BIS sensors
may disturb the
patient. Muscle
movements
may disturb BIS
measurement.
Once the mea-
surement is
complete, it is
necessary to
upload the data
to a personal
computer for
analysis
Not performed
in routine clin-
ical sleep
assessment.
Validation of
the examina-
tion and algo-
rithm develop-
ment are
required
Actigraphy Correlation with
polysomnography
for TST 0.72–0.98
(Chang et al.
2020;
Grossman et al.
2017). Not vali-
dated versus
polysomnography
in the ICU setting
Noninvasive.
May be
performed by
non-technicians
and
non-specialists.
Inexpensive
once the device
and accessories
are purchased
Neuromuscular
fatigue
increases the
risk of
overestimating
sleep quality.
Nursing staff
may displace
the sensor, in
the form of a
watch, during
nursing care
interventions
Used to deter-
mine a circa-
dian rhythm
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Advantages Disadvantages
periods of
physical
inactivity—the
chronic state in
ICU patients,
may be scored
by the sensor as
sleep
15 Sleep Disturbances in Hospitalized and Intensive Care Unit Patients 247
Table 15.1 (continued)
Sleep assessment
method
Nature and
reliability
Clinical
application
Patient
assessment
Sleep in the Inten-
sive Care Unit
Questionnaire—
not validated ver-
sus
polysomnography
(Yoder et al. 2012)
Richards-Campbell
Sleep
Question-
naire reliability
(Cronbach’s
alpha = 0.90) cor-
relation versus
polysomnographic
sleep efficiency
index in ICU
patients = 0.58
If capable, a
patient can
compare the
baseline sleep
value with the
one experi-
enced. Rela-
tively quick
Cannot be used
in patients with
cognitive dys-
function. Mem-
ory problems
may reduce its
accuracy. Can-
not be
performed in
sedated
patients. Circa-
dian rhythm
disturbances
may adversely
affect nocturnal
sleep perception
RCSQ scale
does not apply
to sedated
patients,
patients with
cognitive dys-
function and
with delirium
Nurse assessment Direct observation
at 15-min intervals,
assessment of sleep
state compared to
polysomnography
correct for 81.9%
of the time
(Honarmand et al.
2020). RCSQ—
reliability versus
patient’s assess-
ment (Cronbach’s
alpha = 0.83–0.95)
Easy to perform
during routine
nursing care
Overestimated
TST. Frequent
patient assess-
ment is
required. Risk
of data loss
caused by other
direct and indi-
rect nursing
care activities.
It is not possible
to present an
accurate report
of the patient’s
total sleep
quality
Easy and
targeted tool
for sleep
assessment on
ICU patients
who meet the
requirements
for
such an
evaluation
15.11 Strategies to Promote Sleep in the ICU
It has been proven that increasing awareness of this issue and interaction within the
therapeutic team may minimize sleep disorders. The main measures should aim at
increasing the comfort of patients, reducing light and noise intensity at night, and an
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appropriate organization and aggregation of nursing care interventions to prevent
sleep interruptions. An adequat e mode of mechanical ventilation is also important
for the comfort of patients. Regular assessments of pain intensity and appropriate
methods of pain control play a key role as well (Medrzycka-Dabrowska et al.
2018).
248 P. P. Vaishnav et al.
15.11.1 Vital Sign Monitoring
Vital sign monitoring is an essential part of hospital routines. Yet, nocturnal mea-
surements (normally repeated 2–3 times overnight) could impair patients’ sleep
quality.
An intervention to the said problem is to introduce wireless technologies that
transmit patient vital signs information to a central location (for example heart rate,
body temperature, blood glucose level, and blood pressure) (Tan et al.
2019). Some
portable, continuous vital sign monitoring systems have already been piloted in the
clinical setting and might be promising for promoting sleep while safeguarding early
recognition of possible deterioration (Weenk et al.
2017).
15.11.2 Physical Activity
Reduced physical activity may result in impaired sleep. Therefore, interventions
such as encouraging patients to take a walk outside, serving meals in a separate
room, or offering bed exercises, all of which are likely to aid sleep and support the
maintenance of a normal circadian rhythm. Additionally, such interventions increase
exposure to natural light with additional direct positive effects on sleep and circadian
rhythm (Tan et al.
2019).
15.11.3 Pain
Pain and sleep interact in a bidirectional manner (Bjurstrom and Irwin 2016) and
could therefore cause a vicious cycle. Chronotherapy, referring to the appropriate
timing of medication to relieve illness symptoms at times when they are most
disruptive (for example: by targeting pain during nocturnal sleep) should be consid-
ered (Tan et al. 2019).
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15 Sleep Disturbances in Hospitalized and Intensive Care Unit Patients 249
15.11.4 Ambient Temperature
In an article that studied the impact of temperature, researchers exposed 40 patients
to different nighttime temperatures over three nights and found increased total sleep
time and greater sleep efficiency on nights with lower temperatures (DuBose and
Hadi
2016).
15.11.5 Melatonin Therapy
Reduction in plasma melatonin levels, low melatonin secretion, and lack of circadian
increase in melatonin has been found in critical care patients undergoing mechanical
ventilation. In contrast to other sedatives and hypnotics, melatonin causes minimal
side effects even in extremely high doses (700 mg/day). Tolerance to melatonin does
not seem to develop during treatment as it does with other sedatives, so there is no
need for increasing doses for sleep induction (Shilo et al. 2000). Melatonin therapy is
effective in the resetting of sleep–wake cycles and the entrainment of circadian
rhythms (Pulak and Jensen 2016).
15.11.6 Noise Reduction
Noise represents an easily modifiable factor that may impact patients’ sleep patterns
in an ICU setting. Patient satisfaction is said to go up when the unit is less noisy, and
sleep is improved. The introduction of guidelines to decrease noise levels includes
relocating all acoustic alarms to outside the patient’s rooms; adapting all mechanical
alarms (pumps and ventilators) to the nighttime environment; closing the door or
curtain if this can be safely done; and discouraging noisy tasks at night such as
garbage emptying and linen collection (Pulak and Jensen 2016).
Basic noise reduction interventions such as earplugs and white noise machines
have been shown to promote longer and better-quality sleep. Newer ICUs can
consider noise reduction in their structural designs. Quiet time to allow naps in the
afternoon and evening hours is a simple policy that may increase patient satisfaction
with sleep, especially as patient satisfaction is becoming an important benchmark of
care (Chang et al. 2020).
15.11.7 Light
Promoting sleep–wake rhythms through various day/night environmental interven-
tions could improve the patients’ naturally occurring circadian rhythms and was
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associated with a reduction of the prevalence of delirium. Such interventions com-
prise sufficient daylight, encouragement of physical and cognitive activities during
the day, dimming the lights, closing curtains, providing eye masks and/or earplugs,
and reducing nursing activities during the night (Nilius et al.
2021).
250 P. P. Vaishnav et al.
Daylight plays an imp ortant role in sleep
regulation. It suppresses melatonin,
increasing alertness and entraining the circadian rhythm to support better sleep at
night. Elderly patients exposed to bright daytime light for a week slept longer and
awoke later. The use of bright light in the early evening was also found to be
effective in increasing total sleep time and reducing awakenings for elderly patients
(DuBose and Hadi
2016).
15.12 Conclusion
Sleep is an essential component of daily life. It plays a more imp ortant role in people
with ailments as it aids in recovery and promotes general health. The ICU is a high-
intensity environment where the technical and analytical aspects of healthcare could
be given importance over the psychological aspects and comfort of the patient.
While this approach has its benefits, through this chapter we have highlighted the
importance of sleep and the effects of sleep disruption. Healthcare workers have to
be mindful of both the impacts of sleep and sleep disorders and take an active
approach to promote sleep among patients in hospital and ICU settings. This is of
particular importance because recent studies have shown an overall significant
reduction in the length of stay for hospitalized and ICU patients. Each patient has
several factors that impact sleep in the ICU, at the same time each factor is
responsible only for a small percentage of the sleep disruption. Thus, a more
complete action plan with multiple approaches to promote sleep should be
implemented. Finally, more information on the approaches to promote sleep in
ICU patients must be discovered through robust studies to tackle this problem.
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