Dev Patel

IR I G/T 2019

Period 2

#11

Identifying the Causes, Effects, and Potential Solutions of Sleep Disruption in

Hospital Patients

I. Introduction:

Sleep is one of the most basic biological functions of mankind, historically attributed to

positive effects on mental and physical performance. In the last decades, there has been an

enormous amount of research conducted on the adverse effects of sleep deprivation. However,

despite the known adverse effects of sleep disruption on recovery from illness, research has

shown that sleep disruption remains an incompletely addressed problem among acutely ill

inpatients (Tamrat et. al, 2014). There is a high prevalence of poor sleep among patients admitted

to the ICU. There is a dire need to minimize untimely interventions and design

nonpharmacological techniques. (Naik et. al, 2018). Understanding the causes, effects, and

potential solutions of sleep deprivation, is instrumental in order to facilitate the implementation

of measures to conserve sleep in the hospital setting.

II. Background:

A. Classification and Description of Normal Sleep:

 The average adult needs about 8 hours of uninterrupted sleep, which includes multiple

cycles of all four sleep stages. Stages 1 and 2 primarily serve to slow body processes in

preparation for deep sleep. Deep sleep, which consists of Stage 3 and Stage 4, known as REM

sleep, is essential for long-term memory storage, information retention, attentiveness, and

healing (Jenkins, personal communication, 2018).

B. Presence and Significance of Abnormal Sleep:

The prevalence of sleep deprivation throughout hospitals points to the fact that healthcare

workers have been ignorant of novel research regarding the harmful effects of sleep loss and

disturbance, which affect all aspects of hospital procedure, by increasing the risk of falls, harm to

self and others, and other serious medical issues (Delaney et. al, 2018). According to a study

conducted by Elliot et. al, the majority of the sleep monitored was stage 1 and 2 with very short

periods of slow wave and REM sleep. The average sleep time without interruption was

approximately 3 minutes. (2013)

III. Primary Causes of Inpatient Sleep Deprivation:

70.4% out of 2005 observed patients reported having been awakened by external causes

(Wesselius, 2018). Specifically, Noise, light, and nighttime nurse interventions are the main

external contributing factors to sleep disturbance in the hospital setting. These factors are

inherent in a hospital setting, since noise from machines and human sources, adequate hospital

lighting, and routine staff interactions and vital sign readings are inevitable to ensure that

patients receive a high quality of medical care. However, disregarding the purpose of these

factors in the efficient function of a hospital, noise, light, and nurse interventions delay the onset

of, frequently interrupt, and diminish the quality of sleep overall.

 Lighting is a prominent disrupting environmental factor because it is constantly present

throughout the hospital, to guarantee that the hospital staff can perform their duties under visible

conditions at any time. This excessive bright light during nocturnal hours can deter a patient’s

sleep quality through the suppression of the production of the hormone melatonin, which is

responsible for facilitating sleep (Delaney et. al, 2018). Melatonin is essential to the onset of

sleep since it plays a large role in regulating sleep patterns on the cellular level. When a patient’s

body is constantly exposed to sufficient amounts of light, the release of melatonin is delayed, and

as a result, sleep onset is also delayed. (McKenna et. al, 2018) The increase in patient sleep

latency and melatonin suppression due to nighttime hospital lighting can take a significant toll of

the health and hospital experience of a patient.

Noise is also a tangible aspect of a hospital environment, due to sounds from medical

equipment and from human sources such as visitors, staff, and other patients. However,

according to a 2013 study, the mean sound levels was 53.95 decibels during the day and 50,20

decibels at night, exceeding the maximum standards set by the World Health Organization (Elliot

et. al, 2018). Especially due to such elevated noise levels, the incidence of nocturnal dozings and

reawakenings increase, causing patients to spend the majority of their sleep in Stage 1 and 2,

with minimal time spent in Stage 3 and REM sleep (Kamdar et. al, 2018). These frequent noise-

induced arousals decrease overall sleep quantity and the lack of time spent in deep sleep reduces

sleep quality (Freedman et. al, 1999). The extreme sound levels recorded in hospital drastically

impact patients’ sleep by reducing Stage 3 and REM and inducing recurrent arousals, adversely

affecting the recovery and overall physiological state of patients (Delaney et. al, 2018).

Nurse interventions, in the form of vital sign readings, medication administration, and

other patient-staff interactions routinely interrupt patients’ sleep almost hourly throughout the
night on a daily basis (Freedman et. al, 1999). According to a study in 2013, a median of 1.7

nocturnal care events occured hourly on the sample population (Elliot et. al). Over 25% of

patients reported staff disruptions as the main reason for unsound sleep in another sleep study

(Manian et. al, 2015). These nocturnal interactions severely fracture patients’ sleep, making it

unable for most patients to even complete multiple sleep cycles, much less get the attain the

adequate amount of daily sleep or spend sufficient time in Stage 3 and REM sleep (Tamburri et.

al, 2004).

IV. Consequences of Sleep Deprivation in Hospital Patients:

Sleep disruption, delayed sleep onset, and sleep fragmentation caused by noise, light, and

nurse interventions contribute to the prevalence of sleep-deprived patients in the hospital setting.

This rampant sleep deprivation is not without consequences to the patient. Interruptions to the

healing process, increased incidences of delirium during and after hospitalization, and numerous

cognitive and physical impairments experienced by a sleep-deprived patient, demonstrate the

severity of the effects of sleep deprivation.

An uninterrupted night’s sleep is universally known to be inherent in the process of

recovery and healing from illnesses and injuries (Park et. al, 2014). However, Stage 3 and REM

sleep, which are instrumental in physiological healing, are suppressed due to frequent nocturnal

arousals, thus delaying the healing process (Delaney et. al, 2018). In addition, Growth hormones,

which play a major role in recovery and healing on the cellular level, are predominantly secreted

during nighttime hours (Dubose and Hadi, 2016). The recurrent sleep disturbances and

disruptions due to noise and nurse interventions interrupt the nocturnal production and secretion
of Growth hormones (Tamburri et. al, 2014), interrupting and thus delaying the healing process

further (Mostaghimi et. al, 2005).

Routine sleep disruptions lead to sleep deprivation, which is known to precede delirium

(McKenna et. al, 2018) and acts as a contributing factor to the development and incidence of

delirium (Weinhouse et. al, 2009). The tendency of REM sleep to be limited during sleep

deprivation due to frequent dozing and waking, leads to the development of neurobehavioral

issues such as confusion and impaired memory which are the preliminary symptoms of delirium

(Delaney et. al, 2018). According to a 2014 study, the quality of behavior after awakening in the

hospital was decreased in about 52% of patients compared to post-awakening behavior at home

(Park et. al). Thus, incidence of delirium is common in hospitals, especially in the ICU, where it

increases the risk of mortality during hospitalization and post-discharge and has been associated

with increased hospitalization (Knauert et. al, 2018). Most significantly, REM sleep suppressed

induced delirium can impair immune function, drastically affecting the recovery of sleep-

deprived patients, especially those in critical care (McKenna et. al, 2018).

Sleep deprivation causes various cognitive impairments which can reduce the quality of a

patient’s hospital stay and adversely impact them post-discharge as well. A 2009 study on

healthy adults determined that sleep deprivation leads to negative mood changes, debility, and a

decreased cognition, effects that will only be exacerbated when extrapolated to ill hospital

patients (Weinhouse et. al). Another 2018 study on healthy adults found that routine sleep

deprivation of which the consequences can be applied and aggravated to sick patients

substantially impaired neurobehavioral functions, causing neurasthenia and depression, among

other mentally debilitating effects (Van Dongen et. al). In the long term, these significant
impairment can reduce a patient’s performance in daily activities, decrease physical and mental

abilities, increase mortality post discharge (Dubose and Hadi, 2016).

V. Potential Solutions:

The consequences mentioned above necessitate the proposal and implementation of

intuitive solutions that reduce sleep disruption without interfering significantly with hospital

processes. There is a dire need to minimize untimely interventions and design

nonpharmacological techniques (Wesselius et. al, 2018). A 2014 study also recommends the use

of nonpharmacologic, behavioral interventions instead of pharmacologic solutions to control

sleep disruption because of the harmful side effects of sedatives (Tamrat et. al). Potential

behavioral solutions to inpatient sleep disruption can be devised not by finding ways to mitigate

the consequences of sleep disruption, but more importantly and effectively, by controlling the

contributing factors of noise, light, and nurse interventions.

A relatively convenient method tested in a 2016 study targets the causing factors of sleep

disruption to reduce perceived noise and light in patients involves the administration of basic

sleep-promoting tools such as eye masks, earplugs, and white noise machines. Eye masks

prevent light from reaching patients during and prior to sleep, while earplugs and white noise

machines prevent most environmental and human sound from affecting the patient. When such

sleep-promoting measures are implementing during nighttime hours, they can work to decrease

sleep latency and allow patients’ to achieve Stage 3 and REM sleep. The study proved the

efficacy of these measures when it found that patient fatigue, performance, and overall well

being improved after the distribution of sleep-enhancing tools (Farrehi et. al).
 To specifically regulate the causing factor of light, light-controlling measures, such as

large windows and artificial blue lighting during the day, can be used to mimic the diurnal light-

dark, allowing natural and artificial illumination to be bright during the day and dim natural and

artificial lighting during the night (McKenna et. al, 2018). These presence of blue light allows

melatonin production to be suppressed during the day and the dim light at night promote

melatonin production, reducing sleep latency and leading to more time spent in deep sleep

(DuBose and Hadi et. al, 2016).

Nurse interventions are the least modifiable of the three primary causing factors due to

the inevitability of staff-patient interactions to monitor health throughout the day and night,

especially in critical care patients, who require frequent supervision and visitation. However,

according to Knauert et. al, nurse interventions can be scheduled and performed in clusters

through implementation of a Naptime program, which gives patients’ 60-120 minutes of

uninterrupted rest in a quiet and dim environment, allowing for a complete sleep cycle (2018).

The clustering of nighttime patient-staff interactions allows for the nursing staff to effectively

monitor patients while preserving a semblance of the patients sleep.

Each of these simple sleep-preserving and promoting methods works to by theoretically

control the main contributing factors of sleep disruptions, but the question of their feasibility and

real-life efficacy merits further clinical research. However, convenient and targeted therapies,

such as the ones described above, have the potential to ameliorate the quality and quantity of the

sleep in hospital patients, possibly improving the course of their illness and hospital experience

in the long term (dos Santos et. al, 2018). Therefore, the long-term effectiveness and practicality

of the potential methods outlined above should be thoroughly investigated and implemented as

necessary.
Conclusion:

By insightfully identifying the appropriate contributing factors of and using such factors

to investigate the short and long-term consequences and effects of delayed sleep latency, sleep

fragmentation, and sleep disruption, convenient and nondisruptive solutions can be devised to

reduce the overall development and occurrence of sleep deprivation. Thus, in the otherwise

disruptive hospital setting, patients’ sleep can be preserved and promoted. Through the simple,

yet intelligent descriptions of causes, effects, and potential solutions outlined in this analysis, the

groundwork for future clinical research is established and further investigation is facilitated in

the topic of sleep deprivation in hospital patients.

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