Sleep

YOU NEED IT!

Sleep, specifically sleep deprivation, is one of the most under appreciated and consequential factors for the hospitalized patient. Most adults need 7-8 hours of sleep a night. This is essentially guaranteed to not happen in the hospital. A plethora of sleep robbing gremlins exist:

Your medical condition: pain, trouble breathing, nausea, diarrhea, not having a CPAP/BiPAP machine, etc.

The hospital itself: new (uncomfortable) bed, variable room temperature, abnormal lighting, unceasing noise from IV pumps, overhead alarms, telemetry monitors, other patients, the staff, floor cleaners, helicopters landing, ambulance sirens, etc.

Hospital staff: all manners of staff members awakening you at all hours of the day and night for care, vital checks, blood sugars checks, medications, testing, rounds, etc.

Medications: stimulant effects of some, not getting regular home sleep medications, sedated during the say from meds so awake at night.

What is the consequence? Not simply a tired patient but a tired brain. All of our organs (including the brain) have a certain amount of “reserve” to compensate for an increase burden. For example the heart beats faster and muscle contracted stronger when lifting weights. When it comes to our brains sleep is our refuge to heal, specifically deep sleep (stages 3-4/REM). It takes about 90 mins to go through a sleep cycle. When awoken you generally have to start back over in stage 1. Which means when you are awoken by something every few hours your aren’t getting through your normal recuperative stages. Despite sleeping you awake feeling tired and mentally foggy. Now do this night after night, while under the emotional stress/fear of a medical illness and side effects of medication. It adds up quickly. This increase burden on our brains coupled with decrease recuperative time taxes our brains past their compensation point; this is when hospital acquired delirium sets in. Delirium is waxing and waning stages of confusion; develops over hours to days. Often inattention is the first stage. It progresses to difficulty processing information, confusion, emotional mood swings, hallucinations, and aggressive and combative behavior. This IS NOT DEVELOPING DEMENTIA as many family members often fear. Literature suggest the frequency ranges from 25-30% of otherwise normal elderly patients to more than 50% of patients who already have dementia prior to being hospitalized. This is consistent with what I see in the hospital.

There are good guidelines to help address this discussed later. I bring it up now because sleep deprivation is a major contributor and THE ONLY REAL WAY TO IMPROVE delirium. Medications don’t “fix” delirium; they permit the person to rest and sleep fixes delirium. See the section dedicated to hospital-acquired delirium for more details.

Action items to promote sleep:

  1. Recognize its importance; don’t brush it off. How do I get good sleep? Not, I can’t get good sleep.
  2. Request the doctor to order “Sleep Hygiene.” This is an order which tells staff to allow the patient to sleep at night. There are many medical conditions where this isn’t appropriate; but it’s worth asking
  3. Have a plan to sleep. When is bedtime? How do you unwind before bed? Turn off TV? Adjust thermostat (little cooler generally better). Ask for more blankets if needed. Close blinds and turn off lights. Close room door.
  4. White noise from your phone if it helps to drown out the ambient hospital noise.
  5. Ask nurse if any of the IV pumps or cardiac monitors are can have the alarms silenced. Realistically this is often not the case; but worth asking.
  6. If you take medication at home to help sleep discuss this with your provider. It may not be safe to add to other medications in your treatment plan so alternatives may need to be substituted
  7. If you use a CPAP or BiPAP machine make sure you tell staff to get one. If you know your settings tell the respiratory therapist when they bring it; if not we set it to “auto.”
  8. When tired during the day you can take naps but try to keep them to roughly 30 mins. Napping for several hours disrupts the circadian sleep-wake cycle making it harder to sleep the next night and actually adding sleep deprivation.
  9. Sleep works much like money does. When you have too little, or expend too much, you incur a sleep debt. This must be paid back with more sleep later. The greater and longer the debt, the longer it takes to pay back.