Running

Head: EFFECTS OF SLEEP ON HOSPITALIZED PATIENTS 1

Effects of Sleep on Hospitalized Patients

Francisco Gonzalez, Adam J. Sniezek, Brandon W. Rigelsky, Gabriela R. Thomas, Rosemond O.

Darkwa

NURS 3749: Nursing Research

Dr. Valerie O’Dell

4/2/2018

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Abstract

The purpose of this research was to see the relationship between sleep disturbances and how it

negatively impacts the hospitalized patient. This research was drawn from 11 sources, all of

which showed substantial evidence supporting this claim. There was significant evidence

showing different age ranges requiring specific amounts of sleep per night to properly function.

There was also research showing how sleep can impact physiological factors of the body such as

promoting a healthy immune system. The research further exemplifies sleep’s impact on a

patient’s emotional health and mood. The research shows that nonpharmacological measures,

such as relaxation techniques, can greatly improve the patient’s amount of sleep. There are

ongoing studies to prove pharmacological measures such as melatonin can increase sleep

throughout the night. There is significant data that shows educating patients in the hospitalized

setting on sleep can lead to decreased pain and anxiety levels which promotes better sleep.

Overall, the research shows sleep is essential for positive patient outcomes and recovery.

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Effects of Sleep on Hospitalized Patients

Introduction

In hospitalized patients, how do disturbances in the sleep cycle versus uninterrupted sleep

affects overall patient outcomes in recovery over the length of stay? Patient outcomes health

professionals are concerned with include pain, vital signs, infection and comorbidities. Sleep

disturbances in the hospital setting lead to worsening patient outcomes. Therefore, health care

workers must advocate maintaining normal sleep as much as possible for their patients.

Interventions used to assist patients include identifying how sleep deprivation affects

physiological and emotional responses in patients, treating patients with pharmacological and

non-pharmacological methods, and educating patients and healthcare provides about the benefits

of sleep.

Normal Sleep

Throughout the lifespan, we need different amounts of sleep per night based on our

bodies’ needs. According to sleephealthfoundation.org (2015), it is recommended that an

adolescent ages 14-17 gets 8-10 hours of sleep nightly, but 7-11 hours may also be

appropriate. Adolescence is a period of intense growth and physical development, as well as a

circadian shift, resulting in a biologically based tendency to stay up late and sleep in whenever

possible (as cited in Mathews, Hall, Cousins, & Lee, 2015). In adolescence, many factors,

including school, can influence the quality and duration of sleep. Time students spend sleeping

on school nights decreases as they get older, so much so, that they end up with a sleep debt. This

is due to early start times as well as increases in social and educational demands (as cited in

Mathews et al., 2015). There are other factors such as how adolescents cope with stressors that

can affect how they sleep at night. According to (Mathews et al., 2015), students who reported

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using disengagement coping exhibited poor sleep health. They had shorter sleep duration, more

fragmented sleep, delayed sleep, and increased daytime sleepiness. Unexpectedly, positive

engagement coping was related to daytime sleepiness and delayed sleep.

In adults, the recommended amount of sleep decreases throughout the life-

span. According to sleephealthfoundation.org (2015), young adults ages 18-25 and ages 26-64

are recommended to have 7-9 hours of sleep per night, but for both of these age groups 6-10

hours may be appropriate. In adults ages older than 65 years old, 7-8 hours is recommended, but

5-6 hours may be appropriate. Changes in sleep are evident especially in older adult

populations. Some of these come about as a result of the normal aging process, but other factors

have an influence on making sleep more difficult for the aging adult. Increased prevalence of

sleep disturbances in older adults is often related to the higher levels of medical comorbidities

(e.g., chronic pain) and life events (e.g., retirement, loss of spouse) (as cited by Dillon et al.,

2015, p. 46). There are other physiological changes that also affect the normal sleep cycle of

aging adults. There are also changes in sleep architecture occurring across adulthood. Sleep

becomes lighter with age and shifts between the different sleep stages occur more frequently,

with older adults experiencing more awakenings throughout the night (as cited by Dillon et al.,

2015).

Physiology

Sleep has the ability to greatly affect human physiology. Sleep is categorized as being an

anabolic state, meaning that it both promotes growth and stimulates the immune system

(Chokroverty, 2017). The different stages of sleep affect the body physiologically in different

ways. NREM sleep, according to Porkka-Heiskanen, Zitting, and Wigren (2013), causes

“decreases in heart rate, blood pressure, breathing rate and core body temperature” (p. 313). In

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REM sleep, only the muscles that are innervated by cranial nerves or are utilized for breathing

are active; during this stage, all other muscles are paralyzed and all autonomic nervous system

activity is absent (Porkka-Heiskanen, Zitting, & Wigren, 2013). Porkka-Heiskanen et al. (2013)

continues by stating “the cause for these physiological changes is unknown” (p. 313). Regardless

of the origin of the changes, many studies have documented “the healing effects of sleep for

health maintenance, growth, and restorative functions” (as cited in Radtke, Obermann, &

Teymer, 2014, p. 178). Sleep is integral in helping the body remain normal physiologically.

Sleep also helps the body fight infection. Cytokines, which are pro-inflammatory

mediators of immune response, are “somnogenic and promote NREM sleep” (as cited in Porkka-

Heiskanen et al., 2013, p. 314). As cited in Porkka-Heiskanen et al. (2013), “the increase in sleep

following immune challenge is thought to be mediated mainly by the pro-inflammatory

cytokines in response to pathogen recognition and subsequent inflammatory cellular pathways”

(p. 314). Studies show when rats are totally deprived of sleep, they die from systemic bacterial

infections (Porkka-Heiskanen et al., 2013, p. 319). Similarly, in humans, sleep deprivation has

been found to cause “a delay in immune response 10 days after flu vaccination” (as cited in

Chokroverty, 2017, p. 19). Conversely, it has been shown that sufficient sleep in human

populations helps to improve antigen titers after vaccination (as cited in Porkka-Heiskanen et al.,

2013).

Hormones also play an important role in the connection between sleep in immune

response. Growth hormones, which are responsible for tissue repair and regeneration, are

predominantly secreted during sleep (as cited in Dubose & Hadi, 2016). Growth hormone is

secreted from the anterior pituitary gland during slow-wave sleep (part of NREM sleep), and is,

according to Chokroverty (2017), “inhibited during awakening and sleep fragmentation” (p.

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179). Cortisol, another hormone related to sleep, is recognized for having immunomodulating

effects (as cited in Chokroverty, 2017). Sleep loss increases the level of cortisol, which activates

the sympathetic nervous system. This both increases heart rate and blood pressure (as cited in

Porkka-Heiskanen et al., 2013, p. 316). This effect on physiology can have negative impacts on

hospitalized patients.

The sleep-wake cycle, like most other physiological functions, expresses circadian

rhythm (Porkka-Heiskanen et al., 2013). The sleep cycle’s biological clock is located in the

suprachiasmatic nucleus (SCN), right above the optic chiasm of the hypothalamus (as cited in

Chokroverty, 2017). As cited in Giménez et al. (2017), “this pacemaker uses light–dark

information to initiate and control the timing, alignment and stability of the endogenous 24 h

patterns in our sleep, physiology, alertness and mood. Proper timing of the light exposure is

critical” (p. 236). The SCN has many projections that target the hypothalamus, which explains

why there are typical rhythmic secretions of many hormones as well a rhythm to body

temperature (Porkka-Heiskanen et al., 2013). It is no surprise then that many of the hormones

produced by the body also demonstrate circadian patterns, and that when sleep loss occurs, the

levels of hormones in the body are also affected to some degree (Chokroverty, 2017). If someone

is disrupted from sleep, they could end up sleeping more during the day. This can be troubling

because sleeping during the day essentially forces the body to try to rest when, for example, both

temperature and cortisol secretions are typically high (Porkka-Heiskanen et al., 2013). Because

of this, Porkka-Heiskanen et al. (2013) concludes that “the regular daily rhythm is the core

condition for sleep success: waking always at the same time of the day and going to bed equally”

(p. 322). Deep, undisrupted sleep is thus indispensable in preserving the body’s immune system

and normal physiological function.

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Psychological Effects of Sleep Deprivation

The causes of sleep deprivation include environmental factors such as noise and light,

patient care activities, and medications, which will be discussed later. These factors can

influence a patient’s physical or psychological experience of their illness, such as pain and

anxiety (Kamdar, Needham, & Collop, 2012). The consequences of sleep deprivation are vast,

and often sleep deprivation in hospitalized patients leads to negative psychological effects.

Combined, the psychological effects of sleep deprivation relates to cognitive functioning,

delirium, anxiety, fatigue, and depression, among others.

Sleep deprivation can affect our cognitive function. Lack of sleep places significant stress

on the body, which leads to psychological changes that affect brain function. For example, in a

group of healthy subjects, total sleep deprivation resulted in fatigue, cognitive slowing, and

mood changes, which induces endocrine changes that sustain wakefulness (Klumpers et al.

2015). These changes cause significant decrease in energy levels, concentration, and speed of

thought (Klumpers et al. 2015). The effects of such physiological stressors on cognitive

outcomes in critically ill and hospitalized patients have also been well documented (Kamdar et

al., 2012).

Poor sleep quality is also often commonly related to delirium. Even though there is

debate about whether sleep deprivation is a cause or the result of delirium, there is an ample

evidence to suggest that both conditions are common in hospitalized patients, and that both share

common mechanisms and clinical features (Kamdar et al., 2012). Interestingly, both poor sleep

and delirium have been linked to disruptions in circadian rhythms. For instance, variations in

melatonin, the important hormone involved in sleep-wake cycles, has been shown to contribute

to delirium; patients with decreased melatonin levels and altered melatonin cycles prior to

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admission were more likely to develop delirium in a small study, consistent with other studies

that have linked melatonin cycles to sleep and delirium (Kamdar et al., 2012). As a psychiatric

syndrome, delirium in hospitalized patients is associated with several adverse outcomes

including impaired cognition, prolonged hospitalization, and high mortality rates (Kamdar et al.,

2012).

Sleep deprivation can also affect a patient’s mood. Poor sleep places tremendous stress

on the body. This stress can trigger a wide range of emotions that present with mental symptoms

such as depression, fatigue, and anxiety, among others (Kamdar et al., 2012). In a larger study,

reduced sleep increased the risk for major depression, which in turn worsened sleep quality

(Roberts & Duong, 2014). While the mechanisms underlying this association are less

understood, there is some evidence that these associations result from disruptions in hormonal

processes such as increased sympathetic activity during wake periods, which leads to anxiety and

stress (Kamdar et al., 2012). For instance, several studies have demonstrated that levels of

important brain growth factors are disrupted under the stress of poor sleep quality, which

worsens stress and causes depression. The effect of sleep deprivation on mood is pronounced in

illness, especially in the hospitalized patients. Some studies have also reported how disruptions

in circadian rhythms could make patients more vulnerable to mood disorders such as depression

and bipolar disorders (Kamdar et al., 2012).

Treatments

It is music to patient’s ears to hear that there are treatment options to help promote their

sleep. There are both non-pharmacological and pharmacological measures to help promote sleep.

Non-pharmacological measures are the first line of treatment in hospitalized patients because

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there is a chance of adverse effects with medications. Tamrat, Huynh-Le and Goyal (2014)

stated:

Sedative hypnotics are prescribed by a large majority of providers on an as needed basis

and utilized by 31–88 % of hospitalized patients. There are multiple cognitive adverse

effects of sedative hypnotics such as memory loss, confusion, and disorientation;

psychomotor-type events, such as reports of dizziness, loss of balance, or falls; and

reports of daytime fatigue were all more common with sedative use (p.788-789).

There are three common non-pharmacological measures used on patients. These three measures

are relaxation techniques, sleep hygiene or reduced sleep interruption programs and daytime

bright light therapy.

In Tamrat, Huynh-Le and Goyal’s (2014) randomized control trials, an experiment used

to reduce bias when testing a treatment option, showed 0-28% improvement in sleep quality

overall by using relaxation techniques. Interventions were randomly altered on 70 patients. These

interventions consisted of decreasing the amount of noise and light around the room, adjusting

the room temperature, minimizing interruptions, clustering nursing activities and personal

hygiene. These relaxation techniques improved sleep quality by seven percent. There were 96

random post-coronary artery bypass grafting (CABG) patients were exposed to 30 minutes of

soothing music. The Richards Campbell Sleep Questionnaire (RCSQ), which assess the overall

sleep quality, score was 28 % improved. Massage therapy and guided imagery did not have any

effect on the patient’s sleep quality (Tamrat, Huynh-Le, & Goyal, 2014). “Nonrandomized

studies found a 10–38 % improvement in sleep quality using relaxation techniques. 60 post-

CABG surgery patients to usual care or a soft white noise, such as ocean sounds, that played

throughout the night” (Tamrat et al., 2014, p.791). There were 20 chemotherapy patients who

EFFECTS OF SLEEP ON HOSPITALIZED PATIENTS 10

received a massage for 30 minutes three times a week showed a 20 percent improvement in the

Verran Snyder Halpern (VSH) sleep score. Roman Chamomile oil was provided to 37 patients

pillows which improved sleep time by 36 minutes (Tamrat et al., 2014). The sleep hygiene or

reduced sleep interruption study included eliminating day time napping. This study was

performed on 321 random patients. This study showed an 18 minute per night increase in sleep

quality (Tamrat et al., 2014). Even a short amount of extra sleep is beneficial to the patients.

Lastly, daytime bright light therapy was studied. Artificial light was added to 24 patients

room from nine am. to eleven a.m. daily for four weeks. Their average total sleep time increased

by sixty minutes. In another study, artificial light was added between ten AM and three PM each

day for one week. The average total sleep time was increased by 27 minutes (Tamrat et al.,

2014). Although there was not much of an increase with these measures, there was improvement

shown. All patients should begin with these therapies before considering medication options. A

common drug used to help promote sleep is Melatonin. “Melatonin has been given safely to

humans in doses of 1 to 15 mg…They found that the most common side effects of melatonin use

were headache, dizziness, nausea and drowsiness” (Huang et al., 2014). This trial involving 198

hospitalized patients will have both a placebo group and a melatonin group. Both groups will be

told they are receiving three milligrams of melatonin at 9:00 pm. for four consecutive nights.

According to Huang, et al, this is an ongoing trial, but prediction is sleep quality will increase by

20 percent.

Education

When a patient is hospitalized, their sleep schedules become interrupted. The patients are

put into an unfamiliar place, with strangers frequently breaking personal boundaries to provide

care and carry out assessments. The care provided is carried out around the clock including the

EFFECTS OF SLEEP ON HOSPITALIZED PATIENTS 11

middle of the night. Factors such as these and the plan of care affect the patient’s sleep.

According to Ganz and Gilsenan, “rest and sleep are necessary for wound healing, protein

synthesis, immune function, energy conservation, and restoration of the mind” (as cited in Clark

& Mills, 2017, p. 253). Without an adequate amount of sleep, these processes will not occur, and

patients will be led to sleep deprivation. “Sleep deprivation can exacerbate progression of

cardiovascular disease, metabolic disorders, and cancer, and even cause death” (as cited in Clark

& Mills, 2017, p. 253). As medical professionals we should prevent our patients from sleep

deprivation by helping to reduce our patient’s anxiety. “Anxiety is defined as a palpable but

transitory emotional state or condition characterized by feelings of tension, apprehension and

heightened autonomic system activity” (as cited in Wong, Chair, Leung, & Chan, 2014, p. 132).

These feelings associated with fear of the medical treatment, or fear of their outcomes, lead to

anxiety and sleep deprivation. Hospitalized patients must be engaged in many hours of restful

uninterrupted sleep a day to recover. This can be difficult in the hospital setting, however with

medical personal putting time towards education, this outcome could become easier to achieve.

A study carried out by Eliza Mi-Ling Wong, Sek-Ying Chair, Doris Y.P. Leung, and

Sally Wai-Chi Chan, found providing a brief educational teaching intervention with emergency

orthopedic surgical patients effectively assists with not only sleep deprivation, but also pain and

anxiety levels. The study was conducted with 152 Chinese patients admitted for emergency

orthopedic surgeries. The 152 patients in the study were split into 77 controls and 75

experimental participants. The 152 patients all had similar treatment regarding wound and pin

care, analgesic therapy, toileting, physical therapy and other nursing care. The 75 experimental

patients were given an additional 20-minute teaching intervention on sleep and breathing

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relaxation exercises. With this intervention in place sleep in the experimental group was

significantly more likely to receive a better nights sleep (Wong et al., 2017).

In a study carried out by Ann Clark and Mary Mills (2017), hospitalized patients were

given a sleep menu and asked to choose certain preferences that could be carried out to help

obtain a better night’s sleep. Most of the interventions were simple, and included interventions

such as using eye masks, fans, closing doors, dimming the lights, or providing an extra pillow.

The study found that sleep can be improved by just doing simple interventions and showing care.

“Patients in this study did not request elaborate interventions to aid in sleep. Simply asking their

preferences and showing concern for their comfort may have improved their perception of sleep”

(as cited in Clark & Mills 2017, p.253). Nurses need to recognize sleep during hospitalization as

effective method to obtaining positive patient outcomes. By educating patients on sleep, and

simple interventions to obtain a better quality of sleep, recovery could be quicker and more

effective. Minutes of education can make a huge difference in sleep outcomes. Just by showing

care to patients by asking the patient how they slept or what can help them sleep better can be the

first steps to better patient outcomes. If nurses and doctors educate the patient on sleep, overall

outcomes for patients will drastically improve.

Adequate amounts of sleep are a necessity in the treatment of hospitalized patients. There

are many factors to determine how much sleep a person should get, as well as the best methods

of achieving that sleep, so it is important to tend to each patient’s sleeping needs individually. It

is also essential to never lose sight of just how helpful sleep is. Sleep helps the body maintain

normal physiological functioning, and even promotes growth. Sleep is also helpful in preventing

delirium, anxiety, fatigue, depression, and decreases in cognitive functioning in patients. Proper

amounts of sleep are thus paramount in regards to effective recovery in patients. It is important

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to educate not only patients about the benefits of sleep, but also health care provider for best

patient outcomes.

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