Assessment of sleep in hospital patients: a review of methods

Intradermal Acupuncture on Shen-Men and Nei-Kuan Acupoints Improves Insomnia in Stroke Patients by Reducing the Sympathetic Nervous Activity: A Randomized Clinical Trial

This study is a double-blind randomized controlled trial on the effect of intradermal acupuncture on insomnia after stroke. Hospitalized stroke patients with insomnia were enrolled in the study and were randomly assigned to either a real intradermal acupuncture group (RA group) or a sham acupuncture group (SA group). The RA group received intradermal acupuncture on Shen-Men (He-7) and Nei-Kuan (EH-6) for three days, and the SA group received sham acupuncture on the same points. The effect of acupuncture on insomnia was measured using Insomnia Severity Index (ISI) and Athens Insomnia Scale (AIS) at baseline and three days after treatment. To assess the effect of acupuncture on the autonomic nervous function, the subjects' blood pressure and heart rate variability were monitored. Fifty-two subjects (27 in the RA group and 25 in the SA group) were included in the final analysis. The insomnia-related scales ISI and AIS showed greater improvement of insomnia in the RA group than in the SA group. Moreover, there is a greater reduction of the number of non-dippers and a greater decrease of the LF/HF ratio (heart rate variability) in the RA group than in the SA group. These results indicate that sympathetic hyperactivities were stabilized in the RA group. It can thus be concluded that intradermal acupuncture on Shen-Men and Nei-Kuan is a useful therapeutic method for post stroke-onset insomnia as it reduces sympathetic hyperactivities.

Improving actigraph sleep/wake classification with cardio-respiratory signals

Actigraphy for long-term sleep/wake monitoring fails to correctly classify situations where the subject displays low activity, but is awake. In this paper we propose a new algorithm which uses both accelerometer and cardio-respiratory signals to overcome this restriction. Acceleration, electrocardiogram and respiratory effort were measured with an integrated wearable recording system worn on the chest by three healthy male subjects during normal daily activities. For signal processing a Fast Fourier Transformation and as classifier a feed-forward Artificial Neural Network was used. The best classifier achieved an accuracy of 96.14%, a sensitivity of 94.65% and a specificity of 98.19%. The algorithm is suitable for integration into a wearable device for long-term home monitoring.

Sleep and Wake Classification With ECG and Respiratory Effort Signals

We describe a method for the online classification of sleep/wake states based on cardiorespiratory signals produced by wearable sensors. The method was conceived in view of its applicability to a wearable sleepiness monitoring device. The method uses a fast Fourier transform as the main feature extraction tool and a feedforward artificial neural network as a classifier. We show that when the method is applied to data collected from a single young male adult, the system can correctly classify, on average, 95.4% of unseen data from the same user. When the method is applied to classify data from multiple users with the same age and gender, its accuracy is reduced to 85.3%. However, receiver operating characteristic analysis shows that compared to actigraphy, the proposed method produces a more balanced correct classification of sleep and wake periods. Additionally, by adjusting the classification threshold of the neural classifier, 86.7% of correct classification is obtained.

How is sleep quality affected by the psychological and symptom distress of advanced cancer patients?

The aim of this study was to assess the relationship between sleep quality, pain, psychological distress, cognitive status and post-traumatic experience in advanced cancer patients. Participants were 82 advanced cancer patients referred to a palliative care unit for control of pain and other symptoms. A variety of assessment tools were used to examine the prevalence of sleep disturbance, the severity of pain and depression, hopelessness, cognitive function and quality of life. Using the Pittsburgh Sleep Quality Index (PSQI) 96% of patients were 'poor sleepers'. Statistically significant associations were found between PSQI and the SF-12 (Short Form-12) Quality of Life Instrument (MCS, P < 0.0005, PCS, P < 0.0005), depression (Greek Depression Inventory) (P < 0.0005) and hopelessness (Beck Hopelessness Scale) (P = 0.003). Strong associations were also found between PSQI and IES-R (Impact of Event Scale-Revised) (P = 0.004). The strongest predictors of poor sleep quality in this model were MCS (P < 0.0005), PCS (P < 0.0005) and IES-R (P = 0.010). Post-traumatic experience and quality of life seemed to be the strongest predictors of sleep quality in a sample of advanced cancer patients referred for palliative care.

The effect of chronic disorders on sleep in the elderly

Sleep disorders are increasingly common as people age. Along with the numerous physiologic changes that occur with aging, sleep patterns are also altered. Inability to get to sleep, shorter sleep times, and changes in the normal circadian patterns can have an impact on an individual's overall well being. In addition, many common chronic conditions, such as chronic obstructive pulmonary disease, diabetes, dementia, chronic pain, and cancer, that are more common in the elderly, can also have significant effects on sleep and increase the prevalence of insomnia as compared with the general population. This is a result not only of the chronic medical illnesses themselves, but of the psychologic and social factors associated with the disease processes.

Sleep quality in advanced cancer patients

OBJECTIVE

The objective of this study was to evaluate the sleep quality of advanced cancer patients and its relationship with pain, depression, and hopelessness.

METHODS

The participants were 102 advanced cancer patients who were on palliative treatment. Patients completed a sleep quality instrument, the Pittsburgh Sleep Quality Index (PSQI); a pain assessment tool, the Greek Brief Pain Inventory; a self-report measure of depression, the Beck Depression Inventory; and, finally, the Beck Hopelessness Scale.

RESULTS

Multiple regression analyses (forward method) have shown that hopelessness (P=.003), "interference of pain with mood" (P<.0005), and strong opioids (P=.010) seemed to influence patients' sleep quality (PSOI). In an additional regression analysis (enter method), the PSQI is significantly related to opioids (P=.013), hopelessness (P=.035), and "interference of pain with mood" (P=.004).

CONCLUSION

Hopelessness, pain treatment, and "interference of pain with mood" may influence the quality of sleep in advanced stages of cancer.

A comparison of sleep assessment tools by nurses and patients in critical care

AIM

The aim of this critical care sleep assessment pilot study was to evaluate the usefulness of three sleep assessment tools to identify which, if any, provided the closest comparison between the nurses' judgement and the patients' experience of their sleep. The study objectives were to: (i) compare patients' and nurses' assessment of sleep using three different rating tools. (ii) Ascertain patients' preferences with non-interventional, user friendly, practical tools in critical care. (iii) Recommend changes and improvements to the way that sleep is assessed and documented.

BACKGROUND

Sleep is important for promoting critical care recovery and sleep disturbance is known to cause irritability, aggression and increased stress levels. The availability and use of valid critical care sleep assessment tools is limited.

DESIGN

A descriptive comparative study using three sleep assessment-rating scales were constructed to provide easy to understand tools for completion by both patients and nurses in critical care.

METHODS

Structured interviews were undertaken with 82 patients and 82 nurses using a convenience sample from four multispecialty critical care units in one large teaching trust. Patients were included in the study if they met a list of pre-defined criteria to obtain responses from lucid orientated patients.

RESULTS

No tool produced a close association between the nurses' assessment of the patients sleep and the patients' assessment of their sleep. Patients found two of the three tools easy to use when rating their sleep. Discussion. Objective invasive measurements of sleep as well as complex subjective tools appear inappropriate to be used as a part of daily critical care practice. The application of simple rating scores has a high degree of error when nurses assess patients' sleep, even though high levels of patient observation and assessment are practiced in critical care.

CONCLUSIONS

More research is needed to examine the assessment of sleep in critical care, particularly linking rating scales to alternative methods of physiological assessment of sleep. Findings indicate nurses are unable to accurately assess critical care patients' sleep using rating assessment tools. However patients were found to prefer two sleep assessment tools, one banded in hours to assess sleep quantity and one as a comparison against normal sleep to assess sleep quality.

RELEVANCE TO CLINICAL PRACTICE

This study reviews the importance of sleep assessment and the diverse methods available for assessing sleep focussing on the critically ill patient. More noteworthy it highlights how nurses sole judgements of patients sleep is not a reliable method in clinical practice, however it provides some indication on the application of 'easy to use' tools to assist in the patients assessments of their sleep.

Intradermal acupuncture on shen-men and nei-kuan acupoints in patients with insomnia after stroke

This is the first study that focuses on the effects of intradermal acupuncture on insomnia after stroke. We enrolled hospitalized stroke patients with insomnia and assigned them into a real intradermal acupuncture group (RA group) or a sham acupuncture group (SA group) by randomization. The RA group received intradermal acupuncture on shen-men (He-7) and nei-kuan (EH-6) for 2 days, and the SA group received sham acupuncture on the same points. The effectiveness was measured by the Morning Questionnaire (MQ), Insomnia Severity Index (ISI), and Athens Insomnia Scale (AIS). These scales were examined by an independent, blinded neurologist before, and 1 and 2 days after treatment, repeatedly. Thirty subjects (15 in the RA group and 15 in the SA group) were included in the final analysis. The RA group showed more improvement on insomnia than the SA group. Repeated measures analysis detected that there were significant between-subjects effects in the MQ, the ISI and the AIS. In conclusion, we suggest that intradermal acupuncture on shen-men and nei-kuan is a useful treatment for post stroke-onset insomnia.

Sleep quality in hospitalized patients

AIMS AND OBJECTIVES

The objective of this study was to evaluate and compare sleep quality of the hospitalized patients and matched healthy controls.

BACKGROUND

Although the functions of sleep are not clearly understood, it is generally accepted that it is necessary for the maintenance of good health. Hospitalized patients' sleep may not be refreshing or restorative. The reasons for this can be categorized into three groups: environmental, physiological and psychological.

DESIGN AND METHODS

This research was conducted at the Cumhuriyet University Hospital in Turkey. One hundred and fifty hospitalized patients (psychiatry = 50; orthopaedic + general surgery + cardiovascular surgery + urology = 50; internal medicine + chest diseases + infectious diseases + physical therapy and rehabilitation = 50) and 50 healthy controls constituted the sample. The researchers administered to the patient and control groups Sociodemographic Information Form and the Pittsburgh Sleep Quality Index. We compared sociodemographic and illness variables with sleep characteristics. The following statistical analyses were used in order to evaluate the data: variance analysis, Tukey HSD test, Student's t-test, Kruskall-Wallis test.

RESULTS

We found that patients in psychiatric ward experienced worse sleep quality than the other patients, worse in female patients than male patients, and worse sleep characteristics in patients than controls.

CONCLUSIONS

Health professionals must be educated about sleep and must provide intervention when needed. Relevance to clinical practice. The enhancing of sleep quality accelerates to the recovery from illness.

The sleep experience of medical and surgical patients

This study described and compared the sleep experience of medical and surgical patients during a hospital stay. During 3 consecutive nights, patients (n = 110) self-reported sleep quality using the Verran and Snyder Sleep Scale (VSH) and potentially disruptive factors using items from the Factors Influencing Sleep Questionnaire (FISQ). Surgical patients, on the first night, received more procedural care (p = .001), less sedative medication (p < .001), reported more sleep disturbance (p = .02), less sleep effectiveness (p = .03), and more need for sleep supplementation (p = .03). Variance in sleep effectiveness was explained by the FISQ score, age, and length of time in hospital (F = 6.86, p < .001). The sleep experience of patients varies between diagnostic groupings and across the hospital stay. Unit environmental and personal factors, factors that are amenable to therapeutic interventions, strongly influence the sleep experience.

Nonpharmacologic sleep promotion: bright light exposure

This paper presents findings on utilizing bright light to entrain the sleep-wake cycle in order to improve the perceived quality of sleep.The feasibility of including bright light as one of the nonpharmacologic nursing interventions for sleep promotion is discussed. A decade ago, nurses relied on sleeping pills to solve patients' sleep problems (Halfens et al. 1991). Reported obstacles to the development of sleep management tools included insufficient knowledge of sleep (Edéll-Gustafasson et al. 1994) and unfamiliarity with effective nursing methods for tackling sleep problems (Halfens et al. 1991). Ten years later, nurses took the initiative in sleep promotion activities. In their book, Morgan and Closs (1999) introduced several sleep management methods in nursing practice. Floyd et al. (2000) summarized that 12 nonpharmacologic interventions used by nurses in the past to promote sleep. These 12 interventions are categorized according to their mechanism of action as relaxation, noise management, circadian repatterning and sleep hygiene. Light is thought to regulate the circadian system (Dawson & Van den Heuvel 1998) as a major synchronizer of endogenous circadian cycles (Dijk et al. 1995).

Relating palliative care principles to the promotion of undisturbed sleep in a hospice setting

Nurses working at night have a specific role in supporting sleep and promoting rest and comfort. Sometimes the role of the night duty nurse in promoting sleep and comfort is taken for granted. One author's experience of working as a night duty nurse led to reflection on her responsibilities in improving practice and addressing the sleep-related needs of patients in a palliative care setting. Following a literature review, it was clear that there are very few publications on sleep disturbance in palliative care. Using the four principles of palliative care (Aranda, 1998a), the authors construct a series of strategies to prevent and manage sleep issues.

Evaluation of zolpidem, triazolam, and placebo as hypnotic drugs the night before surgery

STUDY OBJECTIVE

To compare the hypnotic effects of a bedtime dose of zolpidem, triazolam, and placebo.

DESIGN

"Double-blind, randomized, placebo- and active-controlled, parallel-group" trial.

SETTING

Six Canadian hospitals.

PATIENTS

357 patients (aged 19 to 71 years) hospitalized the night before a surgical procedure.

INTERVENTIONS

At bedtime, each patient received either zolpidem 10 mg, triazolam 0.25 mg, or placebo, and was allowed to sleep for a maximum of 8 hours.

MEASUREMENTS

Outcome measures were subjective in nature and included a morning questionnaire, visual analog scales, and observation forms by study personnel. All continuous variables were analyzed by analysis of variance. All categorical data were compared using the Cochran-Mantel-Haenszel (CMH) test, and the percentage of patients asleep was compared using a CMH chi-square analysis. When significant overall treatment effects were observed, pairwise comparisons were undertaken. Compared with the placebo group, the following parameters were significantly (p < 0.001) different in the zolpidem and triazolam groups: sleep latency was shorter, total sleep time was longer, patients fell asleep more easily, and the number of patients awake 2 hours after drug administration was lower. There were no differences between any groups in next-morning somnolence or ability to concentrate. Both drugs were well tolerated, with adverse event incidence rates nearly identical to placebo.

CONCLUSIONS

In patients suffering from transient insomnia, a single dose of zolpidem 10 mg was as effective as triazolam 0.25 mg, and both were more effective than placebo and were well tolerated.

Reproducibility of Nordic Sleep Questionnaire in spinal cord injured

A recently proposed Nordic Sleep Questionnaire (NSQ) comprises 26 questions concerning qualitative and quantitative aspects of the respondent's sleep habits. Its reproducibility was evaluated in 32 spinal cord injured individuals (SCI), 24 men and eight women (23-72 years), and 79 normal subjects, 23 men and 56 women (19-77 years). They completed the NSQ twice at a median interval of 15 days (range 10-26) and 27 days (range 4-103) respectively. The group of normal subjects were evenly divided into group 26, i.e. those who completed the two NSQs within 26 days, and group 27 with 27 days or more between their replies. Generally, group 27 showed no worse test-retest agreement than group 26. In addition, the respondents' answers, with a few exceptions, were reasonably stable in terms of test-retest agreement or standard deviation. The SCI group exhibited the same level of reproducibility, although they had more 'pathology' to report and thus more scope for contradicting themselves. The questions in the NSQ generally were satisfactorily reproducible. However, answers to the ordered five-point questions about sleepiness in the morning and during the daytime ought to be interpreted with caution. The same may be said about the number of minutes required to fall asleep, and the duration of daytime naps.

Randomized, double blind trial of zolpidem 10 mg versus triazolam 0.25 mg for treatment of insomnia in general practice

OBJECTIVE

To compare the efficacy of two short acting hypnotics, the benzodiazepine triazolam and the imidazopyridine zolpidem, for treatment of insomnia in general practice.

DESIGN

Randomized double-blind study. Patients were given triazolam 0.25 mg or zolpidem 10 mg for 14 days.

SETTING

Multi-practice comprising 40 general practitioners.

SUBJECTS

178 patients suffering from insomnia were included in the study, data from 139 patients were used in the analyses.

MAIN OUTCOME MEASURES

Sleep quality was recorded in the morning (duration of sleep in hours, number of awakenings, and sleep quality on a visual analogue scale (VAS)), and day quality was recorded in the evening (tired/rested, unalert/alert, tired/fresh, all on VAS-scales) during the 14 days' treatment period.

RESULTS

We found no statistically significant differences between the two groups regarding sleeping time, number of awakenings, or sleep quality (VAS). Morning feeling (VAS) and day feeling (VAS) were numerically better for zolpidem, although not statistically significant. There was no statistically significant difference in the number of patients experiencing side effects in the two treatment groups.

CONCLUSION

On a short-term basis administration of zolpidem (10 mg) appeared as effective and well tolerated as triazolam (0.25 mg)--and thus zolpidem constitutes a suitable alternative for the treatment of insomnia in general practice.

A review of literature relating to sleep in hospital with emphasis on the sleep of the ICU patient

The subject of this literature review is the sleep of hospitalised patients, with particular emphasis on the sleep of patients in intensive care units (ICUs). Initially there is an overview of the structure of sleep and the literature related to the main theories of sleep function in order to set the subject in context. A review of some of the work related to the sleep patterns of ICU patients outlines how severely sleep-deprived many patients are. Studies of sleep patterns implicate the environment of ICUs as an important factor in preventing sleep, but factors particular to patients which have an adverse effect on sleep are also reviewed, with particular reference to a study addressing the incidence of pain and discomfort of patients. Finally the sleep patterns of patients whose environment was carefully controlled to exclude factors known to disrupt sleep are reviewed. Thus the review moves from broad issues affecting sleep to the more focused issues personal to individual patients, with implications for nursing practice addressed as each point arises. In this way the complexity of the whole issue of sleep and the lack of sleep experienced by hospitalised patients is highlighted.

Patient assessment in psychiatric nursing

This paper examines the literature on patient assessment in nursing, with particular reference to assessment in psychiatric nursing. It finds that most nursing assessment is concerned with gathering physiological information about patients while effectively ignoring psychosocial indices. This phenomenon, it is argued, is due to historical factors in the socialization of nurses, the particular version of nursing process imported into the UK, and an oversimplification of the concept of 'need' which has encouraged nurses to focus on patient disabilities but has ignored their capabilities. It is proposed that nursing assessment should be a relatively lengthy process, increasing in specificity, involving gathering and analysing information from a holistic perspective about individuals'/families' health concerns. Then, by applying concepts from appropriate conceptual models, a nursing diagnosis to those health concerns is proposed. This proposal is supported by a discussion of the process, functions and methods of nursing assessment. Finally, while recognizing the importance of social causation theories in psychiatric care, it is argued that community health assessments are beyond the scope of individual nurses.

The influence of component parts on the performance of urinary sheath systems

A quasi-experimental trial, yielding 30 data points per system, was carried out to investigate the influence of component parts on the overall performance of urinary sheath systems. Information was obtained on the effect of changing both the sheath and leg-bag. Data from the trial was supported by accurate stock-taking analysis over two periods of 4 weeks' duration when alternative systems were used in a clinical setting. Results suggest that leg-bag design profoundly influences the performance of urinary sheaths. A significant difference in the performance of two urinary sheaths in the presence of the same leg-bag was also observed. The significance of the findings for nursing practice is discussed since the optimum performance, from the components tested, was a 'hybrid' system. A continuing line of investigation is suggested whereby improvements in the composition of urinary sheath systems could be made from nursing research.