Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review

Nonpharmacological interventions to promote sleep in the adult critical patients unit: A scoping review

BACKGROUND

Sleep and circadian rhythms are markedly altered in intensive care unit (ICU) patients. Numerous factors related to the patient and the ICU environment affect the ability to initiate and maintain sleep. Therefore, nonpharmacological interventions could play an essential role in improving sleep and circadian rhythm.

OBJECTIVE

The aim of this study was to examine nonpharmacological interventions evaluated for promoting sleep in adult ICUs.

METHODS

A scoping review was conducted, including randomised controlled trials, nonrandomised controlled trials, quasi-experimental trials, and other controlled studies investigating the effects of nonpharmacological interventions promoting sleep in adult ICU patients.

RESULTS

A total of 57 articles and 14 ongoing trials were included in the review, of which 38 were randomised clinical trials. Nine nonpharmacological interventions to improve sleep in critically ill patients were evaluated: earplugs and/or eye masks, aromatherapy, bundles, music intervention, massage or acupressure, noise masking, bright light, and dynamic light. Most included trials simultaneously assessed the effect of more than one intervention on perceived sleep quality using questionnaires. The association between the interventions and improved sleep varied. In the case of multicomponent interventions, it is difficult to identify which components might have influenced sleep improvement.

CONCLUSIONS

Numerous studies have evaluated various nonpharmacological interventions to promote sleep in critically ill patients, several of which improved perceived sleep quality. However, the substantial variability of the assessed interventions and their implementation complicates drawing reliable conclusions.

REGISTRATION

The protocol for this scoping review was registered with the Open Science Framework under the identifier https://doi.org/10.17605/OSF.IO/MPEQ5.

Prehabilitation to mitigate postintensive care syndrome in surgical patients: The rationale for a peri-critical illness pathway involving anaesthesiologists and intensive care physicians

The post-intensive care syndrome (PICS) refers to the long-term physical, psychological and cognitive impairments experienced by intensive care unit (ICU) survivors, while PICS-Family (PICS-F) affects their family members. Despite preventive strategies during the ICU stay, PICS remains a significant concern impacting survivors' quality of life, increasing the healthcare costs, and complicating recovery. Prehabilitation offers a promising approach to mitigating PICS and PICS-F, especially when the ICU stay can be anticipated, such as in the case of major surgery. Recent literature indicates that prehabilitation - interventions designed to enhance patients' functional capacity before critical illness - may mitigate the risk and severity of PICS. Studies have demonstrated that prehabilitation programs can improve muscle strength, reduce anxiety levels and enhance overall quality of life in ICU survivors. Family prehabilitation (prehabilitation-F) is also introduced as a potential intervention to help families to cope with the stress of critical illness. This article aims to explore the role of multimodal prehabilitation and post-ICU follow-up in preventing and managing PICS and PICS-F, focusing on improving patient outcomes, supporting families and optimising healthcare resources. Combining prehabilitation with post-ICU follow-up in peri-critical care clinics could streamline resources and improve outcomes, creating a holistic care pathway. These clinics, focused on both pre-ICU and post-ICU care, would thus address PICS from multiple angles. However, the heterogeneity of patient populations and prehabilitation protocols present challenges in standardising the interventions. Further research is necessary to establish optimal prehabilitation strategies tailored to individual patient needs and to demonstrate their utility in terms of patient outcome.

Patient-psychologist telemedicine interactions in an intensive care unit recovery clinic: Qualitative secondary analysis

OBJECTIVES

We aimed to describe the content of patient-psychologist mental health related dialogues during a telemedicine intensive care unit recovery clinic visit.

RESEARCH METHODOLOGY/DESIGN

Qualitative descriptive study nested within a randomized controlled pilot trial to assess a telemedicine intensive care unit recovery clinic feasibility and preliminary efficacy. Participants included adults hospitalized with sepsis and/or respiratory failure. Telemedicine visits occurred at 3- and 12-weeks post-discharge involving a critical care pharmacist, physician, and psychologist. The psychologist conducted cognitive and mental health screenings, providing tailored brief psychotherapy and education. Audio-recorded visits were transcribed verbatim and underwent inductive reflexive thematic analysis.

SETTING

Intensive care unit recovery clinic at an academic medical center in the southeastern United States.

MAIN OUTCOME MEASURES

N/A.

FINDINGS

17 participants completed 31 telemedicine intensive care unit recovery clinic visits between December 2019 and March 2022. Caregivers participated in 13 visits. Participant experiences and psychologist responses were identified and separated into two overarching themes: 1) Patient-Identified Challenges and 2) Psychologist-Delivered Strategies. Patient subthemes included 1) mental health challenges (negative thoughts), 2) minimization of mental health impact, and 3) use of coping methods. Psychologist subthemes included 1) rapport building and validation 2) use of psychological assessments, and 3) psychological interventions.

CONCLUSION

The collaborative effort, including a psychologist, exemplifies the role of a mental health professional within the multidisciplinary intensive care unit recovery clinic team, contributing to a comprehensive approach in identifying and managing post-intensive care syndrome impairments. The focus extends to shaping compassionate care strategies for addressing mental health challenges associated with post-intensive care syndrome, fostering a holistic approach to whole-person recovery.

IMPLICATIONS FOR CLINICAL PRACTICE

A mental health professional (e.g., psychologist, psychiatrist, psychiatric nurse practitioner) can contribute to shaping care strategies for the mental health symptoms associated with post-intensive care syndrome, fostering whole-person recovery after hospital discharge.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03926533.

Correlations between clinical insomnia and psychophysiological factors in postoperative patients discharged from the ICU: A cross-sectional study

Aim

Post-intensive care unit (ICU) patients often experience physical or mental dysfunction. This study aims to investigate the relationship between sleep disturbances and mental and physical problems in patients discharged from the ICU to hospital wards, using both subjective and objective sleep measures.

Methods

Patients admitted to the ICU for at least 72 h between November 2021 and June 2022 were included in the study. On the seventh day after ICU discharge, we conducted an objective sleep assessment using an electroencephalogram-based mobile sleep-monitoring device. Patients self-administered severity ratings for fatigue, depression, and post-traumatic stress (PTS) symptoms. Insomnia symptoms were assessed using the insomnia severity index (ISI) before and after ICU admission.

Results

Thirty-five patients (median age 73) were included in the study. Higher ISI scores at ward were significantly correlated with higher levels of fatigue (r = 0.463, P = 0.005), depression (r = 0.343, P = 0.044), and PTS symptoms (r = 0.477, P = 0.004). Among the objective sleep measures, reduced N3 sleep (r = -0.480, P = 0.004) was significantly correlated with more severe PTS symptoms. However, no statistically significant correlations were found between objective sleep indicators and either fatigue or depression.

Conclusion

The observed reduction in N3 sleep and its association with PTS symptoms in this study might have reflected the physical and psychological stress experienced during intensive care. Subjective insomnia severity, which was related to fatigue, depression, and PTS symptoms in the ward, could be an important intervention target after ICU discharge.

Performance of the Healthy Aging Brain Care Monitor Self Report in Monitoring Post-Intensive Care Syndrome Among Acute Respiratory Failure Survivors

OBJECTIVES

To describe the performance of the Healthy Aging Brain Care Monitor Self Report (HABC-M SR) in assessment of post-intensive care syndrome (PICS) among Acute Respiratory Failure ICU survivors.

DESIGN

Secondary data analysis of a randomized controlled trial.

SETTING

Patients evaluated by a nurse care coordinator in an out-of-hospital setting.

PATIENTS

English-speaking adults 18 years old or older who were admitted to the ICU with acute respiratory failure requiring invasive or noninvasive mechanical ventilation for greater than or equal to 24 hours.

INTERVENTIONS

Patients randomized to the intervention arm of the mobile critical care recovery program, a negative trial testing multidisciplinary care to improve quality of life.

MEASUREMENTS AND MAIN RESULTS

HABC-M SR scale was used to assess PICS in the intervention group at ICU discharge, 3, and 6 months post-discharge. Hospital Anxiety and Depression Scale; Pain, Enjoyment of Life, and General Activity Scale; Timed Up and Go; and Patient-Reported Outcomes Measurement Information System sleep scores were obtained at the same time. Mini-Mental State Examination (MMSE) was administered at baseline and 6 months. ICU survivors reported mild PICS symptoms, which improved over 6 months (mean HABC-M SR scores: baseline [8.5, sd 7.6], 3 mo [5.3 mo, sd 6.6 mo], and 6 mo [5.2 mo, sd 6.9 mo; p < 0.001]). HABC-M SR total score had moderate internal consistency that improved over time (Cronbach's alpha = 0.78 at baseline and 0.84 at 6 mo). The psychological subscale of HABC-M SR was moderately correlated with standardized scales for mood, pain, and sleep. The cognitive subscale was not significantly correlated with MMSE.

CONCLUSIONS

While HABC-M SR correlated with mood, physical, and sleep symptoms, the cognitive subscale was less sensitive compared with standardized scales.

Summary of the Best Evidence for Non-Pharmacological Management of Sleep Disturbances in Intensive Care Unit Patients

AIM

To retrieve, evaluate and summarise the best evidence for non-pharmacological management of sleep disturbances in ICU patients, and to provide basis for clinical nursing practice.

DESIGN

This study was an evidence summary followed by the evidence summary reporting standard of Fudan University Center for Evidence-based Nursing.

METHODS

All evidence on non-pharmacological management of sleep disturbances in ICU patients from both domestic and international databases and relevant websites was systematically searched, including guidelines, expert consensuses, best practice, clinical decision-making, evidence summaries and systematic review.

DATA SOURCES

UpToDate, BMJ Best Practice, Joanna Briggs Institute, Scottish Intercollegiate Guidelines Network, National Guideline Clearinghouse, National Institute for Health and Clinical Excellence, Yi Maitong Guidelines Network, Registered Nurses Association of Ontario, Canadian Medical Association: Clinical Practice Guideline, Guidelines International Network, WHO, the Cochrane Library, CINAHL, Embase, PubMed, Web of Science, CNKI, WanFang database, VIP database, SinoMed, The American Psychological Association, European Sleep Research Society, American Academy of Sleep Medicine and National Sleep Foundation were searched from the establishment of the databases to June 1, 2024.

RESULTS

A total of 18 pieces of literature were included, involving 4 guidelines, 2 expert consensuses, 1 best practice and 11 systematic reviews. 25 pieces of evidence covering 4 categories of risk factors, sleep monitoring, non-pharmaceutical intervention, education and training were summarised.

CONCLUSION

This study summarises the best evidence for non-pharmacological management of sleep disturbances in ICU patients. In clinical application, medical staff should make professional judgements and fully combine clinical situations and patient preferences to select evidence, laying a theoretical foundation for later empirical research to reduce the incidence of sleep disturbances in ICU patients and improve the sleep quality of critically ill patients.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

Medical staff can refer to the best evidence to provide reasonable non-pharmacological management plans for sleep disturbances in ICU patients, improving their sleep quality and life satisfaction.

IMPACT

The management of sleep disturbances in critically ill patients has not received sufficient attention and standardisation. This study summarises 25 pieces of the best evidence for non-pharmacological management of sleep disturbances in critically ill patients. Accurate and standardised evaluation and monitoring are the foundation of sleep management for ICU patients. This summary of evidence can help ICU nurses enhance their clinical practice.

REPORTING METHOD

This evidence summary followed the evidence summary reporting specifications of Fudan University Center for Evidence-based Nursing, which were based on the methodological process for the summary of the evidence produced by the Joanna Briggs Institute. This study was based on the evidence summary reporting specifications of the Fudan University Center for the Evidence-based Nursing; the registration number is 'ES20231708'.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Benzodiazepine and z-drug prescribing in critical care survivors and the risk of rehospitalisation or death due to falls/trauma and due to any cause: a retrospective matched cohort study using the UK Clinical Practice Research Datalink

PURPOSE

Benzodiazepines and z-drugs are often prescribed to critical care survivors due to high prevalence of mental health problems and insomnia. However, their safety has not been studied in this population.

METHODS

Retrospective cohort study of 28,678 adult critical care survivors hospitalised in 2010 and 2018: 4844 prescribed benzodiazepines or z-drugs, matched to 23,834 unexposed survivors using UK Clinical Practice Research Datalink linked datasets. Multivariable stratified Cox regression was used to estimate the adjusted hazards ratio (adjHR) with 95% confidence intervals (CI) of community benzodiazepine/z-drug prescribing and falls/trauma-related events, as well as all-cause 30-day rehospitalisation or death. We performed subgroup analyses on patients without pre-critical care admission prescription of benzodiazepines/z-drugs ('treatment-naïve'), and sensitivity analyses excluding patients receiving palliative care after discharge.

RESULTS

Prescription of benzodiazepines or z-drugs showed no conclusive evidence of increased risk of falls/trauma-related events in the whole cohort (adjHR 1.27; 95%CI 0.76-2.14) or in treatment-naïve individuals (adjHR 1.79; 95%CI 0.61-5.26), because estimates lacked precision due to low event rates. For all-cause rehospitalisation or death, benzodiazepines/z-drugs were associated with increased risk (whole cohort adjHR 1.24, 95%CI 1.14-1.36; treatment-naïve adjHR 1.66, 95%CI 1.49-1.86). However, after excluding patients treated for palliative care, the association persisted only in treatment-naïve individuals (whole cohort adjHR 1.08, 95%CI 0.98-1.19; treatment-naïve adjHR 1.42, 95%CI1.25-1.62).

CONCLUSIONS

Community benzodiazepine and z-drug prescribing was associated with increased risk of all-cause, but not falls/trauma-related, rehospitalisations and deaths in critical care survivors who had not been prescribed these before hospitalisation. Clinicians should balance the possible benefits with the likely harms of prescribing these drugs in this potentially vulnerable patient group.

Pharmacologic Sleep Aids in the Intensive Care Unit: A Systematic Review

Background: Patients in the intensive care unit (ICU) often experience poor sleep quality. Pharmacologic sleep aids are frequently used as primary or adjunctive therapy to improve sleep, although their benefits in the ICU remain uncertain. This review aims to provide a comprehensive assessment of the objective and subjective effects of medications used for sleep in the ICU, as well as their adverse effects. Methods: PubMed, Web of Science, Scopus, Embase, and Cochrane Central Register of Controlled Trials were systematically searched from their inception until June 2023 for comparative studies assessing the effects of pharmacologic sleep aids on objective and subjective metrics of sleep. Results: Thirty-four studies with 3498 participants were included. Medications evaluated were melatonin, ramelteon, suvorexant, propofol, and dexmedetomidine. The majority of studies were randomized controlled trials. Melatonin and dexmedetomidine were the best studied agents. Objective sleep metrics included polysomnography (PSG), electroencephalography (EEG), bispectral index, and actigraphy. Subjective outcome measures included patient questionnaires and nursing observations. Evidence for melatonin as a sleep aid in the ICU was mixed but largely not supportive for improving sleep. Evidence for ramelteon, suvorexant, and propofol was too limited to offer definitive recommendations. Both objective and subjective data supported dexmedetomidine as an effective sleep aid in the ICU, with PSG/EEG in 303 ICU patients demonstrating increased sleep duration and efficiency, decreased arousal index, decreased percentage of stage N1 sleep, and increased absolute and percentage of stage N2 sleep. Mild bradycardia and hypotension were reported as side effects of dexmedetomidine, whereas the other medications were reported to be safe. Several ongoing studies have not yet been published, mostly on melatonin and dexmedetomidine. Conclusions: While definitive conclusions cannot be made for most medications, dexmedetomidine improved sleep quantity and quality in the ICU. These benefits need to be balanced with possible hemodynamic side effects.

Post-Intensive Care Syndrome: Physical Impairments and Function

Patients surviving critical illness are at risk of persistent physical impairments related to Post Intensive Care Syndrome. Physical impairments and symptoms have potential for recovery, but frequently impact quality of life, performance of activities of daily living and participation in societal roles. Patient and illness-related risk factors directly relate and may predict physical functional outcomes providing opportunity for clinicians and scientist to develop targeted intervention strategies. Clinicians and scientists should screen and assess physical impairments and symptoms early following Intensive care unit discharge with a serial approach to promote for targeted and individualized treatment.

The Effect of Earplugs and Eye Masks on the Melatonin and Cortisol Levels of Patients Hospitalized in Cardiac Critical Care Units

To determine the effectiveness of using earplugs and eye masks on the melatonin and cortisol levels of patients hospitalized in cardiac critical care units (CCUs). The research population of this study included all patients with acute coronary syndrome hospitalized in the CCU of Shahid Rajaei Hospital affiliated with to Alborz University of Medical Sciences. A total of 60 patients were selected by the available sampling method based on the inclusion criteria and then were divided into 2 control and intervention groups by block randomization method with blocks of 4 (n = 30 in the intervention group, and n = 30 in the control group). Patients in the intervention groups used blindfolds and earmuffs during the night sleep for 3 nights, but patients in the control group received the routine care. Cortisol and melatonin levels of both groups were measured at 8 am, using the urine samples. The findings of the 2 groups were compared and statistically analyzed by SPSS software version 16. The findings showed no significant difference between the 2 groups in terms of demographic characteristics and clinical variables. The intervention had no effect on the cortisol level of patients in the intervention group (P = .24). After the intervention, a statistically significant difference was observed between the control and intervention groups in terms of the melatonin level in the nocturnal urine (P ≤ .001). A statistically significant difference was also observed between the 2 groups in terms of the time taken for patients to fall asleep (P ≤ .001) and the number of times waking up at night (P ≤ .001). The use of earplugs and eye masks had no impact on the level of cortisol hormone, but it affected the level of melatonin hormone and the sleep quality of patients hospitalized in the CCU.

Effects of pharmacological therapy on sleep quality in a postoperative setting: A systematic review of randomized controlled trials

Background and Aims

Postoperative sleep disturbances are associated with delayed recovery and increased incidences of complications. This systematic review aims to determine the impact of perioperative pharmacological therapies on postoperative sleep quality in the hospital.

Material and Methods

We searched MEDLINE, MEDLINE ePubs and In-Process Citations (Daily), Embase Classic + Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and PubMed for randomized controlled trials (RCTs) from inception to May 2022, with continued literature surveillance until August 2023. Studies included consisted of noncardiac surgical patients aged ≥18 years with postoperative sleep in the hospital. The primary outcome was improvement in postoperative sleep outcomes such as sleep quality, duration, efficiency, architecture, and insomnia ratings after pharmacological treatment. Additional outcomes included postoperative pain scores and opioid consumption.

Results

The search strategy yielded 21 studies (n = 3276), and 18 reported improved sleep outcomes using eight validated sleep measurement tools. Eight of 10 studies using dexmedetomidine via patient-controlled analgesia or intravenous infusion reported better sleep quality versus controls. Opioids (nalbuphine, tramadol plus sufentanil), nonopioids (zolpidem, midazolam, pregabalin), propofol total intravenous anesthesia (TIVA), S-ketamine, and ropivacaine nerve blocks were superior to controls in enhancing postoperative sleep quality. Eleven studies (52%) which included the combination of dexmedetomidine with opioids reported concurrent improvements in postoperative pain and sleep. Dexmedetomidine also decreased postoperative opioid analgesia consumption.

Conclusions

Evidence for the effects of perioperative pharmacological approaches on postoperative sleep are limited. High-quality RCTs of adequate power and methodology on the effects of pharmacology interventions on postoperative sleep are warranted.

Are circadian rhythms in disarray in patients with chronic critical illness?

Aim

The aim of our study is to assess circadian rhythms in patients with chronic critical illness due to severe brain injury in intensive care unit by establishing the relation between melatonin and cortisol secretion, considering astronomical time and the sleep-wake cycle in chronic critical illness.

Materials and methods

The study included 54 adult patients with chronic critical illness who resided in the intensive care unit for at least 30 days. The level of consciousness was determined using the CRS-R scale. We did the continuous electroencephalographic (EEG) monitoring with polygraphic leads for 24 h. Also, we determined the serum levels of cortisol and melatonin using the tandem mass spectrometry method with ultra-performance liquid chromatography.

Results

90.74 % of patients had one acrophase in melatonin secretion curve, which suggests the preservation of the rhythmic secretion of melatonin. These acrophases of the melatonin rhythm occurred during the night time in 91.8 % of patients. Most of the patients (69.3 %) slept during the period from 2:00 to 4:00 a.m. The evening levels of cortisol and melatonin had an inverse relation (rs=0.61, p<0.05), i.e., a decrease in the level of cortisol secretion accompanies an increase in melatonin.

Conclusions

We concluded from our study that the rhythmic secretion of melatonin and cortisol is preserved in patients with chronic critical illness that resulted from severe brain injury. No statistically significant discrepancy between melatonin and cortisol secretion, day-and-night time and the sleep-wake cycle are found. We may focus our future work on finding more reliable methods to stabilize the preservation of circadian rhythms to protect vital organ functions.

Adding Insult to Injury: Sleep Deficiency in Hospitalized Patients

Sleep deficiency is a common problem in the hospital setting. Contributing factors include preexisting medical conditions, illness severity, the hospital environment, and treatment-related effects. Hospitalized patients are particularly vulnerable to the negative health effects of sleep deficiency that impact multiple organ systems. Objective sleep measurement is difficult to achieve in the hospital setting, posing a barrier to linking improvements in hospital outcomes with sleep promotion protocols. Key next steps in hospital sleep promotion include improvement in sleep measurement techniques and harmonization of study protocols and outcomes to strengthen existing evidence and facilitate data interpretation across studies.

Validation and cutoff score for the single-item sleep quality scale

PURPOSE

The Sleep Quality Scale (SQS) is a popular single-item measure of sleep quality that has been used in research and clinical settings. The aim of the current paper is to validate the SQS and provide a cutoff score.

METHODS

We conducted two studies to validate the SQS and provide a cutoff score to simplify the interpretation of SQS scores. We collected data from 747 physicians and nurses working in Oman.

RESULTS

In Study 1, conducted during the first two weeks of April 2020, a significant positive relationship was observed between the SQS and The World Health Organization Wellbeing Index (r. = 0.90) and a significant negative relationship was found with the Generalized Anxiety Disorder scale (r = .88) and the Intolerance of Uncertainty Scale-12 (r = .88). In Study 2, conducted between October 12 and November 19, 2020, we proposed a cutoff score for the SQS using the Insomnia Severity Index cutoff score of ≥ 10. The estimated area under the receiver operating characteristics curve was 0.881 (95% CI = 0.84-0.92). A cutoff score of ≤ 6 was identified with a sensitivity of 87.50 (95% CI = 0.78-0.94), and a specificity of 74.10 (95% CI = 0.67-0.81).

CONCLUSIONS

The findings of this study suggest that the single-item SQS is valid and an acceptable substitute for longer scales for initial assessment of sleep quality. The suggested cutoff value should help in easily classifying individuals into poor sleepers and good sleepers.

Using patient and care partner experiences to confirm outcomes of relevance for inclusion in a core outcome set for trials of physical rehabilitation in critical illness: A qualitative interview study

BACKGROUND

Incorporating the perspectives of patients and care partners is crucial in the development of core outcome sets. One effective approach for achieving this involvement is by seeking input to refine the outcomes for consensus. The objectives of the study were to: i) to determine patient and care partner views on outcomes that should be measured in trials of physical rehabilitation interventions across the critical illness recovery continuum; (ii) to map these views with a pre-established list of thirty outcomes for potential inclusion in a core outcome set for these trials; and (iii) to identify any new outcomes that could be considered for inclusion.

METHODS

A qualitative semistructured telephone interview study was conducted with a convenience sample of post-critical illness patients and care partners, as part of core outcome set development work. Anonymised interview transcripts were analysed using a framework approach, and exemplary narrative quotes from participants were reported used to illustrate outcome reporting.

FINDINGS

Fourteen participants were recruited (male:female ratio = 8:6, age range [minimum-maximum]: 50-80 years, 13 former patients, one spouse). Time since intensive care unit discharge ranged from less than 1 year to 10 years at the time of interview. Participants described a range of outcomes that could be measured in trials of physical rehabilitation after critical illness that mapped closely with the pre-established list. No new outcomes were introduced by participants during the interviews. Experiences described by participants commonly reflected outcomes related to physical ability and performance, functional level, activities of daily living, and emotional and mental wellbeing. Participants spoke to how the different outcomes directly impacted their day-to-day lives and highlighted their priorities centred around resumption of tasks and activities that had value to them at personal, functional, and societal level.

CONCLUSION

Qualitative interviews confirmed the relevance of existing outcomes for potential inclusion in a core outcome set for trials of physical rehabilitation interventions across the critical illness recovery continuum. The added significance of our findings is to provide real-world meaning to these outcomes.

REGISTRATION

COMET Initiative, ID288, https://www.comet-initiative.org/studies/details/288.

Navigating post-ICU care: understanding family members' experiences - a qualitative study

Background

Comprehending and addressing the needs of caregivers during the post-intensive care unit (ICU) phase is vital for establishing sustainable support systems and improving the overall quality of life (QoL) for both patients and caregivers.

Objective

To explore the experiences of family members (FMs) caring for loved ones three-months after ICU discharge and their related QoL.

Methods and measures

A qualitative, descriptive research was conducted. Participants were recruited from two general ICUs in an Italian Academic Hospital. Data collection lasted two months and was performed with telephonic interviews led by ICU nurses. Thematic analysis was conducted using a hybrid approach, incorporating both deductive and inductive coding strategies. This process has been facilitated by Atlas.ti software.

Results

Twenty-four FMs participated, representing a diverse range of familial relationships with the patients. Thematic analysis revealed four overarching themes: 1) QoL underwent transformations; 2) Positive emotions laden with significance; 3) Supporting role taken on by a caregiver; and 4) Life's transience through the meaning-making of the illness event. These themes highlighted the multifaceted nature of the caregiving experience.

Conclusions

This study provides valuable insights into the challenges and dynamics faced by FMs following ICU discharge. Findings underscore the importance of addressing environmental challenges, cultivating positive emotions, and strengthening caregiver-patient relationships to enhance the caregiving experience and promote overall QoL. FMs can adapt their personal concepts and reach their full potential by learning to coexist with the demanding role of caregiver and achieve a new level of resilience and fulfillment.

Sleep quality after autologous breast reconstruction

BACKGROUND

Sleep is a fundamental aspect of human health and well-being, but is often interrupted in a hospital setting. Especially after surgery, poor sleep quality can negatively affect postoperative recovery and quality of life. Therefore, the aim of this study was to gain insights into the quality of sleep in patients after autologous breast reconstruction and evaluate factors associated with the quality of sleep.

MATERIALS AND METHODS

In this single-center observational cohort study, participants completed a sleep diary, including the Pittsburgh sleep quality index (PSQI) and EQ-5D-5L quality of life questionnaire, before surgery, during hospital admission, and two weeks and three months postoperative. Additional variables such as pain and anesthesia duration were collected.

RESULTS

Twenty-nine patients were included. Before the surgery, 58% of them experienced poor quality of sleep, with a median PSQI score of 5.0. During hospital admission, 83% of the patients had poor quality of sleep, with a PSQI score of 6.0. The PSQI score two weeks postoperative increased to 7.0 and decreased three months postoperative to 5.0. Patients with pain scores >4 ("pain" group), had higher median PSQI scores than patients with pain scores ≤4 ("no pain" group) at all postoperative time points previously mentioned. No correlation was observed between anesthesia duration or quality of life.

CONCLUSION

Poor sleep quality was experienced by most women after autologous breast reconstruction, especially in those with higher postoperative pain scores. This knowledge offers an opportunity to improve the postoperative care for such patients.

Sleep and Circadian Health of Critical Survivors: A 12-Month Follow-Up Study

OBJECTIVES

To investigate the sleep and circadian health of critical survivors 12 months after hospital discharge and to evaluate a possible effect of the severity of the disease within this context.

DESIGN

Observational, prospective study.

SETTING

Single-center study.

PATIENTS

Two hundred sixty patients admitted to the ICU due to severe acute respiratory syndrome coronavirus 2 infection.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The cohort was composed of 260 patients (69.2% males), with a median (quartile 1-quartile 3) age of 61.5 years (52.0-67.0 yr). The median length of ICU stay was 11.0 days (6.00-21.8 d), where 56.2% of the patients required invasive mechanical ventilation (IMV). The Pittsburgh Sleep Quality Index (PSQI) revealed that 43.1% of the cohort presented poor sleep quality 12 months after hospital discharge. Actigraphy data indicated an influence of the disease severity on the fragmentation of the circadian rest-activity rhythm at the 3- and 6-month follow-ups, which was no longer significant in the long term. Still, the length of the ICU stay and the duration of IMV predicted a higher fragmentation of the rhythm at the 12-month follow-up with effect sizes (95% CI) of 0.248 (0.078-0.418) and 0.182 (0.005-0.359), respectively. Relevant associations between the PSQI and the Hospital Anxiety and Depression Scale (rho = 0.55, anxiety; rho = 0.5, depression) as well as between the fragmentation of the rhythm and the diffusing lung capacity for carbon monoxide (rho = -0.35) were observed at this time point.

CONCLUSIONS

Our findings reveal a great prevalence of critical survivors presenting poor sleep quality 12 months after hospital discharge. Actigraphy data indicated the persistence of circadian alterations and a possible impact of the disease severity on the fragmentation of the circadian rest-activity rhythm, which was attenuated at the 12-month follow-up. This altogether highlights the relevance of considering the sleep and circadian health of critical survivors in the long term.

Use of actigraphy for monitoring agitation and rest-activity cycles in patients with acute traumatic brain injury in the ICU

BACKGROUND

In traumatic brain injury patients (TBI) admitted to the intensive care unit (ICU), agitation can lead to accidental removal of catheters, devices as well as self-extubation and falls. Actigraphy could be a potential tool to continuously monitor agitation. The objectives of this study were to assess the feasibility of monitoring agitation with actigraphs and to compare activity levels in agitated and non-agitated critically ill TBI patients.

METHODS

Actigraphs were placed on patients' wrists; 24-hour monitoring was continued until ICU discharge or limitation of therapeutic efforts. Feasibility was assessed by actigraphy recording duration and missing activity count per day.

RESULTS

Data from 25 patients were analyzed. The mean number of completed day of actigraphy per patient was 6.5 ± 5.1. The mean missing activity count was 20.3 minutes (±81.7) per day. The mean level of activity measured by raw actigraphy counts per minute over 24 hours was higher in participants with agitation than without agitation.

CONCLUSIONS

This study supports the feasibility of actigraphy use in TBI patients in the ICU. In the acute phase of TBI, agitated patients have higher levels of activity, confirming the potential of actigraphy to monitor agitation.

Enhancing Sleep Quality in Pediatric Intensive Care: A Chronobiological Perspective

Biologic synchronized rhythmicity is a critical physiologic process. The lack of synchronized rhythms, mainly those showing a circadian basis, like sleep, heart rate, and arterial pressure, often leads to several organic challenges usually associated with adverse outcomes. Sleep itself, as an independent regulator of many crucial body functions, should preferentially occur with minimum interferences to optimize its plastic role toward structural and functional recovery and regeneration. Hence, patients will mostly benefit from both circadian and sleep-related optimized functions in order to improve prognosis and reduce patients' discharge times.

An Exploratory Analysis of Preclinical and Clinical Factors Associated With Sleep Disturbance Assessed via the Neuro-QoL After Hemorrhagic Stroke

Background and Purpose

Sleep disturbance after hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) can impact rehabilitation, recovery, and quality of life. We sought to explore preclinical and clinical factors associated with sleep disturbance after hemorrhagic stroke assessed via the Quality of Life in Neurological Disorders (Neuro-QoL) short form sleep disturbance inventory.

Methods

We telephonically completed the Neuro-QoL short form sleep disturbance inventory 3-months and 12-months after hemorrhagic stroke for patients >18-years-old hospitalized between January 2015 and February 2021. We examined the relationship between sleep disturbance (T-score >50) and social and neuropsychiatric history, systemic and neurological illness severity, medical complications, and temporality.

Results

The inventory was completed for 70 patients at 3-months and 39 patients at 12-months; 18 (26%) had sleep disturbance at 3-months and 11 (28%) had sleep disturbance at 12-months. There was moderate agreement (κ = .414) between sleep disturbance at 3-months and 12-months. Sleep disturbance at 3-months was related to unemployment/retirement prior to admission (P = .043), lower Glasgow Coma Scale score on admission (P = .021), higher NIHSS score on admission (P = .041) and infection while hospitalized (P = .036). On multivariate analysis, sleep disturbance at 3-months was related to unemployment/retirement prior to admission (OR 3.58 (95% CI 1.03-12.37), P = .044). Sleep disturbance at 12-months was related to premorbid mRS score (P = .046).

Conclusion

This exploratory analysis did not demonstrate a sustained relationship between any preclinical or clinical factors and sleep disturbance after hemorrhagic stroke. Larger studies that include comparison to patients with ischemic stroke and healthy individuals and utilize additional techniques to evaluate sleep disturbance are needed.

Sleep Disruptions in Hospitalized Adults Sustaining a Traumatic Brain Injury: A Scoping Review

OBJECTIVE

Adults sustaining a traumatic brain injury (TBI) are at risk of sleep disturbances during their recovery, including when such an injury requires hospitalization. However, the sleep-wake profile, and internal and external factors that may interfere with sleep initiation/maintenance in hospitalized TBI patients are poorly understood. This review aimed to: (1) identify/summarize the existing evidence regarding sleep and sleep measurements in TBI adults receiving around-the-clock care in a hospital or during inpatient rehabilitation, and (2) identify internal/external factors linked to poor sleep in this context.

METHODS

A scoping review was conducted in accordance with the PRISMA Scoping Review Extension guidelines. A search was conducted in MEDLINE, PsycINFO, CINAHL, and Web of Science databases.

RESULTS

Thirty relevant studies were identified. The most common sleep variables that were put forth in the studies to characterize sleep during hospitalization were nighttime sleep time (mean = 6.5 hours; range: 5.2-8.9 hours), wake after sleep onset (87.1 minutes; range: 30.4-180 minutes), and sleep efficiency (mean = 72.9%; range: 33%-96%) using mainly actigraphy, polysomnography, and questionnaires (eg, the sleep-wake disturbance item of the Delirium Rating Scale or the Pittsburgh Sleep Quality Index). Twenty-four studies (80%) suggested that hospitalized TBI patients do not get sufficient nighttime sleep, based on the general recommendations for adults (7-9 hours per night). Sleep disruptions during hospitalization were found to be associated to several internal factors including TBI severity, cognitive status, and analgesia intake. External and modifiable factors, such as noise, light, and patient care, were consistently associated with sleep disruptions in this context.

CONCLUSION

Although the literature on sleep disturbances in hospitalized TBI patients has been increasing in recent years, many gaps in knowledge remain, including phenotypes and risk factors. Identifying these factors could help clinicians better understand the multiple sources of TBI patients' sleep difficulties and intervene accordingly.

Post-Intensive Care Syndrome in Neurocritical Care Patients

Post-intensive care syndrome (PICS) refers to unintended consequences of critical care that manifest as new or worsening impairments in physical functioning, cognitive ability, or mental health. As intensive care unit (ICU) survival continues to improve, PICS is becoming increasingly recognized as a public health problem. Studies that focus on PICS have typically excluded patients with acute brain injuries and chronic neurodegenerative problems. However, patients who require neurocritical care undoubtedly suffer from impairments that overlap substantially with those encompassed by PICS. A major challenge is to distinguish between impairments related to brain injury and those that occur as a consequence of critical care. The general principles for the prevention and management of PICS and multidomain impairments in patients with moderate and severe neurological injuries are similar including the ICU liberation bundle, multidisciplinary team-based care throughout the continuum of care, and increasing awareness regarding the challenges of critical care survivorship among patients, families, and multidisciplinary team members. An extension of this concept, PICS-Family (PICS-F) refers to the mental health consequences of the intensive care experience for families and loved ones of ICU survivors. A dyadic approach to ICU survivorship with an emphasis on recognizing families and caregivers that may be at risk of developing PICS-F after neurocritical care illness can help improve outcomes for ICU survivors. In this review, we will summarize our current understanding of PICS and PICS-F, emerging literature on PICS in severe acute brain injury, strategies for preventing and treating PICS, and share our recommendations for future directions.

Psychotropic prescribing after hospital discharge in survivors of critical illness, a retrospective cohort study (2012-2019)

Background

Many people survive critical illness with the burden of new or worsened mental health issues and sleep disturbances. We examined the frequency of psychotropic prescribing after critical illness, comparing critical care to non-critical care hospitalised survivors, and whether this varied in important subgroups.

Methods

This retrospective cohort study included 23,340 critical care and 367,185 non-critical care hospitalised adults from 2012 through 2019 in Lothian, Scotland, who survived to discharge.

Results

One-third of critical care survivors (32%; 7527/23,340) received a psychotropic prescription within 90 days after hospital discharge (25% antidepressants; 14% anxiolytics/hypnotics; 4% antipsychotics/mania medicines). In contrast, 15% (54,589/367,185) of non-critical care survivors received a psychotropic prescription (12% antidepressants; 5% anxiolytics/hypnotics; 2% antipsychotics/mania medicines). Among patients without psychotropic prescriptions within 180 days prior to hospitalisation, after hospital discharge, the critical care group had a higher incidence of psychotropic prescription (10.3%; 1610/15,609) compared with the non-critical care group (3.2%; 9743/307,429); unadjusted hazard ratio (HR) 3.39, 95% CI: 3.22-3.57. After adjustment for potential confounders, the risk remained elevated (adjusted HR 2.03, 95% CI: 1.91-2.16), persisted later in follow-up (90-365 days; adjusted HR 1.38, 95% CI: 1.30-1.46), and was more pronounced in those without recorded comorbidities (adjusted HR 3.49, 95% CI: 3.22-3.78).

Conclusions

Critical care survivors have a higher risk of receiving psychotropic prescriptions than hospitalised patients, with a significant proportion receiving benzodiazepines and other hypnotics. Future research should focus on the requirement for and safety of psychotropic medicines in survivors of critical illness, to help guide policy for clinical practice.

Patient-reported sleep and physical function during and after hospitalization

PURPOSE

Poor sleep is associated with morbidity and mortality in the community; however, the health impact of poor sleep during and after hospitalization is poorly characterized. Our purpose was to describe trends in patient-reported sleep and physical function during and after hospitalization and evaluate sleep as a predictor of function after discharge.

METHODS

This is a secondary analysis of trial data with 232 adults followed for 3months after hospital discharge. Main measures were patient-reported surveys on sleep (Pittsburgh Sleep Quality Index) and physical function (Katz Activities of Daily Living, Lawton Instrumental Activities of Daily Living, and Nagi Mobility Scale) were collected during hospitalization and at 1, 5, 9, and 13weeks postdischarge.

RESULTS

Patient-reported sleep declined significantly during hospitalization and remained worse for 3months postdischarge (median Pittsburgh Sleep Quality Index=8 vs. 6, p < .001). In parallel, mobility declined significantly from baseline and remained worse at each follow-up time (median Nagi score=2 vs. 0, p < .001). Instrumental activities of daily living similarly decreased during and after hospitalization, but basic activities of daily living were unaffected. In adjusted time-series logistic regression models, the odds of mobility impairment were 1.48 times higher for each 1-point increase in Pittsburgh Sleep Quality Index score over time (95% CI 1.27-1.71, p < .001).

CONCLUSIONS

Patient-reported sleep worsened during hospitalization, did not improve significantly for 3months after hospitalization, and poor sleep was a significant predictor of functional impairment over this time. Sleep dysfunction that begins with hospitalization may persist and prevent functional recovery after discharge.

TRIAL REGISTRATION

The primary study was registered at ClinicalTrials.gov NCT03321279.

Sleep and Alcohol Use Among Veterans Living With Long COVID

OBJECTIVES

Study objectives were to: (1) better understand sleep experiences and unhealthy alcohol use among Veterans with long COVID and (2) explore providers' perceptions of barriers and facilitators to delivering evidence-based care for sleep problems and unhealthy alcohol use in patients with long COVID.

METHODS

VA electronic health records were used to conduct chart reviews (n = 57) of patients evaluated in a VA COVID-19 Recovery Clinic during 1 calendar year; semi-structured interviews were completed with Veterans (n = 5) and clinicians (n = 7) recruited from the clinic. Veteran participants also completed quantitative, self-report measures assessing sleep- and alcohol-related experiences and behaviors.

RESULTS

Data from chart reviews and interviews suggested that Veterans with long COVID often had pre-existing sleep problems that were exacerbated during long COVID. Patients and providers agreed that sleep interventions would be beneficial and acceptable in the COVID-19 Recovery clinic. Conversely, few Veterans with long COVID had a pre-existing alcohol use disorder (AUD) diagnosis; alcohol use occurred less frequently and was less often discussed between patients and providers. Providers had mixed viewpoints on delivering alcohol-related care in the clinic; some were highly amenable, others were unsure whether patients would be receptive.

CONCLUSIONS

This study is among the first to take a mixed-method approach to understanding experiences of sleep-wake behaviors and unhealthy alcohol use in Veterans with long COVID. Characterizing sleep and alcohol-related experiences, examining associations with functioning, and exploring perspectives on treatment approaches is critical to support efforts to refine, personalize, and optimize evidence-based sleep and alcohol care for Veterans living with long COVID.

Expanding Critical Care Delivery beyond the Intensive Care Unit: Determining the Design and Implementation Needs for a Tele-Critical Care Consultation Service

BACKGROUND

 Unplanned intensive care unit (ICU) admissions from medical/surgical floors and increased boarding times of ICU patients in the emergency department (ED) are common; approximately half of these are associated with adverse events. We explore the potential role of a tele-critical care consult service (TC3) in managing critically ill patients outside of the ICU and potentially preventing low-acuity unplanned admissions and also investigate its design and implementation needs.

METHODS

 We conducted a qualitative study involving general observations of the units, shadowing of clinicians during patient transfers, and interviews with clinicians from the ED, medical/surgical floor units and their ICU counterparts, tele-ICU, and the rapid response team at a large academic medical center in St. Louis, Missouri, United States. We used a hybrid thematic analysis approach supported by open and structured coding using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

 Over 165 hours of observations/shadowing and 26 clinician interviews were conducted. Our findings suggest that a tele-critical care consult (TC3) service can prevent avoidable, lower acuity ICU admissions by offering a second set of eyes via remote monitoring and providing guidance to bedside and rapid response teams in the care delivery of these patients on the floor/ED. CFIR-informed enablers impacting the successful implementation of the TC3 service included the optional and on-demand features of the TC3 service, around-the-clock availability, and continuous access to trained critical care clinicians for avoidable lower acuity (ALA) patients outside of the ICU, familiarity with tele-ICU staff, and a willingness to try alternative patient risk mitigation strategies for ALA patients (suggested by TC3), before transferring all unplanned admissions to ICUs. Conversely, the CFIR-informed barriers to implementation included a desire to uphold physician autonomy by floor/ED clinicians, potential role conflicts with rapid response teams, additional workload for floor/ED nurses, concerns about obstructing unavoidable, higher acuity admissions, and discomfort with audio-visual tools. To amplify these potential enablers and mitigate potential barriers to TC3 implementation, informed by this study, we propose two key characteristics-essential for extending the delivery of critical care services beyond the ICU-underlying a telemedicine critical care consultation model including its virtual footprint and on-demand and optional service features.

CONCLUSION

 Tele-critical care represents an innovative strategy for delivering safe and high-quality critical care services to lower acuity borderline patients outside the ICU setting.

An aromatherapy massage intervention on sleep in the ICU: A randomized controlled feasibility study

We conducted a feasibility randomized controlled trial exploring the effect of aromatherapy massage on sleep in critically ill patients. Patients were randomized to receive aromatherapy massage or usual care, and feasibility of recruitment and outcome data completion was captured. Sleep (depth) was assessed through Bispectral Index monitoring and self/nurse-reported Richards-Campbell Sleep Questionnaires, and the Sleep in the ICU Questionnaire. Thirty-four patients participated: 17 were randomized to aromatherapy massage and 17 to control. Five participants who received the intervention completed outcomes for analysis (alongside eight controls). A larger study was deemed unfeasible in this population, highlighting the value of testing feasibility of complex interventions, such as massage for sleep in ICU.

Changes in Restricting Symptoms after Critical Illness among Community-Living Older Adults

Rationale: Survivors of critical illness have multiple symptoms, but how restricting symptoms change after critical illness and whether these changes differ among vulnerable subgroups is unknown. Objectives: To evaluate changes in restricting symptoms over the six months after critical illness among older adults and to determine whether these changes differ by sex, multimorbidity, and individual- and neighborhood-level socioeconomic disadvantage. Methods: From a prospective longitudinal study of 754 community-living adults ⩾70 years old interviewed monthly (1998-2018), we identified 233 admissions from 193 participants to the ICU. The occurrence of 15 restricting symptoms, defined as those leading to restricted activity, were ascertained during interviews in the month before ICU admission (baseline) and each of the six months after hospital discharge. Measurements and Main Results: The occurrence and number of restricting symptoms increased more than threefold in the six months after a critical illness hospitalization (adjusted rate ratio [95% confidence interval], 3.1 [2.1-4.6] and 3.3 [2.1-5.3], respectively), relative to baseline. These increases were largest in the first month after hospitalization (adjusted rate ratio [95% confidence interval], 5.3 [3.8-7.3] and 5.4 [3.9-7.5], respectively] before declining and becoming nonsignificant in the third month. Increases in restricting symptoms did not differ significantly by sex, multimorbidity, or individual- or neighborhood-level socioeconomic disadvantage. Conclusions: Restricting symptoms increase substantially after a critical illness before returning to baseline three months after hospital discharge. Our findings highlight the need to incorporate symptom management into post-ICU care and for further investigation into whether addressing restricting symptoms can improve quality of life and functional recovery among older ICU survivors.

Sleep Architecture Patterns in Critically Ill Patients and Survivors of Critical Illness: A Retrospective Study

Rationale: Sleep abnormalities are very frequent in critically ill patients during and after intensive care unit (ICU) stays. Their mechanisms are poorly understood. The odds ratio product (ORP) is a continuous metric (range, 0.0-2.5) of sleep depth measured in 3-second intervals and derived from the relationship of powers of different electroencephalographic frequencies to one another. When expressed as the percentage of epochs within 10 ORP deciles covering the entire ORP range, it provides information about the mechanism(s) of abnormal sleep. Objectives: To determine ORP architecture types in critically ill patients and survivors of critical illness who had previously undergone sleep studies. Methods: Nocturnal polysomnograms from 47 unsedated critically ill patients and 23 survivors of critical illness at hospital discharge were analyzed. Twelve critically ill patients were monitored also during the day, and 15 survivors underwent subsequent polysomnography 6 months after hospital discharge. In all polysomnograms, each 30-second epoch was characterized by the mean ORP of the 10 3-second epochs. The number of 30-second epochs with mean ORP within each of 10 ORP deciles covering the entire ORP range (0.0-2.5) was calculated and expressed as a percentage of total recording time. Thereafter, each polysomnogram was characterized using a two-digit ORP type, with the first digit (range, 1-3) reflecting increasing degrees of deep sleep (ORP < 0.5, deciles 1 and 2) and the second digit (range, 1-3) reflecting increasing degrees of full wakefulness (ORP > 2.25, decile 10). Results from patients were compared with those from 831 age- and gender-matched community dwellers free of sleep disorders. Results: In critically ill patients, types 1,1 and 1,2 (little deep sleep and little or average full wakefulness) dominated (46% of patients). In the community, these types are uncommon (<15%) and seen primarily in disorders that preclude progression to deep sleep (e.g., very severe obstructive sleep apnea). Next in frequency (22%) was type 1,3, consistent with hyperarousal. Day ORP sleep architecture was similar to night results. Survivors had similar patterns, with little improvement after 6 months. Conclusions: Sleep abnormalities in critically ill patients and survivors of critical illness result primarily from stimuli that preclude progression to deep sleep or from the presence of a hyperarousal state.

Association between Acute Respiratory Distress Syndrome Due to COVID-19 and Long-Term Sleep and Circadian Sleep-Wake Disorders

Current studies agree on the impact of sleep and circadian rest-activity rhythm alterations in acute respiratory distress syndrome (ARDS) survivors. However, research on the duration of this impact is scarce. In this study, we evaluate the impact of ARDS on the sleep and circadian rest-activity rhythm of COVID-19 survivors twelve months after hospital discharge. This is a prospective study including COVID-19 survivors with and without ARDS during hospitalization. Data was collected four and twelve months after hospital discharge. The interventions included one-week wrist actigraphy and a home sleep apnea test (HSAT), and evaluations were conducted according to the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). Fifty-two patients were evaluated (ARDS = 31 and non-ARDS = 21); they had a median age of 49.0 [39.0;57.2] years and 53.8% were male. After twelve months, 91.3% presented poor sleep quality, 58.7% presented insomnia, 50% presented daytime somnolence, and 37% presented comorbid insomnia and obstructive sleep apnea (COMISA). No significant improvement was observed in relation to sleep or the circadian rest-activity rhythm between four and twelve months. A tendency of poor sleep quality, insomnia, daytime somnolence, and COMISA was observed. Finally, there was no significant impact on the circadian rest-activity rhythm between four and twelve months or between the groups.

Sleep and critical illness: a review

Critical illness and stays in the Intensive Care Unit (ICU) have significant impact on sleep. Poor sleep is common in this setting, can persist beyond acute critical illness, and is associated with increased morbidity and mortality. In the past 5 years, intensive care clinical practice guidelines have directed more focus on sleep and circadian disruption, spurring new initiatives to study and improve sleep complications in the critically ill. The global SARS-COV-2 (COVID-19) pandemic and dramatic spikes in patients requiring ICU level care also brought augmented levels of sleep disruption, the understanding of which continues to evolve. This review aims to summarize existing literature on sleep and critical illness and briefly discuss future directions in the field.

Evaluation of sleep quality in faculty members of Isfahan university of medical sciences

BACKGROUND

Sleep disorders can significantly impair the quality of life and daily functions. Evaluating sleep quality can provide valuable information about working conditions. This study aims to evaluate the sleep quality of faculty members at Isfahan University of Medical Sciences (IUMS).

METHODS

This descriptive-analytic study was conducted from 2020 to 2021, involving 106 faculty members from the medical school. A questionnaire collected demographic information, including age, sex, height, weight, body mass index (BMI), level of education, history of faculty membership, major, working hours during the day and night, residency place, and medical history. The Pittsburgh Sleep Quality Index (PSQI) and Symptom Checklist-25 (SCL-25) questionnaire were used to assess participants' sleep quality. Data were compared between clinicians and basic science faculty members.

RESULTS

PSQI subtypes were examined among the participants. The total PSQI score was 6.20±3.4. A comparison of PSQI scores and subtypes based on age categories did not show any significant differences (P > 0.05 for all). Clinicians had significantly lower total PSQI scores (P=0.044), sleep latency (P=0.024), sleep disturbances (P=0.012), and daytime dysfunction (P=0.022). Additionally, clinicians had a lower severity of sleep latency (P=0.024), sleep disturbances (P=0.012), and total PSQI score (P=0.044). However, clinicians exhibited a higher intensity of daytime dysfunction (P=0.022).

CONCLUSION

Faculty members exhibited a high prevalence of sleep disorders, with the most common disorders being sleep disturbance and high sleep latency. The prevalence of sleep disorders was higher among basic science faculty members compared to clinicians.

Effects of sleep disturbance on dyspnoea and impaired lung function following hospital admission due to COVID-19 in the UK: a prospective multicentre cohort study

BACKGROUND

Sleep disturbance is common following hospital admission both for COVID-19 and other causes. The clinical associations of this for recovery after hospital admission are poorly understood despite sleep disturbance contributing to morbidity in other scenarios. We aimed to investigate the prevalence and nature of sleep disturbance after discharge following hospital admission for COVID-19 and to assess whether this was associated with dyspnoea.

METHODS

CircCOVID was a prospective multicentre cohort substudy designed to investigate the effects of circadian disruption and sleep disturbance on recovery after COVID-19 in a cohort of participants aged 18 years or older, admitted to hospital for COVID-19 in the UK, and discharged between March, 2020, and October, 2021. Participants were recruited from the Post-hospitalisation COVID-19 study (PHOSP-COVID). Follow-up data were collected at two timepoints: an early time point 2-7 months after hospital discharge and a later time point 10-14 months after hospital discharge. Sleep quality was assessed subjectively using the Pittsburgh Sleep Quality Index questionnaire and a numerical rating scale. Sleep quality was also assessed with an accelerometer worn on the wrist (actigraphy) for 14 days. Participants were also clinically phenotyped, including assessment of symptoms (ie, anxiety [Generalised Anxiety Disorder 7-item scale questionnaire], muscle function [SARC-F questionnaire], dyspnoea [Dyspnoea-12 questionnaire] and measurement of lung function), at the early timepoint after discharge. Actigraphy results were also compared to a matched UK Biobank cohort (non-hospitalised individuals and recently hospitalised individuals). Multivariable linear regression was used to define associations of sleep disturbance with the primary outcome of breathlessness and the other clinical symptoms. PHOSP-COVID is registered on the ISRCTN Registry (ISRCTN10980107).

FINDINGS

2320 of 2468 participants in the PHOSP-COVID study attended an early timepoint research visit a median of 5 months (IQR 4-6) following discharge from 83 hospitals in the UK. Data for sleep quality were assessed by subjective measures (the Pittsburgh Sleep Quality Index questionnaire and the numerical rating scale) for 638 participants at the early time point. Sleep quality was also assessed using device-based measures (actigraphy) a median of 7 months (IQR 5-8 months) after discharge from hospital for 729 participants. After discharge from hospital, the majority (396 [62%] of 638) of participants who had been admitted to hospital for COVID-19 reported poor sleep quality in response to the Pittsburgh Sleep Quality Index questionnaire. A comparable proportion (338 [53%] of 638) of participants felt their sleep quality had deteriorated following discharge after COVID-19 admission, as assessed by the numerical rating scale. Device-based measurements were compared to an age-matched, sex-matched, BMI-matched, and time from discharge-matched UK Biobank cohort who had recently been admitted to hospital. Compared to the recently hospitalised matched UK Biobank cohort, participants in our study slept on average 65 min (95% CI 59 to 71) longer, had a lower sleep regularity index (-19%; 95% CI -20 to -16), and a lower sleep efficiency (3·83 percentage points; 95% CI 3·40 to 4·26). Similar results were obtained when comparisons were made with the non-hospitalised UK Biobank cohort. Overall sleep quality (unadjusted effect estimate 3·94; 95% CI 2·78 to 5·10), deterioration in sleep quality following hospital admission (3·00; 1·82 to 4·28), and sleep regularity (4·38; 2·10 to 6·65) were associated with higher dyspnoea scores. Poor sleep quality, deterioration in sleep quality, and sleep regularity were also associated with impaired lung function, as assessed by forced vital capacity. Depending on the sleep metric, anxiety mediated 18-39% of the effect of sleep disturbance on dyspnoea, while muscle weakness mediated 27-41% of this effect.

INTERPRETATION

Sleep disturbance following hospital admission for COVID-19 is associated with dyspnoea, anxiety, and muscle weakness. Due to the association with multiple symptoms, targeting sleep disturbance might be beneficial in treating the post-COVID-19 condition.

FUNDING

UK Research and Innovation, National Institute for Health Research, and Engineering and Physical Sciences Research Council.

Factors Associated with Sleep Disorder among Korean Cancer Survivors: A Cross-Sectional Study

BACKGROUND

The factors associated with sleep disorder are controversial. This study aimed to evaluate the prevalence of sleep disorder and the factors associated with sleep disorder among Korean adult cancer survivors.

METHODS

In this cross-sectional study, we collected data on sleep problems as outcome variables, and sociodemographic and clinical information as predictor variables from cancer survivors at two university-affiliated hospitals. Sleep disorder was defined as "a difficulty in sleep initiation or sleep maintenance at least 3 times a week that started after a cancer diagnosis." Multiple logistic regression analysis was performed with odds ratios (OR) and 95% confidence intervals (95% CI) to evaluate the factors associated with sleep disorder.

RESULTS

The participants were 1,893 Korean cancer survivors (mean age, 58.1 years; females 68.0%). The prevalence of sleep disorder among male and female cancer survivors were 16.5% and 20.3%, respectively. An increase of age by 1-year was associated with a 1.04 (95% CI, 1.01-1.07; P=0.011) times higher risk of sleep disorder in males, while an inverse association was found in females. In female survivors, high fear of cancer recurrence (FCR), high anxiety, menopause, and high EuroQol Visual Analog Scale were associated with 1.45 (95% CI, 1.06-1.98; P=0.020), 1.78 (95% CI, 1.25-2.55; P=0.002), 1.70 (95% CI, 1.08-2.67; P=0.022), and 0.59 (95% CI, 0.43-0.82; P=0.002) times higher risk of sleep disorder, respectively. In male survivors, living with a spouse/or partner was associated with 57% (95% CI, 0.20-0.95; P=0.036) lower risk of sleep disorder. Analyses of cancer sites showed that the factors associated with sleep disorder varied across cancer sites.

CONCLUSION

One-fifth of adult cancer survivors had sleep disorder. Age, menopausal status, FCR, anxiety, living with a spouse or partner, and quality of life were independently associated with sleep disorder in Korean cancer survivors.

Sleep during and following critical illness: A narrative review

Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.

Development and validation of a nomogram for postoperative sleep disturbance in adults: a prospective survey of 640 patients undergoing spinal surgery

BACKGROUND

Postoperative sleep disturbance (PSD) is a prevalent clinical complication that may arise due to various factors. The purpose of this investigation is to identify the risk factors for PSD in spinal surgery and establish a risk prediction nomogram.

METHODS

The clinical records of individuals who underwent spinal surgery from January 2020 to January 2021 were gathered prospectively. The least absolute shrinkage and selection operator (LASSO) regression, along with multivariate logistic regression analysis, was employed to establish independent risk factors. A nomogram prediction model was devised based on these factors. The nomogram's effectiveness was evaluated and verified via the receiver operating characteristic (ROC) curve, calibration plot, and decision curve analysis (DCA).

RESULTS

A total of 640 patients who underwent spinal surgery were analyzed in this investigation, among which 393 patients experienced PSD with an incidence rate of 61.4%. After conducting LASSO regression and logistic regression analyses using R software on the variables in training set, 8 independent risk factors associated to PSD were identified, including female, preoperative sleep disorder, high preoperative anxiety score, high intraoperative bleeding volume, high postoperative pain score, dissatisfaction with ward sleep environment, non-use of dexmedetomidine and non-use of erector spinae plane block (ESPB). The nomogram and online dynamic nomogram were constructed after incorporating these variables. In the training and validation sets, the area under the curve (AUC) in the receiver operating characteristic (ROC) curves were 0.806 (0.768-0.844) and 0.755 (0.667-0.844), respectively. The calibration plots indicated that the mean absolute error (MAE) values in both sets were respectively 1.2% and 1.7%. The decision curve analysis demonstrated the model had a substantial net benefit within the range of threshold probabilities between 20% and 90%.

CONCLUSIONS

The nomogram model proposed in this study included eight frequently observed clinical factors and exhibited favorable accuracy and calibration.

TRIAL REGISTRATION

The study was retrospectively registered with the Chinese Clinical Trial Registry (ChiCTR2200061257, 18/06/2022).

Effects of nursing interventions to improve inpatients' sleep in intensive and non-intensive care units: Findings from an umbrella review

AIM

This review aimed to synthesise the available reviews on the effects of nursing interventions on sleep quality among patients hospitalised in intensive care and non-intensive care units.

BACKGROUND

Poor sleep quality is a common fact in hospitalised patients. Nurses can contribute to the improvement of patients' sleep quality and duration.

DESIGN

A review of intervention reviews was carried out and reported following the PRISMA guidelines and checklist.

METHODS

We systematically searched for reviews published from January 2009 to December 2019 in PubMed, CINAHL Plus, Scopus, Institute for Scientific Information Web of Science, Joanna Briggs Database of Systematic Reviews and Cochrane Central Register of Controlled Trials databases. Searches were repeated at 24 November 2020 to include the most recent evidence. A narrative synthesis of the results was conducted.

RESULTS

Nine reviews (representing 109 original papers) met the selection criteria and were included for critical appraisal. Overall, nursing interventions and sleep quality were poorly defined. We grouped the interventions into 3 categories (environmental, barrier and internal interventions) to provide a more comprehensive overview and examine effects of nursing interventions on inpatients sleep quality. Inconsistent results were obtained and low quality of the original articles was reported, making it difficult to establish absolute conclusions.

CONCLUSION

The impact of environmental changes on patients' sleep was positive but inconclusive, while use of earplugs and eye masks, music and acupuncture generally showed positive results with moderate quality of evidence, and no harmful effects were reported.

Effectiveness of music therapy within community hospitals: an EMMPIRE retrospective study

Introduction

Given the challenges health systems face in providing effective nonpharmacologic treatment for pain and psychological distress, clinical effectiveness studies of evidence-based strategies such as music therapy (MT) are needed.

Objectives

This study examined changes in patient-reported outcomes (PROs) after MT and explored variables associated with pain reduction of ≥2 units on a 0 to 10 numeric rating scale (NRS).

Methods

A retrospective review was conducted on initial MT interventions provided to adults receiving community hospital care between January 2017 and July 2020. Sessions were included if participants reported pre-session pain, anxiety, and/or stress scores of ≥4 on the NRS. Data analysis included a bootstrap analysis of single-session changes in PROs and a logistic regression exploring variables associated with pain reduction (ie, ≥2 units vs <2 units).

Results

Patients (n = 1056; mean age: 63.83 years; 76.1% female; 57.1% White; 41.1% Black/African American) reported clinically significant mean reductions in pain (2.04 units), anxiety (2.80 units), and stress (3.48 units). After adjusting for demographic, clinical, and operational characteristics in the model (c-statistic = 0.668), patients receiving an MT session in which pain management was a goal were 4.32 times more likely (95% confidence interval 2.26, 8.66) to report pain reduction of ≥2 units than patients receiving an MT session in which pain management was not a session goal.

Conclusion

This retrospective study supports the clinical effectiveness of MT for symptom management in community hospitals. However, additional research is needed to determine which characteristics of MT interventions and patients influence pain change.

The prevalence and risk factors of sleep disturbances in surgical patients: A systematic review and meta-analysis

Determining the prevalence and risk factors related to sleep disturbance in surgical patients would be beneficial for risk stratification and perioperative care planning. The objectives of this systematic review and meta-analysis are to determine the prevalence and risk factors of sleep disturbances and their associated postoperative complications in surgical patients. The inclusion criteria were: (1) patients ≥18 years old undergoing a surgical procedure, (2) in-patient population, and (3) report of sleep disturbances using a validated sleep assessment tool. The systematic search resulted in 21,951 articles. Twelve patient cohorts involving 1497 patients were included. The pooled prevalence of sleep disturbances at preoperative assessment was 60% (95% Confidence Interval (CI): 50%, 69%) and the risk factors for postoperative sleep disturbances were a high preoperative Pittsburgh sleep quality index (PSQI) score indicating preexisting disturbed sleep and anxiety. Notably, patients with postoperative delirium had a higher prevalence of pre- and postoperative sleep disturbances and high preoperative wake after sleep onset percentage (WASO%). The high prevalence of preoperative sleep disturbances in surgical patients has a negative impact on postoperative outcomes and well-being. Further work in this area is warranted.

Causes, Consequences, and Treatments of Sleep and Circadian Disruption in the ICU: An Official American Thoracic Society Research Statement

Background: Sleep and circadian disruption (SCD) is common and severe in the ICU. On the basis of rigorous evidence in non-ICU populations and emerging evidence in ICU populations, SCD is likely to have a profound negative impact on patient outcomes. Thus, it is urgent that we establish research priorities to advance understanding of ICU SCD. Methods: We convened a multidisciplinary group with relevant expertise to participate in an American Thoracic Society Workshop. Workshop objectives included identifying ICU SCD subtopics of interest, key knowledge gaps, and research priorities. Members attended remote sessions from March to November 2021. Recorded presentations were prepared and viewed by members before Workshop sessions. Workshop discussion focused on key gaps and related research priorities. The priorities listed herein were selected on the basis of rank as established by a series of anonymous surveys. Results: We identified the following research priorities: establish an ICU SCD definition, further develop rigorous and feasible ICU SCD measures, test associations between ICU SCD domains and outcomes, promote the inclusion of mechanistic and patient-centered outcomes within large clinical studies, leverage implementation science strategies to maximize intervention fidelity and sustainability, and collaborate among investigators to harmonize methods and promote multisite investigation. Conclusions: ICU SCD is a complex and compelling potential target for improving ICU outcomes. Given the influence on all other research priorities, further development of rigorous, feasible ICU SCD measurement is a key next step in advancing the field.

Dynamic prevalence of sleep disturbance among critically ill patients in intensive care units and after hospitalisation: A systematic review and meta-analysis

BACKGROUND

Sleep disturbance is a common complaint among critically ill patients in intensive care units and after hospitalisation. However, the prevalence of sleep disturbance among critically ill patients varies widely.

OBJECTIVE

To estimate the prevalence of sleep disturbance among critically ill patients in the intensive care unit and after hospitalisation.

METHODS

Electronic databases were searched from their inception until 15 August 2022. Only observational studies with cross-sectional, prospective, and retrospective designs investigating sleep disturbance prevalence among critically ill adults (aged ≥ 18 years) during intensive care unit stay and after hospitalisation were included.

RESULTS

We found 13 studies investigating sleep disturbance prevalence in intensive care units and 14 investigating sleep disturbance prevalence after hospitalisation, with 1,228 and 3,065 participants, respectively. The prevalence of sleep disturbance during an ICU stay was 66 %, and at two, three, six and ≥ 12 months after hospitalisation was 64 %, 49 %, 40 %, and 28 %, respectively. Studies using the Richards-Campbell Sleep Questionnaire detected a higher prevalence of sleep disturbance among patients in intensive care units than non-intensive care unit specific questionnaires; studies reported comparable sleep disturbance prevalence during intensive care stays for patients with and without mechanical ventilation.

CONCLUSION

Sleep disturbance is prevalent in critically ill patients admitted to an intensive care unit and persists for up to one year after hospitalisation, with prevalence ranging from 28 % to 66 %. The study results highlight the importance of implementing effective interventions as early as possible to improve intensive care unit sleep quality.

Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization

This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.

Effects of dexmedetomidine on postoperative sleep quality: a systematic review and meta-analysis of randomized controlled trials

STUDY OBJECTIVES

To assess the effect of dexmedetomidine (DEX) on postoperative sleep quality using polysomnography (PSG) to identify possible interventions for postoperative sleep disturbances.

METHODS

An electronic search of PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science was conducted from database inception to November 20, 2022. Randomized controlled trials (RCTs) on the effect of DEX administration on postoperative sleep quality using PSG or its derivatives were included. No language restrictions were applied. The sleep efficiency index (SEI), arousal index (AI), percentages of stage N1, N2 and N3 of non-rapid eye movement (NREM) sleep, and rapid eye movement (REM) sleep were measured in our meta-analysis.

RESULTS

Five studies, involving 381 participants were included. Administration of DEX significantly improved SEI, lowered AI, decreased the duration of stage N1 sleep and increased the duration of stage N2 sleep compared to placebo groups. There were no significant differences in the duration of stage N3 sleep and REM sleep. DEX administration lowered the postoperative Visual Analogue Scale (VAS) score and improved the Ramsay sedation score with no adverse effect on postoperative delirium (POD). However, high heterogeneity was observed in most of the primary and secondary outcomes.

CONCLUSIONS

Our study provides support for the perioperative administration of DEX to improve postoperative sleep quality. The optimal dosage and overall effect of DEX on postoperative sleep quality require further investigation using large-scale randomized controlled trials.

Long-term quality of life and work ability among severe COVID-19 survivors: A multicenter study

Background

Coronavirus disease 2019 (COVID-19), is known for its variable severity and high infectivity. Though fewer than 15% of infected cases develop severe disease, a major proportion had prolonged stay in the intensive care unit (ICU). Prolonged ICU stay is known to have a long-term impact on behavior and quality of life.⁸ Therefore, it is likely that patients discharged after severe COVID-19 have issues that persist for long term. The current study aimed to assess the long-term impact of severe COVID-19 on the Quality of life (QOL), sleep pattern, behavior, and workability.

Methods

The current multicenter study adopted a cross-sectional design to analyze data from two tertiary care COVID-19 dedicated hospitals. All experimental procedures were approved by the ethics committee of the M.L.B Medical College. Participants were 20–60 age group who had been admitted to the ICU because of severe COVID-19 and had elapsed at least one and a half year since their discharge. After informed written consent the participants were assessed for: EUROHIS-QOL 8-item index; Workability Score; Quality of sleep; The major depression inventory (MDI) questionnaire; Generalized anxiety disorder 7 item scale (GAD-7); Current global health status score: an innovative subjective scale (1−10) to determine the current global health status when 5 is the status before COVID-19.

Findings

491 participants were assessed, the median follow-up time after discharge from the hospital was 561·0 days (range, 548–580 days). The mean duration of ICU stay was 8·72 ± 2·85 days. There was significant reduction in the prevalence of obesity, diabetes, and hypertension as compared with discharge time. The mean of EUROHIS-QOL score, workability score, current global health status score was 3·28 ± 0·98, 6·87 ± 0·85, 4·53 ± 1·36 respectively. The mean MDI and anxiety scores were 4·12 ± 1·45 and 18·63 ± 3·28, respectively.

Interpretation

Severe COVID-19 survivors have new-onset psychological disorders and sleep disturbances. Long term quality of life and work ability remains poor after prolong ICU admission secondary to severe COVID-19.

Sleep Quality in the Advanced Heart Failure ICU

In this study, we evaluated sleep quality changes in persons with advanced heart failure (HF) who were admitted to the intensive care unit. Sleep quality was assessed at admission, during hospitalization, and post-discharge. Statistical tests compared within subject mean sleep quality over time (n = 22). Poor quality sleep was reported by 96% of participants at admission, 96% during hospitalization, and 86% post-discharge. Significant differences were found between timepoints in global sleep quality, subject sleep quality, sleep duration, and habitual sleep efficiency. A greater proportion of these participants had poor global sleep quality during hospitalization than previously reported. Participants reported better sleep post-discharge than admission and during hospitalization. Interventions enhancing hospital sleep, along with home sleep self-management education, would improve HF outcomes. Implementation science methods are warranted to integrate efficacious interventions in this population.