Insomnia in the ICU—and After

According to 2 studies, one conducted by researchers from Yale University in New Haven, Connecticut, and one conducted by researchers from VA Puget Sound Health Care System in Seattle, Washington, it is possible to help patients get better sleep both in the intensive care unit (ICU) and after ICU discharge.

Yale researchers say that in order to maintain better sleep while in the ICU, it is important to have the “buy-in” of health care providers (HCPs). The researchers interviewed 19 nurses and physicians who worked the night shift in the medical ICU at Yale-New Haven Hospital. They asked the participants, who ranged from interns 1 year out of medical school to nurses with 20 years of ICU experience, about what they perceived as barriers to sleep in the ICU.

Nearly all the respondents in the Yale study cited noise, such as monitor beeps and other patients; nursing procedures, such as performing vital signs; physician procedures; and family in the patient’s room. Several participants mentioned hospital- or ICU-policy-based barriers to sleep, such as delaying nonurgent diagnostic imaging for hospitalized patients until the evening or night. Other respondents commented on delays in patient discharges or transfers contributing to poor sleep.

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The respondents also described what the researchers called explicit and intrinsic barriers, such as dyspnea, pain, severe illness, delirium, and alterations in circadian rhythm.

The open-ended questions in the Yale survey brought up a number of responses the researchers designated as implicit. These included varying beliefs about the clinical importance of sleep in the ICU. Attending physicians and experienced nurses often spontaneously brought up the importance of patient sleep, the researchers say, whereas physicians in training and less-experienced nurses did not. Experienced caregivers were also more likely to note that certain ICU protocols, such as measuring blood pressure, did not always need to be done as often as required.

The respondents also differed on the benefits and harms of sedative-hypnotics, whether sedation equaled sleep, and whether that sedated sleep actually promoted recuperative rest.

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A cultural shift is leading to more interest in improving the quality of life in the ICU, the Yale researchers note. Promoting better sleep in the ICU, they say, could be helped by a protocol that first identifies where the patient lies on the spectrum of critical care, with more uninterrupted time allotted to patients in recovery from or in a plateau phase of their illness.

Policy changes could help as well, the Yale researchers suggest. Scheduling outpatients’ studies for later in the day could allow ICU patients to have tests done earlier. Early discharges could cut down on noise, with hospital beds available earlier in the day for patients ready to be transferred out of the ICU.

The identified barriers can also be used to develop an educational program to increase knowledge on the importance of sleep, maintaining circadian rhythm, and sleep promotion. But first, the Yale researchers suggest, it might be a good idea to start by educating HCPs about the effects of sleep deprivation. They point to a study that found delirium and coma in a medical ICU dropped significantly after a multifaceted intervention to promote sleep.

Indeed, insomnia is not only an issue for patients while they are still in the hospital, but also for months afterward, according to the researchers from VA Puget Sound. In their study of 120 patients with an ICU stay > 24 hours, 33 patients (28%) were still experiencing clinically meaningful insomnia at a 12-month follow-up. Moreover, the insomnia was significantly associated with worse health-related quality-of-life (HRQOL) scores, such as vitality, physical function, and pain.

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The VA researchers say, to their knowledge, this is the first study to examine post-ICU insomnia and its associations with HRQOL using a validated, insomnia-specific sleep metric, and to perform detailed adjustment for “a host of factors that may influence sleep and [QOL].”

Acute stress symptoms and more hospital days on opioids were related to post-ICU insomnia. However, those associations were no longer significant after the researchers adjusted for psychiatric symptoms. In fact, they found the relationship between insomnia and HRQOL was not affected by premorbid function but was “highly linked” to concurrent substantial PTSD (38% vs 7% of patients, P < .01) and depression (52% vs 6% of patients, P < .01).

Their findings have important public health and clinical implications, the researchers say. For one thing, patients may be more comfortable talking with HCPs about sleep problems than about often-stigmatized conditions such as depression. Thus, the researchers say, ICU survivors with insomnia should be screened for psychiatric disorders, including PTSD. Also, they suggest that insomnia may serve as a warning sign of a mood disorder or pain and could influence response to treatment.