Sleep in the Hospitalized Patient

Robyn Woidtke MSN,RN, RPSGT,CCP,CCSHOCTOBER 24KASP 2014Sleep in the Hospitalized Patient1ObjectivesAt the completion of the session, the attendees will:Summarize contributors to sleep lossDescribe the impact of sleep loss in the hospitalized patient Explain the rationale for screening for sleep apnea in patients admitted to the hospitalEmphasis The perioperative environmentThe ICU

2Why is sleep important?Animal models, sleep loss leads to Failure of body temperature regulationIncreased metabolismDeterioration of hypothalamic neuronsProgressive breakdown of host defensesDeathRedeker &McEnany, 20113

FunctionsConserve energy and metabolismPhysiologic systems within homeostatic mechanismsMaintain host defensesReverse/restore physiologic processes that degrade during wakefulnessMemory ConsolidationLearning

Redeker &McEnany, 20114

Factors Contributing to Sleep LossVoluntary curtailment (social)Environment (i.e. work, technology, etc)Role (new mom, school)Sleep DisordersMedical and psychiatric disordersRedeker &McEnany, 20115

Sleep DeprivationPoor job performanceCognition ImpairedLose the ability to make sound judgment; interpretation of events is affectedReduced ability to handle stressGreater alcohol useHigher incidence of drowsy driving

Redeker &McEnany, 20116

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Acute Sleep Deprivation 8Excess diuresis and natriuresis during acute sleep deprivation in healthy adults (Kamperis, 2010). Acute sleep deprivation reduces energy expenditure in healthy men (Benedict, 2011)Increase levels of ghrelin in the morningDeclines in neurocognition, increased sympathetic and decreased parasympathetic modulation (Zhong et al., 2004)

Outcomes of Disturbed Sleep9Alterations in immune functionIncreased stress hormones (catacholamines)Insulin and glucose regulationAbility to perform activities of daily livingLack of mental processing of self care activities upon dischargeDecrease in SWS HGHAlterations in processing and consolidating newly acquired information Increases calcium retention, and strengthens and increases the mineralization of boneIncreases muscle mass through sarcomere hypertrophyPromotes lipolysisIncreases protein synthesisStimulates the growth of all internal organs excluding the brainPlays a role in homeostasisReduces liver uptake of glucosePromotes gluconeogenesis in the liver[31]Contributes to the maintenance and function of pancreatic isletsStimulates the immune system

9Correlates and Consequences 10SleepQuantityContinuity Diurnal TimingQualityPerceptionsAcute IllnessAge, Gender, ComorbiditySymptomsHospital EnvironmentTreatmentSleep DisordersFunctional StatusPhysiologic StatusAdapted from Redeker and Hedges, 2002General Sleep Assessment (1)ChallengesSleep problems typically occur gradually; patients may not be aware or concernedMay attribute daytime symptoms to other causesAssessmentBEARS (all ages)B-bedtime problemsE-Excessive SleepinessA-AwakeningsR- Regularity of sleep S-Sleep disordered breathingRedeker &McEnany, 201111

General Sleep Assessment (2)General healthSpecific ConditionsCo-morbid/bi-directionality (heart disease, asthma, diabetes, Parkinsons, pain, depression and anxiety)Anthropometric dataHT/Wt (BMI >30), neck circumference (17 m, 16 f) correlate with OSA in adultsWaist circumference and BMI>95th percentile in childrenInspection of the profile, oral and nasal cavitiesMallampatiCardiovascular (BP, EKG, heart sounds)Pulmonary system (scoliosis, muscle tone)Neuromuscular (restless legs syndrome)Glycemic controlRedeker &McEnany, 201112Nursing Staff: Do Not assume While knowledge of findings like these (referring to sleep apnea) have raised my awareness of the dangers of untreated sleep apnea, I can tell you that a majority of the nurses at my hospital, and even those within my own critical care unit still do not aggressively address the issue of having the MD order studies to diagnose and/or treat OSA which has been diagnosed (2012, Personal Communication, Anonymous Critical Care RN, MSN student) Sleep in the ICUSleep ParameterChangesTotal Sleep TimeUnchanged/decreasedSleep LatencyUnchanged/increasedSleep EfficiencyDecreasedNREM Stage 1IncreasedNREM Stage 2IncreasedNREM Stage 3DecreasedREMDecreasedFriese, R. (2008) Crit Care Med14Environmental and Pathophysiological Factors Friese, R. (2008) Crit Care Med15ICU Delirium16Delirium affects up to 80% of ICU patients, and it is estimated that ICU costs associated with delirium equal between $4 billion and $16 billion annually in the US.(1)This form of acute brain dysfunction is associated with increased length of ICU and hospital stays, time on the ventilator, mortality, and long-term neuropsychological deficits (1)Characteristic features of the syndrome include impaired short-term memory, impaired attention, disorientation, development over a short period of time, and a fluctuating course(2)Caused by a general medical illness, intoxication, or substance withdrawal (2)OSA has been demonstrated as a risk factor (3)American Association of Critical Care Nurses, 2014Cavallazzi, et al., 2012 Annals of Intensive CareFlink, et al.2012 Anesthesology Medications17OpioidsIncrease arousalPrecipitate osaWorsen hypoxiaVentilator asynchronyBenzodiazapinesIncrease theta; reduce SWSLoss of SWS has been shown to increase delirium Dexmedetomidine Reduces ventilator daysReduces delirium

Interventions18Reduce Effects of Environmental StimuliDecrease noiseCluster patient care interventionsProvide eye masks and ear plugs if appropriateComplementary and Alternative MedicineRelaxation, music and biofeedback White noise may improve sleep quality in cardiac post op patientsMassageMeditation Review Drug interactions, understand the consequencesInterventions Plan for uninterrupted time for sleepMinimize night time assessmentsSet monitor alarms down to reasonable loudnessOrient patient frequentlyIf possible, cycle light to day/night frequencySleep may change ventilator synchrony, proportional assist has demonstrated improved ventilatory matching requirements and improved sleep Friese, R. (2008) Crit Care Med19

"We haven't recognized the importance of prescribing sleepFriese, R 200719Measuring Sleep QualityRichards-Campbell Sleep QuestionnaireBrief validated 5 item questionnaire; visual analog scale (100mm), higher numbers= betterStudy to determine nurses vs. patients subjective ratings of sleep; inter-rater reliability Johns Hopkins (June-July 2010; 16 bed private room MICU; nurse to patient ratio 1:2; 12 hour shifts); questionnaires completed 30 minutes prior to the end of shift; 33 patients/92 paired assessmentsResults: Patient/Nurse agreement was slight to moderate; nurses tended to over estimate sleep quality

Kamdar et al. (2012) AJCC20Sleep DepthMy sleep last night was 0 = did not sleep -100 =deep sleepSleep LatencyLast night the first time I got to sleep 0 = never could fall asleep-100 = fell asleep almost immediatelyAwakeningsLast night I was 0 = awake all night long -100 = awake very littleReturning to sleepLast night when I work up or was awakened I 0 = could not get back to sleep- 100 = got back to sleep immediatelySleep QualityI would describe my sleep last night as: 0 = bad nights sleep- 100 = good nights sleepNoise (note, this question was added for this study)I would describe the noise level as :0 = very noisy -100 = very quiet20OSA in the Hospital2125% of candidates for elective surgeryOSA undiagnosed in 80% at the time of surgeryEstimates of OSA in hospitalized patients>50%National Hospital Discharge Survey5.8% received CPAP with a diagnosis of OSA (Spurr, 2008) 1 million

Svider, et al., AAO 2013

Cost of CPAP in the Hospital51Prospective cohort study tertiary academic medical center (JH); evaluate costs associated with hospital vs patient provided CPAPAll new pt admissions >18 prescribed CPAP as an in-patient (1/1-2/28, 2012)N=162; 1.2% of admissionsCost to provide CPAP to hospitalized patients vs use of home CPAP (avg nights of use 5.35.5)RVUs (110; 8--$2.68)Patient Provided=$0.00 (27.50 for the RT charge)Hospital provided 27.50/day; differential charge = 416.10 (daily rental fee and RT follow ups) for a patient who stayed more than 1 dayAvg stay 5.35.5Cost savings to the hospital and insured can be significant >1.1 million per year

Smith et al., 2014, doi.1002/lary.24604SummarySleep deprivation can be acute or chronicBoth have resulting physiological consequencesSleep in hospitalized patients is disturbed resulting in sleep deprivation. A large proportion of patients who enter the hospital have not been diagnosed with sleep apnea or have CPAP initiated or continued from homeIncreased awareness of sleep deprivation and sleep apnea can provide for improvement in interventions and early recognition of patients with a potential for adverse consequencesProgram implementation can have important financial considerations5253

Contact InformationRobyn.Woidtke@gmail.com, Office 510-728-0828.