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Sleep Quality in Adult Hospitalized Patients With Infection: An Observational Study
CLINICAL INVESTIGATION
Sleep Quality in Adult Hospitalized Patients With Infection: An Observational Study Farrin A. Manian, MD, MPH and Cyrus J. Manian, BA
Abstract: Background: Sleep deprivation may adversely affect host defenses against infection while infection may impact sleep. We studied sleep quality in hospitalized patients with infection-related diagnoses. Methods: This was an observational study in a 900-bed tertiary care community teaching hospital involving consecutive patients seen by an infectious disease consultant from June 26, 2008 to December 31, 2011. During routine part of their care, patients were enquired about their sleep quality, categorized into either “sound” or “unsound” sleep and the reason (s) for experiencing unsound sleep. Results: Of 1,238 unique patients (mean age, 59 years), 592 (47.8%) reported unsound sleep. Patients of 50 years or younger were more likely to report unsound sleep compared with those in the age groups of 50 to 79 years (57.1% versus 45.7%) and 80 years or older (57.1% versus 36.5%) (OR: 1.58 [95% CI: 1.23–2.0] and OR: 2.32 [95% CI: 1.59–3.38], respectively). Skin and soft tissue infections, central nervous system infections, osteomyelitis/diskitis and the head and neck infections were associated with $50% rates of unsound sleep. Staff disruptions, pain and anxiety were the most commonly cited reasons for unsound sleep (28.9%, 26.4% and 9.6%, respectively). Patients receiving sedating and/or hypnotic medications were no more likely to report sound sleep, compared with those not receiving such medications (50.7% versus 58.7%, respectively, OR: 0.71 [95% CI: 0.5–1.00]). Conclusions: Self-reported unsound sleep is common among hospitalized patients with an infection-related diagnosis, is associated with less advanced age and is often attributed to staff disruptions, pain and/or anxiety. Interventions at improving sleep quality in this patient population seem warranted. Key Indexing Terms: Sleep; Infection; Hospital; Pain; Staff disruption; Anxiety. [Am J Med Sci 2015;349(1):56–60.]
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he importance of quality sleep in hospitalized patients is increasingly recognized.1 Sleep deprivation is associated with numerous physiological and psychological disturbances, including worsening glucose tolerance, hypertension, decreased ventilator drive, increased sympathetic cardiovascular activation, anxiety, decreased cognitive performance and poor balance.1–5 Lack of adequate sleep may also cause immunological abnormalities and lead to increased susceptibility to infections.6–11 Conversely, infectious disease conditions may lead to increasing requirements for sleep.11 Interestingly, despite the commonly held belief that sleep is important to recovery from illness,10 relatively few studies have addressed sleep in hospitalized patients outside the intensive care unit (ICU) settings.12–15 Even less is known From the Department of Medicine (FAM), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and Department of Psychology (CJM), University of Missouri-Kansas City, Kansas City, Missouri. Submitted April 16, 2014; accepted in revised form August 15, 2014. The authors have no financial or other conflicts of interest to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University, it affiliate academic healthcare centers, its corporate contributors, or the University of Missouri-Kansas City. Correspondence: Farrin A. Manian, MD, MPH, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Suite 503B, Boston, MA 02114 (E-mail: [email protected]).
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about sleep quality in hospitalized patients with infection despite several infectious disease–related conditions (eg, pneumonia and skin and soft tissue infections [SSTI]) frequently being listed among the most common discharge diagnoses.16 We, herein, report our experience with adult patients who, as part of their care under an infectious disease consultation service, were routinely asked about the quality of their sleep and the reason(s) for their unsound sleep experience during their hospitalization.
METHODS This was a prospective observational study performed at Mercy Hospital, a 900-bed tertiary care community hospital, in St. Louis. From June 26, 2008 to December 31, 2011, all adult inpatients (18 years or older) seen in consultation by 1 of the authors (F.A.M.), an infectious disease physician, were routinely enquired about their sleep quality during the previous night as part of their initial encounter or, if not possible, during a subsequent hospital visit; exceptions included those with persistent cognitive impairment (eg, those with dementia). Patients from all adult hospital wards, including ICUs, were included. Patients were routinely asked “How did you sleep last night?” as part of their initial interview by the infectious disease consultant; enquiry was postponed to a later hospital date if the patient’s cognitive abilities did not allow for a reliable response at the time, or if the patient had not spent a full night in a hospital wardroom (eg, partial stay in the emergency room). Patient responses were categorized into either “Sound” or “Unsound” categories. Responses such as “great,” “good,” “no problem” or similar terms were classified as sound sleep. “Unsound” sleep encompassed both “Fair” and “Poor” categories. “Fair,” “so-so,” “on and off” or similar descriptions were classified as “Fair” sleep, whereas “Poor” sleep encompassed terms such as “terrible,” “bad,” “none,” “not much” or similar terms. Patients were also asked to provide the reason(s) for their unsound sleep. No patient was included in the study more than once. For each patient, age, race and gender were recorded. In addition, during a 14-month period from June 26, 2008 through August 30, 2009, ward location (ICU versus non-ICU), the number of days of hospitalization at the time of enquiry, the primary infection-related diagnosis at the time of consultation and the list of potentially sedating and/or hypnotic (S/H) medications administered between 8 PM and 12 AM on the night before enquiry were recorded in real time. Patient diagnosis was based on the providing physicians’ assessment. No attempt was made to distinguish surgical from medical patients. Abdominal infection diagnosis included diverticulitis, abscess and postoperative deep organ space infection. Bloodstream infections included those with primary (eg, vascular access–related) or secondary (ie, extravascular) sources. “Miscellaneous” category included diagnoses that were initially presumed but not necessarily proven to be infectious in origin (eg, fever of unclear source, encephalopathy and leukocytosis). S/H medications were grouped into 5 major categories: narcotics (eg, morphine, oxycodone, hydrocodone and fentanyl), benzodiazepines (eg, lorazepam, diazepam, temazepam and alprazolam), nonbenzodiazepine gamma butyric acid agonists
The American Journal of the Medical Sciences
Volume 349, Number 1, January 2015
Sleep in Hospitalized Patients
(eg, zolpidem), antihistamines (eg, diphenhydramine) and miscellaneous drugs (eg, quetiapine, tricyclic antidepressants, trazodone and melatonin). Patients were considered to have received these medications if 1 or more dose was administered independent of dosage between 8 PM and 12 AM during the night before the sleep query was made. Because enquiry into the quality of sleep should be a routine part of the care of hospitalized patients,12 patients were not made aware of the conduction of the study. The study protocol was approved by the Mercy Hospital Institutional Review Board with exemption for patient informed consent granted. The x2 with Yates’ correction and Fisher’s exact tests of significance were used for the comparison of categorical data. STATISTICA (StatSoft, Inc, Tulsa, OK) and InStat (GraphPad Software, Inc, San Diego, CA) software were used for data analysis, with P , 0.05 considered statistically significant.
RESULTS Of 1,357 potentially eligible patients, 119 (8.8%) were excluded because of persistent cognitive limitations. Of the remaining 1,238 cases, 626 (50.6%) were male, 612 (49.4%) were female, 1,117 (90.2%) were white, 108 (8.7%) were black and 13 (1.1%) belonged to other races. The mean age was 59 years (range, 18–100 years). Unsound sleep was reported by 592 (47.8%) patients, of which 183 (14.8%) and 409 (33.0%) responses were classified as either fair or poor sleep quality, respectively. Table 1 shows reported sleep quality by patient characteristics. There were no significant differences in sleep quality by race or gender. As a group, patients younger than 50 years had a significantly higher rate of unsound sleep compared with age groups of 50 to 79 years (57.1% versus 45.7%; OR: 1.58 [95% CI: 1.23–2.0]) and 80 years or older (57.1% versus 36.5%; OR: 2.32 [95% CI: 1.59–3.38]). Of 592 patients who reported unsound sleep, 447 (75.5%) provided 1 or more specific reasons for their unfavorable experience (Table 2). Staff disruptions, pain and anxiety were the most frequently cited reasons for unsound sleep (28.9%, 26.4%, and 9.6%, respectively); with noise cited by 6.7% of patients.
TABLE 1. Self-reported sleep quality in hospitalized patients by patient characteristics Sound Unsound Patient (N 5 1,238), (N 5 1,238), characteristic n (%) n (%) Total P Race White Non-white Gender Male Female Age, yr ,50 50–79 $80
582 (52.1) 64 (52.9)
535 (47.9) 57 (47.1)
1,117 121
0.87
330 (52.7) 316 (51.6)
296 (47.3) 296 (48.4)
626 612
0.70
157 (42.9) 381 (54.3) 108 (63.5)
209 (57.1) 321 (45.7) 62 (36.5)
366 702 0.0005a 170 ,0.0001b
a vs. age group less than 50 years, OR: 1.58 (95% CI: 1.23–2.0), P 5 0.0005. b vs. age group less than 50 years, OR: 2.32 (95% CI: 1.59–3.38), P , 0.0001.
TABLE 2. Reasons cited for unsound sleep by hospitalized patients Reason N 5 447, n (%)a Staff disruptions Pain Anxiety Noise Fever Roommate IV access Frequent urination Diarrhea Poor sleep at home Uncomfortable bed Sleep during daytime Dyspnea Cough Hospital Itching No sleeping pill Heartburn Room cold Chills Room hot Sweating Constipation Sinus drainage Corticosteroids Nocturnal profession Watch television I want my own bed Baby in the room Miscellaneousb
129 118 43 30 20 19 10 9 9 9 6 6 5 4 4 3 3 3 3 3 2 2 2 2 2 2 2 2 2 19
(28.9) (26.4) (9.6) (6.7) (4.5) (4.3) (2.2) (2.0) (2.0) (2.0) (1.3) (1.3) (1.1) (0.9) (0.9) (0.7) (0.7) (0.7) (0.7) (0.7) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (4.3)
a
26 patients cited more than 1 reason. Reasons cited only once: bi-pap machine, nosebleed, burping, hiccoughs, compression stockings, thirsty, pillow, pillow between legs, hyperactive due to propoxyphene, staples, visitors, spasms, lack of activity, nightmares, 10 cups of coffee, sore throat, chest tightness, surgery and throat clearing. b
Table 3 shows the 3 most commonly cited reasons for unsound sleep by age group, gender and race. The age group of less than 50 years was significantly more likely to cite pain as a reason for unsound sleep compared with age groups of 50 to 79 years (36.0% versus 22.1%; OR: 2.0 [95% CI: 1.3–3.1]) and 80 years or older (36.0% versus 14.3%; OR: 3.4 [95% CI: 1.3– 8.5]). Male patients were significantly more likely to cite staff disruptions than female patients (34.4% versus 23.6%; OR: 1.7 [95% CI: 1.1–2.6]), whereas female patients were significantly more likely than male patients to cite anxiety as a cause of unsound sleep (12.7% versus 6.4%; OR: 2.2 [95% CI: 1.1– 4.3]). No other significant associations between selected patient characteristics and cited reasons for unsound sleep were found. Of a total of 638 eligible patients seen during the 14month period from June 26, 2008 through August 30, 2009, duration of hospitalization at the time of the sleep query, the time of S/H medication administration, primary infectious disease–related diagnosis and ward location could not be determined and/or were inadvertently not recorded in 65, 68, 57 and 28 cases, respectively. The duration of hospitalization at the
Copyright © 2014 by the Southern Society for Clinical Investigation. Unauthorized reproduction of this article is prohibited.
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TABLE 3. Common reasons for unsound sleep by age group, gender and race Reason Patient characteristic N 5 447 Age, yr ,50 50–79 $80 Gender Male Female Race White Non-white
Staff interruption (%)
Pain (%)
Anxiety (%)
161 244 42
45 (28.0) 69 (28.3) 15 (35.7)
58 (36.0)a 12 (7.4) 54 (22.1) 24 (9.8) 6 (14.3) 7 (16.7)
218 229
75 (34.4)b 54 (23.6)
59 (27.1) 59 (25.8)
404 43
121 (30.0) 8 (18.6)
101 (25.0) 17 (39.5)
14 (6.4) 29 (12.7)c 40 (9.9) 3 (7.0)
TABLE 4. Self-reported sleep quality by primary infectious disease–related diagnosis Total Sound Unsound Diagnosis N 5 581 (%)a sleep (%)b sleep (%)b SSTI RTI UTI Abdominal infection BSI Osteomyelitis/diskitis CDI Septic arthritis CNS infection Head/neck infection Miscellaneousd
196 60 53 53 51 28 16 12 10 9 93
(33.7) (10.3) (9.1) (9.1) (8.8) (4.8) (2.8) (2.1) (1.7) (1.5) (16.0)
91 32 32 33 29 14 9 7 5 3 42
(46.4) (53.3) (60.4) (62.3) (56.9) (50) (56.3) (58.3) (50.0) (33.3) (45.2)
105 28 21 20 22 14 7 5 5 6 51
(53.6)c (46.7) (39.6) (37.7)c (43.1) (50) (43.7) (41.7) (50.0) (66.7) (54.8)
Percentage of total number of patients (N 5 581). Row percentage. c SSTI vs. abdominal infection, OR: 1.9 (95% CI: 1.02–3.5), P 5 0.045; no other significant differences in the rates of unsound sleep among various diagnoses. d Includes cases presumed but not necessarily documented to be related to an infection, for example, fever of unclear source (48 cases), and ,1% each of tick-borne infections, viral syndromes, HIV infection, lymphadenopathy, sepsis syndrome, encephalopathy and leukocytosis. SSTI, skin and soft tissue infections; RTI, respiratory tract infection; UTI, urinary tract infection; BSI, bloodstream infection; CDI, Clostridium difficile infection. a b
a
Age group less than 50 years vs. 50 to 79 years, OR: 2.0 (95% CI: 1.3–3.1), P 5 0.003; vs. age group of 80 years or older, OR: 3.4 (95% CI: 1.3–8.5), P , 0.001. b Male vs. female, OR: 1.7 (95% CI: 1.1–2.6), P 5 0.01. c Female vs. male, OR: 2.2 (95% CI: 1.1–4.3), P 5 0.03.
time of the sleep query ranged from 1 day to 81 days with a mean of 5.5 days (median, 3.0 days). Comparison of the frequency of unsound sleep by hospital days revealed the highest rate among patients hospitalized for 1 day (58.9%, 96 of 163 patients) with lower rates found among those hospitalized for 2 days (44.0%, 48 of 109 patients), or 3 or more days (42.5%, 128 of 301 patients) (df 5 2, P 5 0.002). Of 610 evaluable patients, 546 (89.5%) were in general wards and 64 (10.5%) were in the ICUs at the time of the sleep query. There was no significant difference between the rates of unsound sleep in ICU and non-ICU patients: 31 (48.4%) of 64 cases versus 260 (47.6%) of 546 cases, respectively (P 5 0.9). There were also no significant differences in the rates of staff disruptions, pain, anxiety and noise between the 2 groups (data not shown). Table 4 shows the distribution of various infectious disease–related diagnoses in the study patients. SSTI was the most common diagnosis (33.7%), followed by respiratory tract infection (10.3%), urinary tract infection (9.1%), abdominal infection (9.1%) and bloodstream infections (8.8%). SSTI, osteomyelitis/diskitis, infection, central nervous system infection and the head and neck infection were associated with $50% rates of unsound sleep. Patients with SSTI were significantly more likely to report unsound sleep compared with those with abdominal infection (53.6% versus 37.7%, respectively; OR: 1.9 [95% CI: 1.02–3.5]). There were no other significant differences in the rates of unsound sleep among patients with various diagnoses. Of 540 evaluable patients, 303 (56.1%) received 1 or more classes of S/H medications: narcotics: 229 (42.4%), nonbenzodiazepine gamma butyric acid agonists: 46 (8.5%), benzodiazepines: 30 (5.6%), antihistamines: 13 (2.4%) and miscellaneous S/H drugs: 31 (5.7%) patients. There was a significant association between age group and use of S/H medications: aged younger than 50 years, 108 (68.4%); age 50 to 79 years, 173 (56.0%) and age 80 years or older, 22 (30.1%), (df 5 2, P , 0.0001). There was no significant association between sleep quality and use of individual medication classes when compared with either no drug in the respective category
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or no S/H drugs at all (Table 5). Overall, there was no significant association between the use of S/H medications and sound sleep (OR: 0.71 [95% CI: 0.50–1.00], P 5 0.06). Comparison of the top 5 infectious disease–related conditions revealed that patients with SSTI were more likely to cite pain as a cause of unsound sleep compared with those with UTI (34.5% versus 6.7%; OR: 7.5 [95% CI: 0.94–59.6]); there were no other significant associations between condition and reason for unsound sleep (data not shown).
DISCUSSION To the best of our knowledge, this is the largest study to date of self-reported sleep quality in adult hospitalized and the only one devoted to patients with an infection-related diagnosis. Although the use of a variety of often lengthy patient questionnaires has been proposed in the evaluation of sleep,17 they are impractical for everyday application in hospitalized patients. Similar to ours, others have used a more subjective approach by asking patients to rate their overall sleep.15 Although perceived quality of sleep may not necessarily correlate with its stages or objective sleep assessment,18,19 it may reflect other important aspects of sleep such as continuity, number of awakenings and time awake and may impact patient satisfaction with overall care in the hospital. Indeed, the Centers for Medicare and Medicaid Services HCAHPS (Hospital Consumer Assessment of Healthcare Provider Systems) postdischarge patient survey specifically enquires about perception of nighttime noise.20 Overall, we found that nearly one-half of our patients failed to report sound sleep, similar to the previously reported 43% to 47% rates of sleep difficulties in patients on general hospital wards.13,21 For several infectious disease–related conditions, the majority of patients reported unsound sleep, despite Volume 349, Number 1, January 2015
Sleep in Hospitalized Patients
TABLE 5. Use of sedating/hypnotic (S/H) self-reported sleep quality in hospitalized Medication Total Sound category N 5 540 sleep (%) Narcotics No narcotics Narcotics alone No S/H drugs Benzodiazepines No benzodiazepines Benzodiazepines alone No S/H drugs NB-GABAa agonists No NB-GABA agonists NB-GABA agonists alone No S/H drugs Anti-histamines No anti-histamines Anti-histamines alone Any S/H drug No S/H drugs a b
(49.8) (56.9) (49.7) (58.3) (50.0) (54.1) (52.4)
medications and patients Unsound sleep (%) P
229 311 189 235 30 510 21
114 177 94 137 15 276 11
235 46 494
137 (58.3) 21 (45.7) 270 (54.7)
98 (41.7) 25 (54.3) 224 (45.3)
0.28
29
12 (41.4)
17 (58.6)
0.11
235 13 527 3
137 7 284 1
(58.3) (53.8) (53.9) (33.3)
303 237
152 (50.7) 139 (58.7)
115 134 95 98 15 234 10
98 6 243 2
(50.2) (43.1) (50.3) (41.7) (50.0) (45.9) (47.6)
(41.7) (46.2) (46.1) (66.7)
151 (49.8) 98 (41.3)
0.1 0.1 0.71 0.65
1.0 0.57 0.06b
Nonbenzodiazepine gamma butyric acid. OR: 0.71 (95% CI: 0.50–1.00).
the potent somnogenic properties of many cytokines released during infectious processes.22 One possible explanation is that although sleep may be one of the body’s responses to infection, more severe infections may have the opposite effect.11 In addition, sleep alterations may be dependent on the stage of infection (not examined in our study), with early phase of infection associated with an increase and the later phase associated with a decrease in slow-wave sleep.22 It is likely that many of our patients were seen in consultation during the severe or later stage of their infection. We found that unsound sleep was least likely to be reported by patients 80 years of age or older despite the general notion that older patients have more difficulty with sleep.23 Of interest, a recent population-based U.S. survey reported improvement in sleep quality over lifetime with the fewest complaints among people in their 80s.23 Whether our findings are reflective of higher threshold for reporting physical complaints among older persons23 or other factors is unclear. We found no significant differences in self-reported sleep quality by gender despite the fact that women are generally considered to have a higher rate of insomnia than men in the general population.24,25 Staff disruptions, pain and anxiety were the most commonly cited reasons for unsound sleep; noise did not seem to be a major factor, consistent with a recent report.2 Staff disruption was the most commonly cited reason (nearly 30%), consistent with previous reports,1,2 with male patients more likely to report staff disruptions as a cause of unsound sleep. Of interest, lower resilience and weaker homeostatic response to sleep disturbing effects of blood drawing have been reported among men,26 and in laboratory studies, male mice seem to be more sensitive to disturbances by certain environmental stressors and more prone to initial loss of sleep.27
Pain was cited as the second most common factor in unsound sleep (over 25%) in our patient population with higher frequency found among the age group less than 50 years. Of interest, higher likelihood of reporting significant pain among hospitalized patients 65 years of age or younger has been reported on general medical wards.28 Because pain may not be adequately treated among hospitalized patients,29 better pain control might have improved sleep quality in some of our patients. We found no significant association between the use of S/H medications and sound sleep, possibly related to patient-related factors, use of inappropriate medications or dosages, or sleep deprivation itself increasing sensitivity to pain.30 Anxiety, the third most common (nearly 10%) reason cited for unsound sleep in our patients, was more likely to be reported by women, possibly a reflection of the higher prevalence of this disorder among females in the general population.25 Anxiety is also not uncommon among other hospitalized patients including the elderly31 and those following myocardial infarction.32 We cannot exclude the possibility of “infection anxiety” (eg, “flesh-eating bacteria”) among some of our patients given the power of media coverage.33 Unsound sleep was particularly common during the first full night of hospitalization, consistent with previous reports of improved sleep later in the course of hospitalization.2,14 We also found no significant difference in the rates of unsound sleep between ICU and non-ICU patients. Several limitations of our study are noteworthy. First, it was conducted in a single center involving only patients on an infectious disease service, potentially limiting the generalizability of the results. Second, sleep quality was based on the subjective assessment by patients in their own words, a methodology that may need validation by more objective means. Finally, 1 night’s sleep experience does not necessarily reflect the overall hospital sleep experience. The strengths of our study lie in its conduction under “real” conditions during the course of routine patient care minimizing the inherent risk of influencing patient responses often observed when formal surveys are performed; for example, after patient discharge,34 or through use of questionnaires in face-to-face or telephone interviews, or self-administered through postal or electronic means.35 In addition, our approach to data gathering during the course of patient care allowed us to maximize our response rate to essentially 100% of eligible patients, rates that have been difficult to achieve with other survey techniques.35
CONCLUSIONS Self-reported unsound sleep is common among hospitalized patients with infection-related diagnoses. Given the potential deleterious impact of suboptimal sleep quality on susceptibility to and recovery from infectious conditions, interventions at improving sleep quality in this patient population seem warranted. REFERENCES 1. Young JS, Bourgeois JA, Hilty DM, et al. Sleep in hospitalized medical patients, part I: factors affecting sleep. J Hosp Med 2008;3:473–82. 2. Bartick MG, Thai X, Schmidt T, et al. Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. J Hosp Med 2010;5:E20–4. 3. Kahn-Greene ET, Killgrove DB, Kamimori GH, et al. The effects of sleep deprivation on symptoms of psychopathology in healthy adults. Sleep Med 2007;8:215–21.
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4. Irwin MR, Wang M, Campomayor CO, et al. Sleep deprivation and activation of morning levels of cellular and genomic markers of inflammation. Arch Intern Med 2006;166:1756–62.
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Volume 349, Number 1, January 2015
Sleep Quality in Adult Hospitalized Patients With Infection: An Observational Study Farrin A. Manian, MD, MPH and Cyrus J. Manian, BA
Abstract: Background: Sleep deprivation may adversely affect host defenses against infection while infection may impact sleep. We studied sleep quality in hospitalized patients with infection-related diagnoses. Methods: This was an observational study in a 900-bed tertiary care community teaching hospital involving consecutive patients seen by an infectious disease consultant from June 26, 2008 to December 31, 2011. During routine part of their care, patients were enquired about their sleep quality, categorized into either “sound” or “unsound” sleep and the reason (s) for experiencing unsound sleep. Results: Of 1,238 unique patients (mean age, 59 years), 592 (47.8%) reported unsound sleep. Patients of 50 years or younger were more likely to report unsound sleep compared with those in the age groups of 50 to 79 years (57.1% versus 45.7%) and 80 years or older (57.1% versus 36.5%) (OR: 1.58 [95% CI: 1.23–2.0] and OR: 2.32 [95% CI: 1.59–3.38], respectively). Skin and soft tissue infections, central nervous system infections, osteomyelitis/diskitis and the head and neck infections were associated with $50% rates of unsound sleep. Staff disruptions, pain and anxiety were the most commonly cited reasons for unsound sleep (28.9%, 26.4% and 9.6%, respectively). Patients receiving sedating and/or hypnotic medications were no more likely to report sound sleep, compared with those not receiving such medications (50.7% versus 58.7%, respectively, OR: 0.71 [95% CI: 0.5–1.00]). Conclusions: Self-reported unsound sleep is common among hospitalized patients with an infection-related diagnosis, is associated with less advanced age and is often attributed to staff disruptions, pain and/or anxiety. Interventions at improving sleep quality in this patient population seem warranted. Key Indexing Terms: Sleep; Infection; Hospital; Pain; Staff disruption; Anxiety. [Am J Med Sci 2015;349(1):56–60.]
T
he importance of quality sleep in hospitalized patients is increasingly recognized.1 Sleep deprivation is associated with numerous physiological and psychological disturbances, including worsening glucose tolerance, hypertension, decreased ventilator drive, increased sympathetic cardiovascular activation, anxiety, decreased cognitive performance and poor balance.1–5 Lack of adequate sleep may also cause immunological abnormalities and lead to increased susceptibility to infections.6–11 Conversely, infectious disease conditions may lead to increasing requirements for sleep.11 Interestingly, despite the commonly held belief that sleep is important to recovery from illness,10 relatively few studies have addressed sleep in hospitalized patients outside the intensive care unit (ICU) settings.12–15 Even less is known From the Department of Medicine (FAM), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and Department of Psychology (CJM), University of Missouri-Kansas City, Kansas City, Missouri. Submitted April 16, 2014; accepted in revised form August 15, 2014. The authors have no financial or other conflicts of interest to disclose. The content is solely the responsibility of the authors and does not necessarily represent the official views of Harvard Catalyst, Harvard University, it affiliate academic healthcare centers, its corporate contributors, or the University of Missouri-Kansas City. Correspondence: Farrin A. Manian, MD, MPH, Department of Medicine, Massachusetts General Hospital, 50 Staniford Street, Suite 503B, Boston, MA 02114 (E-mail: [email protected]).
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about sleep quality in hospitalized patients with infection despite several infectious disease–related conditions (eg, pneumonia and skin and soft tissue infections [SSTI]) frequently being listed among the most common discharge diagnoses.16 We, herein, report our experience with adult patients who, as part of their care under an infectious disease consultation service, were routinely asked about the quality of their sleep and the reason(s) for their unsound sleep experience during their hospitalization.
METHODS This was a prospective observational study performed at Mercy Hospital, a 900-bed tertiary care community hospital, in St. Louis. From June 26, 2008 to December 31, 2011, all adult inpatients (18 years or older) seen in consultation by 1 of the authors (F.A.M.), an infectious disease physician, were routinely enquired about their sleep quality during the previous night as part of their initial encounter or, if not possible, during a subsequent hospital visit; exceptions included those with persistent cognitive impairment (eg, those with dementia). Patients from all adult hospital wards, including ICUs, were included. Patients were routinely asked “How did you sleep last night?” as part of their initial interview by the infectious disease consultant; enquiry was postponed to a later hospital date if the patient’s cognitive abilities did not allow for a reliable response at the time, or if the patient had not spent a full night in a hospital wardroom (eg, partial stay in the emergency room). Patient responses were categorized into either “Sound” or “Unsound” categories. Responses such as “great,” “good,” “no problem” or similar terms were classified as sound sleep. “Unsound” sleep encompassed both “Fair” and “Poor” categories. “Fair,” “so-so,” “on and off” or similar descriptions were classified as “Fair” sleep, whereas “Poor” sleep encompassed terms such as “terrible,” “bad,” “none,” “not much” or similar terms. Patients were also asked to provide the reason(s) for their unsound sleep. No patient was included in the study more than once. For each patient, age, race and gender were recorded. In addition, during a 14-month period from June 26, 2008 through August 30, 2009, ward location (ICU versus non-ICU), the number of days of hospitalization at the time of enquiry, the primary infection-related diagnosis at the time of consultation and the list of potentially sedating and/or hypnotic (S/H) medications administered between 8 PM and 12 AM on the night before enquiry were recorded in real time. Patient diagnosis was based on the providing physicians’ assessment. No attempt was made to distinguish surgical from medical patients. Abdominal infection diagnosis included diverticulitis, abscess and postoperative deep organ space infection. Bloodstream infections included those with primary (eg, vascular access–related) or secondary (ie, extravascular) sources. “Miscellaneous” category included diagnoses that were initially presumed but not necessarily proven to be infectious in origin (eg, fever of unclear source, encephalopathy and leukocytosis). S/H medications were grouped into 5 major categories: narcotics (eg, morphine, oxycodone, hydrocodone and fentanyl), benzodiazepines (eg, lorazepam, diazepam, temazepam and alprazolam), nonbenzodiazepine gamma butyric acid agonists
The American Journal of the Medical Sciences
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Sleep in Hospitalized Patients
(eg, zolpidem), antihistamines (eg, diphenhydramine) and miscellaneous drugs (eg, quetiapine, tricyclic antidepressants, trazodone and melatonin). Patients were considered to have received these medications if 1 or more dose was administered independent of dosage between 8 PM and 12 AM during the night before the sleep query was made. Because enquiry into the quality of sleep should be a routine part of the care of hospitalized patients,12 patients were not made aware of the conduction of the study. The study protocol was approved by the Mercy Hospital Institutional Review Board with exemption for patient informed consent granted. The x2 with Yates’ correction and Fisher’s exact tests of significance were used for the comparison of categorical data. STATISTICA (StatSoft, Inc, Tulsa, OK) and InStat (GraphPad Software, Inc, San Diego, CA) software were used for data analysis, with P , 0.05 considered statistically significant.
RESULTS Of 1,357 potentially eligible patients, 119 (8.8%) were excluded because of persistent cognitive limitations. Of the remaining 1,238 cases, 626 (50.6%) were male, 612 (49.4%) were female, 1,117 (90.2%) were white, 108 (8.7%) were black and 13 (1.1%) belonged to other races. The mean age was 59 years (range, 18–100 years). Unsound sleep was reported by 592 (47.8%) patients, of which 183 (14.8%) and 409 (33.0%) responses were classified as either fair or poor sleep quality, respectively. Table 1 shows reported sleep quality by patient characteristics. There were no significant differences in sleep quality by race or gender. As a group, patients younger than 50 years had a significantly higher rate of unsound sleep compared with age groups of 50 to 79 years (57.1% versus 45.7%; OR: 1.58 [95% CI: 1.23–2.0]) and 80 years or older (57.1% versus 36.5%; OR: 2.32 [95% CI: 1.59–3.38]). Of 592 patients who reported unsound sleep, 447 (75.5%) provided 1 or more specific reasons for their unfavorable experience (Table 2). Staff disruptions, pain and anxiety were the most frequently cited reasons for unsound sleep (28.9%, 26.4%, and 9.6%, respectively); with noise cited by 6.7% of patients.
TABLE 1. Self-reported sleep quality in hospitalized patients by patient characteristics Sound Unsound Patient (N 5 1,238), (N 5 1,238), characteristic n (%) n (%) Total P Race White Non-white Gender Male Female Age, yr ,50 50–79 $80
582 (52.1) 64 (52.9)
535 (47.9) 57 (47.1)
1,117 121
0.87
330 (52.7) 316 (51.6)
296 (47.3) 296 (48.4)
626 612
0.70
157 (42.9) 381 (54.3) 108 (63.5)
209 (57.1) 321 (45.7) 62 (36.5)
366 702 0.0005a 170 ,0.0001b
a vs. age group less than 50 years, OR: 1.58 (95% CI: 1.23–2.0), P 5 0.0005. b vs. age group less than 50 years, OR: 2.32 (95% CI: 1.59–3.38), P , 0.0001.
TABLE 2. Reasons cited for unsound sleep by hospitalized patients Reason N 5 447, n (%)a Staff disruptions Pain Anxiety Noise Fever Roommate IV access Frequent urination Diarrhea Poor sleep at home Uncomfortable bed Sleep during daytime Dyspnea Cough Hospital Itching No sleeping pill Heartburn Room cold Chills Room hot Sweating Constipation Sinus drainage Corticosteroids Nocturnal profession Watch television I want my own bed Baby in the room Miscellaneousb
129 118 43 30 20 19 10 9 9 9 6 6 5 4 4 3 3 3 3 3 2 2 2 2 2 2 2 2 2 19
(28.9) (26.4) (9.6) (6.7) (4.5) (4.3) (2.2) (2.0) (2.0) (2.0) (1.3) (1.3) (1.1) (0.9) (0.9) (0.7) (0.7) (0.7) (0.7) (0.7) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (0.4) (4.3)
a
26 patients cited more than 1 reason. Reasons cited only once: bi-pap machine, nosebleed, burping, hiccoughs, compression stockings, thirsty, pillow, pillow between legs, hyperactive due to propoxyphene, staples, visitors, spasms, lack of activity, nightmares, 10 cups of coffee, sore throat, chest tightness, surgery and throat clearing. b
Table 3 shows the 3 most commonly cited reasons for unsound sleep by age group, gender and race. The age group of less than 50 years was significantly more likely to cite pain as a reason for unsound sleep compared with age groups of 50 to 79 years (36.0% versus 22.1%; OR: 2.0 [95% CI: 1.3–3.1]) and 80 years or older (36.0% versus 14.3%; OR: 3.4 [95% CI: 1.3– 8.5]). Male patients were significantly more likely to cite staff disruptions than female patients (34.4% versus 23.6%; OR: 1.7 [95% CI: 1.1–2.6]), whereas female patients were significantly more likely than male patients to cite anxiety as a cause of unsound sleep (12.7% versus 6.4%; OR: 2.2 [95% CI: 1.1– 4.3]). No other significant associations between selected patient characteristics and cited reasons for unsound sleep were found. Of a total of 638 eligible patients seen during the 14month period from June 26, 2008 through August 30, 2009, duration of hospitalization at the time of the sleep query, the time of S/H medication administration, primary infectious disease–related diagnosis and ward location could not be determined and/or were inadvertently not recorded in 65, 68, 57 and 28 cases, respectively. The duration of hospitalization at the
Copyright © 2014 by the Southern Society for Clinical Investigation. Unauthorized reproduction of this article is prohibited.
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TABLE 3. Common reasons for unsound sleep by age group, gender and race Reason Patient characteristic N 5 447 Age, yr ,50 50–79 $80 Gender Male Female Race White Non-white
Staff interruption (%)
Pain (%)
Anxiety (%)
161 244 42
45 (28.0) 69 (28.3) 15 (35.7)
58 (36.0)a 12 (7.4) 54 (22.1) 24 (9.8) 6 (14.3) 7 (16.7)
218 229
75 (34.4)b 54 (23.6)
59 (27.1) 59 (25.8)
404 43
121 (30.0) 8 (18.6)
101 (25.0) 17 (39.5)
14 (6.4) 29 (12.7)c 40 (9.9) 3 (7.0)
TABLE 4. Self-reported sleep quality by primary infectious disease–related diagnosis Total Sound Unsound Diagnosis N 5 581 (%)a sleep (%)b sleep (%)b SSTI RTI UTI Abdominal infection BSI Osteomyelitis/diskitis CDI Septic arthritis CNS infection Head/neck infection Miscellaneousd
196 60 53 53 51 28 16 12 10 9 93
(33.7) (10.3) (9.1) (9.1) (8.8) (4.8) (2.8) (2.1) (1.7) (1.5) (16.0)
91 32 32 33 29 14 9 7 5 3 42
(46.4) (53.3) (60.4) (62.3) (56.9) (50) (56.3) (58.3) (50.0) (33.3) (45.2)
105 28 21 20 22 14 7 5 5 6 51
(53.6)c (46.7) (39.6) (37.7)c (43.1) (50) (43.7) (41.7) (50.0) (66.7) (54.8)
Percentage of total number of patients (N 5 581). Row percentage. c SSTI vs. abdominal infection, OR: 1.9 (95% CI: 1.02–3.5), P 5 0.045; no other significant differences in the rates of unsound sleep among various diagnoses. d Includes cases presumed but not necessarily documented to be related to an infection, for example, fever of unclear source (48 cases), and ,1% each of tick-borne infections, viral syndromes, HIV infection, lymphadenopathy, sepsis syndrome, encephalopathy and leukocytosis. SSTI, skin and soft tissue infections; RTI, respiratory tract infection; UTI, urinary tract infection; BSI, bloodstream infection; CDI, Clostridium difficile infection. a b
a
Age group less than 50 years vs. 50 to 79 years, OR: 2.0 (95% CI: 1.3–3.1), P 5 0.003; vs. age group of 80 years or older, OR: 3.4 (95% CI: 1.3–8.5), P , 0.001. b Male vs. female, OR: 1.7 (95% CI: 1.1–2.6), P 5 0.01. c Female vs. male, OR: 2.2 (95% CI: 1.1–4.3), P 5 0.03.
time of the sleep query ranged from 1 day to 81 days with a mean of 5.5 days (median, 3.0 days). Comparison of the frequency of unsound sleep by hospital days revealed the highest rate among patients hospitalized for 1 day (58.9%, 96 of 163 patients) with lower rates found among those hospitalized for 2 days (44.0%, 48 of 109 patients), or 3 or more days (42.5%, 128 of 301 patients) (df 5 2, P 5 0.002). Of 610 evaluable patients, 546 (89.5%) were in general wards and 64 (10.5%) were in the ICUs at the time of the sleep query. There was no significant difference between the rates of unsound sleep in ICU and non-ICU patients: 31 (48.4%) of 64 cases versus 260 (47.6%) of 546 cases, respectively (P 5 0.9). There were also no significant differences in the rates of staff disruptions, pain, anxiety and noise between the 2 groups (data not shown). Table 4 shows the distribution of various infectious disease–related diagnoses in the study patients. SSTI was the most common diagnosis (33.7%), followed by respiratory tract infection (10.3%), urinary tract infection (9.1%), abdominal infection (9.1%) and bloodstream infections (8.8%). SSTI, osteomyelitis/diskitis, infection, central nervous system infection and the head and neck infection were associated with $50% rates of unsound sleep. Patients with SSTI were significantly more likely to report unsound sleep compared with those with abdominal infection (53.6% versus 37.7%, respectively; OR: 1.9 [95% CI: 1.02–3.5]). There were no other significant differences in the rates of unsound sleep among patients with various diagnoses. Of 540 evaluable patients, 303 (56.1%) received 1 or more classes of S/H medications: narcotics: 229 (42.4%), nonbenzodiazepine gamma butyric acid agonists: 46 (8.5%), benzodiazepines: 30 (5.6%), antihistamines: 13 (2.4%) and miscellaneous S/H drugs: 31 (5.7%) patients. There was a significant association between age group and use of S/H medications: aged younger than 50 years, 108 (68.4%); age 50 to 79 years, 173 (56.0%) and age 80 years or older, 22 (30.1%), (df 5 2, P , 0.0001). There was no significant association between sleep quality and use of individual medication classes when compared with either no drug in the respective category
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or no S/H drugs at all (Table 5). Overall, there was no significant association between the use of S/H medications and sound sleep (OR: 0.71 [95% CI: 0.50–1.00], P 5 0.06). Comparison of the top 5 infectious disease–related conditions revealed that patients with SSTI were more likely to cite pain as a cause of unsound sleep compared with those with UTI (34.5% versus 6.7%; OR: 7.5 [95% CI: 0.94–59.6]); there were no other significant associations between condition and reason for unsound sleep (data not shown).
DISCUSSION To the best of our knowledge, this is the largest study to date of self-reported sleep quality in adult hospitalized and the only one devoted to patients with an infection-related diagnosis. Although the use of a variety of often lengthy patient questionnaires has been proposed in the evaluation of sleep,17 they are impractical for everyday application in hospitalized patients. Similar to ours, others have used a more subjective approach by asking patients to rate their overall sleep.15 Although perceived quality of sleep may not necessarily correlate with its stages or objective sleep assessment,18,19 it may reflect other important aspects of sleep such as continuity, number of awakenings and time awake and may impact patient satisfaction with overall care in the hospital. Indeed, the Centers for Medicare and Medicaid Services HCAHPS (Hospital Consumer Assessment of Healthcare Provider Systems) postdischarge patient survey specifically enquires about perception of nighttime noise.20 Overall, we found that nearly one-half of our patients failed to report sound sleep, similar to the previously reported 43% to 47% rates of sleep difficulties in patients on general hospital wards.13,21 For several infectious disease–related conditions, the majority of patients reported unsound sleep, despite Volume 349, Number 1, January 2015
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TABLE 5. Use of sedating/hypnotic (S/H) self-reported sleep quality in hospitalized Medication Total Sound category N 5 540 sleep (%) Narcotics No narcotics Narcotics alone No S/H drugs Benzodiazepines No benzodiazepines Benzodiazepines alone No S/H drugs NB-GABAa agonists No NB-GABA agonists NB-GABA agonists alone No S/H drugs Anti-histamines No anti-histamines Anti-histamines alone Any S/H drug No S/H drugs a b
(49.8) (56.9) (49.7) (58.3) (50.0) (54.1) (52.4)
medications and patients Unsound sleep (%) P
229 311 189 235 30 510 21
114 177 94 137 15 276 11
235 46 494
137 (58.3) 21 (45.7) 270 (54.7)
98 (41.7) 25 (54.3) 224 (45.3)
0.28
29
12 (41.4)
17 (58.6)
0.11
235 13 527 3
137 7 284 1
(58.3) (53.8) (53.9) (33.3)
303 237
152 (50.7) 139 (58.7)
115 134 95 98 15 234 10
98 6 243 2
(50.2) (43.1) (50.3) (41.7) (50.0) (45.9) (47.6)
(41.7) (46.2) (46.1) (66.7)
151 (49.8) 98 (41.3)
0.1 0.1 0.71 0.65
1.0 0.57 0.06b
Nonbenzodiazepine gamma butyric acid. OR: 0.71 (95% CI: 0.50–1.00).
the potent somnogenic properties of many cytokines released during infectious processes.22 One possible explanation is that although sleep may be one of the body’s responses to infection, more severe infections may have the opposite effect.11 In addition, sleep alterations may be dependent on the stage of infection (not examined in our study), with early phase of infection associated with an increase and the later phase associated with a decrease in slow-wave sleep.22 It is likely that many of our patients were seen in consultation during the severe or later stage of their infection. We found that unsound sleep was least likely to be reported by patients 80 years of age or older despite the general notion that older patients have more difficulty with sleep.23 Of interest, a recent population-based U.S. survey reported improvement in sleep quality over lifetime with the fewest complaints among people in their 80s.23 Whether our findings are reflective of higher threshold for reporting physical complaints among older persons23 or other factors is unclear. We found no significant differences in self-reported sleep quality by gender despite the fact that women are generally considered to have a higher rate of insomnia than men in the general population.24,25 Staff disruptions, pain and anxiety were the most commonly cited reasons for unsound sleep; noise did not seem to be a major factor, consistent with a recent report.2 Staff disruption was the most commonly cited reason (nearly 30%), consistent with previous reports,1,2 with male patients more likely to report staff disruptions as a cause of unsound sleep. Of interest, lower resilience and weaker homeostatic response to sleep disturbing effects of blood drawing have been reported among men,26 and in laboratory studies, male mice seem to be more sensitive to disturbances by certain environmental stressors and more prone to initial loss of sleep.27
Pain was cited as the second most common factor in unsound sleep (over 25%) in our patient population with higher frequency found among the age group less than 50 years. Of interest, higher likelihood of reporting significant pain among hospitalized patients 65 years of age or younger has been reported on general medical wards.28 Because pain may not be adequately treated among hospitalized patients,29 better pain control might have improved sleep quality in some of our patients. We found no significant association between the use of S/H medications and sound sleep, possibly related to patient-related factors, use of inappropriate medications or dosages, or sleep deprivation itself increasing sensitivity to pain.30 Anxiety, the third most common (nearly 10%) reason cited for unsound sleep in our patients, was more likely to be reported by women, possibly a reflection of the higher prevalence of this disorder among females in the general population.25 Anxiety is also not uncommon among other hospitalized patients including the elderly31 and those following myocardial infarction.32 We cannot exclude the possibility of “infection anxiety” (eg, “flesh-eating bacteria”) among some of our patients given the power of media coverage.33 Unsound sleep was particularly common during the first full night of hospitalization, consistent with previous reports of improved sleep later in the course of hospitalization.2,14 We also found no significant difference in the rates of unsound sleep between ICU and non-ICU patients. Several limitations of our study are noteworthy. First, it was conducted in a single center involving only patients on an infectious disease service, potentially limiting the generalizability of the results. Second, sleep quality was based on the subjective assessment by patients in their own words, a methodology that may need validation by more objective means. Finally, 1 night’s sleep experience does not necessarily reflect the overall hospital sleep experience. The strengths of our study lie in its conduction under “real” conditions during the course of routine patient care minimizing the inherent risk of influencing patient responses often observed when formal surveys are performed; for example, after patient discharge,34 or through use of questionnaires in face-to-face or telephone interviews, or self-administered through postal or electronic means.35 In addition, our approach to data gathering during the course of patient care allowed us to maximize our response rate to essentially 100% of eligible patients, rates that have been difficult to achieve with other survey techniques.35
CONCLUSIONS Self-reported unsound sleep is common among hospitalized patients with infection-related diagnoses. Given the potential deleterious impact of suboptimal sleep quality on susceptibility to and recovery from infectious conditions, interventions at improving sleep quality in this patient population seem warranted. REFERENCES 1. Young JS, Bourgeois JA, Hilty DM, et al. Sleep in hospitalized medical patients, part I: factors affecting sleep. J Hosp Med 2008;3:473–82. 2. Bartick MG, Thai X, Schmidt T, et al. Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. J Hosp Med 2010;5:E20–4. 3. Kahn-Greene ET, Killgrove DB, Kamimori GH, et al. The effects of sleep deprivation on symptoms of psychopathology in healthy adults. Sleep Med 2007;8:215–21.
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