May 19, 2024

Advanced Ailment Care

Elevating Health Solutions

The Hospital Is an Enemy of Sleep

8 min read

“I couldn’t sleep because there were people complaining about pains, the hall light was reflecting into the room, which had its door left open for some reason, and neither I nor my roommate could move from the bed,” a patient wrote to Univadis Italy. “I remember the irony of a night nurse, saying to a lady from another room who was asking for something to sleep, ‘You never really sleep in the hospital.'” The patient was describing an experience in a hospital in northern Italy.

The word “hospital” comes from the Latin hospitale, a place where strangers were hosted. But the hospital setting is not that hospitable after all. In this place dedicated to care and rest, a fundamental need is neglected: Sleep. Almost everyone who has spent a night in the hospital, whether admitted or assisting a loved one, knows that resting is difficult. But does it have to be this way? What do the data and patients say?

Studying Hospital Sleep

Sleep in the hospital is poor. A meta-analysis from 2022 that examined 203 studies showed that the average total sleep time for hospitalized patients varies significantly between age groups. Children and adolescents sleep an average of about 7.8 hours per night, while adults and older adults manage to sleep only 5.6 and 5.8 hours, respectively. A substantial majority of studies, approximately 76% of those examined, reported sleep duration below the average considered healthy. Almost half of the studies indicated that adults slept less than 6 hours per night: A threshold commonly associated with adverse health outcomes. Furthermore, patients frequently experience numerous nocturnal awakenings (up to 42 times per night) and prolonged awakenings after sleep onset of over 105 minutes.

Pediatric patients, however, are a separate case. According to the meta-analysis, sleep efficiency in children overall remains comparable to that in healthy populations. But sleep quality in hospitalized children is deficient, and hospitalization affects children of various ages differently. Finally, sleep quality can be altered by the development of conditions, such as insomnia, restless leg syndrome, or sleep-related breathing disorders, that are rarely taken into consideration.

Noise: The Main Problem

The primary reason that patients in the hospital do not sleep is because they are unwell. Pain or medication effects often reduce sleep quality and quantity. Psychological stress resulting from anxiety about health problems, the unfamiliar hospital environment, disruption of routine, or reduced personal autonomy also significantly contributes to sleep degradation.

But if these factors are at least partially unavoidable, the hospital environment does not seem to consider sleep quality adequately. One of the most common problems is noise. “The call bells in the nursing station, the continuous maneuvers of ambulances, which had their alarms on when they reversed right under the window,” one patient wrote to Univadis Italy. “We were close to where nurses stay. I kept hearing the beeps of various room call bells…All night long, a nightmare,” wrote another.

Not surprisingly, several studies have shown a correlation between the number of sound peaks in a hospital setting and the number of patient awakenings during sleep. One of these studies attributed 20% of sleep awakenings to noise level peaks, while another indicated that environmental noise caused 11.5% of interruptions and 17% of awakenings. The average noise level in hospitals could also play a crucial role.

At least one study has noted a significant dose-response relationship between self-reported sleep disturbances and average noise levels, suggesting that constant background noise may have a greater effect than louder intermittent noises. Sharing a room with other patients, and thus with their noises, is one of the most common sources of discomfort and often remains in patients’ memories, although some studies show that the use of single rooms does not necessarily improve the situation. Simple measures can alleviate the patient’s discomfort. For example, one can try to admit patients with sleep disturbances to rooms with quiet roommates.

Light and Sleep

Light is an equally important problem. Many patients report difficulty sleeping because light constantly shines into the rooms from the hall. Several studies have identified light intensity as a factor that disturbs sleep in intensive care units, as well as in regular admissions.

According to at least one study, lighting conditions had an even more pronounced effect than noise on sleep quality. Proper lighting conditions are also as important as reduced nighttime lighting to maintain a proper sleep-wake cycle. Several studies have reported that bright light during the day improves the quality of nighttime sleep, and patients admitted near windows, and thus exposed to a natural light rhythm, tend to sleep better.

Night Shifts

Night nursing activities are another important factor in sleep disturbance. Many patients have told Univadis Italy about experiences where nighttime staff interventions thwarted hopes of good rest. “The night goes on, but every 2 hours, a nurse comes in and turns on the light to take measurements, ask if you feel nauseous, have intestinal gas, and give you painkillers,” said one. “The nurses who came in for nighttime blood draws were loud and turned the light on my face without warning,” said another.

On this point, things are changing. “In the past, measurements could be taken or the room entered at any time of day or night. Now there is a tendency to absolutely avoid entering at night, or it is done only to check that the patient is not unwell. The patient is not awakened unless something urgent happens,” said Francesca Casoni, MD, a neurophysiopathologist at the Sleep Medicine Center of the IRCCS San Raffaele Turro Hospital in Milan, Italy. “Often at shift change, the nurse is instructed to check the patients. If the shift change occurs at midnight or 1 in the morning, the patient is awakened because although the lights go out at 10 PM, the nurse checks the patients and performs a series of tasks. In some hospitals, where the shift is 12 hours, the situation is more manageable because the shift change occurs at 7:00 in the morning, and the next shift at 7:00 in the evening.”

What Consequences?

Sleeping poorly and insufficiently is a risk factor for many conditions such as cardiovascular events, cancer, metabolic disorders, and all-cause mortality, as well as for cognitive function deterioration. It also leads to a weakened immune system and a higher risk for falls. Poor sleep can hinder recovery processes, increase the length of hospital stay, and negatively affect patients’ subjective well-being. Reduced quantity and quality of sleep during hospitalization have been correlated, for example, with hyperglycemia.

“Not sleeping disturbs recovery mechanisms from illness. The circadian rhythms of production of numerous hormones are altered, including insulin, nighttime blood pressure often increases with increased cardiac workload, oxidative stress increases, and a general inflammatory state is observed. So obviously, the patient struggles to recover, and moreover, in a vicious cycle, stress, anxiety, and concern increase. Consequently, this will only lead to further worsening of insomnia,” said Casoni.

Data suggest that hospitalization may be a risk factor for the development of long-term insomnia, which can persist for months or even years after discharge. A 2022 study also suggests that sleep disturbances experienced during hospitalization, such as decreased total sleep time, poor quality, and increased nocturnal awakenings, may in some cases persist for as long as 12 months after discharge.

Sleep deprivation can be even more critical in worsening the conditions of older adult patients. “Sleep disturbance is one of the major risk factors for delirium,” said Casoni. “An elderly patient, perhaps delirious and disoriented, could get up, fall, and suffer, for example, a hip fracture. All this only prolongs hospitalization times and risks worsening their condition because they will need more rehabilitation and more medication.”

Possible Remedies

A hospital cannot always be a place of perfect quiet. In some cases, such as in intensive care, the presence of equipment and various needs make suboptimal light and noise levels unavoidable. There is room for improvement, however. “There are several guidelines that impose certain standards for nighttime light and decibel levels in the hospital setting. The problem is that they are not always respected, and this is one of the main aspects that needs to be worked on,” said Casoni. As a 2016 review showed, reducing noise and light during hospitalization is associated with sleep improvements. Providing simple and inexpensive tools such as earplugs and eye masks can also change patients’ experiences for the better. Implementing “quiet periods” during which noise is minimized and lights are dimmed has proved promising.

Nevertheless, an approach that considers the entire hospital environment and routine, which has so far neglected the importance of rest, is necessary, said Casoni. For example, the concept of hospitalization where all the patient’s time is spent in a single environment needs to be reconsidered, she added.

“Recently, efforts have been made to include nonhealthcare figures, such as architects, in the rest discourse,” said Casoni. “For example, when building a hospital, there is now a tendency to think about the structure of a room in a somewhat more targeted way. One thing that may seem trivial (but in sleep medicine it is not at all) is that the hospitalized patient eats, sleeps, and does all their activities in the same space. This is fundamentally wrong. One of the rules we always give to patients with sleep disorders is that the bed is only for two things: Sleeping and sexual activity. Attention to how the room is structured or taking the patient to a different environment to eat could be very useful.”

Approaches to medications and therapies can also be modified. “Pain is one of the most frequent causes of insomnia onset during hospitalization and therefore, if possible, should be treated,” said Casoni. “Secondly, many drugs that are prescribed have consequences on sleep. There are drugs that might be better to avoid in the evening. When absolutely necessary, sleep therapy can be given, but it’s kind of a last resort. It’s better to avoid starting immediately with the pharmacological solution, also because the right drug is not always chosen.”

The main and most immediate intervention, however, is to listen to the patient, said Casoni. “The doctor should ask questions and talk to the patient, understand, for example, if they already suffered from a sleep disorder before entering the ward. The most human aspect, dialogue with the patient and understanding of sleep quality, is fundamental. Talking and reassuring the patient helps a lot.”

This story was translated from Univadis Italy, which is part of the Medscape professional network, using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

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