Assessment of sleep quality post-hospital discharge in survivors of critical illness

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.

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 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.

Improve sleep in critically ill patients: Study protocol for a randomized controlled trial for a multi-component intervention of environment control in the ICU

INTRODUCTION

In critically ill patients, sleep and circadian rhythms are greatly altered. These disturbances have been associated with adverse consequences, including increased mortality. Factors associated with the ICU environment, such as exposure to inadequate light and noise levels during the day and night or inflexible schedules of daily care activities, have been described as playing an essential role in sleep disturbances. The main objective of this study is to evaluate the impact of the use of a multifaceted environmental control intervention in the ICU on the quantity and quality of sleep, delirium, and post-intensive care neuropsychological impairment in critically ill patients.

METHODS

This is a prospective, parallel-group, randomized trial in 56 critically ill patients once they are starting to recover from their acute illness. Patients will be randomized to receive a multifaceted intervention of environmental control in the ICU (dynamic light therapy, auditory masking, and rationalization of ICU nocturnal patient care activities) or standard care. The protocol will be applied from enrollment until ICU discharge. Baseline parameters, light and noise levels, polysomnography and actigraphy, daily oscillation of plasma concentrations of Melatonin and Cortisol, and questionnaires for the qualitative evaluation of sleep, will be assessed during the study. In addition, all patients will undergo standardized follow-up before hospital discharge and at 6 months to evaluate neuropsychological impairment.

DISCUSSION

This study is the first randomized clinical trial in critically ill patients to evaluate the effect of a multicomponent, non-pharmacological environmental control intervention on sleep improvement in ICU patients. The results will provide data about the potential synergistic effects of a combined multi-component environmental intervention in ICU on outcomes in the ICU and long term, and the mechanism of action.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT. Registered on January 10, 2023. Last updated on 24 Jan 2023.

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.

Hospital-acquired insomnia scale: A validity and reliability study

BACKGROUND

Sleep breathing, one of the basic human needs, is a physiological need that affects cardiac functions, body temperature, daily vitality, muscle tone, hormone secretion, blood pressure, and many more. In the international literature, studies reported that patients have had sleep problems in the hospital since the 1990s, but no measurement tool has been developed to determine the causes of hospital-acquired insomnia in individuals. These findings suggest that sleep remains in the background compared to activities such as nutrition and breathing. Although patients generally experience hospital-acquired sleep problems, there is no measurement tool to determine hospital-acquired sleep problems. These features show the originality of the research.

AIM

To develop a measurement tool to determine the sleep problems experienced by patients in the hospital.

METHODS

A personal information form, hospital-acquired insomnia scale (HAIS), and insomnia severity index (ISI) were used to collect research data. The study population consisted of patients hospitalized in the internal and surgical clinics of a research hospital in Turkey between December 2021 and March 2022. The sample consisted of 64 patients in the pilot application stage and 223 patients in the main application stage. Exploratory factor analysis and confirmatory factor analysis (CFA) analyses were performed using the SPSS 20 package program and the analysis of moment structure (AMOS) package program. Equivalent forms method used.

RESULTS

The HAIS consisted of 18 items and 5 subscales. The Cronbach alpha values of the subscales ranged between 0.672 and 0.842 and the Cronbach alpha value of the overall scale was 0.783. The scale explained 58.269% of the total variance. The items that constitute the factors were examined in terms of content integrity and named as physical environmental, psychological, safety, socioeconomic, and nutritional factors. CFA analysis of the 5-factor structure was performed in the AMOS package program. The fit indices of the obtained structure were examined. It was determined that the values obtained from the fit indices were sufficient. A significant correlation was determined between the HAIS and the ISI, which was used for the equivalent form method.

CONCLUSION

The HAIS is a valid and reliable measurement tool for determining patients’ level of hospital-acquired insomnia. It is recommended to use this measurement tool to determine the insomnia problems of patients and to adapt it in other countries.

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.

Exploring Wearables to Focus on the “Sweet Spot” of Physical Activity and Sleep After Hospitalization: Secondary Analysis

Background

Inadequate sleep and physical activity are common during and after hospitalization, but their impact on patient-reported functional outcomes after discharge is poorly understood. Wearable devices that measure sleep and activity can provide patient-generated data to explore ideal levels of sleep and activity to promote recovery after hospital discharge.

Objective

This study aimed to examine the relationship between daily sleep and physical activity with 6 patient-reported functional outcomes (symptom burden, sleep quality, physical health, life space mobility, activities of daily living, and instrumental activities of daily living) at 13 weeks after hospital discharge.

Methods

This secondary analysis sought to examine the relationship between daily sleep, physical activity, and patient-reported outcomes at 13 weeks after hospital discharge. We utilized wearable sleep and activity trackers (Withings Activité wristwatch) to collect data on sleep and activity. We performed descriptive analysis of device-recorded sleep (minutes/night) with patient-reported sleep and device-recorded activity (steps/day) for the entire sample with full data to explore trends. Based on these trends, we performed additional analyses for a subgroup of patients who slept 7-9 hours/night on average. Differences in patient-reported functional outcomes at 13 weeks following hospital discharge were examined using a multivariate linear regression model for this subgroup.

Results

For the full sample of 120 participants, we observed a “T-shaped” distribution between device-reported physical activity (steps/day) and sleep (patient-reported quality or device-recorded minutes/night) with lowest physical activity among those who slept <7 or >9 hours/night. We also performed a subgroup analysis (n=60) of participants that averaged the recommended 7-9 hours of sleep/night over the 13-week study period. Our key finding was that participants who had both adequate sleep (7-9 hours/night) and activity (>5000 steps/day) had better functional outcomes at 13 weeks after hospital discharge. Participants with adequate sleep but less activity (<5000 steps/day) had significantly worse symptom burden (z-score 0.93, 95% CI 0.3 to 1.5; P=.02), community mobility (z-score –0.77, 95% CI –1.3 to –0.15; P=.02), and perceived physical health (z-score –0.73, 95% CI –1.3 to –0.13; P=.003), compared with those who were more physically active (≥5000 steps/day).

Conclusions

Participants within the “sweet spot” that balances recommended sleep (7-9 hours/night) and physical activity (>5000 steps/day) reported better functional outcomes after 13 weeks compared with participants outside the “sweet spot.” Wearable sleep and activity trackers may provide opportunities to hone postdischarge monitoring and target a “sweet spot” of recommended levels for both sleep and activity needed for optimal recovery.

Trial Registration

ClinicalTrials.gov NCT03321279; https://clinicaltrials.gov/ct2/show/NCT03321279

Precision Medicine and Physical Therapy: A Healthy Living Medicine Approach for the Next Century

There is a reciprocal relationship between common health conditions encountered in physical therapist practice, disability, and healthy living factors, such as physical inactivity, blood pressure, sleep quality, diet, and obesity. This relationship is apparent across all practice settings. Physical therapists are well positioned in the health care system to mitigate chronic disease by routinely screening and addressing healthy living factors to improve overall health and lower the risk for chronic disease (healthy living medicine). However, there are several challenges to the successful implementation of this framework in physical therapist practice. This Perspective will elucidate this relationship between healthy living behaviors and physical therapist practice, review the current state of practice regarding screening and intervention of 5 key healthy living behaviors, and outline future steps the profession can take toward implementing precision medicine using a healthy living medicine approach.

A Prospective Study Evaluating Sleep Quality and Disorders in Post-ARDS Patients

Introduction

Critically ill patients are predisposed to developing sleep disorders due to multiple factors like pre-existing sleep disorders, severe acute illness, sleep-altering medical interventions, and the disturbing intensive care unit (ICU) environment. In the current study, a multi-modality approach has been attempted to capture the different aspects of sleep disturbances, including insomnia (using ISI), daytime sleepiness (using ESS), sleep quality (using PSQI), sleep architecture, and SDB (using PSG).

Materials and Methods

The eligible ARDS survivor patients were updated about the study's design prior to hospital discharge. At admission, data regarding demographic details, clinical history, etiology of ARDS, and PaO₂/FiO₂ (P/F) ratio at presentation, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment (SOFA) scores was collected. All enrolled patients were evaluated twice (early-within 7 days of admission and late-after 6 weeks of discharge) by the Richards-Campbell Sleep Questionnaire (RCSQ), Insomnia severity index (ISI), and level 1 PSG. Additionally, ESS questionnaire and the Pittsburgh Sleep Quality Index (PSQI) were also recorded in late evaluation. Abnormal sleep was defined if one or more of the following characteristics met: ISI > 15, ESS > 10, global PSQI > 5, AHI ≥ 5 events/h.

Results

Thirty patients were recruited out of the total of 88 ARDS patients screened at admission. The median (IQR) PaO₂/FiO₂ ratio and APACHE II scores were 176 (151-191.5) and 14 (14-16), respectively. The median (IQR) duration of stay in the ICU was 10 (7.3-19.5) days. The median RCSQ score in the early and late evaluation was 42 and 69, respectively. The mean ISI score in the early evaluation was 16.67 ± 4.72, which decreased to 11.70 ± 5.03 in late evaluation (p < 0.05). ISI score > 15 (clinical insomnia) was found in 18 out of 30 subjects (60%) in early evaluation and 11 out of 30 (36%) in late evaluation. During the early evaluation, sleep efficiency was low (median 59.9% and predominantly N1 and N2) which improved in late evaluation (median 80.6%). Of the 30 patients, only 4 had AHI > 5 in early evaluation and none in late evaluation. Neither of P/F ratio, SOFA, and APACHE II scores did correlate with ICU events in the early and late evaluations. Regression analysis showed subjects with ICU stay more than 10 days, duration of IMV more than 7 days, Fentanyl more than 7 mg, duration of sedative use more than 7 days was independently associated with poor objective sleep quality (low sleep efficiency, low TST and high arousal index) during the early and late evaluations after ICU discharge compared to counterparts (p value < 0.05).

Conclusion

We conclude that sleep quality in ARDS survivors was poor within 7 days of ICU discharge, characterized by severe disruption of sleep architecture and sleep-disordered breathing. After 6 weeks of ICU discharge sleep quality showed significant improvement in the N3 stage and AHI, however persistent insomnia was observed even at 6 weeks. Therefore, prior identification of risk factors and early diagnosis of sleep quality disorders in post-ARDS patients is essential.

Sleep-wake rhythms determined by actigraphy during in-hospital stay following discharge from an intensive care unit

BACKGROUND

Sleep and circadian disturbances play a major role in recovery after critical illness. Ample research has shown sleep to be disturbed during the stay at the intensive care unit (ICU); however, the trajectory of sleep after ICU discharge is sparsely described. The current study aimed to describe the development of the sleep-wake rhythm in subjects discharged from ICU to a hospital ward.

METHODS

Following discharge from the ICU to a general hospital ward, the participants were monitored with an ActiGraph for sleep assessment for 7 days or until hospital discharge or death. Data were analysed for day-to-day change with t-tests and for the whole period with repeated measures analysis.

RESULTS

For the 38 included patients, repeated measures analysis showed no significant improvement in total sleep time and wake time. However, for secondary outcomes, improvements for wake after sleep onset (P = .02) and reduction in the number of naps (P = .03) both in the day-to-day and overall trend analysis were observed.

CONCLUSION

The duration of sleep and wake time did not improve during ward stay. However, sleep became less fragmented and naps during the day declined. Due to the small sample size further, larger trials are needed.

Nighttime Sleep Duration Is Associated With Length of Stay Outcomes Among Older Adult Survivors of Critical Illness

BACKGROUND

Older adults who required mechanical ventilation while in an intensive care unit (ICU) require adequate sleep throughout recovery from critical illness. Poor post-ICU sleep quality may contribute to worsening impairments in physical, cognitive, or psychological status after critical illness, known as post-ICU syndrome. Previous research has evaluated post-ICU sleep with qualitative or mixed methods (eg, interviews, questionnaires). We proposed measurement of sleep with actigraphy. We hypothesized that nighttime sleep is associated with length of stay (LOS).

OBJECTIVES

The aims of this study were to describe sleep quality of previously mechanically ventilated older adults recently transferred out of ICU and explore relationships between sleep duration and LOS outcomes.

METHODS

We enrolled 30 older adults, 65 years and older, within 24 to 48 hours after ICU discharge. We collected actigraphy data on post-ICU sleep duration (total sleep time [TST]) and sleep fragmentation (wake time after sleep onset) over 2 consecutive nights. We explored associations between TST and LOS (in days) outcomes using multivariate regression.

RESULTS

Subjects' mean TST was 7.55 ± 2.52 hours, and mean wake time after sleep onset was 2.26 ± 0.17 hours. In exploratory regression analyses, longer ICU LOS (β = 0.543, P < .001) and longer length of mechanical ventilation (β = 0.420, P = .028) were associated with greater post-ICU TST, after adjusting for potential confounding factors. Total sleep time was prospectively associated with total hospital LOS (β = 0.535, P < .001).

DISCUSSION

Older ICU survivors demonstrate greater sleep duration and worse sleep fragmentation. Poor sleep may contribute to longer LOS, secondary to post-ICU syndrome and sequelae. We recommend nursing interventions to promote sleep consolidation throughout transitions of care in the acute post-ICU recovery period.

Sleep Deprivation Etiologies Among Patients in the Intensive Care Unit: Literature Review

BACKGROUND

Sleep deprivation among patients is a common problem in the intensive care unit (ICU). Studies have tried to find the etiologies of sleep deprivation. Poor sleep quality in the ICU has effects such as delirium, weakening the wound healing, and anxiety. Researches have concluded that the etiologies for sleep deprivation are multifactorial.

OBJECTIVES

The aim of this review is to discuss the etiologies of sleep deprivation among ICU patients. This review also aims to discuss effects of sleep deprivations and provide implications for promoting sleep quality in the ICU.

METHODS

For this literature review, ProQuest, MEDLINE, and Up To Date were used to find articles about sleep deprivation among ICU patients. The search was narrowed to articles between 2008 and 2019. A total of 23 articles were included that were found to match the inclusion criteria.

RESULTS

Findings indicated that sleep deprivations etiologies among ICU patients can be environmental and nonenvironmental. Sensory overload, sensory deprivation, and patients' care activities are environmental etiologies for sleep deprivation. The nonenvironmental factors include pharmacological, physical, and psychological factors.

DISCUSSION

Sleep deprivation etiologies are multifactorial and have several effects on ICU patients. Sleep protocol and staff training should be introduced to reduce unnecessary interventions by ICU staff. Tele-ICU monitoring can also be introduced to reduce unnecessary interventions where clinicians can monitor patients remotely and therefore enhance sleep in the ICU. During their stay in the ICU, patients can be instructed to wear earplugs and also have aromatherapy massage to reduce stress and enhance sleep quality. More research on the physical pain and the psychological factors using objective methods should be conducted in the future.

Daytime-to-Nighttime Sleep Ratios and Cognitive Impairment in Older Intensive Care Unit Survivors

BACKGROUND

Sleep duration and proportion of daytime versus nighttime sleep may affect cognitive function in older patients in the transition out of the intensive care unit.

OBJECTIVE

To explore the relationship between the daytime-to-nighttime sleep ratio and cognitive impairment in older intensive care unit survivors.

METHODS

The study enrolled 30 older adults within 24 to 48 hours after intensive care unit discharge. All participants were functionally independent before admission and underwent mechanical ventilation in the intensive care unit. Actigraphy was used to estimate daytime (6 AM to 9:59 PM) and nighttime (10 PM to 5:59 AM) total sleep duration. Daytime-to-nighttime sleep ratios were calculated by dividing the proportion of daytime sleep by the proportion of nighttime sleep. The National Institutes of Health Toolbox Cognition Battery Dimensional Change Card Sort Test (DCCST) was used to assess cognition. Associations between sleep and cognition were explored using multivariate regression after adjusting for covariates.

RESULTS

The mean (SD) daytime sleep duration was 7.55 (4.30) hours (range, 0.16-14.21 hours), and the mean (SD) nighttime sleep duration was 4.99 (1.95) hours (range, 0.36-7.21 hours). The mean (SD) daytime-to-nighttime sleep ratio was 0.71 (0.30) (range, 0.03-1.10). Greater daytime sleep duration (β = -0.351, P = .008) and higher daytime-to-nighttime sleep ratios (β = -0.373, P = .008) were negatively associated with DCCST scores.

CONCLUSIONS

The daytime-to-nighttime sleep ratio was abnormally high in the study population, revealing an altered sleep/wake cycle. Higher daytime-to-nighttime sleep ratios were associated with worse cognition, suggesting that proportionally greater daytime sleep may predict cognitive impairment.

Post-Intensive-Care Syndrome for the Pediatric Neurologist

The number of children who survive critical illness has steadily increased. However, lower mortality rates have resulted in a proportional increase in post-intensive-care morbidity. Critical illness in childhood affects a child's development, cognition, and family functioning. The constellation of physical, emotional, cognitive, and psychosocial symptoms that begin in the intensive care unit and continue after discharge has recently been termed post-intensive-care syndrome. A conceptual model of the post-intensive-care syndrome experienced by children who survive critical illness, their siblings, and parents has been coined post-intensive-care syndrome in pediatrics. Owing to their prolonged hospitalizations, the use of sedative medications, and the nature of their illness, children with primary neurological injury are among those at the highest risk for post-intensive-care syndrome in pediatrics. The pediatric neurologist participates in the care of children with acute brain injury throughout their hospitalization and remains involved after the patient leaves the hospital. Hence it is important for pediatric neurologists to become versed in the early recognition and management of post-intensive-care syndrome in pediatrics. In this review, we discuss the current knowledge regarding post-intensive-care syndrome in pediatrics and its risk factors. We also discuss our experience establishing Pediatric Neurocritical Care Recovery Programs at two large academic centers. Last, we provide a battery of validated tests to identify and manage the different aspects of post-intensive-care syndrome in pediatrics, which have been successfully implemented at our institutions. Dissemination of this "road map" may assist others interested in establishing recovery programs, therefore mitigating the burden of post-intensive-care morbidity in children.

Impact of Patient and Family Involvement in Long-Term Outcomes

Surviving a critical illness can have long-term effects on both patients and families. These effects can be physical, emotional, cognitive, and social, and they affect both the patient and the family. Family members play a key role in helping their loved one recover, and this recovery process can take considerable time. Transferring out of an intensive care unit, and discharging home from a hospital, are important milestones, but they represent only the beginning of recovery and healing after a critical illness. Recognizing that these challenges exist both for patients and families is important to improve critical illness outcomes.

Sleep and Circadian Rhythms in Survivors of Acute Respiratory Failure

Background: Little is known about sleep and circadian rhythms in survivors of acute respiratory failure (ARF) after hospital discharge. Objectives: To examine sleep and rest-activity circadian rhythms in ARF survivors 3 months after hospital discharge, and to compare them with a community-dwelling population. Methods: Sleep diary, actigraphy data, and insomnia symptoms were collected in a pilot study of 14 ARF survivors. Rest-activity circadian rhythms were assessed with wrist actigraphy and sleep diary for 9 days, and were analyzed by cosinor and non-parametric circadian rhythm analysis. Results: All participants had remarkable actigraphic sleep fragmentation, 71.5% had subclinical or clinical insomnia symptoms. Compared to community-dwelling adults, this cohort had less stable rest-activity circadian rhythms (p < 0.001), and weaker circadian strength (p < 0.001). Conclusion: Insomnia and circadian disruption were common in ARF survivors. Sleep improvement and circadian rhythm regularity may be a promising approach to improve quality of life and daytime function after ARF.

Sleep and activity patterns in older patients discharged from the hospital

STUDY OBJECTIVES

Although sleep disturbance is common in acutely ill patients during and after a hospitalization, how hospitalization affects sleep in general medicine patients has not been well characterized. We describe how sleep and activity patterns vary during and after hospitalization in a small population of older, predominately African American general medicine patients.

METHODS

Patients wore a wrist accelerometer during hospitalization and post-discharge to provide objective measurements of sleep duration, efficiency, and physical activity. Random effects linear regression models clustered by subject were used to test associations between sleep and activity parameters across study days from hospitalization through post-discharge.

RESULTS

We recorded 404 nights and 384 days from 54 patients. Neither nighttime sleep duration nor sleep efficiency increased from hospitalization through post-discharge (320.2 vs. 320.2 min, p = 0.99; 74.0% vs. 71.7%, p = 0.24). Daytime sleep duration also showed no significant change (26.3 vs. 25.8 min/day, p = 0.5). Daytime physical activity was significantly less in-hospital compared to post-discharge (128.6 vs. 173.2 counts/min, p < 0.01) and increased 23.3 counts/min (95% CI = 16.5 to 30.6, p < 0.01) per hospital day. A study day and post-discharge period interaction was observed demonstrating slowed recovery of activity post-discharge (β 3 = -20.8, 95% CI = -28.8 to -12.8, p < 0.01).

CONCLUSIONS

Nighttime sleep duration and efficiency and daytime sleep duration were similar in-hospital and post-discharge. Daytime physical activity, however, was greater post-discharge and increased more rapidly during hospitalization than post-discharge. Interventions, both in hospital and at home, to restore patient sleep and sustain activity improvements may improve patient recovery from illness.

Psychiatric symptoms and their association with sleep disturbances in intensive care unit survivors

Background

Sleep disturbances in critically ill patients are associated with poorer long-term clinical outcomes and quality of life. Studies are needed to better characterize associations and risk factors for persistent sleep disturbances after intensive care unit (ICU) discharge. Psychiatric disorders are frequently associated with sleep disturbances, but the role of psychiatric symptoms in sleep disturbances in ICU survivors has not been well-studied.

Objective

To examine the association between psychiatric symptoms and sleep disturbances in ICU survivors.

Methods

112 adult ICU survivors seen from July 2011 to August 2016 in the Critical Care Recovery Center, an ICU survivor clinic at the Eskenazi Hospital in Indianapolis, IN, USA, were assessed for sleep disturbances (insomnia, hypersomnia, difficulty with sleep onset, difficulty with sleep maintenance, and excessive daytime sleepiness) and psychiatric symptoms (trauma-related symptoms and moderate to severe depressive symptoms) 3 months after ICU discharge. A multivariate logistic regression model was performed to examine the association between psychiatric symptoms and sleep disturbances. Analyses were controlled for age, hypertension, history of depression, and respiratory failure.

Results

ICU survivors with both trauma-related and depression symptoms (OR 16.66, 95% CI 2.89–96.00) and trauma-related symptoms alone (OR 4.59, 95% CI 1.11–18.88) had a higher likelihood of sleep disturbances. Depression symptoms alone were no longer significantly associated with sleep disturbances when analysis was controlled for trauma-related symptoms.

Conclusion

Trauma-related symptoms and trauma-related plus moderate to severe depressive symptoms were associated with a higher likelihood of sleep disturbances. Future studies are needed to determine whether psychiatric symptoms are associated with objective changes on polysomnography and actigraphy and whether adequate treatment of psychiatric symptoms can improve sleep disturbances.

Sleep quality in survivors of critical illness

PURPOSE

There is limited data regarding the sleep quality in survivors of critical illness, while the time course of the sleep abnormalities observed after ICU discharge is not known. The aim of this study was to assess sleep quality and the time course of sleep abnormalities in survivors of critical illness.

METHODS

Eligible survivors of critical illness without hypercapnia and hypoxemia were evaluated within 10 days (1st evaluation, n = 36) and at 6 months after hospital discharge (2nd evaluation, n = 29). At each visit, all patients underwent an overnight full polysomnography and completed health-related quality of life questionnaires (HRQL). Lung function and electro-diagnostic tests (ED) were performed in 24 and 11 patients, respectively.

RESULTS

At 1st evaluation, sleep quality and HRQL were poor. Sleep was characterised by high percentages of N1, low of N3 and REM stages, and high apnea-hypopnea index (AHI, events/h). Twenty-two out of 36 patients (61%) exhibited AHI ≥ 15 (21 obstructive, 1 central). None of the patients' characteristics, including HRQL and lung function, predicted the occurrence of AHI ≥ 15. At 6 months, although sleep quality remained poor (high percentages of N1 and low of REM), sleep architecture had improved as indicated by the significant increase in N3 [4.2% (0-12.5) vs. 9.8% (3.0-20.4)] and decrease in AHI [21.5 (6.5-29.4) vs. 12.8 (4.7-20.4)]. HRQL improved slightly but significantly at 6 months. Neither the changes in HRQL nor in lung function tests were related to these of sleep architecture. Six out of eight patients with abnormal ED at 1st evaluation continued to exhibit abnormal results at 6 months.

CONCLUSIONS

Survivors of critical illness exhibited a high prevalence of obstructive sleep-disordered breathing and poor sleep architecture at hospital discharge, which slightly improved 6 months later, indicating that reversible factors are partly responsible for these abnormalities.

Sleep Disturbance after Hospitalization and Critical Illness: A Systematic Review

RATIONALE

Sleep disturbance during intensive care unit (ICU) admission is common and severe. Sleep disturbance has been observed in survivors of critical illness even after transfer out of the ICU. Not only is sleep important to overall health and well being, but patients after critical illness are also in a physiologically vulnerable state. Understanding how sleep disturbance impacts recovery from critical illness after hospital discharge is therefore clinically meaningful.

OBJECTIVES

This Systematic Review aimed to summarize studies that identify the prevalence of and risk factors for sleep disturbance after hospital discharge for critical illness survivors.

DATA SOURCES

PubMed (January 4, 2017), MEDLINE (January 4, 2017), and EMBASE (February 1, 2017).

DATA EXTRACTION

Databases were searched for studies of critically ill adult patients after hospital discharge, with sleep disturbance measured as a primary outcome by standardized questionnaire or objective measurement tools. From each relevant study, we extracted prevalence and severity of sleep disturbance at each time point, objective sleep parameters (such as total sleep time, sleep efficiency, and arousal index), and risk factors for sleep disturbance.

SYNTHESIS

A total of 22 studies were identified, with assessment tools including subjective questionnaires, polysomnography, and actigraphy. Subjective questionnaire studies reveal a 50-66.7% (within 1 mo), 34-64.3% (>1-3 mo), 22-57% (>3-6 mo), and 10-61% (>6 mo) prevalence of abnormal sleep after hospital discharge after critical illness. Of the studies assessing multiple time points, four of five questionnaire studies and five of five polysomnography studies show improved aspects of sleep over time. Risk factors for poor sleep varied, but prehospital factors (chronic comorbidity, pre-existing sleep abnormality) and in-hospital factors (severity of acute illness, in-hospital sleep disturbance, pain medication use, and ICU acute stress symptoms) may play a role. Sleep disturbance was frequently associated with postdischarge psychological comorbidities and impaired quality of life.

CONCLUSIONS

Sleep disturbance is common in critically ill patients up to 12 months after hospital discharge. Both subjective and objective studies, however, suggest that sleep disturbance improves over time. More research is needed to understand and optimize sleep in recovery from critical illness.

Association of intensive care unit delirium with sleep disturbance and functional disability after critical illness: an observational cohort study

Background

In medical intensive care unit (MICU) patients, the predictors of post-discharge sleep disturbance and functional disability are poorly understood. ICU delirium is a risk factor with a plausible link to sleep disturbance and disability. This study evaluated the prevalence of self-reported post-ICU sleep disturbance and increased functional disability, and their association with MICU delirium and other ICU factors.

Methods

This was an observational cohort study of MICU patients enrolled in a biorepository and assessed upon MICU admission by demographics, comorbidities, and baseline characteristics. Delirium was assessed daily using the Confusion Assessment Method for the ICU. Telephone follow-up interview instruments occurred after hospital discharge and included the Pittsburgh Sleep Quality Index (PSQI), and basic and instrumental activities of daily living (BADLs, IADLs) for disability. We define sleep disturbance as a PSQI score > 5 and increased disability as an increase in composite BADL/IADL score at follow-up relative to baseline. Multivariable regression modeled the associations of delirium and other MICU factors on follow-up PSQI scores and change in disability scores.

Results

PSQI and BADL/IADL instruments were completed by 112 and 122 participants, respectively, at mean 147 days after hospital discharge. Of those surveyed, 63% had sleep disturbance by PSQI criteria, and 37% had increased disability by BADL/IADL scores compared to their pre-MICU baseline. Total days of MICU delirium (p = 0.013), younger age (p = 0.013), and preexisting depression (p = 0.025) were significantly associated with higher PSQI scores at follow-up. Lower baseline disability (p < 0.001), older age (p = 0.048), and less time to follow-up (p = 0.024) were significantly associated with worsening post-ICU disability, while the occurrence of MICU delirium showed a trend toward association (p = 0.077).

Conclusions

After adjusting for important covariates, total days of MICU delirium were significantly associated with increased post-discharge sleep disturbance. Delirium incidence showed a trend toward association with increased functional disability in the year following discharge.

Intensive care survivor-reported symptoms: a longitudinal study of survivors' symptoms

BACKGROUND

There is growing interest in potential long-term outcomes following intensive care, but few researchers have studied the prevalence of multiple symptoms or the association between pain and other symptoms.

AIMS

To investigate the prevalence of anxiety, depression, fatigue, sleep disturbance and post-traumatic stress symptoms (PTSS) among intensive care survivors 3 months and 1 year after being discharged from an intensive care unit (ICU) and to determine whether pain is associated with higher prevalence of these symptoms 3 months and 1 year after ICU stay.

STUDY DESIGN

Exploratory, longitudinal cohort of intensive care survivors from two mixed ICUs in a tertiary referral hospital in Norway.

METHODS

Intensive care survivors completed surveys at 3 months (n = 118) and 1 year (n = 89) after ICU discharge. Clinical Trials: NCT02279212.

RESULTS

Prevalence rates of intensive care survivors' symptoms were pain 58 (49·2%), anxiety/depression 24/118 (20·8%), fatigue 18/118(15·3%), PTSS 15 (12·8%) and sleep disturbance 58/118 (49·2%) at 3 months after ICU discharge (n = 118). Prevalence rates at 1 year (n = 89) changed only slightly to pain 34 (38·2%), anxiety/depression 17 (20·0%), fatigue 12 (13·8%), PTSS 13 (15·1%) and sleep disturbance 40/89 (46·5%). Associations were strong between pain and presence of sleep disturbance, anxiety/depression, PTSS and fatigue.

CONCLUSIONS

Intensive care survivors have multiple symptoms and the prevalence rates of these symptoms remained almost unchanged from 3 months to 1 year after ICU discharge. The presence of pain was associated with high odds for the presence of sleep disturbance, anxiety/depression, PTSS and fatigue, compared to a no-pain group. ICU survivors may benefit from targeted interventions designed to alleviate the symptom burden.

RELEVANCE TO CLINICAL PRACTICE

Knowledge about ICU survivor's prevalence and risk for having multiple symptoms may help health care professionals to give better care, if needed, to the ICU survivors.

Patients' Outcomes After Acute Respiratory Failure: A Qualitative Study With the PROMIS Framework

BACKGROUND

As mortality rates for patients treated in intensive care units decrease, greater understanding of the impact of critical illness on patients' well-being is needed.

OBJECTIVE

To describe the survivorship experience of patients who had acute respiratory failure by using the Patient Reported Outcomes Measurement Information System (PROMIS) framework.

METHODS

A total of 48 adult patients who had acute respiratory failure completed at least 1 semistructured telephone-based interview between 5 and 18 months after their stay in the intensive care unit. Participants were asked about overall well-being and important health outcomes.

RESULTS

Major themes were identified within each of the 3 PROMIS components: physical health, mental health, and social health. The following themes were particularly prominent: mobility impairments, pulmonary symptoms, fatigue, anxiety and depression symptoms, and decreased ability to work and participate in valued activities. Impacts on overall well-being and on relationships with friends and family members varied among the survivors. Some survivors reported gratitude, increased appreciation of life, and closer relationships to loved ones. Other survivors reported boredom, social isolation, and wishing they had not survived.

CONCLUSIONS

Survivors of acute respiratory failure reported substantial issues with their physical, mental, and social health. Holistic assessments of outcomes of survivors of critical illness should capture the complex beneficial and adverse impacts of critical illness on survivors' well-being and social health.