Journal of PeriAnesthesia Nursing 36 (2021) 194e196

Contents lists available at ScienceDirect

Journal of PeriAnesthesia Nursing

journal homepage: www.jopan.org

Critical Care Connection

Pragmatic Nonpharmacologic Interventions to Improve Patient Sleep

and Decrease Delirium
Brian A. Rottweiler, MS, RN, AGCNS-BC, CMSRN a,
Mary Beth Flynn Makic, PhD, RN, CCNS, CCRN-K, FAAN, FNAP, FCNS b, *
a
Civilian Institution Program, Air Force Institute of Technology, Wright-Patterson Air Force Base, OH
b
College of Nursing, University of Colorado, Aurora, CO

Sleep disruption is a common complaint affecting up to 50% of changes to sleep have been observed and are thought to be highly
patients during hospitalization; the top three extrinsic factors are modifiable; increased sleep during the day (as high as 57%) with
noise, lighting, and nursing care.1,2 Improving sleep in acutely ill increased time in N1 and N2 sleep and decreased time in N3 and
hospitalized patients is important as the quality of sleep plays a key REM sleep.1
role in promoting improved recovery in the critically ill and out- A circadian rhythm is our internal 24-hour clock that cycles
comes.3,4 The normal sleep cycle consists of two cycles: nonrapid our brain between states of sleep and alertness at somewhat
eye movement (NREM) and rapid eye movement (REM). NREM regular intervals. Alterations in circadian rhythm can cause sleep
consists of three stages (N1, N2, N3) before an individual reaches disruption and lead to delirium; delirium can cause alterations
REM which is required for a true state of sleep or feeling rested.1,5 A in circadian rhythm and cause sleep disruptions.1,3,4,6 Melatonin
typical sleep cycle lasts 70 to 90 minutes and may be as long as or 6-sulfaxymelatonin urinary metabolite is a common marker
120 minutes.4,6 Normal framework for cycling through these stages used to track circadian rhythms.8 Melatonin, one of many reg-
consists of 2 to 8% in N1, 45 to 55% in N2, 13 to 23% in N3, and 20 to ulatory hormones, is controlled by the primary pacemaker in the
25% in REM.1,4 Adults should have 7 to 8 hours of sleep a night brain, the suprachiasmatic nucleus.4,7,9 The suprachiasmatic nu-
which takes about five cycles of NREM and REM sleep.5 cleus uses many cues to create a circadian rhythm such as
Sleep stage N1 is when individuals shift from being awake to interaction with light, which occurs via timekeepers in the pe-
sleep and body temperature begins to drop, but they are easily riphery that interact with light.3,4,6,10 Dessap et al8 found during
arousable.1,5 Sleep stage N2 results in slowing of respirations and a weaning trial that those who had delirium had significantly
heart rate with increased resistance to being awakened.1,5 In sleep lower peak, mean, and total 24-hour secretion of 6-
stage N3, individuals are harder to arouse as well as having sig- sulfaxymelatonin than those who were not delirious as
nificant decreases in cerebral metabolic rate (glucose consumption) measured by the confusion assessment method for the ICU.8
and oxygen, and blood pressure and heart rate drop further, and Establishing circadian rhythms during critical illness is essen-
there is an increase in tissue development and muscle restora- tial to reducing the risk of delirium, adverse effects of lack of
tion.5,7 REM sleep is the hardest to wake individuals from and is REM sleep, and improving patient outcomes. Several practical
highly associated with improved emotion, cognitive abilities, and measures can be implemented in daily care of patients during
memory collation.5,7 Sleep stage N3 and REM are associated with the daytime and nighttime to support circadian rhythm, which
being restorative in nature.6,7 will improve patient sleep as well as decrease the incidence of
Poor or fragmented sleep is thought to adversely affect glucose delirium.
regulation, immune response, blood pressure regulation, cognition,
increase risk for falls, increased risk for development of delirium,
and increased mortality.1,3,4 In critically ill patients, three key Nursing Nonpharmacologic Interventions Promoting Sleep

The Society of Critical Care Medicine (SCCM) has provided

Conflict of interest: None to report. guidelines that call for the routine assessment of patient sleep as
Disclaimer: This publication was cleared for public release by the 460th Space Wing well as promotion of nonpharmacologic measures to promote
Public Affairs Office, June 11, 2020. The views expressed in this article are those of sleep.1 Multimodal interventions to prevent delirium overlap with
the author and do not reflect the official policy or position of the United States Air recommendations on sleep optimization and promotion of
Force, Department of Defense, or the U.S. Government.
* Address correspondence to Mary Beth Flynn Makic, College of Nursing, Uni-
mobility.1 To improve patient sleep and potentially improve patient
versity of Colorado, 13120 E 19th Avenue, Aurora, CO 80045. experience, it takes a consistent effort, both day and night, of the
E-mail address: [email protected] (M.B. Flynn Makic). implementation of nonpharmacologic interventions.

https://doi.org/10.1016/j.jopan.2020.07.008
1089-9472/Published by Elsevier, Inc. on behalf of American Society of PeriAnesthesia Nurses. All rights reserved.
B.A. Rottweiler and M.B. Flynn Makic Journal of PeriAnesthesia Nursing 36 (2021) 194e196

Daytime Interventions Noise over 40 to 55 dB cause adverse health effects; specifically,

noises over 80 dB are associated with spontaneous awakenings.
Critically ill patients often experience an increase in daytime These spontaneous awakenings lead to decreased quality of sleep
sleep estimated to be up to 57% of their total sleep time.1 Daytime as a result of sleep disruption and or fragmentation.7,13,15 Explicit
sleep is problematic as this sleep pattern is predominantly stage N1 measures to control noise need to be implemented to promote
and N2, light phases of sleep, which is nonrestorative and further sleep within the acute and critical care unit settings.3,4,13
causes circadian rhythm and normal sleep-wake cycle disrup- Programs to improve environmental noise have included envi-
tion.1,3,4,7 Several simple daytime interventions such as having the ronmental reviews, noise awareness and education. They also use
blinds up, lights on in the rooms, and mobilizing patients are aimed multidisciplinary involvement with a champion, operational lead-
at restoring circadian rhythms and wakefulness in patients. ership involvement, or noise feedback systems.13 While meta-
analysis has not shown a statistically significant improvement in
Blinds Up, Lights On, and Patients Engaged (Not Lying in Bed) many measured outcomes, there have been several studies that
show improvement in total sleep time, decreased awakenings, and
Extrinsic light sources incite activation of the circadian peak noise levels.13
rhythm.8,10 Light is commonly measured in lux. Outside on an
overcast day, light can provide over 1,000 lux while on a sunny day Care Interruptions Minimized
over 100,000 lux can be provided.11 Depending on various factors
such as room orientation, light levels in critical care areas vary Even though there is a growing body of knowledge, it has been
during the day, and lux can range from 30 to 165.4 It takes some- reported that as low as 8% of multidisciplinary staff (physicians,
where between 100 and 500 lux to suppress melatonin.3,6 The respiratory therapists, nurses, and care technicians) feel that
recommendation to have blinds up and lights on in patient rooms, prioritizing sleep is important.15 When patients are interrupted
starting in the morning, is physiologically based to maximize light more at night, they experience less time in deep restorative sleep.14
which suppresses melatonin and promotes wakefulness. The This interrupted sleep causes further disruption in circadian
addition of mobilization also promotes wakefulness and is felt to be rhythm and sleep-wake cycles as total sleep time plays a role the
beneficial in the prevention of delirium.1,4 process whether it is a full cycle or partial cycle3,4,7 To combat this,
care should be prioritized to allow for 90 to 120 minutes without
Nighttime Interventions interruption, as much as possible, so patients can fall asleep and
complete a full cycle.14
Variations in nighttime lighting in the ICU range from 30 to Providing 90 to 120 minutes of uninterrupted time at night is
1,000 lux with procedural lights omitting as much as 10,000 lux4,12 challenging as it is a multidisciplinary problem. A coordinated and
This is concerning because it takes as little as 100 to 500 lux to multidisciplinary effort is needed to achieve this goal.15 Without a
suppress melatonin, disrupt the inner circadian pacemaker, or coordinated effort, labs could be arbitrarily drawn at 1 a.m., med-
both.4,10,12 Additionally, noise levels in care areas have been docu- ications could be given at times that are not clinically necessary;
mented as high as 96.48 dB which is concerning for two reasons: and physicians, nurses, or technicians could be entering the room
(1) noise levels greater than 40 dB have adverse health effects such sporadically contributing to the 60 interruptions of sleep a
as increased stress and decreased sleep quality and (2) levels night.14,15
greater than 80 dB have been associated with awakenings.3,13
Another factor compounding risk for sleep disruption is nursing Offering Earplugs and Eye Masks
care during the night. While essential, studies have found that in-
dividuals received nursing care at a median rate of 0.6 activities per A simple low-cost intervention that can be offered to patients at
hour, and this has been documented to be as high as 60 in- night are earplugs and eye masks. Earplugs or eye masks or both
terruptions a night.3,14 This is problematic because it takes 90 to have been shown to increase subjective sleep quality and signifi-
120 minutes for individuals to achieve a normal sleep cycle which cantly reduce the risk of delirium.16,17 Subjective sleep quality is
does not account for variation in how long it takes an individual to measured by a validated tool for critical care such as the Richards-
fall asleep.4,14 Bundling interventions so that interruptions are Campbell Sleep Questionnaire; a visual analog given to patients to
minimized during the night can facilitate a patient achieving a full self-report their perception of sleep across the five sleep domains
sleep cycle (on average 90 to 120 minutes). which is recommended by SCCM. Objectively, a meta-analysis has
found that when earplugs, eye masks, or both were used over usual
Blinds Down and Lights Off care, the incidence of delirium was significantly reduced.17 Two
pilot studies have shown utilization rate of earplugs to be from 0.9%
The intervention of ensuring blinds are down and lights are off is to 32% by patients, eye mask utilization of 12% to 44%, and both
simplistic in nature. Having the blinds down offers some orienta- earplugs and eye mask utilization of 60%2,18 While a majority of
tion that it is night as well as ensuring any outside light sources are studies have not shown any benefit of length-of-stay from these
minimized. The combination of having the lights off, which can measures, they also typically only follow patients for 24 to 48 hours.
omit as much as 810 lux if the light source is not purposefully The aforementioned pilot studies followed participants on wards
chosen or up to 10,000 lux for a procedural light, will ensure throughout the patient's stay and found a decrease in length-of-
melatonin is not suppressed, therefore promoting sleepiness.3,4,10 stay in interventions groups to be 0.9 to 1.16 days; however,
One also needs to keep in mind that it can take 2 hours after while findings were not statistically significant, these interventions
beginning of endogenous secretion of melatonin before one be- had a positive effect on length-of-stay when applied across the
comes sleepy.9 hospitalization.2,18

Noise Control Sleep Disruptions and Delirium

Background noise at night should not exceed 30 dB or peak The sleep cycle is a 24-hour period in which during hospi-
greater than 45 dB according to the World Health Organization.13 talization, there are many threats to altering this natural process.

195
B.A. Rottweiler and M.B. Flynn Makic Journal of PeriAnesthesia Nursing 36 (2021) 194e196

Owing to the multiplex interplay of critical illness, chronic References

illness, medications, pain, and environmental factors, a clear
cause and effect has not been made.1,4,6 Whether sleep disrup- 1. Devlin JW, Skrobik Y, Gelinas C, et al. Clinical practice guidelines for the pre-
vention and management of pain, agitation/sedation, delirium, immobility, and
tion causes delirium or delirium caused the sleep disruption, sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46:e825ee873.
REM sleep is decreased in individuals who are delirious.1 2. Gathecha E, Rios R, Buenaver LF, Landis R, Howell E, Wright S. Pilot study
Moreover, delirium can lead to increased daytime sleep which aiming to support sleep quality and duration during hospitalizations. J Hosp
Med. 2016;11:467e472.
further complicates normal sleep cycles,1 and decreased time in 3. Pisani MA, Friese RS, Gehlbach BK, Schwab RJ, Weinhouse GL, Jones SF. Sleep in
REM sleep leads to cognitive dysfunction and risk for the intensive care unit. Am J Respir Crit Care Med. 2015;191:731e738.
delirium.4,6,10 When circadian rhythm becomes disrupted as 4. Telias I, Wilcox ME. Sleep and circadian rhythm in critical illness. Crit Care.
2019;23:82.
evidenced by increase daytime sleep, evidence suggests it is 5. Improving Sleep: A Guide to a Good Night’s Rest (2019). Boston, MA: Harvard
more likely for individuals to experience delirium.1 So, although Health Publications; 2019.
a strong cause and effect is not established, there is a clear 6. Pulak LM, Jensen L. Sleep in the intensive care unit: A review. J Intensive Care
Med. 2016;31:14e23.
association with sleep fragmentation or disruption leading to
7. Brown RE, Basheer R, McKenna JT, Strecker RE, McCarley RW. Control of sleep
delirium and bundles aimed at improving sleep have shown to and wakefulness. Physiol Rev. 2012;92:1087e1187.
decrease the incidence of delirium.1,17 8. Dessap AM, Roche-Campo F, Launay J-M, et al. Delirium and circadian rhythm
of melatonin during weaning from mechanical ventilation. Chest. 2015;148:
1231e1241.
9. Zisapel N. New perspectives on the role of melatonin in human sleep, circadian
rhythms and their regulation. Br J Pharmacol. 2018;175:3190e3199.
Implications for Practice
10. Engwall M, Fridh I, Johansson L, Bergbom I, Lindahl B. Lighting, sleep and
circadian rhythm: An intervention study in the intensive care unit. Intensive
In caring for critically ill patients throughout their acute and Crit Care Nurs. 2015;31:325e335.
critical care hospitalization, there are several ways in which envi- 11. The National Optical Astronomy Observatory (NOAO). Recommended light
levels (illuminance) for outdoor and indoor venues. Available at: https://www.
ronmental factors can contribute to sleep disruption and delirium. noao.edu/education/QLTkit/ACTIVITY_Documents/Safety/LightLevels_outdoor
As bedside clinicians, there are several ways risk can be reduced by þindoor.pdf. Accessed May 16, 2020.
implementation of simple measures consistently to promote the 12. Pagnucci N, Tolotti A, Cadorin L, Valcarenghi D, Forfori F. Promoting nighttime
sleep in the intensive care unit: Alternative strategies in nursing. Intensive Crit
best outcomes. This requires a multi-disciplinary coordinated effort Care Nurs. 2019;51:73e81.
to ensure timing of patient care allows for minimal disruption 13. Garside J, Stephenson J, Curtis H, Morrell M, Dearnley C, Astin F. Are noise
specifically at night. However, successful and consistent efforts to reduction interventions effective in adult ward settings? A systematic review
and meta analysis. Appl Nurs Res. 2018;44:6e17.
promote circadian rhythms and normalization of day and night 14. Ritmala-Castren M, Virtanen I, Leivo S, Kaukonen KM, Leino-Kilpi H. Sleep and
routines with decreased noise are known to improve subjective nursing care activities in an intensive care unit. Nurs Health Sci. 2015;17:
sleep experience, reduce delirium, and improve patient satisfac- 354e361.
15. Ding Q, Redeker NS, Pisani MA, Yaggi HK, Knauert MP. Factors influencing
tion.1,13,17 We need to advocate for patients to have earplugs and patients' sleep in the intensive care unit: perceptions of patients and clinical
eye masks routinely stocked. Patients need to be educated about staff. Am J Crit Care. 2017;26:278.
the importance of sleep, decreasing light sources, and benefits of 16. Bani Younis MK, Hayajneh FA, Alduraidi H. Effectiveness of using eye mask and
earplugs on sleep length and quality among intensive care patients: A quasi-
earplugs and eye masks. Care areas need to have environmental
experimental study. Int J Nurs Pract. 2019;25:e12740.
reviews to ensure lighting is optimal during the day to suppress 17. Hu RF, Jiang XY, Chen J, et al. Non-pharmacological interventions for sleep
melatonin and promote wakefulness. Care areas also need envi- promotion in the intensive care unit. Cochrane Database Syst Rev. 2015:
ronmental review to ensure excess and unnecessary noises are Cd008808.
18. Sweity S, Finlay A, Lees C, Monk A, Sherpa T, Wade D. SleepSure: a pilot
reduced. The combination of all efforts above are needed to ensure randomized-controlled trial to assess the effects of eye masks and earplugs
the optimal potential to improve patient outcomes during their on the quality of sleep for patients in hospital. Clin Rehabil. 2019;33:
hospitalization. 253e261.

196