Sleep in Hospitalized Patients: Non-Pharmacologic Interventions Interview with:
Ruth Tamrat, Minh-Phuong Huynh-Le, and Madhav Goyal

Johns Hopkins University School of Medicine, MSIV What are the main findings of the study?

Answer: Despite the known adverse effects of sleep deprivation on recovery from illness, studies have shown that sleep deprivation remains an incompletely addressed problem among inpatients.  Behavioral interventions are recommended as first line therapy prior to using pharmacologic therapy due to the adverse side effects of sedative hypnotics. This systematic review sought to identify the efficacy of non-pharmacologic interventions that have been used to improve the sleep of general inpatients.  The results of this review demonstrate a lack of high quality evidence regarding the efficacy of these non-pharmacologic interventions in improving the sleep quality or quantity of patients in the hospital. Were any of the findings unexpected?

Answer: The dearth of high quality studies was surprising. Only two out of the thirteen studies included in this review were rated as low risk of bias. The other eleven studies had shortcomings, including lack of blinding, high attrition rates, and controls that were not matched for time and attention, that reduced our confidence in their results.

The lack of efficacy of the interventions to reduce insomnia was another unexpected finding.    One would think that if we didn’t disturb patients as much at night then they would sleep better.  That may be the case, but only two poor-quality studies looked at this and it was hard to draw conclusions from them.  Most studies tried to get patients to relax in some form, and there was overall some evidence that relaxation techniques may help, but much more work needs to be done in this area. What should clinicians and patients take away from your report?

Answer: Current guidelines recommend non-pharmacologic interventions for hospitalized patients with insomnia prior to instituting pharmacologic therapy.  Unfortunately, the studies that have been conducted examining the effectiveness of various non-pharmacologic interventions have been of poor quality, providing us with little evidence that any of these interventions are of use.  Until further high quality studies have been performed to provide more definitive evidence identifying the best non-pharmacologic interventions, clinicians can take several simple, common sense steps to try to improve the sleep of their patients prior to prescribing them sedative hypnotics. These include: decreasing nighttime vital sign frequency to a safe minimum, ordering medication administration times in a manner that least interrupts patient nighttime sleep, and facilitating normal circadian rhythms by opening patient window blinds/turning on lights during the day and closing window blinds/turning off lights at night. What recommendations do you have for future research as a result of this study?


Answer: future studies should address:

1) The development of computerized order entry protocols that make decreasing interruptions to patient nighttime sleep the default, requiring overrides if interruptions are absolutely necessary. These studies would need to evaluate the effectiveness of this type of order entry system in improving sleep as well as ensure that patient care and safety is not compromised.

2) Various relaxation techniques have been explored individually and/or in combination with others. It is currently still unclear which of these is most helpful, to what degree they are helpful, and which patients they benefit.

3) Does the inpatient setting and its associated alterations in light, noise, and activity levels influence circadian rhythms and homeostatic sleep drives?

4) Studies in this area should limit their risk of bias by using blinding, appropriate randomization, allocation concealment, and objective measures of sleep quality and quantity.

5) In what sub-groups are non-pharmacologic interventions not effective? How can we better define the threshold at which to consider pharmacologic therapies?



Non-Pharmacologic Interventions to Improve the Sleep of Hospitalized Patients: A Systematic Review.

Tamrat R, Huynh-Le MP, Goyal M.

Division of General Internal Medicine, Johns Hopkins School of Medicine, 2024 E. Monument St, Suite 1-500W, Baltimore, MD, 21287
J Gen Intern Med. 2013 Oct 10. [Epub ahead of print]