Insomnia Among Hospitalized Older Persons

https://doi.org/10.1016/j.cger.2007.08.012Get rights and content

Among hospitalized older persons, rates of insomnia are alarmingly high, as is evident by the high rates of use of sedative-hypnotic drugs, ranging from 31% to 88%. Insomnia among hospitalized patients may represent undiagnosed sleep disorders, underlying medical problems, and underlying psychiatric problems. Causes of insomnia can be intrinsic or extrinsic. In the intensive care unit, which is one of the most studied areas of the hospital related to insomnia, most studies using polysomnography monitoring have shown that although sleep times seem normal (about 7&8 hours per night), no patients have normal sleep patterns. There is evidence supporting the use of nonpharmacologic interventions, which are preferable to the use of sedating drugs because of the risk associated with their use.

Section snippets

Importance of sleep and consequences of sleep deprivation

When we are ill, the thought of restful sleep is paramount in our minds. The paradox is that it is as if the body is telling the brain to “heal, I need you to fall asleep,” while the brain is yelling at our body, “I know, I know, if I could fall asleep, I would feel better too.” This struggle becomes obvious when one examines the definition of sleep as “a natural occurrence having a psychological and physiological function that activates the restorative repair process of the body” [1]. How

Secondary disorders and sleep disturbances

Although the emphasis of this article is on insomnia, the phrase “sleep disturbance” has also been used to give a broader scope to the problems that can occur and that can be identified. Queries about the quantity and quality of sleep, about the subjective and objective patterns of sleep, should be part of the standard medical evaluation of older patients. When something is amiss, it may represent an opportunity to identify or diagnose a treatable or reversible problem.

In one study, where

Causes of insomnia

The causes of insomnia among hospitalized older persons are numerous and varied. They can be categorized as intrinsic or extrinsic to the patient (Box 1). Most causes in both categories are modifiable and treatable.

The intensive care unit

One of the most studied areas of the hospital related to sleep disturbance is the Intensive Care Unit (ICU). Although everything noted above in this section applies to the ICU environment, some special remarks are needed.

The ICUs are one of the nosiest and busiest locations in hospitals. While several studies have shown that noise levels and patient care activities by nurses and other staff are so high that sleep disturbances seem unavoidable, results of two studies using polysomnography (PSG)

Interventions

Nonpharmacologic interventions are preferable to the use of medication for sleep problems because of the risk associated with the use of sedating drugs in the elderly. These risks among hospitalized older persons include the risk of delirium, falls, hip fractures, dependency, and rebound insomnia [11], [12], [13], [14], [15]. No medication in this category is without some risk for an adverse drug event. Although newer agents continue to come to market, and are possibly safer if they have

Summary

Rates of insomnia and rates of use of sedative-hypnotic drugs among older hospitalized persons are high. Insomnia may represent undiagnosed sleep disorders or underlying medical or psychiatric problems. Evaluation and management of insomnia should target intrinsic (underlying medical illnesses, medications, or withdrawal from medications or alcohol) and extrinsic causes (hospital environment, patient care activities, noise, and medical technology or monitoring). Nonpharmacologic interventions

References (94)

  • P.H. Black

    Psychoneuroimmunology: brain and immunity

    Science & Medicine

    (1995)
  • S.M. Spenceley

    Sleep inquiry: a look with fresh eyes

    Image J Nurs Sch

    (1993)
  • R.M. Berlin

    Management of insomnia in hospitalized patients

    Ann Intern Med

    (1984)
  • K. Manabe et al.

    Sleep patterns and mortality among elderly patients in a geriatric hospital

    Gerontology

    (2000)
  • D. Morrison et al.

    Sleep insurance: a valid use of hypnotics?

    N C Med J

    (1972)
  • R. O'Reilly et al.

    The use of sedative-hypnotic drugs in a university teaching hospital

    CMAJ

    (1990)
  • S.W. Perry et al.

    Rationale for the use of hypnotic agents in a general hospital

    Ann Intern Med

    (1984)
  • M.H. Zisselman et al.

    Sedative-hypnotic use and increased hospital stay and costs in older people

    J Am Geriatr Soc

    (1996)
  • J.D. Bowen et al.

    Drug-induced cognitive impairment. Defining the problem and finding solutions

    Drugs Aging

    (1993)
  • G.L. Gottlieb

    Sleep disorders and their management. Special considerations in the elderly

    Am J Med

    (1990)
  • A.J. Campbell

    Drug treatment as a cause of falls in old age. A review of the offending agents

    Drugs Aging

    (1991)
  • A. Foy et al.

    Benzodiazepine use as a cause of cognitive impairment in elderly hospital inpatients

    J Gerontol A Biol Sci Med Sci

    (1995)
  • R.M. Grad

    Benzodiazepines for insomnia in community-dwelling elderly: a review of benefit and risk

    J Fam Pract

    (1995)
  • S. Joshi

    Current concepts in the management of delirium

    Mo Med

    (2007)
  • K.B. King et al.

    Patient perceptions of recovery from coronary artery bypass grafting after discharge from the hospital

    Heart Lung

    (1988)
  • B.B. Tack et al.

    Nurse-monitored cardiac recovery: a description of the first 8 weeks

    Heart Lung

    (1990)
  • N.S. Redeker

    Symptoms reported by older and middle-aged adults after coronary bypass surgery

    Clin Nurs Res

    (1993)
  • K.M. Schaefer et al.

    Sleep disturbances post coronary artery bypass surgery

    Prog Cardiovasc Nurs

    (1996)
  • H.H. Meissner et al.

    Failure of physician documentation of sleep complaints in hospitalized patients

    West J Med

    (1998)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders: DSM-IV

    (1994)
  • J. Francis et al.

    A prospective study of delirium in hospitalized elderly

    JAMA

    (1990)
  • S.K. Inouye et al.

    A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics

    Ann Intern Med

    (1993)
  • J.C. Johnson et al.

    Using DSM-III criteria to diagnose delirium in elderly general medical patients

    J Gerontol A Biol Sci Med Sci

    (1990)
  • E.W. Ely et al.

    Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit

    JAMA

    (2004)
  • S.K. Inouye

    Delirium in hospitalized older patients: recognition and risk factors

    J Geriatr Psychiatry Neurol

    (1998)
  • D.K. Miller et al.

    Controlled trial of a geriatric case-finding and liaison service in an emergency department

    J Am Geriatr Soc

    (1996)
  • S.K. Inouye et al.

    Nurses' recognition of delirium and its symptoms: comparison of nurse and researcher ratings

    Arch Intern Med

    (2001)
  • J.M. Lyness

    Delirium: masquerades and misdiagnosis in elderly inpatients

    J Am Geriatr Soc

    (1990)
  • P. Pompei et al.

    Delirium in hospitalized older persons: outcomes and predictors

    J Am Geriatr Soc

    (1994)
  • M. Cole et al.

    The prognostic significance of subsyndromal delirium in elderly medical inpatients

    J Am Geriatr Soc

    (2003)
  • J. McCusker et al.

    Predictors of functional decline in hospitalized elderly patients: a systematic review

    J Gerontol A Biol Sci Med Sci

    (2002)
  • J. McCusker et al.

    Environmental risk factors for delirium in hospitalized older people

    J Am Geriatr Soc

    (2001)
  • J. McCusker et al.

    The course of delirium in older medical inpatients: a prospective study

    J Gen Intern Med

    (2003)
  • K. Rockwood

    Educational interventions in delirium

    Dement Geriatr Cogn Disord

    (1999)
  • S.K. Inouye et al.

    Does delirium contribute to poor hospital outcomes? a three-site epidemiologic study

    J Gen Intern Med

    (1998)
  • S. O'Keeffe et al.

    The prognostic significance of delirium in older hospital patients

    J Am Geriatr Soc

    (1997)
  • R.I. Thomas et al.

    A prospective study of delirium and prolonged hospital stay. Exploratory study

    Arch Gen Psychiatry

    (1998)
  • Cited by (30)

    View all citing articles on Scopus
    View full text