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
patients during hospitalization; the top three extrinsic factors are
noise, lighting, and nursing care.1,2 Improving sleep in acutely ill
hospitalized patients is important as the quality of sleep plays a key
role in promoting improved recovery in the critically ill and out-
comes.3,4 The normal sleep cycle consists of two cycles: nonrapid
eye movement (NREM) and rapid eye movement (REM). NREM
consists of three stages (N1, N2, N3) before an individual reaches
REM which is required for a true state of sleep or feeling rested.1,5 A
typical sleep cycle lasts 70 to 90 minutes and may be as long as
120 minutes.4,6 Normal framework for cycling through these stages
consists of 2 to 8% in N1, 45 to 55% in N2, 13 to 23% in N3, and 20 to
25% in REM.1,4 Adults should have 7 to 8 hours of sleep a night
which takes about five cycles of NREM and REM sleep.5
Sleep stage N1 is when individuals shift from being awake to
sleep and body temperature begins to drop, but they are easily
arousable.1,5 Sleep stage N2 results in slowing of respirations and
heart rate with increased resistance to being awakened.1,5 In sleep
stage N3, individuals are harder to arouse as well as having sig-
nificant decreases in cerebral metabolic rate (glucose consumption)
and oxygen, and blood pressure and heart rate drop further, and
there is an increase in tissue development and muscle restora-
tion.5,7 REM sleep is the hardest to wake individuals from and is
highly associated with improved emotion, cognitive abilities, and
memory collation.5,7 Sleep stage N3 and REM are associated with
being restorative in nature.6,7
Poor or fragmented sleep is thought to adversely affect glucose
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
Conflict of interest: None to report.
Disclaimer: This publication was cleared for public release by the 460th Space Wing
Public Affairs Office, June 11, 2020. The views expressed in this article are those of
the author and do not reflect the official policy or position of the United States Air
Force, Department of Defense, or the U.S. Government.
* Address correspondence to Mary Beth Flynn Makic, College of Nursing, Uni-
versity of Colorado, 13120 E 19th Avenue, Aurora, CO 80045.
E-mail address: marybeth.makic@cuanschutz.edu (M.B. Flynn Makic).
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.
changes to sleep have been observed and are thought to be highly
modifiable; increased sleep during the day (as high as 57%) with
increased time in N1 and N2 sleep and decreased time in N3 and
REM sleep.1
A circadian rhythm is our internal 24-hour clock that cycles
our brain between states of sleep and alertness at somewhat
regular intervals. Alterations in circadian rhythm can cause sleep
disruption and lead to delirium; delirium can cause alterations
in circadian rhythm and cause sleep disruptions.1,3,4,6 Melatonin
or 6-sulfaxymelatonin urinary metabolite is a common marker
used to track circadian rhythms.8 Melatonin, one of many reg-
ulatory hormones, is controlled by the primary pacemaker in the
brain, the suprachiasmatic nucleus.4,7,9 The suprachiasmatic nu-
cleus uses many cues to create a circadian rhythm such as
interaction with light, which occurs via timekeepers in the pe-
riphery that interact with light.3,4,6,10 Dessap et al8 found during
a weaning trial that those who had delirium had significantly
lower peak, mean, and total 24-hour secretion of 6-
sulfaxymelatonin than those who were not delirious as
measured by the confusion assessment method for the ICU.8
Establishing circadian rhythms during critical illness is essen-
tial to reducing the risk of delirium, adverse effects of lack of
REM sleep, and improving patient outcomes. Several practical
measures can be implemented in daily care of patients during
the daytime and nighttime to support circadian rhythm, which
will improve patient sleep as well as decrease the incidence of
delirium.
Nursing Nonpharmacologic Interventions Promoting Sleep
The Society of Critical Care Medicine (SCCM) has provided
guidelines that call for the routine assessment of patient sleep as
well as promotion of nonpharmacologic measures to promote
sleep.1 Multimodal interventions to prevent delirium overlap with
recommendations on sleep optimization and promotion of
mobility.1 To improve patient sleep and potentially improve patient
experience, it takes a consistent effort, both day and night, of the
implementation of nonpharmacologic interventions.
B.A. Rottweiler and M.B. Flynn Makic
Daytime Interventions
Critically ill patients often experience an increase in daytime
sleep estimated to be up to 57% of their total sleep time.1 Daytime
sleep is problematic as this sleep pattern is predominantly stage N1
and N2, light phases of sleep, which is nonrestorative and further
causes circadian rhythm and normal sleep-wake cycle disrup-
tion.1,3,4,7 Several simple daytime interventions such as having the
blinds up, lights on in the rooms, and mobilizing patients are aimed
at restoring circadian rhythms and wakefulness in patients.
Blinds Up, Lights On, and Patients Engaged (Not Lying in Bed)
Extrinsic light sources incite activation of the circadian
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
over 100,000 lux can be provided.11 Depending on various factors
such as room orientation, light levels in critical care areas vary
during the day, and lux can range from 30 to 165.4 It takes some-
where between 100 and 500 lux to suppress melatonin.3,6 The
recommendation to have blinds up and lights on in patient rooms,
starting in the morning, is physiologically based to maximize light
which suppresses melatonin and promotes wakefulness. The
addition of mobilization also promotes wakefulness and is felt to be
beneficial in the prevention of delirium.1,4
Nighttime Interventions
Variations in nighttime lighting in the ICU range from 30 to
1,000 lux with procedural lights omitting as much as 10,000 lux4,12
This is concerning because it takes as little as 100 to 500 lux to
suppress melatonin, disrupt the inner circadian pacemaker, or
both.4,10,12 Additionally, noise levels in care areas have been docu-
mented as high as 96.48 dB which is concerning for two reasons:
(1) noise levels greater than 40 dB have adverse health effects such
as increased stress and decreased sleep quality and (2) levels
greater than 80 dB have been associated with awakenings.3,13
Another factor compounding risk for sleep disruption is nursing
care during the night. While essential, studies have found that in-
dividuals received nursing care at a median rate of 0.6 activities per
hour, and this has been documented to be as high as 60 in-
terruptions a night.3,14 This is problematic because it takes 90 to
120 minutes for individuals to achieve a normal sleep cycle which
does not account for variation in how long it takes an individual to
fall asleep.4,14 Bundling interventions so that interruptions are
minimized during the night can facilitate a patient achieving a full
sleep cycle (on average 90 to 120 minutes).
Blinds Down and Lights Off
The intervention of ensuring blinds are down and lights are off is
simplistic in nature. Having the blinds down offers some orienta-
tion that it is night as well as ensuring any outside light sources are
minimized. The combination of having the lights off, which can
omit as much as 810 lux if the light source is not purposefully
chosen or up to 10,000 lux for a procedural light, will ensure
melatonin is not suppressed, therefore promoting sleepiness.3,4,10
One also needs to keep in mind that it can take 2 hours after
beginning of endogenous secretion of melatonin before one be-
comes sleepy.9
Noise Control
Background noise at night should not exceed 30 dB or peak
greater than 45 dB according to the World Health Organization.13
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Journal of PeriAnesthesia Nursing 36 (2021) 194e196
Noise over 40 to 55 dB cause adverse health effects; specifically,
noises over 80 dB are associated with spontaneous awakenings.
These spontaneous awakenings lead to decreased quality of sleep
as a result of sleep disruption and or fragmentation.7,13,15 Explicit
measures to control noise need to be implemented to promote
sleep within the acute and critical care unit settings.3,4,13
Programs to improve environmental noise have included envi-
ronmental reviews, noise awareness and education. They also use
multidisciplinary involvement with a champion, operational lead-
ership involvement, or noise feedback systems.13 While meta-
analysis has not shown a statistically significant improvement in
many measured outcomes, there have been several studies that
show improvement in total sleep time, decreased awakenings, and
peak noise levels.13
Care Interruptions Minimized
Even though there is a growing body of knowledge, it has been
reported that as low as 8% of multidisciplinary staff (physicians,
respiratory therapists, nurses, and care technicians) feel that
prioritizing sleep is important.15 When patients are interrupted
more at night, they experience less time in deep restorative sleep.14
This interrupted sleep causes further disruption in circadian
rhythm and sleep-wake cycles as total sleep time plays a role the
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
interruption, as much as possible, so patients can fall asleep and
complete a full cycle.14
Providing 90 to 120 minutes of uninterrupted time at night is
challenging as it is a multidisciplinary problem. A coordinated and
multidisciplinary effort is needed to achieve this goal.15 Without a
coordinated effort, labs could be arbitrarily drawn at 1 a.m., med-
ications could be given at times that are not clinically necessary;
and physicians, nurses, or technicians could be entering the room
sporadically contributing to the 60 interruptions of sleep a
night.14,15
Offering Earplugs and Eye Masks
A simple low-cost intervention that can be offered to patients at
night are earplugs and eye masks. Earplugs or eye masks or both
have been shown to increase subjective sleep quality and signifi-
cantly reduce the risk of delirium.16,17 Subjective sleep quality is
measured by a validated tool for critical care such as the Richards-
Campbell Sleep Questionnaire; a visual analog given to patients to
self-report their perception of sleep across the five sleep domains
which is recommended by SCCM. Objectively, a meta-analysis has
found that when earplugs, eye masks, or both were used over usual
care, the incidence of delirium was significantly reduced.17 Two
pilot studies have shown utilization rate of earplugs to be from 0.9%
to 32% by patients, eye mask utilization of 12% to 44%, and both
earplugs and eye mask utilization of 60%2,18 While a majority of
studies have not shown any benefit of length-of-stay from these
measures, they also typically only follow patients for 24 to 48 hours.
The aforementioned pilot studies followed participants on wards
throughout the patient's stay and found a decrease in length-of-
stay in interventions groups to be 0.9 to 1.16 days; however,
while findings were not statistically significant, these interventions
had a positive effect on length-of-stay when applied across the
hospitalization.2,18
Sleep Disruptions and Delirium
The sleep cycle is a 24-hour period in which during hospi-
talization, there are many threats to altering this natural process.
B.A. Rottweiler and M.B. Flynn Makic
Owing to the multiplex interplay of critical illness, chronic
illness, medications, pain, and environmental factors, a clear
cause and effect has not been made.1,4,6 Whether sleep disrup-
tion causes delirium or delirium caused the sleep disruption,
REM sleep is decreased in individuals who are delirious.1
Moreover, delirium can lead to increased daytime sleep which
further complicates normal sleep cycles,1 and decreased time in
REM sleep leads to cognitive dysfunction and risk for
delirium.4,6,10 When circadian rhythm becomes disrupted as
evidenced by increase daytime sleep, evidence suggests it is
more likely for individuals to experience delirium.1 So, although
a strong cause and effect is not established, there is a clear
association with sleep fragmentation or disruption leading to
delirium and bundles aimed at improving sleep have shown to
decrease the incidence of delirium.1,17
Implications for Practice
In caring for critically ill patients throughout their acute and
critical care hospitalization, there are several ways in which envi-
ronmental factors can contribute to sleep disruption and delirium.
As bedside clinicians, there are several ways risk can be reduced by
implementation of simple measures consistently to promote the
best outcomes. This requires a multi-disciplinary coordinated effort
to ensure timing of patient care allows for minimal disruption
specifically at night. However, successful and consistent efforts to
promote circadian rhythms and normalization of day and night
routines with decreased noise are known to improve subjective
sleep experience, reduce delirium, and improve patient satisfac-
tion.1,13,17 We need to advocate for patients to have earplugs and
eye masks routinely stocked. Patients need to be educated about
the importance of sleep, decreasing light sources, and benefits of
earplugs and eye masks. Care areas need to have environmental
reviews to ensure lighting is optimal during the day to suppress
melatonin and promote wakefulness. Care areas also need envi-
ronmental review to ensure excess and unnecessary noises are
reduced. The combination of all efforts above are needed to ensure
the optimal potential to improve patient outcomes during their
hospitalization.
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Journal of PeriAnesthesia Nursing 36 (2021) 194e196
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