Skip to main content
SpringerLink
Log in

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

  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

ABSTRACT

OBJECTIVES

Despite the known adverse effects of sleep deprivation on recovery from illness, studies have shown that sleep deprivation remains an incompletely addressed problem among acutely ill inpatients. Behavioral interventions are recommended as first-line therapy prior to using pharmacologic therapy due to the side effects of sedative hypnotics. The objective of this systematic review was to identify non-pharmacologic interventions that have been used to improve sleep quality and quantity of non-intensive care unit (ICU) inpatients.

DATA SOURCES

PubMed, Embase, Web of Science, CINAHL, and Cochrane Library through January 2013; manual searches of reference lists.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, INTERVENTIONS

Any study in which a non-pharmacologic intervention was conducted in a general inpatient setting, and nighttime sleep quantity or quality was assessed.

STUDY APPRAISAL AND SYNTHESIS METHODS

Information on study design, populations, interventions, comparators, outcomes, time frame, and risk of bias were independently abstracted by two investigators.

RESULTS

13 intervention studies with 1,154 participants were included. Four studies were randomized controlled trials. Seven studies had a low to medium risk of bias, and there was significant heterogeneity in the interventions. Relaxation techniques improved sleep quality 0–38 %, interventions to improve sleep hygiene or reduce sleep interruptions improved sleep quantity 5 %, and daytime bright light exposure improved sleep quantity 7–18 %.

LIMITATIONS

The heterogeneity in the types and dose of interventions, outcome measures, length of follow-up, differences in patient populations, and dearth of randomized trials may dilute effects seen or make it more difficult to draw conclusions.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

There is insufficient to low strength of evidence that any non-pharmacologic intervention improves sleep quality or quantity of general inpatients. Further studies are needed in this area to guide clinicians.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1

Similar content being viewed by others

REFERENCES

  1. Murphy WJ, Rui H, Longo DL. Effects of growth hormone and prolactin immune development and function. Life Sci. 1995;57(1):1–14.

    Article  CAS  PubMed  Google Scholar 

  2. Spiegel K, Follenius M, Simon C, Saini J, Ehrhart J, Brandenberger G. Prolactin secretion and sleep. Sleep. 1994;17(1):20–27.

    CAS  PubMed  Google Scholar 

  3. Redwine LHR, Gillin JC, Irwin M. Effects of sleep and sleep deprivation on interleukin-6, growth hormone, cortisol, and melatonin levels in humans. J Clin Endocrinol Metabol. 2000;85(10):6.

    Google Scholar 

  4. Palmblad JPB, Wasserman J, Akerstedt T. Lymphocyte and Granulocyte Reactions during sleep deprivation. Psychosom Med. 1979;41(4):5.

    Google Scholar 

  5. Palmblad J, Cantell K, Strander H, et al. Stressor exposure and immunological response in man: interferon-producing capacity and phagocytosis. J Psychosom Res. 1976;20(3):193–199.

    Article  CAS  PubMed  Google Scholar 

  6. Van Cauter E. Review Article—Sleep disturbances and insulin resistance. Diabet Med. 2011;28(12):1455–1462.

    Article  PubMed  Google Scholar 

  7. Broussard JL, Erhrmann DA, Cauter EV, Tasali E, Brady MJ. Impaired insulin signaling in human adipocytes after experimental sleep restriction: A randomized, crossover study. Ann Intern Med. 2012;157(8):549–557.

    Article  PubMed  Google Scholar 

  8. Cappuccio FP, Miller MA. A new challenge to widely held views on the role of sleep. Ann Intern Med. 2012;157:593–594.

    Article  PubMed  Google Scholar 

  9. Arora VM, Fazal AZ, Zee PC, Knutson KL. Objective sleep duration and quality in hospitalized older adults: Associations with blood pressure and mood. J Am Geriatr Soc. 2011;59(11):2185–2186.

    Article  PubMed Central  PubMed  Google Scholar 

  10. Smith MT, Klick B, Koachik S, et al. Sleep onset insomnia symptoms during hospitalization for major burn injury predict chronic pain. Pain. 2008;138(3):497–506.

    Article  PubMed Central  PubMed  Google Scholar 

  11. Griffiths M, Peerson A. Risk factors for chronic insomnia following hospitalization. J Adv Nurs. 2005;49(3):245–253.

    Article  PubMed  Google Scholar 

  12. Gay P. Sleep and sleep-disordered breathing in the hospitalized patient. Respir Care. 2010;55(9):1240–1254.

    PubMed  Google Scholar 

  13. Frighetto L, Marra C, Bandali S, Wilbur K, Naumann T, Jewesson P. An assessment of quality of sleep and the use of drugs with sedating properties in hospitalized adult patients. Health Qual Life Outcome. 2004;2:17.

    Article  Google Scholar 

  14. Southwell MT, Wistow G. Sleep in hospitals at night: are patients’ needs being met? J Adv Nurs. 1995;21(6):1101–1109.

    Article  CAS  PubMed  Google Scholar 

  15. Raymond I, Ancoli-Israel S, Choiniere M. Sleep disturbances, pain and analgesia in adults hospitalized for burn injuries. Sleep Med. 2004;5(6):551–559.

    Article  PubMed  Google Scholar 

  16. Manabe K, Matsui T, Yamaya M, et al. Sleep patterns and mortality among elderly patients in a geriatric hospital. Gerontology. 2000;46(6):318–322.

    Article  CAS  PubMed  Google Scholar 

  17. Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med. 2008;24(1):51–67. vi.

    Article  PubMed  Google Scholar 

  18. Tranmer JE, Minard J, Fox LA, Rebelo L. The sleep experience of medical and surgical patients. Clin Nurs Res. 2003;12(2):159–173.

    Article  PubMed  Google Scholar 

  19. Topf M, Thompson S. Interactive relationships between hospital patients’ noise-induced stress and other stress with sleep. Heart Lung. 2001;30(4):237–243.

    Article  CAS  PubMed  Google Scholar 

  20. Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 1: factors affecting sleep. J Hosp Med. 2008;3(6):473–482.

    Article  PubMed  Google Scholar 

  21. Young JS, Bourgeois JA, Hilty DM, Hardin KA. Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances. J Hosp Med. 2009;4(1):50–59.

    Article  PubMed  Google Scholar 

  22. Glass J, Lactot KL, Herrmann N, Sproule BA, Busto UE. Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. Br Med J (Clin Res Ed). 2005;331:1169–1175.

    Article  Google Scholar 

  23. Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med. 2013;8(1):1–6.

    Article  PubMed  Google Scholar 

  24. Jarman H, Jacobs E, Walter R, Witney C, Zielinski V. Allowing the patients to sleep: flexible medication times in an acute hospital. Int J Nurs Pract. 2002;8(2):75–80.

    PubMed  Google Scholar 

  25. Lenhart SE, Buysse DJ. Treatment of insomnia in hospitalized patients. Ann Pharmacother. 2001;35:1449–1457.

    Article  CAS  PubMed  Google Scholar 

  26. Blair B, Martin J. Toward a good night’s sleep: An approach to insomnia in older patients. Consultant. 2012;52(12):795–803.

    Google Scholar 

  27. Suggested risk of bias criteria for EPOC reviews. Cochrane Effective Practice and Organization of Care Group. Available at http://epoc.cochrane.org/epoc-resources. Accessed September 4, 2013.

  28. Methods Guide for Effectiveness and Comparative Effectiveness Reviews. Agency for Healthcare Research and Quality. Available at http://effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?productid=318&pageaction=displayproduct. Accessed September 4, 2013.

  29. Owens DK, Lohr KN, Atkins D, et al. AHRQ Series Paper 5: Grading the strength of a body of evidence when comparing medical interventions. J Clin Epidemiol. 2010;63:513–523.

    Article  PubMed  Google Scholar 

  30. Lareau R, Benson L, Watcharotone K, Manguba G. Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients. Geriatr Nurs. 2008;29(3):197–206.

    Article  PubMed  Google Scholar 

  31. Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med. 2004;2:87–92.

    Article  Google Scholar 

  32. Toth M, Wolsko PM, Foreman J, et al. A pilot study for a randomized, controlled trial on the effect of guided imagery in hospitalized medical patients [5]. J Alternative Compl Med. 2007;13(2):194–197.

    Article  Google Scholar 

  33. Zimmerman L, Nieveen J, Barnason S, Schmaderer M. The effects of music interventions on postoperative pain and sleep in coronary artery bypass graft (CABG) patients… including commentary by Miaskowski C. Sch Inq Nurs Pract. 1996;10(2):153–174.

    CAS  PubMed  Google Scholar 

  34. Williamson JW. The effects of ocean sounds on sleep after coronary artery bypass graft surgery. Am J Crit Care. 1992;1(1):91–97.

    CAS  PubMed  Google Scholar 

  35. McDowell JA, Mion LC, Lydon TJ, Inouye SK. A nonpharmacologic sleep protocol for hospitalized older patients. J Am Geriatr Soc. 1998;46(6):700–705.

    CAS  PubMed  Google Scholar 

  36. Smith MC, Kemp J, Hemphill L, Vojir CP. Outcomes of therapeutic massage for hospitalized cancer patients. J Nurs Scholarsh. 2002;34(3):257–262.

    Article  PubMed  Google Scholar 

  37. Connell FEA, Tan G, Gupta I, Gompertz P, Bennett GCJ, Herzberg JL. Can aromatherapy promote sleep in elderly hospitalized patients? Geriatr Today. 2001;4(4):191–195.

    Google Scholar 

  38. Bartick MC, Thai X, Schmidt T, Altaye A, Solet JM. Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff. J Hosp Med. 2010;5(3):E20–24.

    PubMed  Google Scholar 

  39. Edinger JD, Lipper S, Wheeler B. Hospital ward policy and patients’ sleep patterns: a multiple baseline study. Rehabil Psychol. 1989;34(1):43–50.

    Google Scholar 

  40. Mishima K, Okawa M, Hishikawa Y, Hozumi S, Hori H, Takahashi K. Morning bright light therapy for sleep and behavior disorders in elderly patients with dementia. Acta Psychiatr Scand. 1994;89:1–7.

    Article  CAS  PubMed  Google Scholar 

  41. Wakamura T, Tokura H. Influence of bright light during daytime on sleep parameters in hospitalized elderly patients. J Physiol Anthropol Appl Human Sci. 2001;20(6):345–351.

    Article  CAS  PubMed  Google Scholar 

  42. Yamadera H, Ito T, Suzuki H, Asayama K, Ito R, Endo S. Effects of bright light on cognitive and sleep-wake (circadian) rhythm disturbances in Alzheimer-type dementia. Psychiatry Clin Neurosci. 2000;54:352–353.

    Article  CAS  PubMed  Google Scholar 

  43. Bonnett MHAD. Heart rate variability in insomniacs and matched normal sleepers. Psychosom Med. 1998;60(5):610–615.

    Google Scholar 

  44. Brown THMT. The Influence of PTSD, Sleep Fears, and Neighborhood Stress on Insomnia and Short Sleep Duration in Urban, Young Adult African Americans. Behav Sleep Med. 2013;11:1–9.

    Article  Google Scholar 

  45. Kompier MATT, van Veldhoven M. Tossing and turning–insomnia in relation to occupational stress, rumination, fatigue, and well-being. Scan J Work Environ Health. 2012;38(3):238–246.

    Article  Google Scholar 

  46. Gross CRKM, Reilly-Spong M, Wall M, Winbush NY, Patterson R, Mahowald M, Cramer-Bornemann M. Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized controlled clinical trial. Explore. 2011;7(2):76–87.

    Article  PubMed Central  PubMed  Google Scholar 

  47. Hoge EAML, Metcalf CA, Morris LK, Robinaugh DJ, Worthington JJ, Pollack MH, Simon NM. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013;74.

  48. Nakamura YLD, Kuhn R, Donaldson GW. Investigating efficacy of two brief mind-body intervention programs for managing sleep disturbance in cancer survivors: a pilot randomized controlled trial. J Cancer Surviv. 2013;7(2):165–182.

    Article  PubMed Central  PubMed  Google Scholar 

  49. Czeisler CA, Richardson GS, Zimmerman JC, Moore-Ede MC, Weitzman ED. Entrainment of human circadian rhythms by light–dark cycles: a reassessment. Photochem Photobiol. 1981;34(2):239–247.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

The authors thank Daniel J. Brotman, MD, Johns Hopkins University for his thoughtful comments during preparation of the manuscript. No compensation was given for his contributions. All authors had full access to the data in the study and take full responsibility for the integrity of the data and the accuracy of the analysis.

No funding was received for this work.

An earlier version of this work was presented at the Society of General Internal Medicine Annual Conference in Denver, CO in April 2013.

Author Contributions

All authors contributed to the collection, extraction, synthesis, and analysis of the data for this systematic review.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Author information

Authors and Affiliations

  1. Division of General Internal Medicine, Johns Hopkins School of Medicine, 2024 E. Monument St, Suite 1-500W, Baltimore, MD, 21287, USA

    Ruth Tamrat BS & Madhav Goyal MD, MPH

  2. Division of General Internal Medicine, Johns Hopkins University, Baltimore, MD, USA

    Minh-Phuong Huynh-Le BS

Authors
  1. Ruth Tamrat BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Minh-Phuong Huynh-Le BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Madhav Goyal MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ruth Tamrat BS.

Additional information

Author Contributions

All authors contributed to the collection, extraction, synthesis, and analysis of the data for this systematic review.

Electronic supplementary material

Below is the link to the electronic supplementary material.

ESM 1

(DOCX 124 kb)

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tamrat, R., Huynh-Le, MP. & Goyal, M. Non-Pharmacologic Interventions to Improve the Sleep of Hospitalized Patients: A Systematic Review. J GEN INTERN MED 29, 788–795 (2014). https://doi.org/10.1007/s11606-013-2640-9

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-013-2640-9

KEY WORDS

Search

Navigation