Meditation is a way of relaxing the mind through techniques such as

focusing and controlled breathing. People meditate to reduce stress and

relieve a variety of physical ailments. Recent research showed meditation
can also help people with diabetes.

Meditation helps people achieve a more peaceful state of mind. It

takes focus and practice to reach a peaceful meditative state of mind.
No special equipment is required to meditate. Effective meditative
techniques have been shown to reduce mental stress, hormone release
and lower blood pressure.

There are different types of meditation. Research presented at an

American Diabetes Association Conference showed mindfulness
meditation is beneficial for people with diabetes. Quiet contemplation
helps you put aside worries about the past and future. The motions of
breathing can bring you into the present moment. This helps you quiet
the mind. Mindfulness meditation relieves anxiety and depression,
which are common symptoms for people with diabetes.

Mindfulness meditation can be done sitting on a chair or the floor.

You can also lie on the floor. The object is to bring yourself into the
present moment by focusing on your breathing. Always wear loose
fitting comfortable clothing while meditating. Beginners can start for
10 minutes a day then work up to 20 minutes daily.

Another type of meditation is transcendental meditation. This is

typically done sitting on the floor. You focus on one word or phrase,
which is called a mantra. Your mantra can be as simple as the word
one. or om . Chant the word and keep breathing for 10 minutes
each day. After a week, try 15 minutes daily then work up to 20
minutes everyday. This helps clear the mind of any thoughts.

If you are unsure about how to meditate, there are books and CDs
available to help you learn. There are web sites on meditation as well.
Yoga instructors and community centers may also offer classes in
meditation.

Mindfulness meditation helps minimize stress levels and lowers

blood pressure. It reduces levels of stress hormones including cortisol,
norepinephrine and epinephrine. Hormones such as cortisol contribute
toward weight gain and belly fat and insulin resistance. Excess weight
increases the risk of high blood pressure and related heart problems.

A study in the Archives of Internal Medicine showed transcendental

meditation can help people with diabetes control their blood sugar
levels. It can also lower blood pressure and reduce insulin resistance.

Meditation is also used to relieve chronic pain. People with diabetes

who have nerve pain or back pain are subject to increased stress and
blood sugar levels. Reducing pain through meditation minimizes
anxiety and related health problems as well as blood sugar readings.

Use blood pressure monitors or blood pressure machines before and

after meditation sessions to gauge your progress. Have a glucose
meter handy to keep track of your blood sugar levels prior and
subsequent to meditation. Give yourself a few weeks to master the
techniques and start seeing real results.

ABSTRACT
The etiology of sleep disruption in patients in intensive care units
(ICUs) is poorly understood, but is thought to be related to
environmental stimuli, especially noise. We sampled 203 patients
(121 males and 82 females) from different ICUs (cardiac [CCU],
cardiac stepdown [CICU], medical [MICU], and surgical [SICU]) by
questionnaire on the day of their discharge from the unit, to
determine the perceived effect of environmental stimuli on sleep
disturbances in the ICU. Perceived ICU sleep quality was significantly
poorer than baseline sleep at home (p = 0.0001). Perceived sleep
quality and daytime sleepiness did not change over the course of
the patients' stays in the ICU, nor were there any significant
differences (p > 0.05) in these parameters among respective units.
Disruption from human interventions and diagnostic testing were
perceived to be as disruptive to sleep as was environmental noise.
In general, patients in the MICU appeared to be more susceptible to
sleep disruptions from environmental factors than patients in the
other ICUs. Our data show that: (1) poor sleep quality and daytime
sleepiness are problems common to all types of ICUs, and affect a
broad spectrum of patients; and (2) the environmental etiologies of
sleep disruption in the ICU are multifactorial.
Several polysomnographic studies have demonstrated sleep
deprivation, sleep fragmentation, and altered sleep architecture in
patients in intensive care units (ICUs) (1-8). Sleep in ICU patients
has been characterized by a predominance of Stages 1 and 2 sleep,
decreased or absent Stage 3 and 4 and rapid eye movement (REM)
sleep, shortened periods of REM sleep, frequent arousals, and sleep

fragmentation. Studies have also shown that 40 to 50% of the total

sleep time in an ICU occurs during the day (2, 6). Altered sleep
patterns may not improve over the course of the patient's ICU stay
(3), and may take several days to normalize after transfer of the
patient to a general hospital ward (7).
The mechanisms responsible for altered sleep/wake cycles are
poorly understood. Studies examining the etiologies of sleep
deprivation in the ICU have focused on environmental stimuli (e.g.,
increased noise and interruptions from human interventions) as the
basis for arousals and sleep fragmentation (1, 9-21). Altered
light/dark cycles, which depend on window orientation and the
ambient light, may make it difficult to achieve sleep, and may alter
circadian rhythms (15, 22). Frequent interruptions for diagnostic
tests and routine patient care also may cause frequent arousals
from sleep. Woods and colleagues (23) found that postcardiotomy
patients had their sleep interrupted on an average of 59.5 times per
night, with the greatest amount of uninterrupted sleep time being
43 min on postoperative Day 1.
The environmental stimulus most often cited in the literature as
disturbing sleep is noise (10, 15, 16). The U.S. Environmental
Protection Agency (EPA) recommends that hospital noise levels not
exceed 45 dB during the day and 35 dB at night (24). Several
studies have shown that noise levels in the ICU are substantially
higher than the EPA recommendations (12, 15, 16, 25, 26). Noise
levels in the ICU range from 60 dB to 84 dB throughout a 24-h
period (10, 15). As references, a busy office has average noise
levels of 70 dB and a pneumatic drill heard from 50 ft away has a
noise level measured at 80 dB (16). Noise levels below 40 dB are
generally required for a normal individual to fall asleep, and
increases in noise intensity are known to cause arousals from sleep
(9). Exposure of normal individuals in a sleep laboratory to nocturnal
ICU noise levels results in decreased total sleep time, decreased
total REM sleep time, and decreased sleep efficiency; and to
increased REM sleep latency and an increased arousal index
(number of arousals from sleep/hour of sleep) (19, 20). However,
polysomnographic studies of ICU patients have so far only indirectly
linked noise to sleep disruption (1).
The effect of environmental stimuli on sleep disruption in ICU
patients has never been examined in a large-scale study. To gain a
better understanding of the underlying mechanisms of altered
sleep/wake patterns in ICU patients, and specifically to determine
the effect of the ICU environment on sleep quality, we sampled a
cohort of ICU patients. Our primary hypothesis was that noise would
be the most disruptive environmental stimulus to subjective sleep

quality. Secondary aims of the study were to determine: (1) whether

sleep quality and daytime sleepiness changed over the course of a
patient's ICU stay; (2) whether there were differences in sleep
quality between ventilated and nonventilated patients; (3) whether
there were differences in sleep quality between different types of
ICUs; and (4) the relative roles of other environmental factors
(human interventions, light) on perceived sleep disruption.

METHODS
Site
The study was conducted between July 1996 and April 1997 at the
University of Pennsylvania Medical Center, and was approved by the
Institutional Review Board of the university.
Questionnaires were given to patients on the day of their discharge
from four ICUs: (1) a 12-bed cardiac care unit (CCU); (2) an 18-bed
cardiac intermediate care unit (CICU); (3) a 24-bed surgical
intensive care unit (SICU); and (4) a 24-bed medical intensive care
unit (MICU).
Patients
Patients were volunteers who received no remuneration for their
participation. Patients scheduled for discharge from their respective
ICU were selected to participate in the study. All patients except
those who had insufficient cognitive function to allow them to
cooperate were candidates for the study. Patients gave oral consent
prior to their participation. Those patients unable to fill out the
questionnaire because of muscle weakness or poor eyesight had the
questionnaire read aloud to them and their verbal responses
recorded.
Questionnaire
A questionnaire was developed that assessed the sleep quality of
ICU patients and the factors that contributed to sleep disruption
among these patients (Figure 1). Patients evaluated their sleep
quality on a scale of 1 to 10 (1 = poor, 10 = excellent) at home and
in the ICU. Sleep quality over the duration of the patients' ICU stay
was assessed with the same scale. Participants were asked to
determine their degree of daytime sleepiness over the duration of
their ICU stay on a scale of 1 to 10 (1 = unable to stay awake, 10 =
fully alert and awake). The effect of environmental stimuli on sleep
disruption was measured on a scale of 1 to 10 (1 = no disruption, 10
= significant disruption). The environmental stimuli that were
evaluated included noise, light, nursing interventions (bathing, etc.),
diagnostic tests (i.e., chest radiographs), evaluation of vital signs,

blood sampling, and the administration of medications. Patients

were also asked to assess the effects of different ICU noises on
sleep disruption, using a scale of 1 (no disruption) to 10 (significant
disruption). The ICU noises that were evaluated included telemetry
alarms, ventilator sounds and ventilator alarms (for applicable
patients), sounds of pulse oximetry, communications between staff
members, intravenous pump alarms, suctioning sounds, doctor's
beepers, and television and telephone sounds. This last section of
the questionnaire was added after the questionnaire was pilot
tested on the first 43 patients.
Fig

The questionnaire utilized in the study. [More]

Statistical Analysis
Demographics. A one-way analysis of variance (ANOVA) was used to
determine differences in age and duration of stay among respective
units. Chi-square analysis was used to determine differences in
sexes and numbers of ventilated patients among units.
Primary analysis. Pearson's correlation analysis was used to
determine the relationship of patient age and duration of stay to the
following factors: sleep quality, daytime sleepiness, environmental
disruptive factors, and specific ICU noises. Spearman's correlation
analysis was used to confirm the Pearson's analysis. Only the
Pearson's correlation coefficients were reported if there was
agreement between these latter two analyses. The square root of
the number of days (instead of the actual number of days) a patient
spent in the ICU was used in the calculation for duration of stay, to
correct for the large range of values. Unpaired Student's t tests were
used to compare differences between males and females and
between ventilated and nonventilated patients in relation to sleep
quality, daytime sleepiness, environmental disruptive factors, and
specific ICU noises. A one-way ANOVA was used to compare
differences between the respective units and these factors.
Multivariate and univariate repeated-measures ANOVAs were used
to test for significant systematic differences among perceived
degrees of disruption by the various environmental activities
examined in the study. First, a Wilks' lambda F-statistic was used to
test the overall null hypothesis of equal mean values at = 0.05.

When this hypothesis was rejected, a set of comparisons between

each disruptive factor and the patient specific mean was examined.
Thus, Type I error was controlled only at the level of the overall
hypothesis.
Factor analysis. Factor analysis was done to establish patterns of
interrelationships and associations between variables, as well as to
internally validate our questionnaire. An orthogonally rotated, fourfactor analysis was used, since it confirmed a clear factor structure.
The data on the disruptive effect of specific ICU noises on ICU sleep
were not included in the factor analysis because only 160 patients
completed this section of the questionnaire. The relative proportion
of variance explained by each of the four factors in the analysis was
computed as the sum of the squared factor loadings divided by the
sum of the shared variance. Bivariate analysis with Factors 1
through 4 was done to determine associations between each of the
factors and: age, duration of ICU stay, gender, ventilator status, and
respective ICU.

RESULTS
Demographics
A total of 203 patients completed the questionnaire (Table 1).
Overall, there were significantly more males than females in the
study (p < 0.05), although there were no significant (p > 0.05)
gender differences among ICUs. The MICU patients were
significantly younger than patients in other units (p = 0.003).
Otherwise, there were no age-dependent differences (p> 0.05)
among the ICUs. The durations of stays in the CICU and MICU were
longer than in other units (p = 0.02). The MICU had significantly
more ventilated patients than did other units (p = 0.001).

Table 1
View Larger Version

DEMOGRAPHICSOFSTUDYPOPULATION*
Primary Analysis
Sleep quality in the ICU was perceived as significantly poorer than
sleep at home (p = 0.0001) by all subjects (Figure 2). Neither quality
nor perceived daytime sleepiness changed significantly over the
course of any patient's ICU stay (p > 0.05). There were no

significant differences between genders or individual ICUs in

perceived ICU sleep quality or daytime sleepiness, nor were there
any significant correlations of perceived ICU sleep quality or
daytime sleepiness with patient age or duration of ICU stay (p >
0.05). Perceived ICU sleep quality was not significantly different for
ventilated and nonventilated patients (p > 0.05). These data
indicate that poor sleep quality and sleep disruption are problems
common to all types of ICUs and to many ICU patients.
Fig

Bar graph highlighting differences in perceived sleep quality

between home and the ICU. [More]
There were statistically significant differences between the
individual environmental factors (p < 0.0001) in terms of their
perceived degrees of ICU sleep disruption (Figure 3). Checking of
vital signs and phlebotomy were perceived as significantly more
disruptive (p = 0.006) to sleep than was the mean of the other
factors. Environmental light and medication administration were
perceived as significantly less disruptive (p= 0.003) to sleep than
was the mean of the other factors. Environmental noise, nursing
interventions, and diagnostic tests were perceived as not
significantly different (p > 0.05) in their disruptive effect on sleep
than was the mean of the other disruptive factors. These data
indicate that multiple environmental factors disturb sleep in the ICU,
with noise being first among a number of important sleep-disruptive
factors. However, there were no significant associations between
individual environmental factors (noise, light, nursing interventions
[bathing, etc.], diagnostic tests [i.e., chest radiography], recording
of vital signs, blood sampling, and the administration of
medications) and perceived sleep disruption in relation to patient
age, gender, length of stay, ventilator status, or respective unit (p >
0.05).
Fig

Bar graph highlighting perceived sleep disruption from the ICU

environment.[More]

 One hundred and sixty ICU patients completed the final section of
the questionnaire, which evaluated the relationship between
specific ICU noises and perceived sleep disruption. There were
significant differences (p < 0.0001) among the specific ICU noises in
terms of their perceived disruptive effect on sleep in the ICU.
Communication between staff members (talking) and telemetry
alarms were significantly more disruptive (p = 0.003) to sleep than
was the mean of the other factors. Noises from telephones,
television, and doctors' beepers were significantly less disruptive (p
= 0.0001) to sleep than was the mean of the other factors. Sounds
of pulse oximetry and intravenous pump alarms were perceived as
not significantly different (p > 0.05) than the mean of the other
disruptive factors (Figure 4). There were no significant associations
between patient age or duration of stay and sleep disruption by
specific noises. There were no significant differences between the
respective ICUs and perceived sleep disruption by specific noises (p
> 0.05).
Fig

Bar graph highlighting perceived sleep disruption by specific

environmental noises. [More]
Factor Analysis
Factor analysis was used to extract patterns of association from the
data set and to reduce the large number of variables from the
questionnaire to a smaller number of reference factors.
Table 2 presents the factor loadings for the four-factor model after
orthogonal rotation. The loadings refer to the correlation of each
variable with each factor. A cutoff value of 0.40 was used to
determine whether a particular variable was strongly associated
with a specific factor. The loadings confirmed a definite factor
structure; each of the questions had a large loading (strong
association) on only one factor. The four factors were interpreted as
follows: Factor 1, sleep disruption secondary to interruptions by
hospital staff and diagnostic tests; Factor 2, ICU sleep quality; Factor
3, daytime sleepiness; and Factor 4, sleep disruption by
environmental factors (light and noise). The total variance explained
by the four-factor model was 54.9%. The proportions of the total
variance that were explained by Factors 1 through 4 were 18.2%,
16.2%, 11.7%, and 8.8%, respectively.

Table 2
View Larger Version

ORTHOGONALLYROTATEDFACTORPATTERN.
Factor analysis confirmed several findings from the primary
analysis. None of the four factors showed significant (p> 0.05)
associations with patient age or gender. The duration of stay was
not (p > 0.05) associated with sleep disruptions caused by human
intervention (Factor 1), sleep quality (Factor 2), or daytime
sleepiness (Factor 3). A patient's ventilator status was not (p > 0.05)
associated with perceived sleep disruptions caused by human
intervention (Factor 1), noise/ light (Factor 4), or sleep quality
(Factor 2). Also, neither sleep quality nor daytime sleepiness was (p
> 0.05) associated with a patient's respective unit.
Factor analysis allowed the detection of specific associations with
respect to sleep quality, daytime sleepiness, and sleep disruption
caused by the ICU environment that were not evident in the primary
analysis. Daytime sleepiness (Factor 3) was significantly different in
ventilated and nonventilated patients (p = 0.008), with ventilated
patients experiencing more daytime sleepiness than nonventilated
patients. Sleep disruption caused by environmental light and noise
(Factor 4) showed a weak but significant positive correlation (r =
0.19; p= 0.006) with duration of ICU stay (i.e., patients who had
longer stays in the ICU were more likely to have their sleep
disturbed by environmental light and noise). Sleep disruptions
caused by human interventions/diagnostic tests and environmental
light/noise (Factors 1 and 4) were significantly different in the
different units (p = 0.0365 and p = 0.0028, respectively) (Table 3).

Table 3
View Larger Version

COMPARISONOFFACTORS1AND4ACROSSUNITS.
Table 3 shows that patients in the MICU perceived interruptions
caused by human interventions and diagnostic tests (Factor 1) to be

significantly more disruptive to their sleep than did patients in the

SICU and CICU (p = 0.012 and 0.016, respectively). There were no
significant differences among the other groups with respect to
Factor 1 (p > 0.05). MICU patients also perceived environmental
light and noise (Factor 4) to be significantly more disruptive to their
sleep than did patients in the SICU and CCU (p = 0.009 and 0.001,
respectively). Patients in the CICU perceived environmental light
and noise to be significantly more disruptive to their sleep than did
patients in the CCU (p = 0.016), with a trend toward significance
versus patients in the SICU (p = 0.06). There were no significant
differences among the other groups with respect to Factors 1 and 4
(p > 0.05).

DISCUSSION
We subjectively evaluated sleep and the environmental factors
disrupting sleep in 203 patients discharged from medical, surgical,
and cardiac ICUs. Overall, perceived ICU sleep quality was poorer
than sleep quality at home. Sleep quality and daytime sleepiness
did not change over the course of the patients' ICU stays, and there
were no significant differences in these parameters among the
different units. Factor analysis showed that patients who had been
mechanically ventilated during their ICU stay were significantly
sleepier during the day than were nonventilated patients. Overall,
sleep quality, daytime sleepiness, and perceived disruptions in sleep
caused by environmental factors were not affected by the patients'
age or gender. Although the primary analyses did not show
significant differences between various environmental sources of
sleep disruption, factor analysis showed that MICU patients
perceived their sleep to be more disrupted by environmental factors
than did patients in other units.
Study Design and Limitations
Our study design had several limitations. Because the study
assessed sleep quality subjectively, we were unable to determine
the patients' true sleep architecture and degree of sleep disruption
caused by the various environmental stimuli. However, we believe
that this investigation was an essential first step in understanding
the factors perceived by ICU patients as disturbing sleep. We did not
control for patients' severity of illness or medication use, both of
which factors may have affected the results of the study. We also
did not have a control group of hospitalized non-ICU patients for
comparison, since our main objectives were to determine whether
sleep quality was disturbed in an ICU setting and to determine the

effect of ICU environmental stimuli (specifically noise) on perceived

sleep disruption. Thus hospitalized non-ICU patients would not have
constituted a suitable control group, since the environmental stimuli
to which they are exposed differ from those to which the ICU patient
is exposed. Future studies, however, should be performed with
polysomnography to accurately quantify total sleep times and
define sleep architecture.
The demographics of our ICU patients were different across the ICUs
in our study. There were significantly more males than females in
the cohort. MICU patients were significantly younger than the
patients in other units, and MICU and CICU patients had significantly
longer durations of stay than did CCU or SICU patients. However, we
do not believe that these demographic differences adversely
affected our results, because patient age, sex, and duration of ICU
stay as a whole were not significantly associated with differences in
perceived sleep quality, daytime sleepiness, or sleep disruptions
caused by environmental stimuli.
Because the present study was the first instance of application of
our questionnaire to a large ICU population, the test-retest reliability
and validity of the questionnaire are unknown, and will require
further study. Our questionnaire appears to be internally valid, on
the basis of the groupings in the factor analysis. Assessment of the
validity of our questionnaire for assessing sleep quality and the
etiologies responsible for sleep disruption in the ICU will require
future objective (polysomnographic) studies in conjunction with the
questionnaire.
Recall bias is another potentially confounding problem for
questionnaire studies in general. This did not appear to be a major
problem with our questionnaire, however, since the duration of ICU
stay was not associated with changes in sleep quality, daytime
sleepiness, or perceived environmental disruptions of sleep.
Because no large studies have objectively evaluated the accuracy of
patient recollections of their ICU stays, and it is clinically apparent
that many ICU patients who undergo heavy sedation do not
remember much of their ICU stay, our results may have been
subject to patient recall bias, especially by those patients with
longer durations of ICU stay and in those patients who were heavily
sedated for a portion of their ICU stay.
Additionally, there may have been a recruitment bias that
potentially prevents application of the results of our study to the
entire ICU population. Although all ICU patients were eligible to
participate in the study, those patients who were not discharged
from their respective ICUs because of increased severity of illness
were not included in the study. Therefore, our results cannot be

generalized to critically ill ICU patients who die before their ICU
discharge.
Sleep Quality and Daytime Sleepiness in the ICU
Our finding that patients perceive their sleep quality to be worse in
the ICU than at home is supported by previous investigations (1-8).
Studies of sleep in ICU patients indicate that their sleep is abnormal,
as demonstrated by a predominance of Stages 1 and 2 sleep,
decreased or absent Stages 3 and 4 and REM sleep, shortened
periods of REM sleep, frequent arousals, and sleep fragmentation
(1-8). Our results also demonstrate that perceived sleep quality and
daytime sleepiness did not improve over the course of our patients'
ICU stays. These results are consistent with those of previous
polysomnographic studies, which showed that 40% to 50% of the
total sleep time in an ICU occurred during the day, and that altered
sleep patterns may not improve over the course of a patient's ICU
stay, and may take several days to normalize after transfer of the
patient to a general hospital ward (2, 3, 6, 7).
Although daytime sleepiness appeared to be a problem common to
all of the types of ICUs investigated in our study, factor analysis
showed that patients who had been mechanically ventilated during
their ICU stay perceived that they were significantly more sleepy
during the day than were nonventilated patients. This finding may
be explained by the typically greater sedation of mechanically
ventilated than of nonventilated patients, and their greater severity
of illness than that of nonventilated patients. Further studies will be
necessary to determine whether sedation and severity of illness are
correlated with sleep disruption in the ICU.
Interestingly, there were no differences among any of the individual
ICUs in perceived sleep quality, nor were there any associations
between sleep quality and patient age, gender, duration of stay, or
ventilator status. This suggests that poor sleep quality and
disrupted sleep are problems common to all ICUs and to many ICU
patients. It also suggests that factors disturbing sleep are generic to
all ICUs.
Sleep Disruption and the ICU Environment
Our findings support the assertion that environmental causes of
sleep disruption in the ICU are multifactorial. Our data indicate that
human interventions and diagnostic testing appear to be as
important to disrupting sleep as is environmental noise. Our findings
do not support our primary hypothesis that ICU noise is the most
disruptive environmental stimulus to sleep for most ICU patients. In
fact, the effect of specific ICU noises on sleep disruption appears to
be low, as shown by the low mean sleep-disruptive scores in our

study. This finding contradicts much of the current literature, which

suggests that noise is the major ICU factor responsible for sleep
disruption (1, 6, 10, 12, 13, 15-18, 21, 27-29).
Why was noise not perceived as the most sleep-disruptive factor in
the ICU? A number of possible explanations exist for this finding.
First, noise in the ICU setting may not be as disruptive to sleep as is
currently thought. Patients in intensive care may adapt quickly to
environmental noise. Previous studies have shown that patients
habituate to sound by increasing their arousal threshold with time,
with some individuals being able to increase their arousal threshold
for noise to more than 80 dB (30, 31). Second, noise may have
caused arousals but not awakenings during sleep among our
patients, leading to sleep fragmentation and poor sleep quality.
Patients may not have been able to recall the etiology of their
fragmented sleep because they were never fully awakened from
sleep. Third, noise may have caused awakenings during delta sleep,
when it is more difficult for individuals to recall the etiology of an
awakening. This last explanation is an unlikely one, since the current
literature indicates that ICU patients show decreased or absent
delta sleep (2, 6).
Our results support the postulate that interruptions of sleep in the
ICU are multifactorial, and that those caused by human
interventions and diagnostic tests are important. This finding is
consistent with the results described earlier in a study done by
Woods and colleagues (23), who found that postcardiotomy patients
had their sleep interrupted by human interventions (recording of
vital signs, phlebotomy, etc.) on an average of 59.5 times per night,
with the greatest amount of uninterrupted sleep time being 43 min
on postoperative Day 1. The number of nocturnal awakenings
decreased and the uninterrupted potential sleep time increased on
subsequent hospital days. Meyer and coworkers monitored sleep
interruptions in ICU patients over a 24-h period and showed that
interruptions caused by human interventions occurred at least
hourly throughout the day and night (15). Future research should
focus on methods for decreasing frequent interruptions of sleep in
ICU patients, especially at night, to allow them to achieve longer
periods of consolidated sleep.
Patient characteristics such as age, gender, or ventilator status were
not related to perceived sleep quality or disruptions caused by any
specific environmental stimulus in our study. That older age was not
associated with poorer sleep quality is not necessarily consistent
with findings reported in the literature. Typically, older individuals
are more likely to be aroused from sleep than are younger
individuals (30, 31), yet the mean age of our patients was 58.6

15.4 yr. We may not have sampled enough younger patients (age <
40 yr) to show a significant association between age, sleep quality,
and sleep disruptions. One would also assume that patients who
were mechanically ventilated and thus exposed to the additional
noise of ventilators and alarms would perceive the ICU environment,
and specifically noise, as more disruptive to their sleep than would
nonventilated patients. This was not the case in our study. Our
results suggest that all ICU patients, and not specific subgroups, are
at risk for sleep disturbances.
Our results support the assertion that sleep disruption in the ICU is
multifactorial, and suggest that other, nonenvironmental factors
may be responsible for causing sleep disruptions in the ICU patient
population. In general, the mean disruption scores for the
environmental factors and specific ICU noises causing sleep
disruption in our study were relatively low, although the perceived
sleep quality among the vast majority of patients was poorer than
that of sleep at home. It is clear that the ICU environment is not
solely responsible for disturbed sleepwake patterns. Several
nonenvironmental factors, such as medications (32), pain, fever
(9, 33), and a patient's underlying chronic disease may have
adverse effects on sleep quality (34, 35). Studies with surgical ICU
patients that have decreased the number of environmental
interruptions of sleep have not demonstrated improvement in the
patients' altered sleep patterns. Other studies have shown
continued alterations in sleep duration and other sleep parameters
when patients were transferred from the ICU to a hospital ward (3).
It is possible that the severity of illness or underlying disease states
contributed to the perceived differences in sleep quality in our
study. Future studies should examine the effects of relationships
between disease severity, age, medications, and time in the ICU on
disruptions of sleepwake patterns in the ICU, although this may
prove difficult, given the number of potentially confounding factors.

CONCLUSIONS
Our results show that good-quality sleep may be difficult to achieve
in patients under intensive care. Poor sleep quality and sleep
disruptions are problems common to many ICU patients, and
environmental factors disturbing sleep are generic to all types of
ICUs. Although environmental noise is an important contributor to
sleep disruption in ICU patients, it is only one of a series of
important factors. Among other environmental factors responsible
for sleep disruptions in ICU patients, interruptions caused by human

interventions and diagnostic testing appear to be as important as

environmental noise. Objective studies are required to accurately
determine the impact of the ICU environment on sleep disruption in
patients under intensive care. Future studies aimed at improving
sleep in ICU patients should focus on decreasing the number of
interruptions caused by human interventions, in addition to means
for alleviating environmental noise.

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