A ReLACSing Blog#14: 8 Tactics to Sleep While Hospitalized
Several days ago, I had the privilege of presenting another webinar for the Restless Legs Syndrome Foundation on Surgery and Hospitalization with RLS (requires RLS Foundation membership to view).
Piggybacking on this presentation, we can review the best strategies for maximizing sleep in the hospital (specifically, as a patient, as we all know doctors, nurses, lab techs, pharmacy, medical techs, and most hospital staff are unlikely to get much sleep in the hospital!). I had a former colleague many years ago who made an excellent Grand Rounds presentation on this topic from the hospital/physician side, and it is pretty evident that despite the growing awareness of sleep and its importance to healthspan and longevity in the general population, the medical field continues to struggle to recognize the importance of this in the hospital setting. The medical field generally does not respect the sleep of its own personnel, so why would it prioritize sleep in the hospital setting for patients?
Despite some changes to duty hours mainly for trainees over the years, most people are aware of physicians who work 36 straight hours without sleep, surgeons who may have to operate on little to no sleep in the morning after being on call at night tending to emergencies, nurses who have an afternoon-evening shift followed by a morning shift due to staffing shortages, pharmacists who work 7 nights followed by 7 days and then another 7 nights, creating such circadian rhythm disruption that they live perpetually jet-lagged. The operation of the hospital does not work itself around patients’ sleep schedules either. However expected the disruption would be, some effort to protect your sleep may help with recovery quite substantially–whether you are hospitalized due to surgery or an infection. Here are some tips for preserving sleep:
1. Find an advocate. This applies not just for sleep. The hospital is often a hectic, busy environment in which urgent matters are prioritized with less attention to some of the basics. Make sure you find an advocate (spouse, friend, relative, or even hospital-assigned) to stay with you as much of the time as you are in the hospital to look after you. If this is a planned hospitalization, then prepare with your surgical and/or anesthesia team before you become incapacitated or less able to look out for yourself, if you have any sleep disorders that require treatment. Fewer misses or mistakes may be made if your care passes through another set of independent eyes.
2. Alert support staff that sleep is a priority for you to minimize unnecessary disruption. If you are not in the medical field, it is important to understand the rounding process for physician teams. Most hospital rounds, in which a physician or their team essentially makes the rounds on all the patients on the list, occurs in the mid-morning period. There is often “pre-rounds,” which could be as early as 4 am for surgical teams who may start operating at 7 am. This is more common in academic or teaching hospitals when the medical students and residents see the patients first to prepare their presentations and gather information for the entire team later in the morning. Much of the evaluation requires a review of labs, which may need to be done 1-2 hours before pre-rounds. Now you can see how you potentially could get disrupted for a blood draw at 4 am, again at 5:30 am for pre-rounds. Just as you doze back off, the whole team is in there at 8 am, and then you’re off to a radiograph (aka X-ray) thereafter. Nevermind the 10 pm medications, the late night wound-check, or even the 1 am rounds the custodial staff may perform to empty the trash. Your nurses may be required to check your vitals every 2 hours even during the night. Some of these disruptions cannot be avoided, but you and your advocate can discuss areas with the nursing staff as to where awakenings can be limited. For example, you could ask that the nurse do the next vitals around 4 am when the phlebotomist is already coming to wake you up to draw your blood.
Nothing like a poke to wake you up at 4 am!
3. Try to mimic your home schedule and home environment as much as possible. Keep the lights off from 9 pm to 6 am. Keep the lights on from 6 am to 9 pm and open the shades. It is unfortunate, but many hospitals still have shared rooms, so have the nurse ask your roommate to use earbuds or headphones or mute the TV if they are up watching at 2 am. Though the hospital schedule may conflict with your home sleep schedule, try to maintain some semblance of night and day. You may sleep more at times due to certain medications, effects of infection and inflammation, or the medical condition itself. It is best not to catch up on sleep with 5 hours of napping in the afternoon only to be up most of the night before the 3:30 am blood draw. Maybe if you have a short night of sleep, try a 90 minute nap and then go to bed earlier that night to stay on your biological schedule.
4. Avoid sleeping pills. At the same time we are saying sleep is important, a medically-induced lower level of consciousness is not what we are after. The disruption of sleep is expected. Yes, if you got 2 hours of sleep during the night and then slept 5 hours during the day, you may have a hard time sleeping the next night. Yes, your roommate may be screaming or be hearing impaired and watching the 12th consecutive episode of Law & Order at 2:30 am at max volume (just before the 3 am blood draw!), but Benadryl, trazodone, and Ambien are not great solutions. Many of these drugs simply may alter your level of consciousness and leave you impaired but still awake. They can also increase risk of a fall or injury, combined with the IV pole to which you are tethered, and those grippy hospital socks won’t save you.
5. If you have obstructive sleep apnea, bring your CPAP (or other PAP device) and supplies to the hospital with you. Unless your sleep apnea is really severe and your oxygen is tanking, your team in the hospital may have other worries than this chronic medical condition. You don’t want to be put on CPAP through a hospital ventilator with whatever clunky hospital mask they have available that may not fit or be at the right settings. Bring your device and mask from home. Use the machine when you are sleeping. Alert your nurse that you need to wear this unless there is a medical reason not to. You don’t want to wake up with a cannula in your nose on 3 liters of oxygen in the morning despite not having any heart or lung issues because the pulse oximeter kept reading low oxygen levels due to sleep apnea. The low oxygen, inflammation, and further disruption to your sleep from untreated sleep apnea are not helpful to healing and recovery.
6. If you have restless legs syndrome (RLS), try to stay on your home medications, and have them administered at the correct time! Restless legs syndrome is a circadian phenomenon that typically occurs at night, even when things become topsy-turvy in the hospital (see #2). Taking your 6 pm and 10 pm gabapentin “twice daily” might mean you get them at 8 am and 8 pm, which may be the default time for twice daily medications, leaving you even drowsier in the morning with less relief of RLS while confined to a hospital bed at night. Some of the medications, including dopamine agonists, if not given at all, may precipitate a withdrawal response and then you may be really miserable.
7. Get as much physical activity as possible. Every patient is a fall risk, and hospitals get dinged on quality metrics any time a patient falls, but get out of your hospital bed as much as (safely) possible! There is tremendous deterioration and decompensation of muscles for each day you are confined to a hospital bed, so if your condition allows you to be active, be more active. This will help you to mimic the daytime activity when at home and allow for better rest at night. If you have restless legs, this will also help with the stimulation to the legs to relieve and prevent some of the restlessness.
8. When you get back home, try to get back to a semblance of a regular sleep-wake schedule, particularly with consistent wake up time. You don’t want your biological clock to spiral out of control when trying to recover from hospitalization. You may be very sleep deprived from the above disruption, fighting an infection, effects of medications, and the illness/injury itself. You may need more sleep for recovery but try to maintain your schedule, even if expanded for more sleep time. Don’t take hours and hours of naps during the day, leading to clock disruption and reduced sleep quality at night. At home, within the safety and restrictions discussed by your doctors and support staff, be aggressive about activity and physical rehabilitation, which will then help you sleep better at night.
- Andy Berkowski, MD of ReLACS Health, who never slept well in the hospital either
