Association of Sleep Duration with Mortality from Cardiovascular Disease and Other Causes for Japanese Men and Women the JACC Study

ABSTRACT

Ikehara S, Iso H, Date C, Kikuchi S, Watanabe Y, Wada Y, Inaba Y, Tamakoshi A; JACC Study Group

STUDY OBJECTIVES: To examine sex-specific associations between sleep duration and mortality from cardiovascular disease and other causes.

DESIGN: Cohort study.

SETTING: Community-based study.

PARTICIPANTS: A total of 98,634 subjects (41,489 men and 57,145 women) aged 40 to 79 years from 1988 to 1990 and were followed until 2003.

INTERVENTIONS: N/A.

MEASUREMENTS AND RESULTS: During a median follow-up of 14.3 years, there were 1964 deaths (men and women: 1038 and 926) from stroke, 881 (508 and 373) from coronary heart disease, 4287 (2297 and 1990) from cardiovascular disease, 5465 (3432 and 2033) from cancer, and 14,540 (8548 and 5992) from all causes. Compared with a sleep duration of 7 hours, sleep duration of 4 hours or less was associated with increased mortality from coronary heart disease for women and noncardiovascular disease/noncancer and all causes in both sexes. The respective multivariable hazard ratios were 2.32 (1.19-4.50) for coronary heart disease in women, 1.49 (1.02-2.18) and 1.47 (1.01-2.15) for noncardiovascular disease/noncancer, and 1.29 (1.02-1.64) and 1.28 (1.03-1.60) for all causes in men and women, respectively. Long sleep duration of 10 hours or longer was associated with 1.5- to 2-fold increased mortality from total and ischemic stroke, total cardiovascular disease, noncardiovascular disease/noncancer, and all causes for men and women, compared with 7 hours of sleep in both sexes. There was no association between sleep duration and cancer mortality in either sex.

CONCLUSIONS: Both short and long sleep duration were associated with increased mortality from cardiovascular disease, noncardiovascular disease/noncancer, and all causes for both sexes, yielding a U-shaped relationship with total mortality with a nadir at 7 hours of sleep. (Sleep. 2009 Mar;32(3):295-301)

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Assessment of Sleep in Ventilator-Supported Critically Ill Patients

ABSTRACT

Ambrogio C; Koebnick J; Quan SF; Ranieri VM; Parthasarathy

Objectives: In critically ill patients, sleep derangements are reported to be severe using Rechtschaffen and Kales (R&K) methodology; however, whether such methodology can reliably assess sleep during critical illness is unknown. We set out to determine the reproducibility of 4 different sleep-assessment methods (3 manual and 1 computer-based) for ventilator-supported critically ill patients and also to quantify the extent to which the reproducibility of the manual methods for measuring sleep differed between critically ill and ambulatory (control) patients.

Design: Observational methodologic study.

Setting: Academic center.

Patients: Critically ill patients receiving mechanical ventilation and age-matched controls underwent polysomnography.

Interventions: None.

Measurements and Results: Reproducibility for the computer-based method (spectral analysis of electroencephalography [EEG]) was better than that for the manual methods: R&K methodology and sleep-wakefulness organization pattern (P = 0.03). In critically ill patients, the proportion of misclassifications for measurements using spectral analysis, sleep-wakefulness organization pattern, and R&K methodology were 0%, 36%, and 53%, respectively (P < 0.0001). The EEG pattern of burst suppression was not observed. Interobserver and intraobserver reliability of the manual sleep-assessment methods for critically ill patients (κ = 0.52 ± 0.23) was worse than that for control patients (κ = 0.89 ± 0.13; P = 0.03). In critically ill patients, the overall reliability of the R&K methodology was relatively low for assessing sleep (κ = 0.19), but detection of rapid eye movement sleep revealed good agreement (κ = 0.70).

Conclusions: Reproducibility for spectral analysis of EEG was better than that for the manual methods: R&K methodology and sleep-wakefulness organization pattern. For assessment of sleep in critically ill patients, the use of spectral analysis, sleep-wakefulness organization state, or rapid eye movement sleep alone may be preferred over the R&K methodology. (SLEEP 2008;31(11):1559–1568)

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Adverse Environmental Conditions in the Respiratory and Medical ICU

ABSTRACT

Meyer TJ, Eveloff SE, Bauer MS, Schwartz WA, Hill NS, Millman RP.

Sleep deprivation and fragmentation occurring in the hospital setting may have a negative impact on the respiratory system by decreasing respiratory muscle function and ventilatory response to CO2. Sleep deprivation in a patient with respiratory failure may, therefore, impair recovery and weaning from mechanical ventilation. We postulate that light, sound, and interruption levels in a weaning unit are major factors resulting in sleep disorders and possibly circadian rhythm disruption. As an initial test of this hypothesis, we sampled interruption levels and continuously monitored light and sound levels for a minimum of seven consecutive days in a medical ICU, a multiple bed respiratory care unit (RCU) room, a single-bed RCU room, and a private room. Light levels in all areas maintained a day-night rhythm, with peak levels dependent on window orientation and shading. Peak sound levels were extremely high in all areas representing values significantly higher than those recommended by the Environmental Protection Agency as acceptable for a hospital environment. The number of sound peaks greater than 80 decibels, which may result in sleep arousals, was especially high in the intensive and respiratory care areas, but did show a day-night rhythm in all settings. Patient interruptions tended to be erratic, leaving little time for condensed sleep. We conclude that the potential for environmentally induced sleep disruption is high in all areas, but especially high in the intensive and respiratory care areas where the negative consequences may be the most severe. (Chest. 1994 Apr;105(4):1211-6)

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Adverse Effects of Sleep Deprivation in the ICU

 Rachel E. Salas, MDa, Charlene E. Gamaldo, MD.

The hospital is not conducive to sleep. Patients commonly recount major issues with sleep initiation and poor sleep quality during their hospital stay. Moreover, patients in the ICU are particularly susceptible to sleep disruption secondary to environmental and medical issues. Despite the frequency of sleep disruption in the ICU, the quality of critically ill patients’ sleep is often overlooked. When questioned following discharge from the ICU, patients frequently report the occurrence of sleep disruption during their stay, suggesting that sleep disruption in the ICU is widespread. Disturbed sleep patterns result in the undesirable consequences of daytime sleepiness, lethargy, irritability, confusion, and poor short-term memory. The potential negative neurologic sequelae from sleep loss may often lead to additional tests to evaluate for change in mentation (eg, frequent neurologic checks, head CTs, or MRIs), potentially resulting not only in an increased financial burden to an already strained health care system but also in extended hospital stays. Patients requiring additional work-up because of their sleep-related change in alertness are less able to receive the care and services, such as physical and occupational therapy, that benefit timely discharges. In fact, increasing evidence supports the concept that

sleep disturbance in the ICU can affect patient mortality during hospitalization and after discharge from the unit. The level of impact of the ICU experience on a patient seems to be multifactorial; hence, this article discusses the following issues essential to understanding the factors associated with sleep loss in the ICU: (1) core elements to consider from the baseline sleep history, (2) impact of the ICU environment on the ICU patient’s sleep pattern, and (3) overall systematic impact of sleep deprivation on the ICU patient. (Crit Care Clin 24 (2008) 461–476)

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Actigraphy in the Critically Ill: Correlation With Activity, Agitation, and Sedation

ABSTRACT

By Mary Jo Grap, RN, PhD, ACNP, C. Todd Borchers, RN, MS, Cindy L. Munro, RN, PhD, ANP, R. K. Elswick, Jr, PhD, and Curtis N. Sessler, MD.

OBJECTIVES To determine the feasibility of continuous measurement of limb movement via wrist and ankle actigraphy (an activity measure) in critically ill patients and to compare actigraphy measurements with observed activity, subjective scores on sedation-agitation scales, and heart rate and blood pressure of patients.

METHODS In a prospective, descriptive, correlational study, all activity of 20 adult patients in medical and coronary care units in a university medical center were observed for 2 hours and documented. Wrist and ankle actigraphy, heart rate, and systolic and diastolic blood pressure data were collected every minute. The Comfort Scale and the Richmond Agitation-Sedation Scale were completed at the beginning of the observation period and 1 and 2 hours later.

RESULTS Wrist actigraphy data correlated with scores on the Richmond Agitation-Sedation Scale (r=0.58) and the Comfort Scale (r=0.62) and with observed stimulation and activity events of patients (r = 0.45). Correlations with systolic, diastolic, and mean arterial pressures were weaker. Wrist and ankle actigraphy data were significantly correlated (r = 0.69; P < .001); however, their mean values (wrist, 418; ankle, 147) were significantly different (t=5.77; P<.001).

CONCLUSIONS Actigraphy provides a continuous recording of patients’ limb movement. Actigraphy measurements correlate well with patients’ observed activity and with subjective scores on agitation and sedation scales. Actigraphy may become particularly important as a continuous measurement of activity for use in behavioral research and may enhance early recognition and management of the excessive activity that characterizes agitation. (American Journal of Critical Care. 2005;14:52-60)

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Abnormal Sleep Wake Cycles and the Effect of Environtmental Noise on Sleep Disruption in the Intensive Care Unit

ABSTRACT

Neil S. Freedman, Joost Gazendam, Lachelle Levan, Allan I. Pack, And Richard J. Schwab

Little is known about sleep/wake abnormalities in intensive care and less is known about the mechanisms responsible for these abnormalities. We studied 22 (20 mechanically ventilated) medical intensive care unit (ICU) patients with continuous polysomnography (PSG) and environmental noise measurements for 24–48 h to characterize sleep–wake patterns and objectively determine the effect of environmental noise on sleep disruption. All 22 patients demonstrated sleep–wake cycle abnormalities. There were large variations in total sleep time (TST) with the mean total sleep time per 24-h study period of 8.8±5.0 h. Sleep–wake cycles were fragmented and nonconsolidated with a mean of 57±18% and 43±18% of the TST occurring during the day and night, respectively. Environmental noise was responsible for 11.5 and 17% of theoverall arousals and awakenings from sleep, respectively. The mean noise arousal index was 1.9±2.1 arousals/h sleep. Conclusions:(1) ICU patients are qualitatively, but not necessarily quantitatively, sleep deprived; and (2) although environmental noise is in part responsible for sleep–wake abnormalities, it is not responsible for the majority of the sleep fragmentation and may therefore not be as disruptive to sleep as the previous literature suggests. (Am J Respir Crit Care Med Vol 163. pp 451–457, 2001)

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Treatment of Hyperglycemia in Critically Ill Patients: Comparison of Different Glucose Management Protocols

ABSTRACT

Blaha J, Kremen J, Anderlova K, Svacina S, Kunstyr J and Haluzik M

Increased blood glucose levels frequently occur in critically ill patients both with and without previous presence of diabetes. Numerous studies have shown that its normalization by intensive insulin treatment markedly improve the outcome of critically ill patients. Several glucose management protocols have been developed and showed different effectiveness in normalizing blood glucose. Here we describe 3 glucose management protocols from 3 different European cardiosurgical centers: General University Hospital in Prague, Medical University in Graz, Royal Brompton Hospital in London and compare them with the glucose management protocol from “Leuven study”. We further tested the effectiveness of these protocols in 10 randomly selected patients from each center. We show that continuous insulin infusion is a necessary prerequisite for satisfactory blood glucose control in critically ill patients both with and without previous history of insulin-treated diabetes. Implementation of iv insulin boluses in combination with continuous insulin infusion did not further improve glucose control in this study.

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