Better sleep means less delirium in ICU

JOHNS HOPKINS (US) — Hospitals can reduce delirium among intensive care patients by quieting nighttime noise, turning off lights, changing medications, and allowing uninterrupted sleep, research shows.

For a study published in the March issue of Critical Care Medicine, a team of doctors, nurses, psychologists and pharmacists in the medical intensive care unit at the Johns Hopkins Hospital found that simple changes made a significant difference.

“We were able to improve a patient’s odds of being free of delirium in the ICU by 54 percent, even after taking into account the diagnosis, need for mechanical ventilation, age, and other factors,” says Biren Kamdar, a pulmonary and critical care fellow. “In addition, many patients said that the ICU was quiet and comfortable enough for them to get a good night’s sleep.”


Delirium—an altered mental state that can affect up to four out of five ICU patients—is a concern not only because it can produce short and long-term confusion and memory problems, but also because it can delay recovery.

The research involved three sets of changes in the ICU, introduced in stages.

The first was a 10-item environmental checklist. It included turning off televisions and room and hallway lights, consolidating staff visits overnight for drawing blood and giving medications, reducing pages on the public address system, and minimizing unnecessary equipment alarms.

In the second stage, patients also were offered eye masks, ear plugs, and tranquil music. In the final stage, a new medication guideline was introduced that discouraged giving patients certain commonly prescribed drugs for sleep, such as benzodiazepines, that are known to cause delirium.

Before all of the interventions had been instituted, the researchers did a baseline assessment of 122 patients in the intensive care unit over an eight-week period. After all of the measures were in place, another 178 patients were evaluated.

“Each patient was evaluated twice a day for delirium using the Confusion Assessment Method for the ICU, a widely used delirium screening tool,” Kamdar says. “After 13 weeks, during which all of the interventions had been in place, we saw a substantial reduction in patient delirium compared to the baseline group.”

A common-sense approach

The researchers also measured patient perception of their sleep quality with a questionnaire given to each patient by MICU nurses every morning. While there were positive findings in that measure, the improvement overall was not statistically significant.

“This is a unique study in terms of the number of patients involved and the three stages of interventions,” says Dale M. Needham, associate professor of pulmonary and critical care medicine at Johns Hopkins and senior author of the study.

“Delirium is a syndrome of confused thinking and lack of attention. It typically comes on quickly with illness, and it’s a marker for the health of the brain,” Needham says. “We put together a common-sense approach to change how care is provided to see if by improving sleep, we could reduce patients’ confused thinking, and it was effective.”

Physical rehabilitation is important for the recovery of intensive care patients; if they’re sleepy or delirious during the day, they can’t appropriately participate in their therapy.

“Up to 80 percent of ICU patients may experience delirium during their stay,” he says. “The longer they have it, the higher their risk of long-lasting problems with memory and other cognitive functions. With advances in medicine and technology, many ICU patients can now recover and go home, so reducing their risk of delirium in the hospital is very important.”

The project was supported by the National Institutes of Health.

Source: Johns Hopkins University