Sleep in the Intensive Care Unit: Strategies for Improvement.

Sleep in the intensive care unit (ICU) is considered to be subjectively poor, highly fragmented, and sometimes referred to as "atypical." Although sleep is felt to be crucial for patient recovery, little is known about the association of sleep with physiologic function among critically ill patients, or those with clinically important outcomes in the ICU. Research involving ICU-based sleep disturbance is challenging due to the lack of objective, practical, reliable, and scalable methods to measure sleep and the multifactorial etiologies of its disruption. Despite these challenges, research into sleep-promoting techniques is growing and has demonstrated a variety of causes leading to ICU-related sleep loss, thereby motivating multifaceted intervention efforts. Through a focused review of (1) sleep measurement in the ICU; (2) outcomes related to poor sleep in the ICU; and (3) ICU-based sleep promotion efforts including environmental, nonpharmacological, and pharmacological interventions, this paper examines research regarding sleep in the ICU and highlights the need for future investigation into this complex and dynamic field.

Sleep and Delirium in Older Adults.

Purpose of Review: Poor sleep and delirium are common in older patients but recognition and management are challenging, particularly in the intensive care unit (ICU) setting. The purpose of this review is to highlight current research on these conditions, their inter-relationship, modes of measurement, and current approaches to management. Recent Findings: Sleep deprivation and delirium are closely linked, with shared clinical characteristics, risk factors, and neurochemical abnormalities. Acetylcholine and dopamine are important neurochemicals in the regulation of sleep and wakefulness and their dysregulation has been implicated in development of delirium. In the hospital setting, poor sleep and delirium are associated with adverse outcomes; non-pharmacological interventions are recommended, but tend to be resource intensive and hindered by a lack of reliable sleep measurement tools. Delirium is easier to identify, with validated tools available in both ICU and non-ICU settings; however, an optimal treatment approach remains unclear. Antipsychotics are used widely to prevent and treat delirium, although the efficacy data are equivocal. Bundled non-pharmacologic approaches represent a promising framework for prevention and management. Summary: Poor sleep and delirium are common problems in older patients. While these phenomena appear linked, a causal relationship is not clearly established. At present, there are no established sleep-focused guidelines for preventing or treating delirium. Novel interventions are needed that address poor sleep and delirium, particularly in older adults.

Practice patterns of board-certified sleep medicine providers: a national analysis among older adult Medicare beneficiaries.

STUDY OBJECTIVES: To examine the proportion of Medicare beneficiaries with sleep disorders who were evaluated by board-certified sleep medicine providers (BCSMPs). METHODS: Using a random 5% sample of Medicare administrative claims data (2007-2011), BCSMPs were identified by employing a novel cross-matching approach based on National Provider Identifiers available within the Medicare database. Sleep disorders were included based partially on the International Classification of Sleep Disorders, Third Edition (insomnia, sleep-related breathing disorders, hypersomnias, circadian rhythm sleep-wake disorders, parasomnias, and restless legs syndrome), and operationalized as International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes. The proportion of beneficiaries with each disorder who were seen by BCSMPs and nonspecialists was computed. RESULTS: Among older adult Medicare beneficiaries with sleep disorders, the most common sleep disorder was insomnia (n = 65,033), and the least common sleep disorder was narcolepsy (n = 784). Individuals with central sleep apnea (n = 1,561) were most likely to be treated by a BCSMP (63.9% of beneficiaries with central sleep apnea), and individuals diagnosed with insomnia were least likely to be treated by a BCSMP (16.4% of beneficiaries with insomnia). Most BCSMPs treated beneficiaries with obstructive sleep apnea (84.9% of BCSMPs) and insomnia (75.8% of BCSMPs). CONCLUSIONS: BCSMPs are involved in the care of a substantial proportion of Medicare beneficiaries with sleep disorders.