Use of complementary and alternative therapies to promote sleep in critically ill patients

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Use of complementary and alternative therapies to promote

sleep in critically ill patients

Kathy Richards, PhD, RN

a,b,

*, Corey Nagel, BSN, RN

c

, Megan Markie, BS

b

,

Jean Elwell, BSN, RN

b

, Claudia Barone, EdD, RN

b

a_{Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, 3J/NLRVA, North Little Rock, AR 72114, USA} b_{University of Arkansas for Medical Sciences 4301 W. Markham, Slot 529 Little Rock, AR 72205, USA}

c_{Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA}

Sleep disturbance is common among patients in intensive care units (ICUs). The impact of acute illness and its treatment, pain, stress, environmental noise, disruption of light/dark cycle, and caregiver interruptions can all contribute to critically ill patients’ inability to get adequate, restful sleep. Occurring at a time when sleep needs are greatest, sleep disturbance is a significant stressor for persons experiencing acute illness. Furthermore, sleep disrup-tion has been implicated in the development of the iatrogenic delirium syndrome known as ICU psycho-sis [1,2]. The mainstay of treatment for sleep disturb-ance has been sedative-hypnotics, although these compounds may have adverse effects including rebound insomnia, falls, tolerance and withdrawal, and delirium [3]. While still largely unexamined in the ICU, the use of complementary and alternative therapies to promote sleep in this setting may offer a promising alternative to the pharmacologic approach. In fact, recent clinical practice guidelines from the American College of Critical Care Medicine on the use of sedatives and analgesics in critically ill adults advocate the use of nonpharmacologic methods such as massage and music therapy to promote sleep [4].

This article uses a review of literature to present factors contributing to sleep disturbance in critically ill patients and interventions to promote sleep. Illness,

medications, environment, and anxiety are discussed as factors contributing to sleep disturbance in crit-ically ill patients. The complementary and alternative therapies presented as possible nursing interventions to promote sleep in critically ill patients are massage, music, relaxation techniques, aromatherapy, thera-peutic touch, environmental interventions, and alter-native sedatives.

Normal sleep patterns

The ‘‘gold standard’’ in the objective measure-ment of sleep is polysomnography, which consists of simultaneous recordings of a patient’s electro-encephalogram, electrooculogram, and electromyo-gram. The stages that make up normal sleep patterns are defined on the basis of these physiologic parameters [5]. Broadly speaking, sleep consists of two separate states: nonrapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. NREM sleep, which accounts for approximately 70% to 75% of total sleep, is further divided into four stages (stages, 1, 2, 3, and 4) of progressively deeper sleep. REM sleep is characterized by muscle atonia, epi-sodic bursts of rapid eye movement, and brain activa-tion. Sleep initiation occurs with stage 1 NREM, then progresses through each stage of NREM sleep, with a brief period of REM sleep occurring approximately 70 to 90 minutes after sleep onset. This cycle repeats itself throughout the sleep period at intervals of 90 to 120 minutes, with periods of REM sleep becoming progressively longer throughout the night [6].

* Corresponding author. Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, 3J/NLRVA, North Little Rock, AR 72114, USA.

E-mail address:richardskathyc@uams.edu (K. Richards).

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Sleep in critically ill patients

A number of studies have found that severely disturbed sleep is common in ICUs [7 – 11]. Patients in the ICU experience reduced sleep efficiency, altered sleep stage patterns, severe fragmentation of sleep, and diminished total sleep time [12]. They also have decreased stages 3 and 4 NREM and REM sleep, with more light sleep (stage 1 NREM) [13]. A number of studies have shown that patients perceive that their sleep is disturbed while they are in the ICU [14]. Patients report having trouble falling and stay-ing asleep, not feelstay-ing rested, increased daytime napping, and a reduction of sleep quality [11]. Although the causes of sleep disturbance among intensive care patients are not fully understood, there are a number of potential sleep disrupters, including the effects of the patients’ illness, medications, envi-ronmental factors specific to the ICU, and patients’ anxiety [13].

Factors contributing to sleep disturbance in critically ill patients

Illness and medications

Health-related changes and the resulting pain, anxiety, and stress may contribute to sleep distur-bance among critically ill patients. Medical prob-lems that contribute to sleep disturbance include cardiovascular disease and chronic obstructive pul-monary disease [15]. For example, hypertension is associated with breathing disturbances during sleep, and chest discomfort from angina pectoris is asso-ciated with awakenings [16]. Patients with chronic bronchitis or emphysema frequently experience hypoxemia while sleeping and have been shown to experience more awakenings and decreased stages 3 and 4 NREM and REM sleep than healthy persons [17]. Pain is frequently reported by hospitalized patients to be a major cause of poor sleep and nighttime awakenings, a fact underscoring the importance of appropriate pain control among the critically ill [18].

Lastly, a number of medications used to treat acute and chronic illness may contribute to disturbed sleep. Beta-adrenergic blockers and bronchodilators are examples of two such medications. For a more com-plete review of medications and sleep, refer to Rob-inson and Zwillich [19]. Beta-adrenergic blockers such as metoprolol, propranolol, and pindolol are commonly used to treat hypertension and angina pectoris in critically ill patients. These three

beta-blockers increase awakenings and decrease REM sleep [20]. In a study of 10 female subjects, pindolol significantly increased awakenings [20]. Two of the bronchodilators used to treat reversible airway obstruction in patients with chronic obstructive pul-monary disease, aminophylline and theophylline, dis-turb sleep [21,22]. In one study, 10 male patients with obstructive sleep apnea were administered aminophyl-line. The patients’ sleep efficiency was significantly reduced and sleep fragmentation significantly increased compared to a placebo [21]. In another study, a trial of oral theophylline was administered to 12 patients and overnight polysomnography was used to measure sleep [22]. Sleep quality was sig-nificantly reduced when theophylline was taken com-pared to placebo. This was evidenced by a significant decrease in the time from onset of sleep to final awakening and an increase in awakenings [22].

Environment

Several environmental factors have been iden-tified as contributing to poor sleep in the ICU. Multiple studies have illustrated that noise is a leading factor in sleep disturbance among hospital-ized patients [23,24]. Most hospitals today have noise levels ranging from 50 to 70 dBA during the day and an average of 67 dBA at night, greatly surpassing the United States Environmental Protection Agency recommendation of 45 dBA throughout the day and 35 dBA at night [25]. A study conducted in the ICU found that 51% of noise was modifiable, with patients reporting staff conversation and television as the most irritating disturbances [24].

Frequent awakenings by care providers present a significant barrier to sleep in the hospital. An obser-vational study of nursing practices in the ICU found that patients were interrupted an average of once every hour by care providers [14]. Light exposure can also serve as an obstacle in attaining adequate sleep. The absence of diurnal light cycles in many hospital environments can result in sleep disruption, because these cycles act as a cue, or zeitgeber, supporting adequate function of the circadian system, which regulates sleep. When this system is disrupted, increased sleep onset latencies and decreased sub-jective sleep quality have been reported [26]. Con-stant light exposure also has been correlated with cognitive disturbance in critically ill patients [27]. Other factors observed to contribute to sleep distur-bance in the ICU environment include patients’ inability to perform their usual bedtime routines, room temperature, and sleeping on an uncomfortable or unfamiliar surface [28].

K. Richards et al / Crit Care Nurs Clin N Am 15 (2003) 329–340

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Anxiety

Patients experiencing anxiety have difficulty going to sleep and staying asleep [28,29]. Being admitted to an ICU with a serious illness can cause patients to experience an increase in anxiety [30]. The patient’s uncertainty about the illness, lack of famil-iarity with the hospital environment, and change in routine can all contribute to increased anxiety. Of 84 postcardiac surgery patients in an ICU, 55% remem-bered anxiety as being ‘‘at least moderately disturb-ing’’ to their sleep [14]. Recognizing that anxiety is one factor contributing to sleep disturbance in crit-ically ill patients, nurses can focus interventions to reduce patients’ anxiety.

Interventions

We conducted a systematic literature review of research examining the use of complementary and alternative therapies in intensive care to promote sleep. We searched CINAHL and MEDLINE using the keywords sleep, intensive care, massage, relaxa-tion, imagery, aromatherapy, therapeutic touch, herbs, melatonin, environment, and music therapy for En-glish language articles from 1982 to 2002. This search resulted in 43 articles. We also searched the bibliographies of these articles. We found only seven studies that reported a test of the effect of comple-mentary and alternative therapies on sleep in ICUs. Each complementary and alternative therapy will be discussed in light of the evidence supporting its efficacy in intensive care and the implications of each therapy for nursing care. Table 1 summarizes studies of the effect of complementary and alternative ther-apies on patients in ICUs.

Massage

Beck defined massage as ‘‘the systematic manual or mechanical manipulations of the soft tissues of the body by such movements as rubbing, kneading, pressing, rolling, slapping, and tapping, for thera-peutic purposes such as promoting circulation of the blood and lymph, relaxation of muscles, relief from pain, restoration of metabolic balance, and other benefits both physical and mental.’’[31] The gliding strokes used in the massage technique of effleurage promote relaxation and sleep. These strokes are performed in a slow, rhythmic fashion, using firm, steady pressure. The palms of the hands are used to perform gliding strokes over large body areas such as the back. Contact is maintained with the skin

when-ever possible [32]. Relaxing massage lasting 5 to 10 minutes can promote sleep [33]. Massage has traditionally been a component of the evening or ‘‘PM’’ care provided by nurses to hospitalized patients, although this practice is virtually nonexistent in today’s healthcare environment [34]. In a system-atic literature review of the effects of massage, Richards et al found that reduction in anxiety was the most consistent effect of massage in acutely and critically ill patients, with eight of ten original research studies reporting decreases in subjective perception of anxiety or tension. In seven of ten studies, physiologic indicators of the relaxation response were reported after administration of a massage intervention; these include reductions in heart rate, respiratory rate, muscle tension, and oxy-gen consumption [32]. Thus, massage may be an effective intervention to reduce anxiety or tension that interferes with sleep.

A limited number of studies have examined the effect of massage on sleep in hospitalized patients. In a recent study of 175 elderly patients hospitalized on a general medical unit, a nonpharmacologic sleep protocol consisting of a warm drink, a 5-minute back rub, and a relaxation audio tape was administered to patients complaining of poor sleep or requesting a sedative-hypnotic [3]. Patients were assessed 1 hour after administration of the protocol, and a sedative-hypnotic was provided if the patient still requested it. A significant positive correlation was found between administration of the massage intervention and improvement in reported sleep quality. Interestingly, a steadily rising correlation was demonstrated as the number of components of the protocol received by the subject increased, suggesting a dose-response relationship. Overall, implementation of this protocol resulted in a reduction in sedative-hypnotic adminis-tration, from 54% at baseline to 31% during the intervention period.

Richards tested the effect of a back massage, a relaxation audiotape, or usual care on the sleep of 69 older men with cardiovascular illness hospitalized in intensive care [35]. Subjects were randomly assigned to receive either a 6-minute effleurage back massage; a 7.5-minute relaxation audiotape consisting of music, guided imagery, and muscle relaxation; or normal nursing care. The subjects’ sleep was objec-tively evaluated using polysomnography. An increase in the sleep efficiency index (the ratio of total sleep time to nocturnal time spent in bed) was reported among subjects in the massage group, who slept an average of 1 hour longer than the control group. The sleep efficiency index for the massage group was 14.7% higher than for the control group. REM sleep

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Table 1

Studies of the effect of alternative and complementary therapy on sleep in the ICU

Author/Year Setting/Sample Intervention Results Type of Study Cox and Hayes

(1999) [58]

.2 Critical care units, ICU

and coronary care unit

.53 subjects, 37 men,

16 women, mean age 65 years

.A specially trained nurse

delivered therapeutic touch to all subjects

.Psychodynamic responses

were measured by patient interviews immediately following the therapeutic touch sessions

.29 patients fell asleep immediately

upon initiation of therapeutic touch or shortly after and stayed asleep until later nursing care was performed

.There were no significant increases

or decreases in any of the physiologic variables measured

.One group pretest-posttest

experimental study

.Physiologic variables were

measured before and after administration by changes in heart rate, blood pressure, respiration, and peripheral oxygen saturation Richards

(1998) [35]

.Veterans with diagnosis

of cardiovascular illness in the ICU

.69 men, mean age 65.8 years

.Group 1 (n = 24) received a

6-minute effleurage back massage at bedtime

.Patients who received a 6-minute

back massage slept 1 hour longer than control group

.Randomized controlled trial

.Group 2 (n = 28) received a

teaching session on relaxation and a 7.5-minute audiotape at bedtime consisting of muscle relaxation, mental imagery, and relaxing background music

.Nonsignificant trend toward increased

sleep efficiency; percent stage 2 nonrapid eye movement (NREM) sleep; REM sleep; percent wake after sleep onset; and latency to sleep onset

.Group 3 (controls, n = 17) received

usual nursing care with a 6-minute rest period at bedtime

Ryan et al (1992) [64]

.Hospitalized patients

with coronary artery disease (unclear if in ICU)

.Convenience sample of

33 subjects: 18 men, 15 women, mean age 68 years

.Night 1: patients administered

nitroglycerin paste treatment according to routine schedule (every 4 hours)

.Night 2: patients administered

nitroglycerin paste treatment every 6 hours

.Sleep on night 2 (M = 6.48) was over

1 hour longer than night 1 (M = 5.24,P< .025)

.Sleep quality, measured by St. Mary’s

Hospital Sleep Questionnaire was significantly (P< .005) better on night 2 compared to control group

experimental study

.None of the participants experienced

nocturnal angina on either night

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Shilo et al (2000) [69]

.Pulmonary ICU .8 patients hospitalized for

respiratory failure, 5 women, 3 men, mean age 62 years

.Control group: 6 patients

in general medical ward

.Day 1: baseline actigraphy scores

collected for all subjects

.Days 2 and 3: patients either received

3 mg of controlled-release melatonin or placebo at 22:00

.Means for sleep variables were either

not provided or were unclear and there were no tests of significance

.In the patients who received melatonin,

only a few (1.4F3.7), short periods (12F5.0 min) of awakenings were observed in 5 participants, 3 experienced no nighttime awakenings

.Pilot study—design unclear

Walder et al (2000) [62]

.Surgical ICU subdivided

into 6 identical 3 bed-rooms

.8 critically ill adults (gender

and mean age not stated)

.Period 1 (n = 9) measurement of

baseline noise levels, using a sound level meter; light levels, using a luxmeter; and patients’ sleep, using a multiple choice questionnaire

.A significant decrease in noise (P = 0.03),

and light (P= 0.01) levels occurred in period 2

.A significant increase in light

variation (P= 0.05)

.Patients estimated a higher number

experimental study

.Period 2 (n = 8) implementation of

guidelines to reduce nighttime light and noise levels

of awakenings in period 2

Williamson (1992) [60]

.A step-down unit of a

large public hospital

.60 postoperative coronary

artery bypass graft patients: 45 men, 15 women, mean age 58.6

.Group 1 (n = 30) Ocean sounds were

played throughout the night for three consecutive nights

.Group 2 (controls, n = 30) No

modification of the environment except for the elimination of white noise

.Patients in group 1 showed a significant

increase in sleep depth (P= 0.001), quality of sleep (P= 0.003) and total sleep scores (P= 0.002) compared to the control group

.Patients in group 1 reported being awake

less during the night (P = 0.026) and returning to sleep quicker (P= 0.009) than control group

Zimmerman et al (1996) [37]

.Convenience sample of 96

postoperative patients having coronary artery bypass surgery

.68% men, 32% women,

mean age 67 years

.Group 1 (n = 32) music therapy:

30-minute sessions on second and third postoperative days

.Group 2 (n = 32) music video therapy:

30-minute sessions of music and visual images on second and third postoperative days

.Music therapy group had significantly

(P< .05) lower scores on the evaluative component of pain than control group on postoperative day 2

.Video music therapy group had significantly

(P< .05) better sleep scores, measured by the Richards-Campbell Sleep Questionnaire, than

.Group 3 (controls, n = 32) scheduled rest:

30-minute sessions of undisturbed rest on second and third postoperative days

the control group on morning of postoperative Day

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in the massage group was 35 minutes, whereas in the control group REM sleep was 25 minutes (Table 1). The results of these studies support the use of relaxing massage as a nursing intervention to promote sleep in ICU patients. Nurses are in a position to be leaders in designing and implementing massage ther-apy interventions. Richards et al have developed protocols that nurses can use to guide development of interventions specific to their setting [33]. By reinstating massage as a nursing intervention, ICU nurses can improve the quality of their patients’ sleep and perhaps reduce the need for sedative-hypnotics.

Music

The use of music to promote health and well being is referred to as music therapy [36]. Music therapy to reduce anxiety has been well documented, with a number of studies examining its effect on patients in the ICU [37 – 42]. White reported that acute myo-cardial infarction patients (N = 15) who received a 20-minute music therapy intervention had significant reductions in heart rate, respiratory rate, and myocar-dial oxygen demand when compared to matched controls (N = 15) [30]. Other investigators have reported similar reductions in subjective reports of anxiety among patients with acute cardiovascular illness and patients receiving ventilatory assistance [39,43]. A recent meta-analysis of the effect of music in acute inpatient settings concluded that music therapy is effective in reducing anxiety during normal care delivery, although it was not found to reduce the anxiety of patients undergoing invasive or unpleasant procedures [44].

Although a significant body of research exists examining the effect of music therapy on anxiety, few studies have explored sleep as an outcome mea-sure. The effect of music therapy on the sleep of 96 postoperative cardiac surgical patients was the focus of a study by Zimmerman et al [37]. Participants received a music intervention, a music video intervention, or scheduled rest period (control group), on the second and third postoperative days. One way analysis of variance was calculated on participants’ subjective sleep scores taken on the third postoperative morning, revealing significant differences between groups. Posthoc analysis revealed that recipients of the music video intervention had significantly higher sleep scores indicating better sleep than did the control group. The sleep scores of the music intervention group also indicated an improvement in sleep when compared with the control group, with the difference between these two groups approaching statistical sig-nificance (Table 1).

ICU nurses can easily integrate music therapy into a patient’s plan of care [36]. A library of taped musical selections is first needed as a radio’s selec-tions and interrupselec-tions can be disruptive to the patient. The characteristics of music best suited for sleep and relaxation promotion are a tempo of approximately 60 beats per minute, are composed primarily of low tones, and are played predominately by stringed instruments [30]. Headphones are neces-sary to control volume and music quality. Tape play-ers are convenient ways to play the music and do not interfere with the other equipment necessary for the patient’s care. Infection control issues must be addressed, especially if tape players and headphones are shared among patients. Before implementing music therapy, the nurse needs to determine that the patient enjoys listening to music.

Aromatherapy

Aromatherapy is the use of essential oils, such as thyme, rosemary, lavender, and jasmine, extracted from plants to facilitate healing or improve mood [45,46]. These oils may be inhaled or applied to the patient’s skin using baths, compresses, and massage. A number of studies have examined the efficacy of aromatherapy oils in improving mood, inducing relaxation, and reducing anxiety, but only a few were found that examined its’ efficacy in promoting sleep [45,47].

Sleep was a variable in a study of the effects of aromatherapy and massage on the well being of nine patients with rheumatoid arthritis [47]. Participants were randomized to received a 10-minute massage with lavender oil, massage alone, or usual nursing care on two consecutive nights. The patients receiv-ing massage with lavender oil reported improved sleep; however, quantitative measures yielded no significant findings. In another study, sleep of 10 hospitalized older people was assessed by patient report before and after aromatherapy [45]. Aroma-therapy consisted of atmospheric vaporization of a blend of basil, juniper, lavender, and sweet mar-joram oils or vaporization of the oils combined with a 5-minute hand massage. Night sedation was avail-able as needed and was given on 34 patient nights versus on 85 patient nights before use of aroma-therapy. Before aromatherapy, patients reported a good nights sleep on 73% of patient nights, whereas after aromatherapy they reported a good nights sleep on 97%.

The effect of aromatherapy on patients’ levels of anxiety has been studied more frequently. The effects of aromatherapy massage were evaluated in an

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experimental study of 122 ICU patients by assessing physiologic stress indicators and patient reports of anxiety levels, mood, and coping abilities [48]. The study resulted in an improvement in levels of anxiety and mood but no statistically significant differences in the physiologic stress indicators [48]. Holmes et al recently demonstrated in a placebo controlled study of 15 severely demented patients that exposure to an aerosolized lavender oil compound from 4PMto 6PM

resulted in modest improvement of agitated behavior for most (66%) of the test subjects [49]. In a study by Kite et al, 58 patients undergoing radical oncologic treatment received a series of six weekly aromather-apy massage treatments. Comparison between base-line and postintervention revealed a significant decrease in anxiety and depression following the aromatherapy[50]; however, one drawback to this and similar studies combining aromatherapy and massage is the difficulty in determining the specific source of the effects observed by the investigators.

Randomized controlled trials to study the efficacy and safety of aromatherapy for promoting sleep in ICU patients are needed. Aromatherapy may be contraindicated for persons with reactive airway dis-ease, although this has not been studied.

Relaxation techniques

Progressive relaxation and guided imagery are two techniques that have been effective in reducing anxiety and promoting rest. Relaxation procedures are aimed at activating the parasympathetic nervous system, which decreases arousal levels and induces a calm state. Progressive relaxation involves the con-traction and relaxation of each major muscle group while identifying areas of tension and consciously releasing it. In guided imagery, the patient imagines being in a peaceful setting, using all senses to experience the situation. Cues, provided by the nurse, are used to lead the patient through the process. Scenes commonly used include lying on a beach, watching a sunset, and floating down a stream. Nurses can teach guided imagery and progressive muscle relaxation to the patient so they can continue to use them independently.

These techniques have been proven efficacious in promoting sleep, reducing pain, and relieving anxiety among hospitalized patients [51,52]. In a study of 30 patients in the coronary care unit, the treatment group was given two cassette tapes guiding progressive muscle relaxation sessions and told to listen to them at least once a day. Patients who used the tapes had significantly lower scores on the state component of the Spielberger State-Trait Anxiety Inventory when

compared to baseline, indicating a decrease in anxi-ety. The treatment group also reported a significantly lower incidence of pain than the control group at discharge [53]. Griffin et al found that when 100 acutely ill hospitalized patients used progressive muscle relaxation, they scored significantly lower than baseline on the Top Disturbance Due to Hospital Noise Scale [54]. Johnson examined the effect of progressive relaxation on sleep in 176 men and women living in their homes. During the intervention phase, participants received instruction in progressive relaxation and were provided a tape for home use at bedtime. Sleep variables were measured by the Sleep Pattern Questionnaire. After using progressive relaxa-tion for 5 days, participants reported a significant increase in bedtime state of mind, lower sleep onset latency, improved soundness of sleep, a decrease in nighttime arousal, and a greater satisfaction with sleep [55]. Guided imagery has been shown to decrease pain and anxiety in perioperative patients. When participants used guided imagery tapes 3 days before surgery and 6 days after surgery, they required almost 50% less postoperative narcotic medications (median 185 mg) than the control group (median 326 mg) [56].

Relaxation techniques have been shown to be effective in improving patient comfort by reducing anxiety and tension. Instruction in progressive relaxation and guided imagery should be part of routine nursing care. No adverse effects have been reported in association with using these methods of treatment. Imagery should be immediately discon-tinued if the patient becomes notably agitated or upset. After initial instruction and outcome evalu-ation, guide tapes can be provided to encourage independent use.

Therapeutic touch

Therapeutic touch, formally introduced into the nursing profession in 1979 by Dolores Krieger [57], is a technique in which a trained practitioner uses mental and physical methods to restore a balanced energy field to the compromised individual. It is used under the assumption that all humans possess an energy field that lies within and immediately outside of the body. With illness and pain, this field becomes disturbed; therefore, ailments can be alleviated by the reorganization of energy by the practitioner through mental intent. Tactile stimulation is often added to facilitate the healing effect, but therapeutic touch also can be performed without physical contact when appropriate. Although this therapy is fairly new and controversial in the United States, similar methods of

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healing extend internationally to areas including Egypt, Japan, China, Thailand, and India where they have been used for centuries.

Therapeutic touch was recently identified as increasing relaxation and sleep in the ICU envi-ronment. Cox and Hayes presented two case studies of patients in the ICU who received a 5-minute therapeutic touch treatment session by a trained practitioner for 5-10 days. Both participants reported falling asleep during or soon after the treatment. One of the patients stated, ‘‘I always go to sleep when you do this. I can’t sleep very well at night because of all the noise and lights and things that go on here. . .

would you come back tonight and do this to help me go to sleep?’’[57] In separate study of 53 critically ill patients who received therapeutic touch, Cox and Hayes found that many of the subjects reported falling asleep during the intervention and slept soundly for several hours after the conclusion of the intervention (see Table 1) [58].

Therapeutic touch also has been shown to reduce anxiety, which may adversely affect sleep. In a study of 31 psychiatric patients, those who were adminis-tered therapeutic touch showed a significant decrease in anxiety as measured by the State-Trait Anxiety Inventory [59].

While the limited research indicates a positive effect, randomized controlled trials are required to determine if therapeutic touch would be an effective intervention to promote sleep in the ICU. There have been no adverse effects reported from this noninva-sive therapy. Perhaps a future study could teach basic techniques for administering therapeutic touch to intensive care nursing staff and evaluate the effective-ness of the program. Outcomes of interest would include sleep, costs, and utilization. Advanced thera-peutic touch practitioners, who have completed 90 hours of formal instruction and 2 or more years of apprenticeship under an established professional, could provide the education in therapeutic touch for the ICU nurses.

Environmental interventions

Interventions to create an environment more con-ducive to sleep can be extremely beneficial and easily implemented. Modifiable sources of noise, such as staff conversations, have been successfully reduced after implementation of behavior modification tech-niques directed toward hospital staff [24]. Following the implementation of an environmental modification program in the ICU, which consisted of staff edu-cation on noise reduction techniques and posted reminders to minimize disruptions, both total noise

levels and the number of sound peaks greater than or equal to 80 dBA were significantly reduced [24].

The masking of noise has been demonstrated to improve self-reported sleep quality and to reduce the number of nighttime awakenings [11,60]. Williamson tested the effect of ocean sounds on the sleep of postoperative coronary artery bypass graft patients. On 3 consecutive nights in a step-down unit, 30 subjects received an intervention consisting of ocean sounds played over a speaker in their room from evening to morning. A comparison group received usual care. An analysis of covariance of subjective sleep scores revealed significant difference in total sleep score between groups, with the intervention group reporting better quality sleep, fewer awaken-ings, quicker return to sleep following awakenawaken-ings, and deeper sleep than did the comparison group (Table 1) [60].

The use of earplugs also has been shown to increase REM sleep onset and duration in adults exposed to ICU noise conditions. Wallace et al conducted a study of six healthy men in a sleep laboratory for 5 nights. Polysomnography was per-formed by experienced technologists to measure sleep parameters. On nights 4 and 5, participants were randomly divided and half were instructed to use earplugs while both groups were exposed to recordings of ICU noise throughout the night. Data revealed that the group using earplugs experienced a significant decrease in REM latency and an increased percentage of REM sleep [61].

Unit lights should be dimmed during normal sleep hours to maintain the circadian light cycles necessary to healthy sleep. Although most hospital units already decrease light levels at night, the increase in light during nighttime interventions continues to be a dis-turbance. Walder et al was successful in significantly lowering light levels at night after implementing guidelines to promote sleep but found that patients’ sleep, estimated by the nurse using a multiple choice questionnaire, was more disturbed (Table 1). This may be because of the greater variation occurring when lights were turned up periodically throughout the night to perform care activities [62]. Perhaps the use of eye masks would be helpful in alleviating this problem.

Whenever possible, patient care activities should be clustered to provide sufficient time for uninter-rupted sleep [63]. For example, when patients with coronary artery disease were administered nitropaste every 6 hours instead of every 4 hours to increase periods of undisturbed rest, increased sleep time and significantly improved sleep quality were reported without the occurrence of nocturnal angina (Table 1) [64].

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While in the ICU, patients are at the mercy of hospital schedules. The loss of power experienced by patients as a result of restrictions enforced in the ICU may increase anxiety and adversely affect sleep. Ziemann and Dracup examined the effects of patient – nurse contracts in 41 patients regarding their visitation, activity, patient teaching, and daily hygiene schedules. They found that when patients were able to maintain some control over their environment, significant decreases in anxiety, depression, and hos-tility occurred [65]. Although we found no studies examining the specific relationship between this intervention and sleep, an intervention that decreases anxiety likely will improve sleep.

Nurses have direct control over the environment and are responsible for creating and maintaining optimum conditions to promote healing. Interven-tions as simple as lowering voices and lights can make the ICU more conducive to sleep. Equipment such as earplugs and eye masks are easily used and inexpensive and should be offered routinely. Nurses need to be aware of the feelings of powerlessness that patients experience and the resulting emotional dam-age that can occur. Patients could take part in deter-mining their own visitation and activity schedules to provide them with a sense of control. Unnecessary interruptions can be easily eliminated by improved coordination of activities and postponement of non-essential procedures while the patient is sleeping. Most importantly, the hospital staff must have an awareness of the important role sleep plays in pre-serving physical and mental health. This realization will compel nurses to take an active role in creating a more sleep friendly environment.

Alternative sedatives

Recently, the use of nontraditional medications as sleep aids has grown in popularity among the public sector. Two of the most common are valerian and melatonin.

Valerian (Valeriana officinalis) is a perennial herb found in North America, Europe, and Asia. Valerian is made up of volatile oils, valepotriates, and additional, currently unidentified, constituents. These substances act as a central nervous system depressant, presum-ably by inhibiting the breakdown of gamma-amino-butyric acid, an amino acid found in the brain, heart, lungs, and kidneys that acts as a neurotransmitter.

In a study consisting of 128 volunteers who were administered 400 mg of valerian 1 hour before bedtime, sleep latency was significantly reduced, sleep quality was increased significantly when com-pared to placebo, and there were no reported

hang-over effects [66]. Donath et al found that when multiple doses of valerian were administered to patients with mild psychophysiologic insomnia, stages 3 and 4 NREM sleep latency was significantly reduced and the percentage increased [67]. Although the only reported side effect is residual sedation with higher doses and there have been no reported drug interactions, further study is needed to validate the safety and efficacy of this substance.

Melatonin, a hormone secreted by the pineal gland in accordance with circadian rhythm, is secreted at the highest level during the night in normal, healthy individuals. A deficit in production and secretion of melatonin may alter sleep function; therefore, the administration of this hormone is thought to promote sleep when imbalances occur.

Garfinkel et al conducted a randomized, double blind cross-over study using 12 elderly subjects. For 3 weeks, participants were administered 2 mg of controlled-release melatonin. Sleep efficiency, mea-sured by actigraphy, was significantly greater and wake time after sleep onset decreased [68]. The only study found pertaining to the use of melatonin therapy in the ICU was a 3-day double-blind study of eight patients in the pulmonary ICU. In this study, Shilo et al found that the administration of 3 mg of controlled-release melatonin induced sleep in all subjects and produced no side effects; however, means for sleep variables were either not provided or were unclear and there were no tests of signifi-cance (Table 1) [69].

Due to the limited knowledge concerning the side effects and drug interactions of nontraditional medi-cations as well as the compromised physical con-dition of patients in the ICU, the present use of these substances in this setting is not recommended. The literature pertaining to the effects of melatonin and valerian on specific sleep parameters is limited. Further, more explicit evidence is needed to deter-mine the safety and benefits of these modes of therapy in the intensive care patient.

Summary

The efficacy of complementary and alternative therapies for sleep promotion in critically ill patients is largely unexamined. We found only seven studies (three on environmental interventions and one each on massage, music therapy, therapeutic touch, and melatonin) that examined the effect of complemen-tary and alternative therapies. A number of studies, however, have shown that massage, music therapy, and therapeutic touch promote relaxation and comfort

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in critically ill patients, which likely leads to improved sleep. Massage, music therapy, and thera-peutic touch are safe for critically ill patients and should be routinely applied by ICU nurses who have received training on how to administer these speci-alized interventions. Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients sleep. Pro-gressive muscle relaxation has been extensively studied and shown to be efficacious for improving sleep in persons with insomnia; however, progressive muscle relaxation requires that patients consciously attend to relaxing specific muscle groups and practice these techniques, which may be difficult for critically ill patients. We do not currently recommend aroma-therapy and alternative sedatives, such as valerian and melatonin, for sleep promotion in critically ill patients because the safety of these substances is unclear.

In summary, we recommend that ICU nurses implement music therapy, environmental interven-tions, therapeutic touch, and relaxing massage to promote sleep in critically ill patients. These inter-ventions are safe and may improve patient sleep, although randomized controlled trials are needed to test their efficacy. Aromatherapy and alternative sed-atives require further investigation to determine their safety and efficacy.

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