Sleep Quality and Its Association With Delirium Among Veterans Enrolled in Hospice

Abstract

Objectives The objectives of this study were to describe sleep quality and evaluate the association of sleep quality with delirium onset amongst patients enrolled in hospice. Design The study utilized secondary data from a prospective, observational, longitudinal study. Setting Veterans enrolled in hospice were recruited from the Portland Veterans Affairs Medical Center, Portland, Oregon. Participants The cohort consisted of 105 patients, of whom 73% had at least one sleep measurement. Measurements Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI). Delirium was measured with the Confusion Assessment Method. Other important variables were recorded from the medical record and/or longitudinal interviews with patients and their caregivers. Cox regression was used to estimate hazard ratios (HR) to measure the association between sleep quality and delirium onset. Results Of the patients who could be assessed, 44% had poor average sleep quality and 58% reported at least one episode of poor sleep. Overall, sleep quality did not appear to worsen as patients neared death although an increasing number of patients were unable to report on sleep quality. Poor sleep quality was associated with an increased risk of developing delirium, with a HR of 2.37 (95% CI 1.50 – 3.74), for every one point worsening in the sleep quality score on a four point scale. Conclusions Poor sleep quality was common amongst Veteran patients enrolled in hospice. These findings may help guide decision making between clinicians, patients, and families regarding the likely impact of sleep disturbance and may help identify patients at higher risk of developing delirium.

Sleep problems in advanced disease

“…11 Hugel et al reported that in their study of 73 patients with advanced cancer, 60% patients related their insomnia to uncontrolled physical symptoms (predominantly pain and urinary frequency). 10 Insomnia may be associated with daytime sleepiness, cognitive impairment, accidents/injuries, anxiety, 12 depression, 12 delirium, 13 fatigue and, unsurprisingly, impaired quality of life. 14 Insomnia is associated with suppression of the immune system, which may have implications in terms of development of infections, and also progression of cancers.…”

Sleep Disruption at Home As an Independent Risk Factor for Postoperative Delirium

“…Several studies have demonstrated that the sleep of individuals with delirium is often disrupted, particularly in the postoperative period, and in individuals at the end of life . Whether sleep disruption is an early symptom of evolving delirium or acts as a precipitant for delirium remains unknown …”

“…7 Several studies have demonstrated that the sleep of individuals with delirium is often disrupted, particularly in the postoperative period, [9][10][11][12][13][14][15] and in individuals at the end of life. 16 Whether sleep disruption is an early symptom of evolving delirium or acts as a precipitant for delirium remains unknown. 6 A longitudinal study was conducted of individuals undergoing elective surgery to determine whether preoperative sleep disturbance predicts postoperative delirium, 17 but the sample population was relatively young (average age 66) and the sample size too small to consider potential covariates.…”

Associations between Sleep Disorders and Comfort at End-of-Life: Opportunities for Improvement

“…Of the remaining eight sources, five were eliminated because all study participants: 1) had cancer diagnoses and 2) did not meet the definition of EOL. Three articles [12][13][14] were included for synthesis and analysis ( Fig. 1).…”

“…In a secondary data analysis of a prospective observational study of veterans in home hospice care, the association between disturbed vs. undisturbed sleep as measured by the Pittsburgh Sleep Quality Index [15] and QoL score, depression worsening, and onset of delirium during hospice was studied [14]. Quality of life score was rated by patients on a scale from 0 to 100, with higher numbers indicating better QoL.…”