The Missing Link in Patient Recovery: Hospital Sleep Medicine

Ki-Hwan Ji; Dong-Kyu Kim; Eun-Hee Kim; Seockhoon Chung

doi:10.17241/smr.2025.02782

Sleep Med Res > Volume 16(1); 2025 > Article

Ji, Kim, Kim, and Chung: The Missing Link in Patient Recovery: Hospital Sleep Medicine

Review Article

Sleep Med Res 2025; 16(1): 7-17.

Published online: Mar 25, 2025

DOI: https://doi.org/10.17241/smr.2025.02782

The Missing Link in Patient Recovery: Hospital Sleep Medicine

Ki-Hwan Ji, MD¹

, Dong-Kyu Kim^2,³

, Eun-Hee Kim⁴

, Seockhoon Chung, MD, PhD^5,⁶

¹Department of Neurology, Busan Paik Hospital, College of Medicine, Inje University, Busan, Korea

²Department of Otorhinolaryngology-Head and Neck Surgery, OneSleep Clinic, Gunpo, Korea

³Institute of New Frontier Research, Division of Big Data and Artificial Intelligence, Hallym University College of Medicine, Chuncheon, Korea

⁴Department of Pediatrics, Sejong Chungnam National University Hospital, Chungnam National University School of Medicine, Sejong, Korea

⁵Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

⁶Life Care Center for Cancer Patients, Asan Medical Center Cancer Institute, Asan Medical Center, Seoul, Korea

Corresponding Author Seockhoon Chung, MD, PhD Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, 86 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel +82-2-3010-3411 Fax +82-2-485-8381 E-mail schung@amc.seoul.kr

Received Jan 10, 2025 Revised Mar 15, 2025 Accepted Mar 17, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Hospital sleep medicine is a burgeoning field that underscores the critical role of sleep in the recovery and overall health of hospitalized patients. Hospitalized patients often suffer from sleep disturbances due to environmental disruptions, medical interventions, and underlying illnesses, each of which can impede healing and extend recovery times. This problem is compounded by multi-patient hospital rooms, frequent nighttime disturbances, and a general lack of focus on sleep management within institutions. Furthermore, many hospitalized patients have undiagnosed sleep disorders such as obstructive sleep apnea (OSA) and insomnia, which can further compromise immune function, increase postoperative complications, and exacerbate cognitive and emotional distress. Integrating sleep assessments and targeted interventions into hospital care promises to improve patient outcomes, accelerate recovery, and reduce healthcare costs. Efficient strategies include early identification and management of sleep disorders, using treatments such as continuous positive airway pressure for OSA, and cognitive behavioral therapy for insomnia. Nonetheless, awareness among healthcare providers is still insufficient, leading to the underutilization of screening and interventions for sleep disorders. This review emphasizes the necessity for systematic sleep evaluations, education for healthcare providers, and the development of customized sleep management strategies. Special consideration should be given to vulnerable populations, including surgical and cancer patients, individuals with psychiatric or neurological disorders, and pediatric inpatients. The integration of hospital sleep medicine into routine clinical practice is crucial for enhancing patient recovery, overall safety, and healthcare quality. A systemic shift towards prioritizing sleep in hospital settings is essential to ensure that sleep medicine becomes a fundamental component of comprehensive patient care.

Key words: Sleep medicine, Sleep disorders, Hospitalization, Obstructive sleep apnea, Insomnia

INTRODUCTION

Sleep is a fundamental pillar of health, playing a crucial role in immune function, tissue repair, cognitive processing, and overall well-being [1]. To achieve quality sleep, the bedroom should be a quiet space exclusively for rest, accompanied by a consistent sleep schedule, a relaxing bedtime routine, and a comfortable sleeping environment. Nevertheless, despite its significance, sleep is frequently disrupted in hospital settings, where patients experience significantly reduced sleep quality and duration compared to their home environment. A recent meta-analysis indicates that hospitalized patients sleep, on average, 1.3 to 3.2 hours less per night than healthy individuals, with up to 76% of inpatients reporting sleep disturbances [2]. These disruptions have serious implications, including an increased risk of postoperative complications, prolonged hospital stays, and higher rates of readmission [3].

Patients are often placed in an environment where maintaining sleep hygiene is challenging due to their underlying illness and the unfamiliar, disruptive nature of hospital settings. A major factor contributing to this issue is the design of hospital environments, which prioritize efficient medical care over patient-centered sleep management. Noise from medical equipment, frequent nighttime interruptions for vital sign checks, and artificial lighting all contribute to fragmented sleep. Additionally, many patients admit to the hospital with pre-existing, yet undiagnosed, sleep disorders such as obstructive sleep apnea (OSA) or insomnia, which exacerbate during hospitalization due to stress, illness, and side effects from medications [4,5]. Despite the growing body of evidence linking poor sleep to adverse health outcomes, sleep medicine continues to be largely overlooked in hospital care protocols.

Hospital sleep medicine endeavors to bridge this gap by incorporating systematic sleep assessments, environmental modifications, and targeted interventions into routine medical practice. This review examines the multifaceted challenges associated with sleep disturbances in hospitals and proposes evidence-based strategies for enhancing sleep care across diverse patient populations. Starting with surgical patients, the manuscript examines the impact of preoperative and postoperative sleep disturbances on recovery. We discuss sleep disorders in patients with cancer, emphasizing the need for a multidisciplinary approach. We also cover the bidirectional relationship between sleep disturbances and psychiatric disorders, followed by an examination of neurological conditions such as stroke, neurodegenerative diseases, neuromuscular diseases, and epilepsy, which frequently present with significant sleep disruptions. Lastly, we address pediatric sleep disturbances, highlighting the unique challenges faced by hospitalized children and their caregivers.

By systematically addressing hospital-related sleep disturbances, we can improve patient recovery, enhance treatment outcomes, and alleviate the overall burden on the healthcare system. The need for hospital sleep medicine has transcended mere convenience; it has become a necessity for modern patient care.

SLEEP DISTURBANCES IN SURGICAL PATIENTS

Understanding and Management of Sleep Disturbances in Surgical Patients

Adequate sleep is a critical component of postoperative recovery, particularly for patients undergoing surgery [6]. However, sleep disturbances are common in this patient population and typically result from factors such as postoperative pain, preoperative anxiety, the hospital environment, and postoperative complications [7-9]. It is crucial for healthcare providers to thoroughly understand the etiology, clinical implications, and proper management strategies for these disturbances in order to enhance recovery and optimize clinical outcomes in surgical patients.

Causes of Sleep Disturbance in Surgical Patients

Sleep disturbances are commonly observed in surgical patients, affecting an estimated 50%–70% of individuals undergoing surgery. The severity of these disturbances can vary depending on the type of surgery and patient-specific characteristics [8,10,11]. Several key factors contribute to sleep disruption in this population.

Postoperative pain is a significant cause of sleep disruptions, with many patients experiencing frequent awakenings and a decline in overall sleep quality due to postsurgical discomfort. Effective pain management is crucial for preserving sleep. Anxiety and stress also play significant roles in sleep disturbances. Patients often encounter preoperative anxiety related to surgical procedures and postoperative stress during recovery. These psychological stressors can result in difficulties in initiating and maintaining sleep, particularly among medical interns. The hospital environment further contributes to sleep fragmentation. Patients are frequently exposed to environmental disturbances such as noise from medical equipment, staff interactions, artificial lighting, and nighttime medical interventions. These factors disrupt natural sleep cycles and contribute to poor sleep outcomes. Certain medications administered during the perioperative period can exacerbate sleep disturbances. Anesthetics and analgesics, especially opioids, alter sleep architecture by reducing rapid eye movement (REM) sleep and causing respiratory depression. These alterations can negatively impact overall sleep quality and can worsen conditions such as OSA. Additionally, physiological changes following surgery may contribute to sleep disturbances. Patients who undergo chest or abdominal procedures often experience significant discomfort, complicating their ability to find a comfortable sleeping position. These challenges impede their ability to achieve restorative sleep.

Impact of Sleep Disturbances on Recovery

The impact of sleep disturbances on recovery is substantial and complex. Poor sleep quality can impede the healing process, as sleep is crucial for tissue repair and immune function. Patients suffering from chronic sleep deprivation may exhibit slower wound healing and an elevated risk of postoperative infections [12,13]. Pain sensitivity is heightened in individuals with inadequate sleep, and sleep deprivation can intensify pain perception, thereby creating a feedback loop where pain leads to further sleep disruption, which in turn, increases pain intensity [14]. This cycle makes effective pain management difficult. Furthermore, cognitive and emotional well-being are adversely affected by sleep disturbances. Patients experiencing sleep deprivation may suffer from cognitive impairments, mood disturbances, and increased irritability. In elderly patients, sleep deprivation is linked to a heightened risk of postoperative delirium, complicating the recovery process further [15]. Extended hospital stays are another consequence of poor sleep. Patients facing significant sleep disturbances frequently require longer hospitalization due to delayed recovery and the necessity for more medical interventions, thus increasing the burden on healthcare resources and escalating overall treatment costs.

Management Strategies

A variety of management strategies are available to mitigate sleep disturbances in surgical patients. These strategies are classified into non-pharmacological and pharmacological interventions.

Non-Pharmacological Interventions

Educating patients on the importance of maintaining a regular sleep-wake cycle, even while hospitalized, is critical for optimizing recovery. Encouraging the use of eye masks and earplugs can aid in minimizing environmental disturbances and enhancing sleep quality. Incorporating sleep hygiene practices into preoperative education involves the implementation of these key strategies.

First, patient education should commence as soon as surgery is scheduled, enabling adoption of these practices prior to hospitalization. To facilitate this, patient-centered educational materials such as brochures or videos should be created to demystify sleep hygiene principles in an accessible format. Preoperative consultations offer an additional opportunity to discuss sleep hygiene, offering advice on maintaining a consistent sleep schedule, establishing a conducive sleep environment, and avoiding stimulants before bedtime. A multidisciplinary approach involving nurses, anesthesiologists, and sleep specialists is crucial to ensure that sleep hygiene is an integral part of patient care across various domains. Recognizing the variability in individual sleep needs, tailored sleep hygiene recommendations should be made based on the patients’ typical sleep patterns, existing sleep disorders, and levels of surgery-related anxiety. Additionally, follow-up initiatives should be instituted to reinforce sleep hygiene education throughout the preadmission and hospital admission phases. Tools such as digital reminders and mobile applications can assist patients in adhering to these recommendations. By adopting these measures, hospitals can improve sleep quality and contribute to enhanced surgical recovery outcomes.

In addition to sleep hygiene education, several targeted interventions can enhance sleep quality and recovery in surgical patients. Initially, cognitive behavioral therapy for insomnia (CBT-I) should be considered for patients with pre-existing sleep disorders. If feasible before surgery, CBT-I can address underlying sleep issues and enhance overall sleep quality. Effective pain management is also vital as poorly managed pain can severely disrupt sleep. A multimodal analgesic regimen should be employed to reduce dependence on opioids, which adversely impact sleep architecture. When feasible, non-opioid analgesics, regional anesthesia, and non-pharmacological pain management techniques such as relaxation exercises should be used to enhance pain control and sleep quality. Relaxation techniques, including deep breathing exercises, guided imagery, and progressive muscle relaxation, can also alleviate preoperative anxiety and promote restful sleep. By integrating these modalities with sleep hygiene education, healthcare providers can develop a comprehensive strategy to improve sleep quality and surgical recovery.

Pharmacological Interventions

Adapting pain management strategies to minimize sleep disturbances while ensuring effective analgesia calls for a multidisciplinary approach that balances pain control with the preservation of sleep quality.

• Analgesics: Non-opioid analgesics such as acetaminophen or NSAIDs can be employed to manage pain with minimal impact on sleep architecture. When opioids are necessary, the lowest effective dose should be prescribed for the shortest possible duration.

• Sedatives and hypnotics: Short-acting agents, such as zolpidem, may be considered for temporary use; however, the risks of dependence and interactions with other medications must be carefully considered.

• Melatonin: The use of melatonin or melatonin agonists should be considered for patients experiencing circadian rhythm disturbances or those having difficulty initiating sleep.

• Nighttime dose adjustments: The timing of analgesic administration should be adjusted to minimize nighttime disruptions. For example, administering long-acting analgesics before bedtime can help maintain overnight pain control without necessitating additional doses that could disrupt sleep.

• Avoiding stimulant medication: Caution is advised with medications that possess stimulating properties or are used in conjunction with pain management drugs (e.g., corticosteroids). If necessary, these should be scheduled earlier in the day to reduce their impact on sleep.

Special Considerations

• Elderly patients: Elderly patients are at an increased risk of sleep disturbances and postoperative delirium. Therefore, careful monitoring and a minimized use of sedative medications in this population are essential [16,17].

• Patients with OSA: Patients with OSA require special attention as sedatives and opioids can exacerbate OSA [18,19]. Continuous positive airway pressure (CPAP) therapy should be maintained postoperatively, and vigilant monitoring for respiratory complications is crucial to prevent them.

• Intensive care unit (ICU) patients: Sleep disturbances are particularly common in ICU settings, attributed to the care intensity and environmental factors [20]. Strategies such as consolidating care activities to minimize nighttime interruptions and enhancing the ICU environment (e.g., reducing noise and adjusting lighting) can be advantageous. Effective management of sleep disturbances in surgical patients is a complex challenge that requires a holistic approach. Recognizing the prevalence and impact of such disturbances, accurately assessing patients, and employing targeted management strategies can significantly improve postoperative outcomes and enhance patient recovery.

SLEEP DISTURBANCES IN PATIENTS WITH CANCER

Patients with cancer may experience sleep disturbances at any point during their diagnosis and treatment [21]. However, the clinical significance of sleep disorders is often underestimated in psycho-oncology. Sleep medicine specialists frequently lack opportunities for intensive training in cancer care, while oncologists find it challenging to gain expertise in sleep disorders. Thus, sleep medicine specialists should integrate a multidisciplinary approach to psycho-oncology to address this gap. Nonetheless, only a few sleep medicine experts are actively engaged in psycho-oncology. Improper management of insomnia in cancer patients can lead to poor sleep habits, altered sleep beliefs, and hyperarousal. Consequently, it is essential to devise and recommend an insomnia treatment plan for patients with cancer in clinical settings.

Causes of Sleep Disturbance among Cancer Patients

Insomnia disorder

It is estimated that 59%–79% of patients with cancer experience insomnia [22]. In Korea, insomnia’s prevalence varies among the ten most common types of cancer [23]. Insomnia is most prevalent in lung cancer patients, while it is least prevalent in those with thyroid cancer. Insomnia may be influenced by cancer treatment modalities such as chemotherapy, radiotherapy, and surgery. Treatment with anti-hormones for breast cancer can lead to menopausal symptoms like night sweats and insomnia. A 3P model demonstrates that physical symptoms such as pain and vomiting, side effects of surgery and chemotherapy, and psychological distress all contribute to insomnia [24]. However, these precipitating factors cannot be entirely eliminated during treatment; hence, insomnia symptoms may persist. Therefore, when managing CBT-I, untreatable precipitating factors should be taken into account. For instance, if insomnia results from severe pain, managing the pain should take precedence over prescribing sleep aids.

Circadian sleep wake rhythm disorder

The assessment of insomnia in patients with cancer starts by differentiating sleep-wake cycles that are excessively early (advanced) or late (delayed) from insomnia disorders. Cancer treatment often disrupts these rhythms, decreases daytime activity, and complicates sleep at night [25]. Chronotherapy proves more beneficial than hypnotics in managing Circadian sleep wake rhythm disorder (CRSWD). Therefore, if sleeping pills are prescribed without adjusting the sleep-wake cycle, the dosage may need to be increased. Melatonin or light therapy could be effective in regulating sleep and wakefulness.

Restless legs syndrome

The primary symptom of restless legs syndrome (RLS) is an uncomfortable sensation and an urge to move the legs while at rest, which complicates sleep. Although usually attributed to inadequate dopamine production, RLS may also be triggered by iron deficiency, which plays a role in dopamine synthesis. Both chemotherapy and iron deficiency can affect RLS symptoms in cancer patients [26]. For cancer patients, it is crucial to assess blood iron and ferritin levels, as iron deficiency can occur due to malnutrition. Iron supplements are given to those with iron deficiency, while patients without this condition may receive clonazepam or dopamine agonists. Additionally, it is vital to differentiate chemotherapy-induced peripheral neuropathy (CIPN) from other types of peripheral neuropathies.

Obstructive sleep apnea syndrome

Patients with head and neck cancer are more susceptible to OSA. Furthermore, obstructive sleep apnea syndrome (OSAS) can be exacerbated by nutritional deficiencies in cancer patients, leading to muscle weakness. Analgesics and tranquilizers should be administered cautiously as they can aggravate OSAS. Symptoms are assessed using polysomnography, and if severe, CPAP or surgical interventions may be considered.

Physical symptoms

Pain is the predominant physical symptom that disrupts sleep. Severe nocturnal pain can lead to insomnia, while substantial daytime pain may also hinder daily activities, further contributing to sleep issues. Due to the ineffectiveness of traditional sleeping pills in severe pain scenarios, effective pain management is essential. Insomnia can also result from chemotherapy. CIPN often results in nocturnal insomnia as a side effect of chemotherapy. Additionally, cancer-related fatigue contributes to sleep disturbances. Moreover, hot flashes, particularly from antihormonal therapy in breast cancer patients, can exacerbate sleep issues.

Treatment of Sleep Disturbance of Cancer Patients

Adapting CBT-I for cancer patients

Cognitive behavioral therapy, a non-pharmacological treatment for insomnia, enhances sleep habits and addresses dysfunctional thoughts about sleep. Typically, it includes 1) sleep hygiene education, 2) stimulus control, 3) sleep restriction, 4) cognitive therapy, and 5) relaxation techniques. Cancer patients experience insomnia differently from the general population, notably in terms of the precipitating and perpetuating factors, necessitating adaptations of CBT-I for this group [24]. Many cancer patients suffer from cancer-related fatigue during the day and spend excessive hours lying down, leading to a merger of their sleep and living spaces. Therefore, it is advisable to encourage them to establish distinct areas for sleeping and living, suggesting they sleep in their bedrooms and spend waking hours in their living rooms. Insomnia patients often harbor dysfunctional beliefs about sleep. For instance, cancer patients in Korea commonly hold misconceptions such as, “If you don’t sleep at a certain time, your immunity will weaken” or “Poor sleep will cause your cancer to recur.” These dysfunctional beliefs may exacerbate sleep disturbances. Consequently, by learning to mitigate these dysfunctional thoughts, cancer patients can significantly improve their sleep.

Pharmacotherapy for sleep disturbance in cancer patients

Patients with cancer exhibit varied physical conditions based on their disease stage and treatment regimen. It is crucial to assess both the physical state and consciousness level of patients when prescribing sleeping pills. Consideration of drug interactions is essential, given the concurrent use of multiple medications in cancer treatment. Narcotic analgesics are contraindicated when the patient’s consciousness is impaired or when benzodiazepines are administered. For initiation disorders, benzodiazepines or short-acting Z-class hypnotics may be prescribed, whereas antidepressants with antihistamine properties like doxepin and trazodone are suitable for maintenance disorders. Since benzodiazepines and Z-class hypnotics can increase delirium in cancer patients, they should be avoided in those presenting with delirium and sleep difficulties. In such cases, antipsychotic drugs are a preferable alternative. The timing of sleeping pills is also crucial [27]. They are generally recommended to be taken 30 minutes before bedtime; however, taking them earlier to fall asleep sooner can lead to prolonged bedtimes, reduced sleep efficiency, and diminished effectiveness of the medication, necessitating an increased dosage [28]. Altering the administration time of sleeping pills to “7 hours before waking up in the morning” could enhance their effectiveness.

SLEEP DISTURBANCES IN PATIENTS WITH PSYCHIATRIC DISORDERS

Hospitalized patients frequently experience psychiatric symptoms including depression, anxiety, and somatic symptoms. Sleep disturbances may be exacerbated by these symptoms; thus, addressing them could aid in alleviating sleep issues.

Major Depressive Disorder

Depression is prevalent among hospitalized patients, with 10%–30% potentially exhibiting symptoms [29]. Multiple factors increase the risk of developing depression, such as chronic illnesses including cancer, heart disease, and diabetes, as well as severe pain, disability, cognitive impairment, side effects from medications like corticosteroids and opioids, and extended ICU stays. Depression can be transient, but a diagnosis of major depressive disorder (MDD) is made when symptoms persist for more than two weeks and disrupt daily activities. MDD feature symptoms such as depressed mood, loss of interest, restlessness, diminished energy, altered appetite, insomnia, excessive daytime sleepiness, and feelings of hopelessness. Severe depression may also present with psychomotor agitation or retardation, impaired concentration or decision-making, and feelings of worthlessness or guilt, potentially leading to suicide.

Patients with depression frequently face difficulties in initiating sleep and maintaining sleep, and experience frequent dreams. Changes in sleep architecture, identified through polysomnography, include increased sleep latency and awakenings during sleep, and reduced overall sleep time and slow-wave sleep, leading to premature morning awakenings [30]. Also, REM sleep disinhibition is commonly observed in patients with MDD [31]. Even after depressive symptoms improve, sleep patterns may take time to normalize. For those with MDD, insomnia remains challenging to treat, persists even after alleviation of other symptoms, and increases the risk of suicide attempts [32]. In these patients, antidepressants can lessen sleep issues as depression improves with treatment. While effective in reducing insomnia, antidepressants may exacerbate the condition in some individuals. For instance, fluoxetine intensifies sleep disturbances while mirtazapine mitigates them [33]. Additionally, tricyclic antidepressants such as doxepin and amitriptyline have been found to enhance sleep quality.

Post-Traumatic Stress Disorder

Various accidents occur in daily life, including traffic collisions, falls, and physical injuries. Hospitalized individuals who sustain physical trauma often concurrently experience psychological trauma. Psychological trauma can adversely affect a patient’s mental health, and individuals with post-traumatic stress disorder (PTSD) suffer from severe psychological trauma characterized by hyperarousal, avoidance, and re-experiencing. Sleep is profoundly impacted by PTSD. Patients frequently suffer from sleep disruptions, which can worsen their overall condition and adversely influence their quality of life. Common symptoms include severe insomnia, nightmares, sleep deprivation, and nighttime hyperarousal [34].

Delirium

Delirium is characterized by fluctuating levels of disorientation, often attributable to the medical or physical conditions of patients in general hospitals. A high incidence of sleep disturbances is observed in patients with delirium. However, it is crucial to differentiate sleep disturbances from behavioral dysregulation and delirium itself. Benzodiazepines, which are commonly prescribed to promote sleep, may exacerbate delirium. Antipsychotics, which can mitigate delirium, may therefore be preferable for treating patients with delirium [35].

SLEEP DISTURBANCES IN PATIENTS WITH NEUROLOGIC DISEASES

Sleep disturbances are highly prevalent in neurological diseases and significantly impact disease progression, cognitive function, and overall quality of life. Neurological conditions frequently disrupt sleep due to damage to brain structures that regulate the sleep-wake cycle, neurotransmitter imbalances, and secondary effects from symptoms such as pain, muscle spasticity, and cognitive impairment. Furthermore, poor sleep can exacerbate neurological dysfunction, impede recovery, and contribute to the deterioration of cognitive and motor outcomes. Thus, addressing sleep disturbances in neurological patients through early screening, targeted interventions, and hospital-based sleep protocols is crucial for optimizing neurological health and rehabilitation outcomes.

Sleep Disturbances in Hospitalized Neurological Patients

Hospitalized patients with neurological disorders often experience disrupted sleep patterns, adversely impacting their recovery, cognitive function, and immune response. Both underlying neurological conditions and factors related to the hospital environment contribute to poor sleep quality. Common sleep disturbances in hospitalized neurological patients include decreased total sleep time, fragmented sleep, increased sleep latency, difficulty maintaining sleep, and excessive daytime sleepiness. Additionally, circadian rhythm disruptions are prevalent, especially in patients with traumatic brain injury (TBI), stroke, and neurodegenerative diseases.

These disturbances impair neuroplasticity, delay recovery from neurological injuries, and contribute to neuroinflammation and metabolic dysfunction. In hospital settings, frequent nighttime awakenings due to medical interventions, environmental noise, light exposure, and side effects of medications further exacerbate sleep problems, thereby highlighting the importance of sleep management in patient care.

OSA and Stroke

The relationship between sleep disturbances and neurological diseases is particularly evident in stroke patients. OSA is highly prevalent in those with stroke, affecting up to 72% of individuals with ischemic or hemorrhagic stroke and transient ischemic attacks. This prevalence far exceeds that observed in the general population [36]. Untreated post-stroke OSA is associated with poorer neurological and cognitive outcomes, prolonged hospital stays, and an increased risk of recurrent stroke and mortality [37,38]. OSA severity is notably high in patients with cardioembolic strokes and those with supratentorial localization [39].

OSA significantly influences stroke prognosis in several ways. It heightens the risk of recurrent stroke as intermittent hypoxia and sympathetic overactivation contribute to endothelial dysfunction and hypertension [40,41]. Studies indicate that stroke patients with untreated OSA are more likely to experience recurrent strokes, with a direct correlation between the apnea-hypopnea index score and stroke recurrence risk. Moreover, OSA is linked to increased post-stroke mortality. Longitudinal studies have shown that patients with moderate-to-severe OSA undergoing stroke rehabilitation face a significantly higher mortality risk than those without OSA [42]. Furthermore, OSA adversely impacts post-stroke recovery by impairing cognitive function, reducing participation in rehabilitation, and contributing to long-term disabilities. It is also associated with cardiovascular complications, amplifying the deterioration of stroke outcomes. Concurrent cognitive impairments from OSA amplify neurological deficits caused by stroke, thereby imposing additional barriers to recovery.

Despite these severe consequences, screening for sleep apnea in stroke patients remains underutilized [43]. In the Brain Attack Surveillance in Corpus Christi project, only 17% of participants underwent evaluation for sleep apnea before experiencing a stroke, and just 6% received sleep evaluations post-stroke [44]. This underscores the pressing need for standardized screening protocols for OSA in stroke patients, which would aid in both primary and secondary prevention. The gold standard for treating moderate-to-severe OSA is CPAP therapy, which has demonstrated potential benefits in improving stroke outcomes. Nonetheless, the efficacy of CPAP in reducing recurrent strokes constitutes an active area of research. While some studies have shown promise, others have yielded inconclusive results [45]. However, adherence to CPAP has been linked to reduced cardiovascular risk and better neurological recovery, reinforcing its expected advantages [46]. Ongoing trials, like the Sleep SMART trial, seek to offer more conclusive recommendations regarding the appropriate timing and strategies for OSA screening and management in stroke patients [47].

RLS in Neurological Diseases

RLS is closely linked to various neurological diseases, particularly Parkinson’s disease (PD) and multiple sclerosis (MS). RLS is more frequently noted in patients with PD, especially after dopaminergic therapy and in advanced stages of the disease [48]. The simultaneous occurrence of PD and RLS, which both implicate disruptions in the dopaminergic system, raises the possibility of underlying neurochemical dysfunction. Similarly, patients with MS are three times more likely to suffer from RLS than the general population, potentially due to iron deficiency, chronic inflammation, and lesions along the dopaminergic pathways that regulate spinal cord circuits [49,50].

Sleep-Disordered Breathing in Neuromuscular Disorders

Patients with neuromuscular disorders such as amyotrophic lateral sclerosis (ALS) and myotonic dystrophy frequently experience nocturnal hypoventilation as a result of respiratory muscle weakness. This condition can lead to fragmented sleep, morning headaches, and excessive daytime sleepiness. Patients with myasthenia gravis and OSA may present atypically with paradoxical morning weakness [51]. In hospital settings, diligent monitoring of respiratory functions during sleep is essential to avert complications like nocturnal hypoxia and hypercapnia. Noninvasive ventilation is often necessary for respiratory support during sleep, particularly in patients with advanced disease [52].

Sleep and Epilepsy

The relationship between sleep and epilepsy is complex and bidirectional. Sleep deprivation is a well-documented trigger for seizures, and nocturnal seizures can disrupt sleep architecture, leading to a detrimental cycle of worsening epilepsy symptoms and poor sleep quality. Several epilepsy syndromes are closely linked to sleep disturbances. There is a high prevalence of sleep disorders such as OSA among epilepsy patients [53], with studies reporting that up to 71% of individuals with epilepsy have undiagnosed OSA, further increasing the seizure burden. Addressing sleep disorders in these patients, particularly with CPAP therapy, has been associated with improved seizure control, enhanced daytime alertness, and an improved quality of life [54]. Sudden unexpected death in epilepsy (SUDEP) has also been associated with sleep disturbances [55], with 40% to 60% of SUDEP cases occurring during sleep, indicating a role for sleep-related respiratory and autonomic dysfunctions.

Antiseizure medications can impact sleep architecture. For instance, lamotrigine has been shown to reduce slow-wave sleep and induce insomnia [56]. Nevertheless, sedative-hypnotics should be used with caution due to potential drug interactions and the risk of excessive daytime sedation. When evaluating epilepsy patients, the use of video polysomnography alongside extended electroencephalography could be beneficial for assessing both seizure activity and coexisting sleep disorders.

REM Sleep Behavior Disorder and Neurodegenerative Diseases

REM sleep behavior disorder (RBD) is frequently observed in patients with PD, dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). Characterized by a loss of REM sleep atonia and resulting in dream-enactment behaviors that may lead to injury, RBD is one of the strongest prodromal markers of α-synucleinopathies. Studies indicate that up to 73.5% of patients with idiopathic RBD will develop PD, DLB, or MSA within 12 years [57]. Management strategies involve safety measures to prevent injuries, withdrawal of medications that could exacerbate RBD, such as serotonergic antidepressants, and treatment of comorbid OSA if present. Pharmacological options like melatonin or clonazepam may be considered for symptomatic relief.

TBI and Sleep Disturbances

Sleep disturbances are highly prevalent following TBI, with insomnia being the most frequently reported disorder. Approximately one-third of TBI patients suffer from insomnia, a rate that is double that of the general population. Additionally, half of these patients experience some form of sleep disturbance [58]. These disturbances can persist throughout the acute, subacute, and chronic phases of TBI. A large multicenter study found that 43.3% of patients experienced insomnia two weeks post-injury, but this prevalence decreased to 27.8% at the one-year follow-up [59]. Hypersomnia and circadian rhythm dysregulation post-TBI are also common and are especially prevalent in cases of severe TBI.

Given the profound impact of sleep disorders on neurological health, optimizing sleep in hospitalized neurological patients necessitates a multifaceted approach. Environmental modifications, behavioral interventions, and targeted pharmacological treatments should be tailored to the specific needs of each patient’s condition.

SLEEP DISTURBANCES IN PEDIATRIC PATIENTS

Sleep Disturbances in Hospitalized Pediatric Patients

The sleep-wake cycle and sleep structure evolve throughout a child’s life, impacting brain and body development during crucial stages of neurodevelopment and physical growth [60]. Younger children exhibit shorter sleep-wake cycles and less structured sleep stages due to immature brain development, resulting in increased sleep instability and heightened risk of sleep disturbances from various internal and external factors during hospitalization [60]. Although research on sleep disturbances in hospitalized pediatric patients is less comprehensive than in adults, numerous studies have identified various sleep issues in pediatric patients across general wards, oncology units, and neonatal ICU (NICU) and pediatric ICUs (PICU). These problems include reduced total sleep time, delayed sleep onset, frequent nocturnal awakenings, increased wake time after sleep onset, reduced sleep efficiency, diminished sleep quality, and circadian rhythm disruption [61-63]. Inadequate sleep during hospitalization can disrupt recovery from critical illnesses by affecting the immune, endocrine, and cardiovascular systems, leading to emotional instability in both pediatric patients and their caregivers [64,65]. Parents staying overnight frequently with hospitalized children often experience sleep deprivation, which complicates medical decision-making for their children and adversely affects the parent-child relationship [64].

Risk Factors Affecting Sleep in Hospitalized Pediatric Patients

As in adults, the risk of sleep disturbance in hospitalized children can be influenced by factors related to illness, environment, psychological state, and medications. Compared to adults, considerations for children include age, developmental level, and family dynamics [66]. The younger the child, the greater the need for prolonged sleep; however, achieving sustained sleep during hospitalization is challenging. This difficulty can lead to sleep deprivation and increased sleep disturbances, such as trouble falling asleep and frequent sleep interruptions [60]. Furthermore, lower developmental levels exacerbate the frequency of anxiety or worry triggered by unfamiliar hospital settings and a lack of understanding regarding interventions or nursing care during sleep, thereby intensifying sleep disturbances [66]. Notably, family dynamics, including the caregiver’s emotional state and parenting attitudes, significantly affect pediatric sleep patterns. Caregivers endure considerable discomfort, anxiety, and worry as they abandon their daily routines and employment to care for their child, comprehend the child’s medical condition and treatment, and make critical health decisions. In scenarios where caregivers also suffer from sleep deprivation, their anxiety and sensitivity heighten, potentially eroding trust and satisfaction with the medical staff and increasing the child’s anxiety and stress [67].

Special Populations at Risk in Hospitalized Pediatric Patients

As with adults, children who are mechanically ventilated, have undergone major surgery, are diagnosed with cancer, or have pre-existing sleep disorders possess additional risk factors for sleep disturbances that require careful consideration. Other subsets of children at increased risk for sleep disturbance include premature infants in the NICU and those with neurodevelopmental disorders. Neonates are particularly susceptible to various environmental factors in the NICU due to their distinct normal sleep patterns, which vary from those of older children, and immature sleep structures [68]. Furthermore, many environmental factors disrupt sleep in the NICU, and rapid intervention is often necessary when there is a critical change in neonates [69,70]. This risk is inevitably higher in premature infants, who face more critical conditions than full-term infants, have more vulnerable sleep functions, and require prolonged hospitalization [71]. Additionally, specialized management of sleep during hospitalization is essential for children with developmental disabilities such as autism spectrum disorder, intellectual disability, or attention-deficit/hyperactivity disorder [72]. This is attributed to the high incidence of insomnia observed in patients with developmental disabilities due to biological factors, with symptoms exacerbated by excessive anxiety and hyperarousal caused by unfamiliar environments and medical interventions during hospitalization [72].

Sleep Promotion Interventions for Hospitalized Pediatric Patients

To improve sleep during hospitalization, both non-pharmacological (environmental or behavioral) and pharmacological interventions are essential. Optimizing sleep in hospitalized pediatric patients poses significant challenges; however, the systematic implementation of non-pharmacological and practical treatment bundles is crucial for improving sleep. Many environmental and iatrogenic factors, rooted in long-standing medical practices and culture, must be modified to mitigate and ultimately eliminate their detrimental effects. Hospitals can most actively and effectively improve these environmental factors. Specific interventions include care coordination during protected sleep periods, established ward schedules (light, naps, visiting times), elimination of unnecessary overnight vital checks, ensuring a comfortable temperature, modulating light exposure (covering windows at night, increasing daylight exposure), reducing ward noise, and using white noise machines [66,73]. Sleep promotion through improving environmental factors is especially vital in the NICU. Several studies have shown that sleep management and environmental improvements in the NICU are crucial for the development and growth of neonates, with strategies such as positioning, body temperature management, managing noise and lighting, and providing sensory stimulation that ensures emotional stability, all of which are beneficial for protecting sleep in neonates [74-76].

Behavioral interventions, incorporating techniques such as music therapy, bedtime storytelling, and massage, can effectively enhance the child’s emotional stability and physical relaxation. Additionally, aligning home routines, increasing physical activity, and maximizing daylight exposure, along with providing age-appropriate sleep education for children and caregivers, can substantially improve familial and child factors [63,66,77]. These interventions are particularly crucial for children with pre-existing sleep disorders, children at risk due to factors like obesity, adenoid and tonsil hypertrophy, and neurodevelopmental disorders, and children likely to experience sleep disturbances due to nighttime interventions or nursing care. Effective strategies include screening at the onset of hospitalization, educating patients and caregivers about potential sleep issues during the stay, and continuously monitoring and managing these concerns [62,78].

Pharmacological interventions become essential when environmental or behavioral strategies alone are insufficient. These should be considered particularly in children at high risk of exacerbating pre-existing conditions, such as insomnia or sleep-disordered breathing, or in those experiencing sleep complications associated with symptoms like fever, pain, cough, or vomiting [66,79]. For children with insomnia, who have trouble initiating sleep or who frequently wake at night and experience sleep deprivation, medications such as melatonin, antihistamines, or clonazepam can be beneficial in improving symptoms [72].

CONCLUSION

Sleep disturbances are highly prevalent among hospitalized patients, especially those who are undergoing surgery, cancer treatment, or intensive care. Contributing factors such as postoperative pain, anxiety, environmental disruptions, and medication-related effects can significantly deteriorate sleep quality, which, in turn, impairs recovery, prolongs hospital stays, and escalates healthcare costs. Effective management strategies, including sleep hygiene education, CBT-I, multimodal pain management, and pharmacological interventions, can significantly enhance recovery outcomes. Patients with cancer often experience sleep disorders due to the physiological impacts of their condition and the psychological stress associated with their treatment. Common issues include insomnia, disturbances in circadian rhythm, RLS, and OSA, all of which require tailored interventions. An interdisciplinary approach that integrates sleep medicine with psycho-oncology is crucial for enhancing treatment efficacy and improving quality of life. Key therapeutic elements such as CBT-I, melatonin regulation, and targeted pain management are essential in treating sleep disturbances. Apart from surgical and cancer care, psychiatric and neurological conditions also exacerbate sleep problems in hospitalized patients. Disorders such as MDD, PTSD, and delirium frequently disturb sleep, necessitating comprehensive psychiatric evaluation and interventions. Similarly, neurological disorders like stroke, MS, and epilepsy affect sleep architecture and require condition-specific management. Pediatric patients, particularly those in NICUs and PICUs, are extremely susceptible to sleep disturbances due to developmental factors, environmental stressors, and parental anxiety. Optimizing sleep for these patients involves environmental modifications, structured behavioral interventions, and judicious pharmacological treatment.

Hospital sleep medicine is an evolving yet critical aspect of patient care that remains largely unexplored. Addressing sleep disturbances in surgical, cancer, psychiatric, neurological, and pediatric patients necessitates a multidisciplinary approach that incorporates routine sleep assessments and targeted interventions into standard medical practice. By implementing structured sleep management protocols, training healthcare professionals, and promoting a cultural shift that recognizes sleep as a critical component of healthcare, hospitals can significantly enhance patient recovery, minimize complications, and improve overall healthcare outcomes.

Prioritizing sleep medicine within hospital settings is not merely an enhancement of care; it is a crucial advancement in contemporary healthcare that holds the potential to transform patient well-being and enhance treatment efficacy [80]. The vision for hospital sleep medicine should expand beyond immediate improvements, encouraging systemic changes in the perception and management of sleep. In conclusion, advancing hospital sleep medicine represents not just a refinement of existing practices but a fundamental evolution in healthcare delivery—one that can lead to quicker recovery, fewer complications, and better patient outcomes.

NOTES

Availability of Data and Material

The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.

Author Contributions

Conceptualization: all authors. Project administration: Ki-Hwan Ji. Writing— original draft: all authors. Writing—review & editing: all authors.

Conflicts of Interest

Seockhoon Chung, a contributing editor of the Sleep Medicine Research, was not involved in the editorial evaluation or decision to publish this article. All remaining authors have declared no conflicts of interest.

Funding Statement

None

Acknowledgements

None

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