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Sleep habits in patients with stroke
ORIGINAL ARTICLE
Sleep habits in patients with stroke: necessity of
sleep hygiene measures
Hábitos de sono de pacientes com acidente vascular cerebral: necessidade de
medidas de higiene do sono
Ana Amália Torres Souza Gandour Dantas1, Luciana Protásio de Melo1, Débora Carvalho de Oliveira1,
Glênia Soares Saldanha1, Tania Fernandes Campos1
ABSTRACT
Introduction/Objectives: Inadequate sleep habits can affect
the physical and mental well-being of the individual; therefore,
the aim of this study was to assess the sleep habits of patients
with chronic stroke and the necessity of sleep hygiene measures.
Methods: A descriptive study was conducted, which involved 154
patients (90 men and 64 women): 55.2% ≥ 60 years of age and
44.8% < 60 years of age; 81 right brain-damaged and 73 left braindamaged. The patients completed a Sleep Habits Questionnaire,
validated in Brazil, with 47 questions related to family, housing,
health, sleep and daily activities. The data were analyzed by the
chi-square test. Results: The results showed that 63.6% of the
patients had an additional person sleeping in their bedroom,
12.3% complained about too much noise in the room and 35%
complained about too much light. Of these patients, 5.8% were
smokers, and 7.8% were alcohol consumers and 70.1% were coffee
drinkers. Regarding the sleep quality, 28.6% had difficulty initiating
sleep, and 37.6% awoke in the middle of the night. In addition, 95%
were unemployed, 80.5% did not perform physical activities, and
95.4% did not perform mental activities. Conclusion: These results
indicate that many patients do not follow sleep hygiene measures,
suggesting a requirement for sleep medicine measures so that these
patients can learn lifestyle habits that ensure good quality of sleep.
Keywords: sleep hygiene, sleep medicine, sleep quality, stroke.
RESUMO
Introdução/Objetivos: Os hábitos inadequados de sono podem
repercutir no bem-estar físico e mental do indivíduo, por isso, o
objetivo do estudo foi de avaliar os hábitos de sono de pacientes
crônicos com Acidente Vascular Cerebral e a necessidade de medidas
de higiene do sono. Métodos: Foi realizado um estudo descritivo,
no qual participaram 154 pacientes (90 homens e 64 mulheres),
55,2% ≥ 60 anos e 44,8% < 60 anos, 81 com lesão cerebral direita
e 73 à esquerda. Os pacientes responderam a um Questionário de
Hábitos de Sono, validado no Brasil, com 47 questões relacionadas
com a família, moradia, saúde, sono e atividades diárias. Os dados
foram analisados pelo teste Qui-quadrado. Resultados: Os
resultados apontaram que 63,6% dos pacientes apresentavam mais
uma pessoa no quarto de dormir, 12,3% se queixavam de muito
barulho no quarto e 35% de muita iluminação. Dos pacientes
avaliados, 5,8% fumavam, 7,8% bebiam e 70,1% tomavam café.
Quanto ao sono, 28,6% apresentavam dificuldade de iniciar o sono
e 37,6% acordavam no meio da noite. Foram apresentadas queixas
de pesadelos (11%), sensação de sufoco (37,7%) e 35% sentiam
muito sono durante o dia. Além disso, 95% não trabalhavam, 80,5%
não realizavam atividades físicas e 95,4% não realizavam atividades
mentais. Conclusão: Esses resultados indicam que muitos
pacientes não seguem as medidas de higiene do sono, sugerindo
a necessidade de atuação da Medicina do sono, a fim de que os
pacientes aprendam hábitos de vida adequados que garantam uma
boa qualidade de sono.
Descritores: acidente vascular cerebral, higiene do sono, medicina
do sono, qualidade do sono.
INTRODUCTION
In several countries, infections and contagious diseases are
being outranked by chronic degenerative diseases, among which
stroke is the most common and can be the leading cause of
death and disabilities(1).
This neurovascular disease exhibits a variety of clinical
manifestations, depending on the type of lesion, its localization
and the size of the affected area, as well as its nature and the
compromised functions(2). Patients who have suffered a stroke
exhibit neurological deficits that require rehabilitation from
Study carried out at Department of Physiotherapy, Federal University of Rio Grande do Norte (Universidade Federal do Rio Grande do Norte - UFRN), Chronobiology
Laboratory, Sleep Laboratory, Natal, state of Rio Grande do Norte, Brazil.
1
Department of Physiotherapy, Federal University of Rio Grande do Norte (Universidade Federal do Rio Grande do Norte - UFRN), Chronobiology Laboratory,
Sleep Laboratory, Natal, state of Rio Grande do Norte, Brazil.
Corresponding author: Tania Fernandes Campos. Departamento de Fisioterapia, Universidade Federal do Rio Grande do Norte. Avenida Senador Salgado Filho,
nº 3000. Natal - RN. Brazil. CEP: 59066-800. Fax: 55 (84) 33422-001. E-mail: [email protected]
Financial Support: National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq)
(process nr. 409797/2006-5). This study is part of the Program for Diagnosis and Intervention of Sleep, Cognitive and Functional Disorders in Patients with
Cerebrovascular Accident (Programa de Diagnóstico e Intervenção das alterações do sono, cognitivas e funcionais em pacientes com Acidente Vascular Cerebral PRODIAVC), Brazil.
Received: May 24, 2013; Accepted: August 10, 2013.
Sleep Sci. 2013;6(4):146-150
Dantas AATSG, Melo LP, Oliveira DC, Saldanha GS, Campos TF
the initial post-stroke stage. Affected individuals often present
sleep-related complaints and thus compromise the rehabilitation
professional’s effort to apply exercises and other procedures
that depend on the patient’s attention, motivation and voluntary
participation.
According to reports from the literature, neurobehavioral
function is directly affected by the sleep and wake times, which,
in turn, depend on sleep habits and lifestyles(3). Indeed, changes
in the nighttime sleep pattern can lead to excessive daytime
sleepiness, which is a predictive factor for various cognitive
impairments, including reduced attention-concentration, spatial
and temporal orientation, and memory performance, as well
as compromised psychological and social functions, which can
aggravate the symptoms and even the prognosis of medical
disorders(4,5).
The recognition of sleep problems by healthcare
professionals is an important component in the overall clinical
approach. Furthermore, prevention or intervention measures
concerning the conditions that contribute to sleep disorders,
as well as the diagnosis and treatment of these disorders, are
considerably important for health and quality of life. In this
context, the patient’s own perception of his/her sleep is a
primary and essential consideration in clinical practice.
In most cases, a large proportion of sleep disorders
can be resolved with simple and efficient measures, such as
behavioral therapy. Specifically, this therapy includes sleep
hygiene measures and aims to teach the patient appropriate life
habits that ensure good sleep quality. Sleep hygiene comprises a
set of common measures, such as avoiding physical activity and
the consumption of stimulant substances (such as caffeine) a few
hours before sleeping and removing televisions, computers and
any other factors that can compromise sleep from the bedroom.
It is also ideal to remain in a dark environment without noise
before sleeping to produce the neurological adaptations that
lead to sleep(3,6).
Based on the above information, we presume that
inadequate sleep habits can have an impact on the individual’s
physical and mental well-being. Therefore, the aim of the present
study was to evaluate the sleep habits of chronic stroke patients
and to discuss the necessity of sleep medicine measures.
METHODS
Participants
The sample consisted of 154 patients (90 men and 64
women) diagnosed with a first stroke episode, as recorded
in physiotherapy departments, with a mean recovery time of
26.5 ± 33 months. The patient exclusion criteria were as follows:
recurrent brain lesions, severe cognitive disorders, aphasia and
the use of anti-anxiety drugs, antidepressants or neuroleptics.
Procedures
The present study was approved by the Research Ethics
Committee under process number 193/2006. All participants
were informed about the research procedures and signed an
informed consent form.
A subjective evaluation of the participants’ sleep was
performed using the Sleep Habits Questionnaire, which was
administered by an interview. The questionnaire is a validated
and standardized instrument with 47 questions that aim to define
the profile of the evaluated individual, rendering information
about his/her family, housing, health, sleep and daily activities(7).
Some of the information obtained from the above-mentioned
instrument was used to identify sleep disorder-related
complaints, such as subjective reports of a sleeping problem;
complaint of insomnia, defined as difficulty initiating sleep
and/or wakening at night and not being able to fall back asleep;
nightmares; awaking with a feeling of suffocation; and daytime
sleepiness.
Data analysis
Data were analyzed with the SPSS 15.0 software (Statistical
Package for the Social Sciences, IBM, Armonk, New York,
USA), with a 5% significance level in all statistical tests.
The frequency of sleep complaints was compared with a
chi-squared test.
RESULTS
There was no statistically significant difference between the
frequency of female and male individuals or between the age
ranges ≥ 60 years and < 60 years in the studied sample. As
for the educational level, there was no statistically significant
difference between patients with no education and those with
some level of education (Table 1).
Table 1. Sample characterization according to gender, age, education level
and side of the brain lesion.
Variables
n
%
Female
64
41.6
Male
90
58.4
≥ 60 years
85
55.2
< 60 years
69
44.8
No formal education
24
15.6
Elementary, incomplete
58
37.7
Elementary, complete
28
18.2
Secondary, incomplete
44
28.6
Right
81
52.6
Left
73
47.4
Gender (p = 0.052)
Age (p = 0.219)
Education level (p > 0.05)
Brain lesion (p = 0.458)
Five domains were evaluated by the Sleep Habits
Questionnaire: family, housing, health, sleep and daily activities.
Regarding the factors related to family and housing, the patients
were found to live with up to nine persons in the same household,
and 63.6% shared a room with at least one person. Moreover, at
least 12.3% of the patients complained about noise in the room,
and 35% complained about too much light during the night.
Sleep Sci. 2013;6(4):146-150
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Sleep habits in patients with stroke
According to the analysis of health-related aspects, few
patients were smokers and drank alcohol, but most were coffee
drinkers. Furthermore, many of the patients were unemployed
and performed no physical and mental activities (Figure 1).
Figure 1. Percent frequency of the habits and daily activities of stroke patients.
Finally, regarding the sleep information obtained, 35.7%
of the patients reported experiencing some type of sleeping
problem. Specifically, the complaints were related to difficulties
initiating sleep, waking at night and having difficulties falling
back asleep, nightmares, waking at night with a feeling of
suffocation and daytime sleepiness (Figure 2).
Figure 2. Percent frequency of sleep complaints in stroke patients.
DISCUSSION
According to the Sleep Habits Questionnaire, it is important to
assess family and housing conditions (i.e., to investigate the number of persons living in the same household, whether the individual sleeps in the bedroom with more than one person and the levels of noise and light in the bedroom) to evaluate the individual’s
sleep state. Given that the patients from the studied sample use
the public health system, it was expected for most of them to live
under low financial conditions and to thus report a high number
of persons living in the same household. This assumption was
confirmed because there were records of up to nine persons per
household. This result suggests that a higher number of persons
Sleep Sci. 2013;6(4):146-150
in the household and in the bedroom can increase the noise level,
which leads to difficulties in initiating or maintaining sleep and
can thus directly affect the sleep quality of these individuals.
The exhibited data show that there were complaints
about noise in the bedroom and too much light during the night.
These findings indicate a requirement for patient and family
member awareness about the necessity of keeping the bedroom
silent during the night and of avoiding light in the bedroom,
which, for example, may change the sleeping times.
When analyzing the health-related aspects, we found
no high rates of smoking and drinking. These are encouraging
results, given that, in addition to the damage nicotine causes
to the respiratory and cardiovascular systems, this substance
also affects behavior, concentration, sleep and eating habits.
Nicotine has also been shown to interfere with the sleep-wake
cycle. Some authors have shown that the stimulation of nicotine
receptors promotes waking, reduces the total sleep time and
disturbs REM sleep(8). Alcohol consumption in turn may be
associated with increased blood pressure, coagulation factors
and cardiac arrhythmia, as well as with an increased risk of
hemorrhagic stroke(9).
Conversely, we observed a high frequency of coffee
drinkers. According to the literature, caffeine interferes with the
total sleep duration and can lead to poor sleep quality(10). In Brazil,
habit of drinking coffee mainly at night (for example, during
dinner) is very common. Thus, these patients should be instructed
to avoid drinking coffee before going to bed to preserve their
sleepiness. Caffeine reduces the secretion of melatonin, which
is a sleep-regulating hormone produced by the pineal gland. If
caffeine is consumed excessively or at unsuitable times, the wake
time is increased, and the total sleep time is reduced(11).
In the studied sample, we found complaints related
to difficulties initiating sleep and to awaking at night and
having difficulty falling back asleep, which can be suggestive
of insomnia. The higher prevalence of patients with sleep
problems after suffering a stroke suggests an association
between this pathology and sleep disorders. In a study by Vock
et al.(12) that evaluated patients after an ischemic stroke, a higher
frequency of sleep changes was found compared with the prestroke period. Furthermore, when evaluating the frequency
and severity of sleep disorders in patients who had suffered
a hemorrhagic atroke, Schuiling et al.(13) found that all studied
patients reported the sleeping problems as having begun after
the disease.
In the literature, insomnia has been demonstrated to be
a common complaint after an ischemic stroke(14,15). According to
Kryger et al.(16), complaints of insomnia and excessive sleepiness
are sleep disorder symptoms that are also considered disease
markers and predictors of increased mortality. The bedroom
conditions and coffee drinking habits evidenced in the present
study are factors that can contribute to the occurrence of complaints suggestive of insomnia.
Patients also complained about nightmares, waking up at
night with a feeling of suffocation and daytime sleepiness. In a
study by Foley et al.(17), stroke was associated with the occurrence
Dantas AATSG, Melo LP, Oliveira DC, Saldanha GS, Campos TF
of one or more sleeping problems, such as difficulties falling
and remaining asleep and daytime sleepiness. Davies et al.(18)
found that daytime sleepiness is significantly associated with
stroke. In further agreement with the exhibited results, Müller
et al.(19) have shown that stroke patients exhibit a higher
frequency of wake episodes after initiating sleep and poorer
sleep efficiency than control individuals. The study of Chasens
et al.(20) evidenced a relationship between sleepiness and sleep
quality, given that individuals with daytime sleepiness reported a
worse sleep quality than those exhibiting no daytime sleepiness.
Furthermore, the complaints about the feeling of suffocation
and daytime sleepiness may be strong indicators of obstructive
sleep apnea syndrome. This disease is a common condition
in stroke patients, being a risk factor for recurrent stroke and
associated with a poor prognosis(21). The mechanisms involved
in the association between stroke and obstructive sleep apnea
syndrome have been thoroughly investigated(22). Therefore,
patients exhibiting these complaints should be referred to a
sleep laboratory for diagnosis and treatment.
Another important result found in the present study
was that most of the patients were unemployed and performed
no physical and mental activities. This evidence is concerning
because the literature states that physical activity reduces the risk
of stroke by 27%, whereas a sedentary lifestyle increases the risk
not only of a first stroke episode but also of recurrent events.
Furthermore, physical exercise favors better sleep quality,
contributes to weight loss and improves severe obstructive
sleep apnea syndrome(9). One of the sleep hygiene measures
recommends that the individual expose himself/herself to
sunlight, which helps to synchronize the circadian sleep-wake
rhythm and prevents insomnia events(3,6).
The sleep complaints observed in the present study
can have several consequences. Specifically, chronic sleep
deprivation can affect the emotional state, behavior and cognitive
functioning and thus lead to a poor quality of life and social and
family disorganization(23). Considering the influence knowledge
has on behavior, we believe that educating individuals regarding
sleep hygiene measures, i.e., behavioral practices, can favor sleep
quality and prevent the worsening of sleep disorders.
The present study exhibited certain limitations. The
relationship between sleeping problems and the specific
localization of brain lesions was not assessed because the
neuroimaging exams were performed in different hospitals and
thus did not allow for standardization of the medical reports.
Furthermore, analyzing the influence of the circadian system
on sleep regulation in these patients, as well as a more objective
evaluation of the sleep complaints, would be important. Another
limitation of the present study was the lack of a control group,
which is the reason that the results cannot be extrapolated to the
entire stroke patient population.
CONCLUSION
The present study reveals that stroke patients exhibit complaints
related to family, housing, health, sleep and daily activities. The
results show that many patients do not follow sleep hygiene
measures. This finding suggests a requirement for sleep medicine
procedures to educate these patients regarding adequate life
habits and to thus ensure good sleep quality.
Acknowledgments
We thank the National Council for Scientific and Technological
Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPq) for funding the study (process nr.
409797/2006-5). This investigation is part of the Program for
Diagnosis and Intervention of Sleep, Cognitive and Functional
Disorders in Patients with Cerebrovascular Accident (Programa
de Diagnóstico e Intervenção das alterações do sono, cognitivas e funcionais em pacientes com Acidente Vascular Cerebral
- PRODIAVC), Brazil.
Conflicts of interest
None.
REFERENCES
1. Lotufo PA, Benseñor IM. Stroke mortality in Brazil: one example of delayed
epidemiological cardiovascular transition. Int J Stroke. 2009;4(1):40-1.
DOI: http://dx.doi.org/10.1111/j.1747-4949.2009.00240.x
2. World Health Organization. The WHO STEPwise approach to stroke
surveillance. Geneva: WHO; 2006.
3. Kakinuma M, Takahashi M, Kato N, Aratake Y, Watanabe M, Ishikawa Y, et
al. Effect of brief sleep hygiene education for workers of an information
technology company. Ind Health. 2010;48(6):758-65. DOI: http://
dx.doi.org/10.2486/indhealth.MS1083
4. Aston-Jones G. Brain structures and receptors involved in alertness.
Sleep Med. 2005;6 Suppl 1:S3-7. DOI: http://dx.doi.org/10.1016/
S1389-9457(05)80002-4
5. Patel M, Coshall C, Rudd AG, Wolfe CD. Natural history of
cognitive impairment after stroke and factors associated with its
recovery. Clin Rehabil. 2003;17(2):158-66. DOI: http://dx.doi.
org/10.1191/0269215503cr596oa
6. Brown FC, Buboltz WC Jr, Soper B. Relationship of sleep hygiene
awareness, sleep hygiene practices, and sleep quality in university
students. Behav Med. 2002;28(1):33-8. PMID: 12244643 DOI: http://
dx.doi.org/10.1080/08964280209596396
7. Andrade MMM, Menna-Barreto L. Diurnal variation in oral
temperature, sleepiness and performance of high school girls. Biol
Rhythm Res. 1996;27(3):336-42. DOI: http://dx.doi.org/10.1076/
brhm.27.3.336.12966
8. Pantic I, Malbasa M, Ristic S, Turjacanin D, Medenica S, Paunovic J, et al.
Screen viewing, body mass index, cigarette smoking and sleep duration
in Belgrade University student population: results of an observational,
cross-sectional study. Rev Med Chil. 2011;139(7):896-901. PMID:
22051827 DOI: http://dx.doi.org/10.4067/S0034-98872011000700010
9. Kline CE, Crowley EP, Ewing GB, Burch JB, Blair SN, Durstine JL, et
al. The effect of exercise training on obstructive sleep apnea and sleep
quality: a randomized controlled trial. Sleep. 2011;34(12):1631-40.
10. Drescher AA, Goodwin JL, Silva GE, Quan SF. Caffeine and screen time
in adolescence: associations with short sleep and obesity. J Clin Sleep
Med. 2011;7(4):337-42.
11.Shilo L, Sabbah H, Hadari R, Kovatz S, Weinberg U, Dolev S, et al.
The effects of coffee consumption on sleep and melatonin secretion.
Sleep Med. 2002;3(3):271-3. DOI: http://dx.doi.org/10.1016/S13899457(02)00015-1
12. Vock J, Achermann P, Bischof M, Milanova M, Müller C, Nirkko A,
et.al. Evolution of sleep and sleep EEG after hemispheric stroke. J
Sleep Res. 2002;11(4):331-8. DOI: http://dx.doi.org/10.1046/j.13652869.2002.00316.x
13.Schuiling WJ, Rinkel GJ, Walchenbach R, de Weerd AW. Disorders
of sleep and wake in patients after subarachnoid hemorrhage.
Stroke. 2005;36(3):578-82. PMID: 15677579 DOI: http://dx.doi.
org/10.1161/01.STR.0000154862.33213.73
14. Leppävuori A, Pohjasvaara T, Vataja R, Kaste M, Erkinjuntti T. Insomnia in ischemic stroke patients. Cerebrovasc Dis. 2002;14(2):90-7. DOI:
http://dx.doi.org/10.1159/000064737
Sleep Sci. 2013;6(4):146-150
149
150
Sleep habits in patients with stroke
15. Poyares D, Aloe F, Rizzo GNV, Minhoto G, Pinto Junior LR, Bezerra MLS,
et al. I Consenso Brasileiro de Insônia. Hypnos. 2003;4(Supl 2):5-39.
16.Kryger M, Monjan A, Bliwise D, Ancoli-Israel S. Sleep, health, and
aging. Bridging the gap between science and clinical practice. Geriatrics.
2004;59(1):24-6.
17. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic
disease in older adults: results of the 2003 National Sleep Foundation
Sleep in America Survey. J Psychosom Res. 2004;56(5):497-502. PMID:
15172205 DOI: http://dx.doi.org/10.1016/j.jpsychores.2004.02.010
18.Davies DP, Rodgers H, Walshaw D, James OF, Gibson GJ. Snoring,
daytime sleepiness and stroke: a case-control study of first-ever stroke.
J Sleep Res. 2003;12(4):313-8. DOI: http://dx.doi.org/10.1046/j.09621105.2003.00371.x
Sleep Sci. 2013;6(4):146-150
19.Müller C, Achermann P, Bischof M, Nirkko AC, Roth C, Bassetti CL.
Visual and spectral analysis of sleep EEG in acute hemispheric stroke. Eur
Neurol. 2002;48(3):164-71. DOI: http://dx.doi.org/10.1159/000065509
20.Chasens ER, Sereika SM, Weaver TE, Umlauf MG. Daytime sleepiness,
exercise, and physical function in older adults. J Sleep Res. 2007;16(1):60-5.
DOI: http://dx.doi.org/10.1111/j.1365-2869.2007.00576.x
21. Brown DL. Sleep disorders and stroke. Semin Neurol. 2006;26(1):117-22.
PMID: 16479450 DOI: http://dx.doi.org/10.1055/s-2006-933315
22.Barone DA, Krieger AC. Stroke and obstructive sleep apnea: a review.
Curr Atheroscler Rep. 2013;15(7):334. DOI: http://dx.doi.org/10.1007/
s11883-013-0334-8
23. Chartier-Kastler E, Davidson K. Evaluation of quality of life and quality
of sleep in clinical practice. Eur Urol Suppl. 2007;6(9):576-84.