Available online http://ccforum.com/content/12/4/R97 Research Vol 12 No Open Access Prevalence of sleep disturbances and long-term reduced health-related quality of life after critical care: a prospective multicenter cohort study Lotti Orwelius1,2, Anders Nordlund4, Peter Nordlund5, Ulla Edéll-Gustafsson2 and Folke Sjöberg1,3 1Department of Intensive Care, Division of Perioperative Medicine, Linköping University/Linköping University Hospital, Garnisonsvägen, 581 85, Linköping, Sweden 2Department of Medicine and Care, Nursing Science, Linköping University/Linköping University Hospital, Garnisonsvägen, 581 85 Linköping, Sweden 3Department of Hand and Plastic Surgery, Division of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University/Linköping University Hospital, Garnisonsvägen, 581 85 4TFS Trial Form Support AB, 222 28 Lund, Sweden 5Department of Anaesthesia and Intensive Care, Intensiv Care Unit, Ryhov Hospital, 551 85 Jönköping, Sweden Corresponding author: Lotti Orwelius, lotti.orvelius@lio.se Received: 28 Mar 2008 Revisions requested: 13 May 2008 Revisions received: Jun 2008 Accepted: Aug 2008 Published: Aug 2008 Critical Care 2008, 12:R97 (doi:10.1186/cc6973) This article is online at: http://ccforum.com/content/12/4/R97 © 2008 Orwelius et al.; licensee BioMed Central Ltd This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited Abstract Introduction The aim of the present prospective multicenter cohort study was to examine the prevalence of sleep disturbance and its relation to the patient's reported healthrelated quality of life after intensive care We also assessed the possible underlying causes of sleep disturbance, including factors related to the critical illness Methods Between August 2000 and November 2003 we included 1,625 consecutive patients older than 17 years of age admitted for more than 24 hours to combined medical and surgical intensive care units (ICUs) at three hospitals in Sweden Conventional intensive care variables were prospectively recorded in the unit database Six months and 12 months after discharge from hospital, sleep disturbances and the healthrelated quality of life were evaluated using the Basic Nordic Sleep Questionnaire and the Medical Outcomes Study 36-item Short-form Health Survey, respectively As a nonvalidated single-item assessment, the quality of sleep prior to the ICU period was measured As a reference group, a random sample (n = 10,000) of the main intake area of the hospitals was used Introduction Intensive care affects the patients in many ways, and also influences the outcome after discharge [1,2] After a period in intensive care, patients have reported poorer health-related quality of life (HRQoL) compared with a reference group [3] Results The prevalence of self-reported quality of sleep did not change from the pre-ICU period to the post-ICU period Intensive care patients reported significantly more sleep disturbances than the reference group (P < 0.01) At both and 12 months, the main factor that affected sleep in the former hospitalised patients with an ICU stay was concurrent disease No effects were related to the ICU period, such as the Acute Physiology and Chronic Health Evaluation score, the length of stay or the treatment diagnosis There were minor correlations between the rate and extent of sleep disturbance and the healthrelated quality of life Conclusion There is little change in the long-term quality of sleep patterns among hospitalised patients with an ICU stay This applies both to the comparison before and after critical care as well as between and 12 months after the ICU stay Furthermore, sleep disturbances for this group are common Concurrent disease was found to be most important as an underlying cause, which emphasises that it is essential to include assessment of concurrent disease in sleep-related research in this group of patients Furthermore, in a previous study we found that this poorer HRQoL is mostly the result of the high prevalence of concurrent disease among the patients rather than due to factors related to intensive care [4] APACHE II = Acute Physiology and Chronic Health Evaluation; HRQoL = health-related quality of life; ICU = intensive care unit; SF-36 = Medical Outcomes Study 36-item Short-form Health Survey Page of 11 (page number not for citation purposes) Critical Care Vol 12 No Orwelius et al Sleep is important for overall wellbeing [5] In the short term, we know that many patients, irrespective of their diagnosis, have disturbed sleep during their time in the intensive care unit (ICU) and up to week afterwards [6-9] Former ICU patients may have more short-term sleep disturbances caused by both the period of critical care and the high prevalence of concurrent diseases [4] Sleep-related problems may persist long after the patients have left the ICU Because of the paucity of studies, however, the prevalence and extent of sleep disturbances that remain long term (>3 months) after intensive care are unknown A partly unanswered question is also the effect of sleep disturbances on HRQoL of former ICU patients There is a difficulty in assessing sleep disturbances, as sleep varies with sex [10,11] and with age [11] Sleep disturbance is also affected by concurrent diseases [12], so a reliable reference group is essential to be able to evaluate the prevalence of sleep disturbances properly The aim of the present study was to investigate the long-term (6-month and 12-month) sleep pattern after critical illness We also wanted to examine specifically the relation between sleep disturbances and HRQoL Furthermore, we wanted to know whether concurrent disease and factors related to intensive care (Acute Physiology and Chronic Health Evaluation (APACHE) II, length of stay, and admission diagnosis) affected the long-term sleep patterns in the ICU group We hypothesised that hospitalised patients with an ICU stay have an affected sleep long after the intensive care period has ended, but we suspected that it is the result of concurrent disease rather than of ICU-related factors Materials and methods Design The present prospective, longitudinal study was carried out between August 2000 and November 2003 in three general ICUs in Sweden: one university hospital, and two general hospitals The ICU at the university hospital has eight beds, and 500 to 750 patients are admitted annually Postoperative patients, those after open-heart surgery and neurosurgery, those with primary coronary disease, neonates, and burned patients are treated in other specialised units, and were not included in the present study The two general hospitals both have six-bed ICUs, and 500 to 700 patients are admitted annually to each The units are the only ICUs at the hospitals except for the care of neonates Over 90% of the admissions to these three ICUs are emergencies, and the primary admission diagnoses are most commonly multiple trauma, sepsis, and disturbances in the respiratory or circulatory systems, or both All adults (18 years old and over) who were consecutively admitted and who remained in the ICU for more than 24 hours, and who were alive months after discharge from hospital, were included Patients who were readmitted were included only for their first admission This database has previ- Page of 11 (page number not for citation purposes) ously been used and will be used in several outcome studies in critical care [4] The clinical databases in each hospital were used to extract data on age, sex, reason for admission to and length of stay in the ICU, APACHE II score [13], length of stay in hospital, and outcome Admissions were categorised into diagnostic groups: multiple trauma, sepsis, respiratory, gastrointestinal, cardiovascular, and other The design of the study was approved by the Committee for Ethical Research at the University of Health in Linköping Eligible patients consented to participate in the study Participants A total of 1,625 patients met the inclusion criteria Of these, 911 patients answered the questionnaire at months and are used in the baseline comparisons In order to achieve comparability with the reference group, 188 patients were excluded because they were older then 74 years of age, the upper age limit for the sample from the reference group Of the patients between 18 and 74 years old, 723 responded to the first inquiry at months and 497 also responded at 12 months, and they then became the study group and are used in the comparisons with the reference group (Figure 1) For the reference group, data from a public health survey of the county of Ưstergưtland (the area in which the university hospital and one of the general hospitals is situated, adjacent to the county where the second general hospital is located) were used for comparison of sleep disturbances, concurrent disease and HRQoL Questionnaires were initially sent out to 10,000 people After two reminders, 6,093 (61%) had responded [14] Questionnaires A set of structured questionnaires with information about the study and a request to participate were sent to the surviving patients and 12 months after their discharge from hospital The questionnaire contained questions about the patients' background data, including concurrent disease (self-reported diagnosis) The questionnaire asked 'Do you have any of the following illnesses and have had it for more than months before the intensive care period with the pre-specified alternatives: cancer; diabetes; heart failure; asthma or allergy; rheumatic; gastrointestinal; blood; kidney; psychiatric; neurological disease; thyroid or any other metabolic disturbance, or other long-term illness?' (Table 1) The questionnaire to the reference group also included, apart from questions on background characteristics, questions about health problems – including sleep and HRQoL (Medical Outcomes Study 36-item Short-form Health Survey (SF-36)) Available online http://ccforum.com/content/12/4/R97 Figure Algorithm of patients who were and were not included in the sleep disturbance study All patients that responded at months were used in baseline and were not included in the sleep disturbance study comparisons, whereas patients that responded both at and 12 months and were younger than 75 years old were used in comparison with the reference group ICU, intensive care unit Instruments Sleep disturbance The questions were taken from the Swedish version of the Basic Nordic Sleep Questionnaire [15] The instrument has been shown to be valid [15,16] Three questions included in the Basic Nordic Sleep Questionnaire were used: 'Were there difficulties in falling asleep?' 'What was the quality of sleep like?' 'Was there a difference between the reported need for sleep and that achieved?' These questions were also used in the public health survey To the second question above ('What was the quality of sleep like?'), yet another, single nonvalidated question [17] was added asking about the quality of sleep prior to the ICU stay This question was only asked of the ICU group The sleep instruments used in the study are presented in Additional file Health-related quality of life The SF-36 was chosen for the evaluation of HRQoL [18,19] The instrument is internationally well known and has often been used [20] The SF-36 has previously been applied in intensive care [4,21,22], and has recently been recommended as one of the best-suited instrument for measuring HRQoL in trials in critical care [23] The SF-36 has been translated into Swedish and validated in a representative sample [24] The survey has 36 questions and generates a health profile of eight subscale scores: physical functioning, role limitations caused by physical problems, bodily pain, general health, vitality, social functioning, role limitations due to emotional problems, and mental health [18,24] The scores on all subscales are transformed to a scale ranging from (the worst score) to 100 (best score) Statistical analysis Data are presented descriptively using parametric statistics (mean, 95% confidence intervals, and one-way analysis of variance) and nonparametric statistics (Pearson's chi-square test and Kruskal–Wallis test) Logistic regression analysis, adjusted for sex, age, and concurrent disease, was used to evaluate the difference between the patients and the reference groups as appropriate Logistic regression was also used to evaluate the independent effects of sex, age, concur Page of 11 (page number not for citation purposes) Critical Care Vol 12 No Orwelius et al Table Characteristics of patients in the study group (6 and 12 months), in the nonresponders/withdrawals at 12 months group, and in the reference group Study group (n = 497) Nonresponders/withdrawals group (n = 226) P valuea Reference group (n = 6093) P valueb Sex (male/female) 274/223 136/90 0.23 2822/3271