Background: Patients with stroke require long-term rehabilitation to return to the pre-morbid level of functioning. Sleep disturbances are associated with a higher risk of stroke reoccurrence and poor poststroke outcomes. Approximately a third of stroke survivors experience sleep disturbances higher than the general population. Early identification of sleep problems after stroke is crucial to improve stroke outcomes.

Objectives: The project’s aim was to improve sleep outcomes among patients with stroke admitted to inpatient rehabilitation. This project integrated sleep protocol which included insomnia severity index (ISI) to assess sleep disturbances and implemented non-pharmacological and pharmacological interventions to manage sleep disturbances [BP3].

Steps of implementation: ISI scores were obtained on admission and weekly throughout patients’ stay in the rehabilitation unit and before discharge. Non-pharmacological interventions were implemented, and handouts on sleep hygiene were provided to all patients with stroke. Physiatrists were provided with a handout for pharmacological interventions and were utilized for patients scoring high on their ISI. Nurses’ end-of-shift notes were reviewed to assess documentation regarding sleep. The patients’ treatment charts were reviewed for medications prescribed to treat sleep disturbances.

Performance improvement outcomes: This project enrolled 48 patients with stroke who were assessed for sleep disturbances with ISI and were provided with pharmacological and non-pharmacological interventions. Improvement in ISI scores were reported by 29 [BP4] % (N=14) of patients with stroke, 17% (N=8) reported a decline in their ISI scores, and 54% (N=26) reported no change on discharge. Melatonin was scheduled in 35% (N=17) of enrolled patients, 6% (N=3) had trazodone, and 56% (N=27) had no prescribed medications. The documentation rate of sleep by the nurses in the end-of-shift note was 57% [BP5] [bs6].

Implications for future research: Multiple barriers cause sleep disturbances and are difficult to assess because of individual differences and subjective symptoms. The symptom profile should be considered to develop stroke-specific interventions targeting the comorbidities. Additionally, follow-up with their primary care providers should be encouraged for continuity of care to improve their sleep disturbances and stroke outcomes.

References
1) Baylan, S., Griffiths, S., Grant, N., Broomfield, N. M., Evans, J. J., & Gardani, M. (2020). Incidence and prevalence of post-stroke insomnia: A systematic review and meta-analysis. Sleep Med Rev, 49. doi:10.1016/j.Smrv.2019.10122
2) Byun, e., Kohen, R., Becker, K. J., Kirkness, C. J., Khot, S., & Mitchell, P. H. (2019). Stroke impact symptoms are associated with sleep-related impairment. Heart Lung, 49(2), 117-122, doi:10.1016/j.Hrtlng.2019.10.010
3) Rosenthal, l. D., Dolan, D. C., Taylor, D. J., & Grieser, E. (2008). Long-term follow-up with insomnia. Baylor University Medical Center Proceedings, 21(3), 264-265. doi:10.1080/08998280.2008.11928409
4) Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., Deruyter, F., Eng, J. J., Fisher, B., Harvey, R. L., Lang, C. E., Mackay-lyons, M., Ottenbacher, K. J., Pugh, s., Reeves, M. J., Richards, L. G., Stiers, W., & Zorowitzmdon, R. D. (2016). Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47, e98-e169. https://doi.Org/10.1161/str.0000000000000098

Babandeep Sidhu DNP, FNP-C

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