Alcohol and Alcoholism Advance Access originally published online on February 16, 2008
Alcohol and Alcoholism 2008 43(3):305-313; doi:10.1093/alcalc/agn007
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Complaints about sleep in trauma patients in an emergency department in respect to alcohol use
Charité – Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Charitéplatz 1, 10117 Berlin, Germany
* Author to whom correspondence should be addressed at: Dr. Tim Neumann, Department of Anaesthesiology and Intensive Care Medicine, Charité – Universitaetsmedizin Berlin, Campus Mitte and Virchow-Klinikum, Charitéplatz 1, 10117 Berlin, Germany. Tel: +49-30-450-631-249; Fax: +49-30-450-531-911; E-mail: tim.neumann{at}charite.de
Received 19 March 2007; first review notified 27 April 2007; in revised form 19 November 2007; accepted 20 December 2007
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ABSTRACT |
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Among other lifestyle problems, sleeping problems have been related to alcohol use. Aim: The aim of this study was to evaluate complaints about sleep in trauma patients in an emergency department and its relation to alcohol use disorders (AUD). Method: In an emergency department, trauma patients (1014 females, 1680 males) were screened using a computerized questionnaire addressing AUD (AUD identification test, AUDIT), smoking, drug and medication use, and sleep (presence of difficulties in falling asleep and/or sleeping through). Age, BMI, income, employment, partner status, and "feeling fit" were additionally assessed. Results: An AUDIT score
8 points was found in 24.2% of the males and 8.3% of the females. Complaints about sleep were reported by 28% and 34% of the patients, respectively. These complaints about sleep were more likely in males at-risk drinkers (AUDIT 8 versus 1–4 points (Adjusted odds ratio: AOR = 1.60, P = 0.001) or abstainers (AUDIT = 0 versus 1–4 points, AOR = 1.55, P = 0.029), and with increasing age (AOR = 1.01, P = 0.010), in patients not feeling "fit" (AOR = 2.15, P < 0.001), and users of pain (AOR = 2.24, P < 0.001) and sleep medication (AOR = 8.03, P < 0.001). In females, complaints about sleep were more likely with higher age (AOR = 1.04, P = 0.023), higher BMI (AOR = 1.04, P = 0.023), with not-feeling-fit (AOR = 1.87, P < 0.001) and sleep medication (AOR = 5.24, P < 0.001), and less likely in patients with a higher education (AOR = 0.57, P < 0.001). Conclusion: Complaints about sleep were reported frequently by trauma patients. There was an association between AUDs and sleep complaints (mainly problems about sleeping through) in males, but not in females. |
Introduction |
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Sleep disturbances have been related to alcohol use (Roehrs and Roth, 2001
). Alcohol consumed at bedtime might decrease the time required to fall asleep after an initial stimulating effect. People might therefore, consume alcohol to promote sleep, but alcohol consumed within an hour of bedtime appears to disrupt the second half of the sleep period (Roehrs and Roth, 2001). The subject may sleep fitfully during the second half of sleep, awakening from dreams and returning to sleep with difficulty. With continued consumption just before bedtime, alcohol's sleep-inducing effect may decrease, while its disruptive effects continue or increase (Roehrs and Roth, 2001). This sleep disruption may lead to daytime fatigue and sleepiness.
Problems with sleep, which include difficulties with sleeping through, difficulties with falling asleep, or nonrestorative sleep, do have a high prevalence in the general population. Sleep complaints did range from 4 to 50% according to the setting and definition used (Bixler et al., 1979; Mellinger et al., 1985; Ohayon et al., 1997; Ohayon and Zulley, 2001; Hajak et al., 2001; Ohayon, 2005). In a German cross-sectional telephone survey, 7% of the participants reported global sleep dissatisfaction (Ohayon and Zulley, 2001). Sleep disorders have been related to a variety of relevant medical conditions, such as mental disorders (e.g., anxiety, depression), cardiovascular, and respiratory diseases (e.g., obstructive sleep apnea) or social and environmental factors as well as to alcohol use and trauma (Kupfer and Reynolds, 1997; Becker, 2006).
However, it is unclear, how these findings might relate to the health of acute trauma patients. Trauma patients-seeking help in an emergency department have been shown to be predominantly male, young, and showed a high rate of alcohol and substance use. Additionally, they have been characterized by showing more risk-taking behavior, sensation-seeking, and low coping mechanisms (Soderstrom et al., 2001; Spies et al., 2001; Neuner et al., 2005; Neumann et al., 2006). Physical health was, in general, good, but mental health seemed to be impaired in comparison to the general population (Neuner et al., 2005). AUDs account for increased post-traumatic morbidity (Spies et al., 2001; D’Onofrio et al., 2006).
The data for this exploratory study were collected in the context of a randomized intervention trial, using a brief tailored advice in order to address risky alcohol use in acute trauma patients seeking medical treatment in an emergency department (Neumann et al., 2006). The provision of a brief-tailored advice was associated with an additional decrease in risky alcohol consumption in the posttraumatic period. The feedback and information was tailored to the patient's answers to the 10-item alcohol use disorder identification test (AUDIT) questionnaire, which screens for alcohol use and related problems (consumption, dependence symptoms, and negative consequences of alcohol use). The AUDIT itself does not address sleep complaints. In order to tailor information to trauma patients, it would be of interest to know how many of these patients had sleep complaints and whether these sleep complaints were associated with AUD next to other relevant factors. In the context of frequent alcohol use, it would be additionally of interest, whether these sleep complaints were more about difficulties sleeping through compared to complaints about falling asleep.
The aim of this study was, therefore, to evaluate the prevalence of complaints about sleep use in male and female trauma patients attending an emergency room and the relation of these complaints about sleep with risky alcohol use in the concert with other relevant factors.
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Method |
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Data for this study were collected as part of the intervention study "Computerized brief tailored advice in trauma patient," supported by the German Health Ministry (BMGS 217-43794-5/5, details can be found elsewhere, Neumann et al., 2006
). The study was approved by the Institutional Review Board of the Charité Universitätsmedizin Berlin, Germany. A written informed consent was obtained.
Participants
The trial was conducted between December 2001 and February 2003. The study population consisted of all the patients 18 years of age with a primary diagnosis of acute injury treated in the emergency department of the Charité Campus Mitte, University Hospital of Berlin, a large, urban teaching facility and regional trauma center located in downtown Berlin. Patients were excluded if they were medically unstable or required hospital admission, had severe pain (>3 points on a 10-point numeric rating scale), had a severe psychiatric condition, did not speak German, were in police custody, were pregnant, were members of the hospital staff, or if they were severely intoxicated (according to the WHOs International Classification of Diseases ICD, 10: F1x.0: Intoxication, World Health Organization, 1993) precluded participation. Some patients may have been intoxicated, but had sufficient tolerance to alcohol, that it remained undetected. However, the staff made every effort to ensure that the patient did not exhibit significant cognitive impairment at the time of study entry. Patients who were readmitted during the study period retained their original group assignment.
Protocol
Patients were approached for participation after provision of initial care and after resolution of significant pain. Injury severity was classified using the injury severity score (ISS, Committee on Injury Scaling, 1990). After obtaining a written informed consent, patients were asked to complete a lifestyle questionnaire using a portable laptop computer. Screening results and all other study data were kept strictly confidential. The computer-based lifestyle screening included among others, the AUDIT (Babor et al., 1989; Saunders et al., 1993; Neumann et al., 2004), questions about tobacco use, illicit drug use, well-being, and sleep. Among 8620 patients in the ED in the 14-month study period, 2114 were not contacted (e.g., technical reasons, such as a very short ED stay). Another 1686 patients were excluded to significant physical impairment (n = 318), mental impairment (psychiatric acute/chronic, n = 724; including intoxication n = 196), insufficient knowledge of German (n = 553), treatment for a second trauma (n = 70), or by being in police custody (n = 21). Out of the 4820 patients approached, 1920 refused to participate. Together with 126 patients from the initiation phase, 3026 were included in the first assessment. Out of all the datasets, 11.0% were incomplete (mainly, the information about income was missing) and 2694 were finally enrolled in this survey.
All the screening and intervention processes were computerized. We used the simplest methods possible (e.g., mouse-only techniques, no typing). The next question was not displayed until one second after completion of each item, which prevented question skipping. Most patients (85%) were able to use the computer after receiving brief instructions (Neumann et al., 2006).
Measures
Sleep
Sleep complaints were assessed using a single question: Do you sleep well? Four possible answers were given: 1. Yes, 2. No, I have difficulties falling asleep, 3. No, I do not sleep through the night, 4. No, I have difficulties falling asleep and I do not sleep through the night.
(Schlafen Sie gut? 1. Ja, 2. Nein, ich schlafe schlecht ein. 3. Nein, ich schlafe nicht durch 4. Nein, ich schlafe schlecht ein und nicht durch). Sleeping problems were analyzed according to
- the difficulty in falling asleep and/or sleeping through versus no problems;
- the presence of difficulties in falling asleep versus no problems in falling asleep; and
- the presence of difficulties sleeping through versus no problems sleeping through.
Alcohol
The AUDIT is a 10-item questionnaire that was designed by the World Health Organisation (WHO) to detect a broad range of alcohol problems, ranging from at-risk drinking to dependence (Babor et al., 1989; Saunders et al., 1993; Neumann et al., 2004).
The patients were divided into the following four groups according to the AUDIT:
- Abstainers (AUDIT 0 points).
- Drinking patients with no indication for risky use (AUDIT 1–4 points).
- Patients with an intermediate risk for AUD (AUDIT 5–7 points).
- Patients with a high risk for AUD (AUDIT 8–40 points).
According to the construction of the AUDIT, patients with 5 points should have at least one addressable AUD, which requires advice according to the computer algorithm, requires advice. The recommended cut-off of 8 points was chosen, because at this cut-off, a reasonable percentage of the patients had a relevant AUD, such as dependence symptoms or harmful use according to the ICD10 classification, or high-risk use according to the WHO (Neumann et al., 2004). Additionally, it was decided a priori to form a separate group of abstainers. This group of patients might form a heterogeneous group, including lifetime abstainers or patients with significant medical conditions that prevent them from drinking, such as mental disorders or alcohol dependence in remission (Rehm, 2000; Rehm et al., 2003). Additionally, a post hoc analysis of the alcohol consumption (using the AUDIT-C, the sum of the first three AUDIT questions: Range 0–12 points, cut-off: 5 points), dependence, and negative consequences items of the AUDIT was conducted in a dichotomous manner (Rheinert and Allen, 2007).
Other data Additionally it was asked, whether the patient feels "fit" (Fühlen Sie sich fit?)
"Smoking" was defined as current smokers, and the "use of illicit drugs" was defined as the use of illicit drugs a minimum of at least 1 to 3 or more times within the last 12 months. Possible categories for the illicit drugs used were the use of "Marihuana; Cocaine; Ecstasy; Heroin, and Other." It was also asked, whether the patient takes pain medication, sleeping medication, or sedatives.
Other recording of information would require typing skills, and some patients were not familiar with the use of a keyboard. Therefore, this information was obtained using a self-administered paper and pencil questionnaire. Socioeconomic parameters (Neuner et al., 2005) were divided into binary variables, including the following: (1) school education: 12- or 13-year-school education ("A-level") versus a school education of 11 years or less than 11 years ("no A-level"); (2) family income: "equal or less than 12,000 Euro net per year" and "more than 12,000 Euro net per year"; (3) partnership: "Yes" and "No," independently of marital status; and (4) "Working" was defined as any legally paid work, either part- or full-time, including civil servant, self-employed, or a paid worker in a family business. "Not working" included all the students, trainees, unemployed people, homemakers, and according to German law, patients in Civilian services (Zivildienst) or military service (except professional soldiers). "Not working" also included retired patients, and patients engaged in nonprofit voluntary work. Patients were additionally asked, whether they had a general practitioner.
Next to the brief-tailored advice regarding their alcohol use (Neumann et al., 2006), all patients with sleep complaints obtained tailored information indicating that the reason for having sleeping problems is quite varied. Additionally, advice was given to contact a doctor in order to rule out other, medically treatable conditions.
Statistical analysis
Analyses were performed using SPSS 14 software. Demographic and alcohol characteristics are reported as frequencies, or as the median and 25th to 75th percentiles for variables with skewed distribution. Frequencies were compared using chi-square tests. Other ordinal or metric data were compared using the Mann–Whitney U Test. A P-value < 0.05 was considered statistically significant.
Regression analysis (multiple logistic regressions) was used to analyze sleep complaints, complaints about falling asleep, and complaints about sleeping through the night separately for men and women. Independent variables were age, body mass index (kg/m2), feeling fit, income, employment, partner, smoking, illicit drug use, and AUDIT status, medication for sleep, sedation, and pain. In the first step, the variable for the AUDIT status was entered into the models. In the second step, variables were selected with a stepwise backward elimination procedure by using the likelihood ratio criterion. Variables with a P-value of 0.1 or more were eliminated from the model, except the variable reflecting the AUD status.
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Results |
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Miscellaneous and substance use-related data of the study participants are presented in Table 1. An AUDIT score
8 points was found in 24.2% of the males and 8.3% of the females. Complaints about sleep were reported by 28% of the males and 34% of the females. Out of all the patients, 83.6% had an injury severity score (ISS) of 1 point, indicating minimal trauma. The highest value was 16 points. There were other considerable gender differences, as complaints about sleeping through the night were more often reported in females. In contrast, females were slightly older, less likely to be employed or have an A-level qualification but more likely to have an appointed general practitioner. In females, substance misuse was less frequent. AUD, smoking, and illicit drugs use were less frequent, but pain medication sleeping pills and sedatives were used more often.
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Patients with sleep complaints were older (Table 1) and had a higher BMI. They were more likely to report having a general practitioner or a family doctor. Patients with sleep complaints had a lower level of education. Additionally, patients with sleep complaints were more likely to report "not feeling fit," and more frequently taking pain medication, sleeping medication, or sedatives. Additionally, males with sleep complaints were less often employed, had a higher rate of lower income, and had a higher rate of at-risk drinking (Table 1).
The results of the multiple logistic regression models were given in Tables 3a and b. Sleep complaints in male trauma patients were more likely with increasing age, and in those not feeling fit, using pain or sleep medication as well as patients with at-risk drinking (AUDIT 8 points) compared to nonrisky social drinkers (AUDIT 1–4 points). For females, sleep complaints were more likely with increasing age, a higher BMI, and with a lower education as well as with not feeling fit and using sleep medication (Table 3b).
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According to the univariate analysis males with "complaints with falling asleep" were more likely to report risky alcohol use, smoking, "not feeling fit," and more frequently taking pain medication, sleeping medication, or sedatives. Additionally, they were more likely to report a lower educational level, lower income, a lower employment rate, and living with a partner. Females with "complaints with falling asleep" were more likely to report taking pain medication, sleeping medication, or sedatives. They were also more likely to report a lower educational level, a lower employment rate, and not living with a partner. An appointed general practitioner was found more frequently. In the multivariate analysis, complaints about falling asleep were associated in males with a lower educational level, not living with a partner, not feeling fit, and the use of sleeping pills and sedatives as well as smoking. In contrast to the findings of the univariate analysis, there was no significant association between a more severe AUD status and "complaints with falling asleep" in males in the multivariate analysis. This might be related to the fact that the smoking status and the AUDIT score were correlated (Spearman Rho correlation coefficients: Males: rho = 0.226; Females: rho = 0.237, P's <0.001). Only in males, there was a significant relation between smoking and "complaints with falling asleep." In females, "complaints with falling asleep" were less likely in patients with a partner and among those with a higher education, and more likely in patients with medication for sleep and sedation and not feeling fit (Tables 2, 3a, and b).
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In the univariate analysis, males and females with "complaints about sleeping through" the night had a higher age and BMI and a lower education, and were more likely to have a general practitioner, used medication for pain, sleep, and sedation, and often reported not feeling fit. Females with "complaints about sleeping through" reported abstaining more frequently from alcohol and using illicit drugs less frequently. Males were more often, risky alcohol users. In the multivariate analysis, males with "complaints about sleeping through the night" had a higher age and BMI. Not feeling fit, lower educational levels, and the use of pain or sleep medication were found more frequently. In females, "complaints of sleeping through" was found more frequently among older women, with a higher BMI, lower income levels as well as lack of fitness and taking a medication for sleep (Tables 2, 3a, and b).
Additionally, a post hoc analysis of the consumption, dependence, and negative consequences items of the AUDIT was conducted. Males with sleep complaints were more likely to be found with a sum score of 5 or more in the first three AUDIT consumption questions (AUDIT-C): 28.5% of those with sleep complaints versus 23.1% of those without sleep complaints, P = 0.02, and among males with complaints of sleeping through versus without: 29.1% versus 23.5%, P = 0.038. However, binge drinking (defined as six or more units of alcohol on one occasion) versus no binge drinking did not show any effect in males or in females.
Dependence and the negative consequence items of the AUDIT were consistently associated with sleep complaints in males. The most prominent were "Morning drinking" (9.7% versus 3.9%, P < 0.001), "Feelings of guilt" (22.4% versus 14.3%, P < 0.001), and "Concern expressed by others" (19.4% versus 9.4%, P < 0.001), whereas in females, only "Trauma under the influence" (3.2% versus 2.7%, P = 0.040) was significantly different.
Similar results were found in males concerning complaints about falling asleep. The following are the most prominent results: "Morning drinking" (9.7% with complaint about falling asleep versus without these complaints: 4.7%, P = 0.001), "Feelings of guilt" (24.3% versus 15.1%, P < 0.001), and "Concern expressed by others" (20.5% versus 10.6%, P < 0.001), and in females there were significant different rates of patients with a positive "Morning drink" item: (4.4% versus 1.4%, P = 0.009) and "Trauma under influence" (5.5% versus 3.2%, P = 0.040).
Complaints about sleeping through were only significantly different in males concerning: "Morning drink" (10.1% with complaints sleeping through versus 4.5% without these sleep complaints, P < 0.001), "Feeling of guilt" (20.6% versus 15.6%, P = 0.033), and "Concern expressed by others" (19.9% versus 10.4%, P < 0.001).
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Discussion |
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Nearly one-third of the trauma patients surveyed complained about their sleep. Not feeling "fit" was nearly twice as often reported by patients with sleep complaints compared to patients without sleep complaints, indicating that some of the reported complaints might reflect relevant sleep disorders. More patients with complaints about sleep also reported using sedating medication or medication for sleep, or pain. Compared to male, non-risky drinkers, males with risky alcohol use were more likely to report more sleep complaints, mainly complaints about sleep disruption. These findings were in accordance with earlier reports, that patients who consumed alcohol at bedtime to promote sleep and alcohol use might disrupt the second half of the sleep period (Roehrs and Roth, 2001
). Additionally, previous research showed consistently that severe AUDs, such as dependence were associated with sleep problems, even after withdrawal (Foster and Peters, 1999; Foster et al., 2002; Brower, 2001). This was supported by the findings of the post hoc analysis which revealed that which sleep complaints were found frequently in patients with a positive answer in AUDIT items, such as drinking in the morning ("Eye-opener"), "Feeling of guilt," or "Concerns expressed by others."
We were unable to show a significant association between sleep complaints and alcohol use in females. Several issues might be considered: the rate of severe AUD's was much lower on females. It is therefore possible, that the association might be different in female groups with a higher prevalence of severe alcohol use disorders. Additionally, other gender differences concerning relevant comorbidity not addressed in this survey might be relevant: e.g., the morbidity risk of depressive disorders is higher in females than in males (Weissman et al., 1993). There has also been some evidence that males and females answer questions on sleepiness differently, and males and females might therefore, perceive sleep and sleep disorders differently (Baldwin et al., 2004). As in previous research (Hajak et al., 2001; Ohayon, 2005; Lauderdale et al., 2006), the frequency of sleep complaints was higher in females compared to males.
In this group of predominately young adults, increasing age was associated with difficulties in sleeping through the night in males and females. As increasing age might reflect increased comorbidity, it is not surprising, that previous studies showed conflicting results due to differences in the definition and differences in the adjustment. Higher age was associated with increased global sleep dissatisfaction in one German cross-sectional telephone survey (Ohayon and Zulley, 2001), but no age effect on severe insomnia was found in another German study (Hajak et al., 2001). In contrast, in one European study, it was found that nonrestorative sleep was positively associated with younger age when adjusted for comorbidity (Ohayon, 2005).
Among the sociodemographic variables reflecting a higher social status, only educational status seemed to play a protective role against sleep complaints. Previous research has shown that a higher social status is protective against sleep problems or sleep dissatisfaction (Ohayon et al., 1997; Hajak et al., 2001; Ohayon, 2005; Lauderdale et al., 2006). Not surprisingly, employed males reported less problems falling asleep. Females with a partner also tended to report less problems falling asleep.
Interestingly, from the other substance-related variables, only smoking was associated with an increase in problems falling asleep in males. Complaints about falling asleep in males were more often reported by smokers compared to nonsmokers. Cigarette smoking has been independently associated with disturbances in sleep (Zhang et al., 2006). This includes not just a longer latency to sleep onset (which has been related to the stimulatory effects of nicotine (Lauderdale et al., 2006), but also a shift towards lighter stages of sleep. This has also been related to withdrawal, as the intake of nicotine is curtailed during sleep or the medical consequences associated with cigarette smoking, such as chronic obstructive lung disease which might disrupt sleep continuity and have a negative impact on sleep architecture (Zhang et al., 2006).
In participants with complaints about sleep, an increased BMI was found. Patients with obstructive sleep apnea are often overweight or obese (Lam and Ip, 2007). However, obesity was found here in 7.2% of the males and 7.4% of the females, and severe obesity was found very rarely among this group of trauma patients (4 males and 7 females).
From a public health perspective, it is important to note, that just less then two-thirds of all the injured patients reported a general practitioner. At least, females but not males with sleeping complaints reported to have a general practitioner more often. In a representative survey (BMGS, 2002), the rate of patients with an appointed general practitioner was higher in Germany (90%). However, research has also shown that a considerable portion of patients with sleep complaints did not address these issues with their doctors (Mellinger et al., 1985; Simen et al., 1995; Hajak et al., 2001; Allaert and Urbinelli, 2004; Leger and Pousain 2005; Ohayon, 2005). One has to keep in mind that our patients were predominantly young and the emergency department served an inner city area. Future research might evaluate the possible benefits of tailored information delivered in the ED for these patients with sleep complaints.
There were important study limitations that should be noted.
- No grading of severity of sleep disturbances or complaints was made. It cannot be ruled out that some of the differences might reflect differences in the subjective perception of the patients. Other symptoms of sleep disorders have not been sufficiently addressed: Information on severity, nonrestorative sleep, early morning awaking, day-time sleepiness, sleeping time, and somatic or mental comorbidity should be obtained in further studies.
- No conclusion concerning the underlying aetiology could be drawn. Information about important aetiological factors (mental disorders, such as anxiety or depression, cardiovascular disease and respiratory disturbances, obstructive sleep apnea, or social and environmental factors) should be assessed not only for research, but might also be included in the form of a template or checklist in order to provide enough information to the patient to put him or her in a position to seek adequate help, if necessary. The use of a tool addressing mental health, such as the "General Health Questionnaire" or the "Hospital Anxiety and Depression Scale" might be helpful in future studies (Bjelland et al., 2002). It is also possible that other factors, which have not been sufficiently addressed also contribute to the risk of having a sleep complaint.
- Cognitively impaired patients, such as obviously intoxicated patients or severely injured patients were excluded due to the problems of obtaining informed consent. Thus, the study results may not be generalizable to all the trauma ED patients with an alcohol use disorder.
- When comparing sleep complaints between genders in respect to alcohol use disorders, one has to keep in mind that the prevalence of the reported more severe AUDs for women is lower compared to males. We did not observe any or tendency towards a higher risk or sleeping problems in females with a more severe AUD. Among women, other unaccounted for factors (e.g., psychological stress) might be more important with regard to sleeping problems.
In conclusion, complaints about sleep were found frequently among trauma patients. There was an association between AUD and complaints about sleep, mainly complaints about difficulties sleeping through in males, but not in females.
Future research might be able to elucidate whether a brief-tailored advice approach might be a tool to encourage—and empower—the patient with tailored information to seek further counselling, when improved sleep hygiene and lifestyle changes fail to improve sleep. Patients with alcohol use disorders and sleep complaints might benefit from the advice, that a change in alcohol consumption might improve sleep and quality of life.
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Funding |
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This work was supported by the German Ministry of Health (BMGS 217-43794-5/5).
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ACKNOWLEDGEMENTS |
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We would like to acknowledge the valuable help with the statistical analysis of Ulrike Grittner (Institute for Biometry and Clinical Epidemiology, Charité Universitaetsmedizin, Berlin).
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