There is a science of sleep.
This evening as I was driving home, I heard Peter White discussing sleep disorders in those who are blind or have significant visual impairment.
Unlike our crepuscular cousins, humans are diurnal; we are designed to sleep when it is dark and potter during the day, creating industry, building things.
Central to this system is the function of the pineal gland and the hormone melatonin, which alongside an array of other chemicals regulates our sleep-wake cycle.
Light plays a central role in this which, via our retina which feeds directly into our brains,* makes us sleepy at bedtime and perky in the morning (for those early-birds like me.)
Sleep and wake are of huge importance to patients in hospital and, in particular those who have dementia and related disorders, where their sleep-wake cycle can be turned upside down; inverted. Added to this, reduced exposure to meaningful daylight and monotony, loneliness, immobility and frequent cat-napping and you have a perfect storm for sleeplessness.
The nurses on Mallard know all about sleeplessness; sometimes preceded by sun-downing – the change in behaviour experienced by people with dementia as light fades, cortisol falls and visitors head for home.
I sometimes jokingly refer to this experience as being akin to Night at the Museum – the Ben Stiller movie where the exhibits come to life as the lights go-down.
When my patients sleep during the day and are awake at night all sorts of bad things can happen. At night, with fewer staff, there is less supervision, with lower levels of light, the likelihood of falling increases, with night, shape-shifting illusions come-out of the dark, worsening confusion and disorientation; meals are missed (although we do our best to be flexible), as are tea-rounds; weight-loss and dehydration can ensue.
It is all a jumble. We aren’t designed to be up and about at three in the morning.
We try to rebalance sleep by increasing daytime activities, by talking, joking and engaging with our patients, getting them up and dressed, dancing, singing, drawing, painting.
Hospitalisation as well as being one of the highest risk experiences for older people can also be one of the most boring.
We try to break the monotony, I know however, despite some great work across the country, the standard experience for the average hospital patient – particularly someone who is older and trapped by pathway delays, is one of days that are long and uneventful and tedious.
Your pineal gland doesn’t get a look-in in these situations.
I sometimes resort to sleeping remedies, when the Horlicks hasn’t worked – Melatonin, the recent addition to the pharmacopoeia has shown some promise, but like all drugs, works for some but not others, more often than not the latter.
This is back to the start – it is shining the light on the complexity of care, on what it means to look holistically; to be responsible for the journey, beginning to end. Acknowledging that the old thinking – the doctor see, doctor do, is no longer adequate; only when all the dimensions of night and day, sickness and health are considered, in the round, can we hope to make a difference.
Enough is not good enough.
It is not just what you see that matters, but the hidden, the esoteric pathways of nursing and medicine, pharmacy and therapy, talking and listening. Night and the day; sleep and wake.
*Never realised I was photovoltaic.