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Orthopedic surgical procedures have been very effective in decreasing pain and restoring function to a great many patients. Joint replacement surgery, in particular, has been extremely successful. Total hip replacement is the number one operation in terms of patient satisfaction, making it the “best” surgery by at least one measure. There are, however, some problems with joint replacements. A very small percentage of patients have problems such as infection, blood clots, or heart problems. A much larger percentage of joint replacement patients, approaching 100 per cent according to many studies, will have problems with post-operative sleep. This is a complex problem that is often underappreciated. Many aspects of sleep can be influenced by the surgical procedure, but in order to fully understand this, we must first understand sleep.
Sleep is a state of decreased consciousness with fewer reactions to sensory stimuli. Sleep is not homogenous, but is divided into two types, REM (Rapid Eye Movement) sleep and non-REM. Non-REM is characterized by decreased brain function. It has different levels, the deepest of which seems to be the most necessary to function. If we are deprived of deeper non-REM sleep it can result in depression or actual physical discomfort. REM sleep is a period when the brain is more active than when we are awake. It is when dreams happen. Lack of REM sleep can a state of pronounced irritability and lability, and with signs of confusion, anxiety and suspicion.
Sleep in the postoperative period is affected by many factors. Patients are not in their normal surroundings, this has an effect on both the amount and quality of sleep. Even if this were not the case, hospitals are rather infamous for being a difficult venue to get a good night’s rest (There are some stories of people being awoken to take a sleeping pill). Noise and frequent observations by nursing staff can have their own negative effect. There are also problems with altered levels of consciousness and being on the hospital’s schedule rather than the patient’s.
Pain has the most significant negative impact. It is much more difficult to fall asleep when you are in pain, and pain can wake a patient up who is actually sleeping. Going a little deeper, pain is one factor that makes what little sleep you get, lest refreshing, as there is less REM and deep non-REM sleep. Of all the factors that affect sleep, pain does appear to be the one that has the greatest impact. Inflammation, a result of the surgical procedure related to pain, also has an independent detrimental effect on sleep.
Drugs are used for many purposes after a joint replacement. Pain relief is one of the most important. Unfortunately, not only does pain interfere with quantity and quality of sleep, but opioids (medicines such as morphine, oxycodone, or hydrocodone), commonly used to control pain, also negatively affect sleep. Opioids have been shown to reduce the amount of REM sleep and increase the percentage of less rejuvenating sleep. Studies have shown that even a small dose of opioid can disturb sleep on the first postoperative day. Other studies have shown that sleep disturbances induced by opioids are somewhat independent of pain.
Other medicines also interfere with sleep. Anesthetics make sleep less refreshing. Benzodiazepines, a class of medicines that include Ativan, Valium, and Xanax, which are used to cause people to fall asleep, decrease the quality of the sleep, decreasing REM and deep non-REM sleep. They allow patients to sleep, but it is of a lesser quality.
So, what can a joint-replacement patient do to maximize the ability to get good, restorative sleep? Your surgeon often can help with some pharmacologic measures. Sometimes Benadryl taken before bedtime can induce sleep. Ambien, a medicine similar to the benzodiazepines, can sometimes offer help in certain cases. It tends to maximize both the ability to get to sleep, and the ability to enjoy the more rejuvenating types of sleep. There are some other common sense measures recommended by both the American Academy of Orthopedic Surgeons and the American Association of Hip and Knee Surgeons. These include:
It is difficult, if not impossible, to recover after a joint replacement if you are unable to be refreshed by sleep. If you are unable to get adequate sleep, be sure to get in touch with your surgeon and see if he can make more specific recommendations.