Sleep disorder
Definition
Presenting symptom
Insomnia
Difficulty initiating or maintaining sleep that causes significant daytime impairment or distress for 3 months or more
Patient complains of difficulty falling asleep, staying asleep, or early morning awakening that impairs daytime function
Obstructive sleep apnea-hypopnea syndrome
Recurrent episodes of partial or complete upper airway obstruction despite ongoing respiratory effort during sleep
Patient wakes with breath-holding, gasping, or choking; bed partner reports habitual snoring
Narcolepsy
Uncontrollable sleepiness and intermittent signs of rapid eye movement sleep that interrupt normal wakefulness
Patient reports repeated episodes of need to sleep and suddenly falling asleep during usual daytime activities
Restless leg syndrome
Urge to move legs and unpleasant and uncomfortable sensations in legs at night that are relieved by movement of limbs
Patient describes feelings of creeping, tingling, or cramping pain in legs that is worse when patient is lying down
Periodic limb movement disorder
Periodic or random leg kicking or arm movements during sleep
Bed partner reports kicking or arm movements by patient during sleep
Circadian rhythm disorder
Advanced or delayed major sleep episode in relation to desired clock time that results in undesired insomnia or sleepiness
Patient reports inability to fall asleep or awaken relative to conventional sleep-wake times
Parasomnias
Undesirable physical events or behaviors that occur during sleep
Bed partner reports behaviors by patient such as sleepwalking, sleep talking, or sleep terrors
Hypersomnias
Constant or recurrent episodes of extreme sleepiness and lapses into sleep
Patient reports excess sleeping at night plus long naps during the day and still feels sleepy
12.2 Current Evidence
Underdiagnosis of sleep-wake disturbances and sleep disorders is a problem that can be linked directly to a lack of screening and assessment in clinical settings. Sleep-related screenings can be included in a brief intake health history and medication review. The release of the Pan-Canadian practice guideline is a promising advancement to improve screening, assessment, treatment, and health outcomes of sleep disturbances in adults with cancer [9], but consensus to disseminate and adopt this or other guidelines is the next challenge. No instrument with reliability and validity established in adults with cancer is used routinely to screen for sleep-wake disturbances comorbid with cancer in primary care or oncology clinics. The Pan-Canadian practice guideline suggests a two-step screening process: a yes/no reply to a question about the occurrence of a sleep problem, followed by two questions that are designed to determine the relationship between the sleep problem and daily functioning.
The Pan-Canadian guideline recommends that those who screen positive for insomnia undergo further assessment to identify the presence of signs and symptoms of sleep disturbances. The assessment is combined with a sleep diary such as the Consensus Sleep Diary [10] and the Insomnia Severity Index [11]. Objective actigraph data may be collected to complement subjective data.
When excessive daytime sleepiness, measured by the Epworth Sleepiness Scale (ESS) [12], is detected, OSA is suspected and immediate referral to a sleep center for polysomnography (PSG) is recommended. The STOP [13], STOP Bang [13], or Berlin [14] OSA screening tools may be preferable to the ESS because of higher sensitivity and inclusion of biomarkers (i.e., body mass index, blood pressure) in addition to age, gender, excessive snoring, witnessed sleep apnea, or gasping for breath [15].
PLMD screening is performed by asking the patient and bed partner about leg kicking or arm movements during sleep, and if the screen is positive, PSG is recommended [1]. RLS is screened for by asking the patient about creeping, tingling, or cramping pain in legs at bedtime, and if the screening is positive, PSG is not routinely indicated. The impact of all sleep disturbances on daily functioning can be determined through clinical interview or by using an outcome of sleep questionnaire (e.g., sleepiness, functioning, and mood).
12.3 Ongoing Research
When screening and assessment are positive for sleep disturbances, there are several interventions to help patients manage chronic and short-term insomnia disorders, OSA, and PLMD/RLS that fluctuate during cancer treatment and survivorship phases [16]. Approaches for managing insomnia include groups of cognitive behavioral, complementary, psychoeducation, exercise, and pharmacologic therapies [17, 18]. Approaches for managing OSA include continuous positive airway pressure and lifestyle modifications such as weight loss [19]. Interventions for PLMD/RLS include pharmacological treatments [20]. The impact of selected approaches needs to be evaluated and modified if the approach is ineffective in improving sleep.
12.3.1 Non-pharmacological Interventions for Insomnia in Patients with Cancer
Which interventions are effective to manage sleep-wake disturbances in people with cancer? AASM has recommended components of cognitive behavioral therapy (CBT) for insomnia as a standard or a guideline for practice in otherwise healthy adults [18]. The National Comprehensive Cancer Network ® (NCCN) presented a new clinical practice guideline for Survivorship in 2013 that includes sleep disorders. The Oncology Nursing Society (ONS) has categorized and synthesized the evidence for sleep-wake disturbances in patients with cancer [21]. No interventions were rated by ONS-Putting Evidence into Practice (ONS-PEP) as “Effectiveness Established,” and only cognitive behavioral interventions were rated as “Likely to be Effective.” These ratings reflect that the majority of research has been conducted in small samples of cancer patients with sleep-wake disturbances rather than with insomnia, and studies have reported only short-term outcomes. NCCN guidelines and ONS-PEP recommendations complement each other.
Table 12.2 reviews interventions for reducing sleep-wake disturbances/insomnia. These interventions are based on randomized controlled trials among patients in the active treatment and survivorship phases of cancer therapy. Currently, large studies are being conducted to reduce sleep-wake disturbances in patients with cancer, such as yoga during radiation therapy. Other studies are testing behavioral therapy and mindfulness-based stress reduction (MBSR) interventions to reduce several symptoms in patients with cancer, including sleep-wake disturbances. Visit www.ons.org/practice-resources/pep/sleep-wake-disturbance to learn more about the interventions listed on the table and others designed to improve sleep.
Table 12.2
Non-pharmacologic interventions that have been tested for sleep-wake disturbances in patients with cancer
Cognitive behavioral interventions/approach |
Instruct patients in the following stimulus control techniques: Go to bed only when sleepy and at about the same time each night Get out of bed and go to another room whenever unable to fall asleep within 20–30 min, return to bed only when sleepy again Use the bedroom for sleep and sex only Instruct patients in the following sleep-restriction techniques Maintain a regular bedtime and rising time each day Avoid daytime napping; if needed, limit to 1 h or less early to midday; avoid unnecessary time in bed during the day Instruct patients in the following relaxation techniques Use a relaxation technique within 2 h of going to bed Schedule a “clear your head time” 90 min before going to bed Instruct patients in the following sleep hygiene techniques: Avoid caffeine and other stimulants after noon; complete dinner 3 h before bedtime; do not go to bed hungry Keep the bedroom dark, cool, and quiet. Avoid pets in bedroom Do not watch television or use computers or tablets in the bedroom Replace mattress every 10–12 years, pillows more frequently; use light sleepwear and covers Ensure at least 20 min of daily exposure to bright, natural light soon after awakening |
Complementary therapies |
Encourage patients to decrease stress by selecting relaxation techniques that suit them, including massage, individual muscle relaxation, mindfulness-based stress reduction, and yoga Refer patients to practitioners in acupuncture, electroacupressure/acupressure, biofeedback, and/or healing touch therapies Encourage patients to keep a journal in which they document their deepest thoughts and feelings about their illness and treatment Encourage patients to decrease stress by focusing on and isolating various muscle groups while moving progressively up and down the body. Encourage focused breathing, with all attention centered on the sensations of breathing, including the rhythm and rise and fall of the chest |
Psychoeducation |
Provide anticipatory education to patients about sleep hygiene techniques Provide patients with information regarding specifics of treatment and expected side effects, including sleep-wake disturbances Repeat this information throughout the treatment Ensure that the patient’s sleep expectations are realistic |
Exercise |
Rule out bone metastasis or exercise contraindications Have patient complete moderate exercise (e.g., brisk walking 20–30 min 4 to 5 times per week) at least 3 h before bedtime Encourage patients to perform strength and resistance training |
12.3.2 Cognitive Behavioral Therapy/Approaches “Likely to Be Effective”
Cognitive behavioral approaches are strategies that include combinations of restructuring and reducing unhelpful thoughts, stimulus control, sleep restriction, relaxation, and sleep hygiene. These approaches are helpful in changing negative thoughts and behaviors surrounding an individual’s sleep and function. These approaches seem to be more effective in managing sleep-wake disturbance during the survivorship phase compared to the treatment phase. Patients have reported improved sleep quality, longer sleep duration, shorter time to fall asleep and less time awake during sleep [22–30], and higher sleep efficiency [31].
12.3.3 Complementary Therapies “Effectiveness Not Established”
Complementary therapies include a broad array of techniques designed to diminish stress and promote relaxation. The ONS “Effectiveness Not Established” rating indicates a lack of published evidence from large randomized controlled studies [17] (www.ons.org/practice-resources/pep/sleep-wake-disturbance). Below are some examples:
12.3.3.1 MBSR
MBSR is an intervention that consists of a combination of psychoeducation, meditation, and stress-reducing mental exercises aimed to promote relaxation. One MBSR technique is based on variations of the Kabat-Zinn group approach focusing on psychoeducation, meditation, and yoga [32]. MBSR may involve a tailored component that might affect sleep.
12.3.3.2 Other Complementary Strategies
Acupuncture and yoga are therapies that have been studied to reduce sleep-wake disturbances in patients with cancer. Acupuncture was associated with less sleep disturbance in patients with malignant tumors during active cancer treatment [35]. Yoga can be performed in a variety of ways, but the general aim is to physically align the body into postures, practice breathing, and mindfulness exercises. Yoga, compared to standard care, was associated with better sleep quality and less reliance on sleeping medications in cancer survivors of mixed diagnoses and various stages [36].
12.3.4 Psychoeducation “Effectiveness Not Established”
The Pan-Canadian Guidelines recommend that all patients receive education about sleep and strategies to manage insomnia [9]. Psychoeducation interventions involve a variety of platforms such as the phone or Internet to impart information to patients. These approaches have been studied with varied success on sleep outcomes in patients with cancer. A web-based education intervention was effective in improving sleep quality in survivors of breast and other cancers [37]. More evidence is needed to determine the effects of psychoeducation interventions on sleep-wake disturbances during cancer treatment and survivorship.
12.3.5 Exercise “Effectiveness Not Established”
Interventions examining the influence of exercise on sleep-wake disturbances in patients with cancer have primarily consisted of strength training and home-based tailored aerobic or walking programs. The evidence is promising for influencing outcomes in patients during active cancer treatment. Subjective sleep quality was improved in patients during treatment for mixed diagnoses of cancer who participated in a variety of physical exercise interventions [38–40] but not in patients with lymphoma. More studies are needed to determine the influence of exercise on sleep-wake disturbances in cancer survivors.
12.3.6 Pharmacological Therapies “Effectiveness Not Established”
12.3.6.1 Insomnia
The effectiveness of the pharmacological management of insomnia has not been established during active treatment or in the survivorship phase of cancer [17]. No large, randomized controlled trials have examined the effect of pharmacological therapies on sleep in patients transitioning through cancer therapies [41].
Pharmacological therapy used for sleep-wake disturbances in otherwise healthy adults includes prescribed medications and supplements. Several medications prescribed for sleep-wake disturbances are classified as psychotropic drugs. These medications have been used off-label for the management of a variety of symptoms of cancer treatment. Psychotropic medications include antidepressants, benzodiazepine and non-benzodiazepine hypnotics, atypical antipsychotics, and anticonvulsants. These medications have sedating/hypnotic effects that are proposed to improve sleep-wake disturbances but need to be used with caution [41].
Antidepressants have varied undesirable side effects associated with their use. Selective serotonin reuptake inhibitors such as paroxetine (Paxil®) have more of a sedative effect [41]. Paroxetine improved sleep problems in both depressed and nondepressed cancer patients receiving treatment, but the rates of sleep problems remained high [42]. Of major concern, paroxetine was found to inhibit the metabolism and benefit of tamoxifen (Nolvadex®) in women being treated with breast cancer [43].
Medications such as trazodone (Desyrel®) have been used in low doses to improve sleep [41]. A descriptive study reported that trazodone may improve insomnia and nightmares in patients with all types of advanced cancers [44]. However, trazodone should be used cautiously in patients with cardiovascular comorbidities because it may cause orthostasis and lead to falls. Tricyclic antidepressants such as amitriptyline are generally not used due to side effects (i.e., dry mouth) that may be bothersome in patients with cancer [41].
Benzodiazepine sedatives (BDZ) and non-benzodiazepine hypnotics have been used for management of insomnia in patients throughout phases of cancer care. Non-BDZ hypnotics, such as zolpidem (Ambien®) and zopiclone (Lunesta®), are used most often, but evidence of their effectiveness is lacking in patients with cancer [41]. Women with breast cancer or at high risk for developing the disease who had hot flashes accompanied by nighttime awakenings were randomized to double-blinded treatment with zolpidem or placebo that was combined with the antidepressant venlafaxine (Effexor®) XR, 75 mg/day. Women in the zolpidem augmentation group reported improved sleep and quality of life [45]. Benzodiazepine and non-BDZ medications may be effective for short-term insomnia management, but clinicians and patients need to be aware of side effects such as drowsiness that may impair daytime functioning of the cancer survivor.
Antipsychotic medications have been suggested for off-label use to help the nonpsychotic patient whose medical condition contradicts using benzodiazepines. Atypical antipsychotic medications are not approved for use in treating sleep-wake disturbances and are associated with cardiometabolic and anticholinergic effects. Anticonvulsants such as pregabalin influence the same brain chemicals as benzodiazepines and have similar side effects. Metabolism of these medications can be altered due to drug-drug interactions with medications such as corticosteroids, which are commonly given during and after cancer treatment [41]. Herbal supplements such as valerian have not been associated with improved sleep in clinical trials of patients undergoing cancer treatment.
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