Sleep Disorders
Background
While sleep disorders affect approximately 20% of the general public,1 up to 50% of cancer patients report difficulty with sleep.2 Causative factors include pain, medications, treatments, and hospitalization, as well as the physical and psychological impact of the disease process.
Paraneoplastic syndromes associated with steroid production and symptoms associated with tumor invasion, such as draining lesions, gastrointestinal and genitourinary symptoms, pain, fever, cough, dyspnea, and pruritus also contribute to sleep problems. Central nervous system stimulants, narcotics, sedatives, hypnotics, steroids, caffeine, nicotine, some antidepressants, and dietary supplements that include vitamins may affect sleep patterns. These factors, as well as the disease process, must be considered when caring for the cancer patient with sleep disturbances.
Assessment Tools
It is important that the nurse assess the patient’s sleep patterns and habits because sleep disorders can cause additional pain, anxiety, and depression, as well as respiratory and other health problems. The assessment should include documentation of predisposing factors, sleep patterns, emotional status, exercise and activity level, diet, symptoms, medications, and caregiver routines.
A more extensive assessment by a sleep specialist can include polysomnography, a test that monitors multiple physical data during a sleep cycle. While usually used to assess and diagnose chronic sleep disorders, polysomnography can provide valuable information for the management of sleep problems in the cancer patient.
Clinical Practice Guidelines
Sleep disturbance guidelines are included in the National Comprehensive Cancer Network (NCCN) guidelines on cancer-related fatigue.3 No specific sleep guidelines currently exist, but there are pharmacologic as well as nonpharmacologic interventions that can help patients with sleep disturbances.4
Nonpharmacologic
- Educate patients to sleep as much as their bodies tell them to, try to exercise at least once a day, and avoid naps unless very fatigued
- Provide a calm, soothing sleep environment that includes a comfortable room temperature, low or no lights, and a quiet room
- Promote skin integrity by keeping the patient's skin clean and dry. Keep bed linen clean and wrinkle free. You may want to provide a back rub or massage for additional comfort and relaxation
- Educate the patient to reduce fluid intake in the evening to avoid frequent awakening for elimination. Encourage bowel and bladder elimination before sleep
- Use a condom catheter for male nocturnal incontinence and an incontinence garment or pad for females, if needed
- Encourage a high-protein snack 2 hours before bedtime (eg, milk, turkey, foods high in tryptophan). A common side effect of tryptophan ingestion is drowsiness
- Avoid beverages with caffeine and other stimulants such as dietary supplements that promote metabolism changes and appetite suppression. Encourage drinking warm, caffeine-free drinks, such as warm milk with honey or decaf tea, before sleep
- Encourage the patient to wear loose, soft bed clothing
- Recommend repositioning and support with pillows, as needed
- Remind the patient to avoid exercise or activity within 2 hours of bedtime
- Promote a routine of keeping regular bedtime and awakening hours
Pharmacologic
- Zolpidem (Ambien) and zaleplon (Sonata) have reportedly not been associated with tolerance, dependence, sleep cycle alterations, or rebound insomnia. They are administered in doses of 5 to 10 mg 30 minutes before bedtime
- Eszopiclone (Lunesta) reportedly has a low risk of dependence and no evidence of tolerance. Dosing ranges from 1 to 3 mg nightly. The prescribing information should be consulted before this medication is used for patients with severe hepatic impairment or concomitantly with CYP34A inhibitors
- Ramelteon (Rozerem) works by altering the body’s use of melatonin, encouraging the body to sleep at night rather than napping during the day. It is not a controlled substance and is reportedly not associated with tolerance or dependence
- Benzodiazepines diazepam (Valium), temazepam (Restoril), triazolam (Halcion), clonazepam (Klonopin), etc) have been commonly used in the management of sleep disturbances. When used in conjunction with other treatment for short periods of time, these agents are safe and effective in producing natural sleep because they are less disruptive of rapid-eye-movement (REM) sleep than are other hypnotic agents
- Nonbenzodiazepine sleep aids include antidepressants, antihistamines, and antipsychotics. The anticholinergic properties of antihistamines relieve nausea and vomiting as well as insomnia and can provide a dual benefit
The Putting Evidence into Practice (PEP) Outcomes Resource Area from the Oncology Nursing Society has guidelines and tools for using evidence to solve problems. What can nurses do to assist people with cancer with sleep-wake disturbances can be assessed and printed from
http://www.ons.org/outcomes/resources/sleep.shtml
http://www.ons.org/outcomes/definitions/sleep.shtml
http://www.ons.org/outcomes/tables/sleep/sleepEvidence.shtml
http://www.ons.org/outcomes/tables/sleep/woe.shtml
References
- National Cancer Institute. Sleep disorders. NCI Website. Available here. Accessed October 30, 2006.
- Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19:895-908.
- NCCN clinical practice guidelines in oncology—Fatigue v.1.2006. National Comprehensive Cancer Network Web site. Available here. Accessed October 29, 2006.
- National Institutes of Health. National Center on Sleep Disorders Research. 2003. National Institutes of Health Web site. Available here. Accessed October 29, 2006.
- Berger A, Parker K, Young-McCaughan S, et al. Sleep/wake disturbances in patients with cancer and their caregivers: state of the science. Oncol Nurs Forum. 2005;32:E98-126.
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