Helping Cancer Patients Get Their Zzzzs (Part 2)

The first section of this blog about sleep provided general information on sleep and described some common sleep disorders in the general population and among cancer patients. This section will concentrate on treatment of sleep disturbances and recommendations for patients.

How are sleep disorders treated? Treatments for sleep disorders will vary, depending on whether the cause(s) of the difficulty are known. If the sleep problems are due to the side effects of the cancer or cancer treatment, those issues would be addressed first. An evidence-based approach is to utilize cognitive behavioral therapy or insomnia (CBT-I), a method that blends cognitive and behavior change strategies aimed at changing dysfunctional thoughts, beliefs, attitudes, and habits concerning sleep.

CBT-I interventions are typically comprised of five elements: sleep hygiene, stimulus control, sleep restriction, cognitive restructuring, and relaxation training.¹ (Many strategies from CBT-I are included in the recommendations section of this blog). The effectiveness of CBT-I has been well established in the general population, and it is recommended by the American Association of Sleep Medicine. A recent review explored the effectiveness of CBT-I among cancer patients in 12 studies and documented that CBT-I produced statistically and clinically significant improvments.¹

Are sleeping medications helpful for cancer patients? The NCI warns that “despite lack of evidence in cancer populations, pharmacologic interventions are widely used by clinicians.”² They go on to list the many pharmacologic options used to treat sleep problems in cancer patients, including benzodiazepines, nonbenzodiazepine receptor agonists, melatonin receptor agonists, antihistamines, antidepressants, antipsychotics, chloral hydrate, and botanical and dietary supplements. The PDQ urges caution when selecting a drug to treat sleep disturbances and lists several factors to take into account, such as rate of absorption and elimination, dose and frequency, etc. A table listing medications, doses, and comments can be located at http://1.usa.gov/1FRSjDf.

The NCI is not alone in urging restraint in prescribing medications, especially hypnotics, for sleep disturbance. In the general population, even a low level of use of hypnotics (fewer than 18 pills per year) has been found to predict a more than threefold increase for death, and an elevated risk of motor vehicle accidents, infection, and impaired cognition.³ Glass, et al⁴ conducted a meta-analysis of 24 studies on the use of sedative hypnotics in people over 60, and documented that although the sedatives did improve sleep, the effect was small, and the risk of adverse events, such as falls, cognitive problems, and daytime fatigue, outweighed the benefits.

For patients who are on medication, advise them to take the medication as prescribed, to inform the healthcare team if they are unable to follow the recommendations, and to not discontinue the medication suddenly. BOTTOM LINE: First-line treatment of sleep disturbances in cancer patients should be CBT-I, with the careful addition of medications if necessary.

What recommendations can I pass along for cancer patients with sleep problems? The following recommendations have been compiled from multiple resources, and most are evidence-based recommendations from CBT-I interventions.

During the day

Maintain a regular sleep/wake cycle (even on the weekends): Sticking to a regular schedule helps the brain organize sleep rhythms.

· Increase your exposure to bright lights during the day.

· Get regular exercise during the morning or afternoon.

o Moderate-intensity walking has been shown to be helpful

· Avoid naps.

· Avoid sleeping outside the bedroom.

In the evening

Eating and drinking tips:

o Avoid caffeine late in the day and at night.

o Eat dinner at least 2-3 hours before bedtime.

o Avoid drinking alcohol within 3 hours of bedtime.

o Avoid a lot of liquids in the evening.

· Use the bed only for sleep and sex.

· Nightly rituals can help the body relax.

o Suggestions: A warm bath one hour before bedtime

o Yoga, meditation

· Turn off electronic devices at least one hour before bedtime.

o The type of light electronic devices emit tricks the brain into think it is daytime. (This blocks melatonin, which delays the onset of sleep).

· Create an environment that is conducive to sleep.

o Keep the bedroom dark, quiet, and cool.

o Avoid bright lights (and TV) in the bedroom.

· Don’t take your problems to bed.

o Be proactive about anxiety. Early in the evening, write down any problems that are worrying you. Then write one or two steps that can help alleviate the problem.

· Put the clock under the bed so it cannot be seen.

o If you can’t fall asleep after 20 minutes, get up and read until you are sleepy. Repeat if needed.

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References:

1. Garland SN, Johnson JA, Savard J, et al: Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatric Disease and Treat. 2014;10:1113-1124.

2. Online PDQ (Health Professional Version) of National Cancer Institute [Internet]. Sleep Disorders. Available from http://www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders/HealthProfessional.

3. Kripke DF, Langer RD, Kline LE: Hypnotics’ association with mortality or cancer: a matched cohort study. BMJ Open. 2012;2:e000850.

4. Glass J, Lanctot KL, Herrmann N, et al: Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ. 2005. doi: 10.1136/bmj.38623.768588.47.