Evidence-based interventions for sleep-wake disturbances

Editor’s note: One of a series of articles on managing cancer-related symptoms from the Oncology Nursing Society

Sleep-wake disturbance is a prevalent issue affecting patients with cancer, with incidence rates ranging from 30%-75% (Berger et al., 2005; Lee, Cho, Miaskowski, & Dodd, 2004). Defined as perceived or actual alterations in night sleep with resultant daytime impairment, the most common forms are insomnia, sleep-related breathing disorders, and sleep-related movement disorders such as restless leg syndrome and periodic limb movement disorder (Page & Berger, 2009). Patients suffering from insomnia often have difficulty initiating and maintaining sleep, wake too early, and, when they do sleep, feel that it was of poor quality and unrestorative (Page & Berger, 2009).

Sleep-wake disturbances in patients with cancer may occur alone or as part of a symptom cluster, with the most common cluster being fatigue, pain, and mood (Miaskowski & Lee, 1999). Quality of life, ability to heal, activities of daily living, work duty fulfillment, and family and intimate relationships all are affected by lack of or poor sleep (Savard & Morin, 2001). In addition, certain factors may make a patient more susceptible to sleep-wake disturbances, such as being of female sex; older age; having a family history of sleep disorder or mood disorders, anxiety, or depression; having a current diagnosis of mood disorder, anxiety, or depression; and physiological distress in relation to cancer diagnosis or treatment (Mills & Graci, 2004).

Perlis, Jungquist, Smith, and Posner (2005) identified nine parameters for measuring sleep-wake disturbances: total sleep time while in bed, sleep latency, awakenings during sleep period, wake time after sleep onset, napping during the day, excessive daytime sleepiness, quality of perceived sleep, circadian rhythm, and sleep efficiency. It is important for oncology nurses to measure the impact sleep-wake disturbances have on their patients. Numerous self-report tools exist, including the Insomnia Severity Index (Bastien et al., 2001; Savard, Savard, Simard, & Ivers, 2005), the Pittsburgh Sleep Quality Index (Beck et al., 2004; Buysse et al., 1999), Morin’s Sleep Diary (Berger et al., 2002, 2003; Morin, 1993; Morin & Espie, 2003), the Epworth Sleepiness Scale (Johns, 1991, 1992), and the Structured Interview for Sleep Disorders (Schramm et al., 1993) (see Table 1).

Weighted Checklist

A key component of oncology nursing is symptom management. By using the reporting tools mentioned in this article, as well as the Putting Evidence Into Practice (PEP) recommendations listed below, nurses have the opportunity to improve patients’ quality of life by evaluating symptoms and implementing various evidence-based modalities.


Putting evidence into practice

To promote nursing practice that is based on evidence, the Oncology Nursing Society (ONS) launched the PEP program in 2005. ONS PEP teams consisting of advanced practice nurses, staff nurses, and a nurse scientist were charged with reviewing the literature to determine what treatments and interventions are proven to alleviate many cancer-related problems that are sensitive to nursing interventions. Each team classified interventions under the following categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice.

Likely to be effective

Although no treatments or therapies fell under the recommended for practice category, cognitive-behavioral therapy is indicated as likely to be effective. Cognitive-behavioral therapy focuses on changing the patient’s negative thought process and attitude about falling asleep, staying asleep, and getting enough sleep (Morin, Culbert, & Schwartz, 1994). Oncology nurses using cognitive-behavioral therapy should instruct patients to

  • Go to bed when they feel tired and usually at the same time each night.
  • Get out of bed and leave the bedroom if they are unable to sleep; only returning when they feel sleepy again.
  • Only use the bedroom for sleep or sex.
  • Wake up at the same time each day
  • And avoid napping during the day. If a nap is necessary, patients suffering from sleep-wake disturbances should limit the nap to 30 minutes occurring at least four hours before bedtime.

Oncology nurses also can recommend sleep hygiene processes. These include creating a bedtime routine, such as taking a bath, reading, or listening to soothing music; avoiding stimulants such as caffeine after noon and eating dinner more than three hours before bedtime; creating a comfortable sleep environment (no television); and receiving at least 20 minutes of natural sunlight each day, preferably in the morning (Page & Berger, 2009).

Benefits balanced with harms

Clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities.

Pharmacologic

Benzodiazepines and nonbenzodiazepines are commonly prescribed for short-term use. Drugs with a longer half-life may cause daytime sleepiness and patient impairment. Those with a shorter half-life may wear off in the middle of the night (NCI, 2008). Common drugs and their dosages include
Benzodiazepines: diazepam (5–10 mg), triazolam (0.125–0.5 mg), and clonazepam (0.5–2 mg)
Nonbenzodiazepines: zolpidem tartrate (5–20 mg), zaleplon (10–-20 mg), and eszopiclone (1–3 mg).
Other classifications of drugs used to treat this patient population include tricyclic antidepressants, second-generation antidepressants, antihistamines, chloral derivatives, and neuroleptics (Page & Berger, 2009). Of note, no published studies found efficacy in herbal supplement use. In fact, some studies describe potential harmful interactions between herbal agents and chemotherapy (Block, Gyllenhaal, & Mead, 2004).

Effectiveness not established

Insufficient or conflicting data or data of inadequate quality currently exist for the following treatments. However, no clear indication of harm has been noted for any (Page & Berger, 2009).

  • Expressive therapy
  • Expressive writing
  • Healing touch
  • Autogenic training
  • Massage
  • Muscle relaxation
  • Mindfulness-based stress reduction
  • Yoga
  • Aromatherapy
  • Music therapy
  • Haptotherapy
  • Guided imagery
  • Education and information
  • Exercise

Interventions for sleep-wake disturbances work best when patients and nurses work together. Oncology nurses can suggest specific changes to a patient’s lifestyle based on that patient’s disclosure of day-to-day activities. For example, if a patient reports that he or she likes watching television before going to bed and enjoys coffee in the evening, the nurse can educate the patient about the negative consequences these two actions have on nighttime sleepiness. Patient compliance and nurses’ understanding of symptoms and recommended interventions are crucial to an optimal outcome.

Sean Pieszak is a copy editor in the publishing division at the Oncology Nursing Society in Pittsburgh, PA. More information about the ONS PEP classification for sleep-wake disturbances can be found at http://www.ons.org/Research/PEP/Sleep

References

Bastien, C.H., Vallieres, A., & Morin, C.M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2, 297–307. doi: 10.1016/S1389-9457(00)00065-4

Beck, S.L., Schwartz, A.L., Towsley, G., Dudley, W., & Barsevick, A. (2004). Psychometric evaluation of the Pittsburgh Sleep Quality Index in cancer patients. Journal of Pain and Symptom Management, 27, 140–148. doi: 10.1016/j.jpainsymman.2003.12.002

Berger, A.M., Parker, K.P., Young-McCaughan, S., Mallory, G.A., Barsevick, A.M., Beck, S.L., Hall, M. (2005). Sleep/wake disturbances in people with cancer and their caregivers: State of the science [Online exclusive]. Oncology Nursing Forum, 32, E98–E126. doi: 10.1188/05.ONF.E98-E126

 

Berger, A.M., VonEssen, S., Khun, B.R., Piper, B.F., Agrawal, S., Lynch, J.C., Higginbotham, P. (2003). Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: Results of a feasibility intervention study. Oncology Nursing Forum, 30, 513–522. doi: 10.1188/03.ONF.513-522

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Block, K.I., Gyllenhaal, C., & Mead, M.N. (2004). Safety and efficacy of herbal sedatives in cancer care. Integrative Cancer Therapies, 3, 128–-148. doi: 10.1177/1534735404265003

Buysse, D.J., Reynolds, C.F., III, Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213. doi: 10.1016/0165-1781(89)90047-4

Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth sleepiness scale. Sleep, 14, 540–545.

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Miaskowski, C., & Lee, K.A. (1999). Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: A pilot study. Journal of Pain and Symptom Management,, 17, 320–332. doi: 10.1016/S0885-3924(99)00008-1

Mills, M., & Graci, G.M. (2004). Sleep disturbances. In C.H. Yarbro, M.H. Frogge, & M. Goodman (Eds.), Cancer symptom management (3rd ed., pp. 111–134). Sudbury, MA: Jones and Bartlett.

Morin, C. (1993). Insomnia. New York, NY: Guilford Press.

Morin, C., & Espie, C. (Eds.). (2003). Insomnia: A clinical guide to assessment and treatment. New York, NY: Kluwer Academic.

Morin, C.M., Culbert, J.P., & Schwartz, S.M. (1994). Nonpharmacological interventions for insomnia: A mega-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172–-1180.

National Cancer Institute. (2008). Medications commonly used to promote sleep. Retrieved from http://www.cancer.gov/cancertopics/pdq/supportivecare/sleepdisorders/healthprofessional/allpages#Section_75

Page, M.S., & Berger, A.M. (2009). Sleep-wake disturbances. In L.H. Eaton & J.M. Tipton (Eds.), Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 285–297). Pittsburgh, PA: Oncology Nursing Society.

Perlis, M.L., Jungquist, C., Smith, M., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York, NY: Springer.

Savard, J., & Morin, C.M. (2001). Insomnia in the context of cancer: A review of a neglected problem. Journal of Clinical Oncology, 19, 895–908.

Savard, M.H., Savard, J., Simard, S., & Ivers, H. (2005). Empirical validation of the Insomnia Severity Index in cancer patients. Psycho-Oncology, 14, 429–441. doi: 10.1002/pon.860

 

Schramm, E., Hohagen, F., Grasshoff, U., Riemann, D., Hajak, G., Weess, H.G., & Berger, M. (1993). Test-retest reliability and validity of the Structured Interview for Sleep Disorders According to DSM-III-R. , 150, 867–872.

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