APOS PSYCHOSOCIAL
POCKET GUIDE

Sleep Disruption

Introduction

Between 30% to 60% of cancer patients have sleep difficulties at some point during their cancer care trajectory and between 15% and 35% meet the diagnostic criteria for an insomnia disorder. Prevalence rates tend to be greater at the peri-operative period and for patients with advanced disease. While studies using polysomnography are lacking for differential diagnosis, insomnia appears to be the most common sleep disorder in this population. Based on DSM-5 classification, insomnia disorder is defined by a predominant complaint of dissatisfaction with sleep quantity/quality associated with at least one of the following: 1) difficulty initiating sleep; 2) difficulty maintaining sleep (e.g., frequent awakenings, problems returning to sleep); 3) early-morning awakenings. In addition, to establish an insomnia disorder diagnosis, the sleep difficulty occurs at least 3 nights per week, for at least 3 months, and is associated with significant distress or functional impairments. Although large-scale epidemiological studies are lacking, obstructive sleep apnea (OSA) also appears to be prevalent in some populations (e.g., head and neck cancer, brain cancer), as well as periodic limb movements (PLMS, e.g., breast cancer). Excessive somnolence can also be found, especially in patients with advanced cancer and when initiating opioids and gabapentin.

Guidelines

Insomnia in the general population

The American Academy of Sleep Medicine (AASM) clinical guidelines for the pharmacological (2017) https://jcsm.aasm.org/doi/10.5664/jcsm.6470 and psychological/behavioral treatment (2006) https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_BTInsomnia_Update.pdf  of chronic insomnia are publicly available.

Sleep difficulties in cancer patients

Canadian practice guideline for the prevention, screening, assessment and treatment of sleep disturbances in adults with cancer (published in 2012) can be found here: https://www.cancercareontario.ca/sites/ccocancercare/files/guidelines/full/Sleep_Disturbances_Guideline_Eng.pdf

The Oncology Nursing Society (updated in 2019) has also published clinical guidelines for cancer-related sleep-wake disturbances : https://www.ons.org/pep/sleep-wake-disturbances?display=pepnavigator&sort_by=created&items_per_page=50

Screening

• Sleep item of the Edmonton Symptom Assessment System-revised (ESAS): score of 2 or greater
• Insomnia Severity Index (ISI): score of 8 or greater
• Pittsburgh Sleep Quality Index (PSQI): score of 5 or greater
• Polysomnography when suspicion of OSA and PLMS
• Epworth Sleepiness Scale (ESS) when daytime somnolence is present

Risk Factors for Insomnia

Predisposing factors

• Younger age
• Female sex
• Hyperarousal (i.e., tendency to be easily physically, emotionally, and cognitively aroused)
• Personal and family antecedents of insomnia
• Personal and family antecedents of other psychological disorders (e.g., depressive or anxiety disorders)

Precipitating Factors

• Psychological reaction (e.g., depressive/anxiety symptoms) and thoughts associated with cancer-related stressors:
  • Initial diagnosis (e.g., “Why me, what did I do wrong?”; “Can I get cured?”)
  • Recurrence diagnosis (e.g., “Am I going to die?”; “I won’t be able to get through another round of treatment”)
  • Progression/End of life (e.g., “I don’t want to die in pain”; “How is my family going to get through this?”; “I don’t want to be a burden”)
  • Treatment (e.g., “What side effects will I experience?”; “Am I still going to be able to function?”)
• Cancer treatments
  • Surgery
    • Hospitalization (e.g., environment factors such as noise, changes in sleep routine)
    • Side effects (e.g., pain, nocturia)
  • Chemotherapy
    • Side effects (e.g., nausea/vomiting, fatigue)
    • Medications used (e.g., antiemetics)
    • Deficiency in sexual hormones (e.g., nocturnal hot flashes)
    • Changes in sleep/wake schedule (e.g., spending more time sleeping during the day)
  • Hormone therapy
    • Deficiency in sexual hormones (e.g., nocturnal hot flashes)
    • Side effects (e.g., pain)
  • Radiation therapy
    • Side effects (e.g., fatigue, nocturia, pain)
    • Changes in sleep/wake schedule (e.g., spending more time sleeping during the day)
  • Cancer symptoms (e.g., pain, dyspnea, cough, nausea) 

Perpetuating factors

• Maladaptive sleep behaviors
  • Excessive amount of time spent awake in bed
  • Irregular sleep-wake schedule
  • Napping
  • Engaging in sleep-interfering activities in the bedroom (e.g., watching TV, using smartphones)
• Faulty beliefs and attitudes about sleep that increase performance anxiety
  • Unrealistic sleep requirement expectations (“I need 8 hours of sleep to function well during the day”)
  • Faulty causal attributions (“My insomnia is the result of my symptoms [e.g., nocturnal hot flashes] and nothing can be done about it until my symptoms disappear”)
  • Misattribution/amplification of perceived consequences of insomnia (“If I don’t sleep well, my cancer will come back”; “I cannot function after a poor night’s sleep”)
  • Decreased perception of control/predictability of sleep (“There is nothing I can do to improve my sleep”)
  • Faulty beliefs about sleep-promoting practices (“Only a sleep medication can improve my sleep”)

Treatment

Pharmacological treatment

• Preferably used occasionally or for acute insomnia
• If insomnia becomes chronic, refer patients for cognitive-behavioral therapy for insomnia (CBT-I)
• Chronic daily usage of hypnotics should be reserved for patients for whom CBT-I is inaccessible or ineffective or for patients who maintain long-term gains with the medication. However, a regular follow-up is needed. Also take into account patient’s preference.
• Chronic usage of hypnotic medications, especially benzodiazepines, can lead to tolerance (i.e., reduction of effects over time and need to increase the dosage to maintain the same effects) and physical and psychological dependence.

Adapted from Sateia et al., 2017

Click here to view table as PDF

Sleep Hygiene

• Sleep hygiene may be used in good sleepers at risk to develop insomnia (e.g., receiving chemotherapy) or in patients with acute insomnia to prevent the development of chronic insomnia
• Sleep hygiene as a single therapy is not an effective treatment for chronic insomnia
• Most commonly, sleep hygiene is used as part of a multicomponent CBT-I

Click here to view table as PDF

Cognitive-Behavioral Therapy

• CBT-I is the treatment of choice for chronic insomnia, it is associated with similar short-term effects as hypnotic medications but with a better sustainment of treatment gains over time
• Generally, a multicomponent CBT-I is used which combines sleep restriction, stimulus control, cognitive restructuring and sleep hygiene (and sometimes relaxation)
• Sleep restriction alone and stimulus control alone are effective alternatives
• To help patients revise their erroneous beliefs about sleep, use psychoeducation and standard cognitive restructuring (i.e., Socratic questioning).
• The efficacy of cognitive restructuring alone is not established but is thought to contribute to the long-term sustainment of treatment gains over time

Click here to view table as PDF

Unique Population Considerations

• Adaptations to CBT-I often need to be done for bedridden patients and those with advanced cancer
  • Rather than going in another room when awake:
    • Sit in a armchair beside the bed
    • Sit in the bed
  • To fight against sleepiness during the day:
    • Remain mentally active (puzzles, sudoku, diary, etc.)
    • Go outside or keep the environment well-lit
    • Bright light therapy in the morning can be helpful

Cultural Considerations

Very little is known on cultural differences in how insomnia is experienced and can be treated in the context of cancer. In the general population, there is evidence showing that sleep disruption is more prevalent in Hispanic and Black individuals, even after controlling for confounders such as socioeconomic status and comorbid medical conditions. Although empirical data is lacking, such differences are likely to be present in cancer patients as well. With regard to treatment, a recent clinical trial conducted in non-cancer Black women suggested that a culturally tailored internet-delivered CBT-I was associated with a higher completion rate than a standard CBT-I, which was associated with a larger insomnia severity reduction (Zhou et al., 2022). In cancer, there is recent preliminary evidence indicating that CBT-I is feasible and effective in Spanish-speaking breast cancer survivors (Oswald et al., 2022) but more research is needed to know if and how the intervention needs to be adapted to be as effective as in White patients.

Conclusion

Sleep difficulties, especially insomnia symptoms, are common in cancer patients but are often overlooked in clinical practice. When left untreated, insomnia is very likely to become chronic. Chronic insomnia is associated with many negative consequences. For instance, research has shown that insomnia is a risk factor for the subsequent development of depressive and anxiety disorders, which are more complex and more costly to treat. Short tools exist to screen sleep difficulties and should be integrated in routine cancer care. Ideally, chronic insomnia should be treated with cognitive-behavioral therapy. Hypnotic medications can also be used in some circumstances.

References and Links

1. Davidson, J. R. ( 2020). Sink into sleep: A step-by-step guide for reversing insomnia (2nd ed.). New York: Springer Publishing Company. (Self-help book for patients using CBT-I)
2. Garland, S. N., Zhou, E., Savard, M.-H., Ancoli-Israel, S., & Savard, J. (2022). Sleep and cancer across the life span. In M. Kryger, T. Roth, C. A. Goldstein, & W. C. Dement (Eds.) Principles and practice of sleep medicine, 7^th edition (chapter 153, pp. 1492-1500). Philadelphia: Elsevier.
3. Oswald, L. B., Morales-Cruz, J., Eisel, S. L., Del Rio, J., Hoogland, A. I., Ortiz-Rosado, V., Soto-Lopez, G., Rodriguez-Rivera, E., Savard, J., Castro, E., Jim, H. S. L., & Gonzalez, B. D. (2022). Pilot randomized controlled trial of eHealth cognitive-behavioral therapy for insomnia among Spanish-speaking breast cancer survivors. Journal of Behavioral Medicine. org/10.1007/s10865-022-00313-6
4. Savard, J. (2019). Cancer. In Savard, J. & Ouellet, M.-C., Handbook of Sleep Disorders in Medical Conditions (pp. 175-200). San Diego: Elsevier Inc/Academic Press.
5. Zhou, E., Ritterband, L. M., Bethea, T. N., Robles, Y. P., Heeren, T. C., & Rosenberg, L. (2022). Effect of culturally tailored, internet-delivered, cognitive behavioral therapy for insomnia in black women: A randomized controlled trial. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2022.0653