Sleep/Wake Disturbances

What can nurses do to assist people with cancer with sleep-wake disturbances?

Recommended for Practice

Interventions for which effectiveness has been demonstrated by strong evidence from rigorously designed studies, meta-analyses, or systematic reviews, and for which expectation of harm is small compared with benefit

No intervention can be recommended for nursing practice as of December 1, 2005.

Likely to Be Effective

Interventions for which the evidence is less well established than for those listed under "Interventions Recommended for Practice"

No intervention is likely to be effective for nursing practice as of December 1, 2005.

Benefits Balanced With Harms

Interventions for which clinicians and patients should weigh the beneficial and harmful effects according to individual circumstances and priorities

Pharmacologic

Despite widespread use, no published meta-analyses or experimental design studies examining the efficacy of hypnotic drugs in people with cancer were found.

Nurses must systematically evaluate how a person with cancer responds to a pharmacologic intervention, particularly the efficacy, side effects, and potential interactions with over-the-counter and prescription medications that he or she is taking.^1,2

Although drugs have not been studied in patients with cancer, hypnotics commonly are prescribed for short-term use. Benzodiazepines and nonbenzodiazepine drugs vary in their half-lives. Drugs with longer half-lives can cause daytime sleepiness and impair functioning, whereas those with shorter half-lives may wear off in the middle of the night. Agents included in the National Cancer Institute's PDQ Sleep Disorders Web site 3 that commonly are prescribed but must be individually evaluated for side-effect profile include

•  Benzodiazepines , such as diazepam (5-10 mg), diazepam (15-30 mg), triazolam (0.125-0.5 mg), and clonazepam (0.5-2 mg)

•  Nonbenzodiazepine hypnotics , such as zolpidem tartrate (5-20 mg), zaleplon (10-20 mg), and eszopiclone (1-3 mg)

•  Other classes of drugs ( tricyclic antidepressants, second-generation antidepressants, antihistamines, chloral derivatives, and neuroleptics are less commonly used but may be considered to improve sleep).

Herbal Supplements

No published meta-analyses or experimental design studies were found that are specific to the efficacy of herbal therapy in people with cancer. Studies describe potential interactions between herbal agents with chemotherapy and other common drugs, making herbal agents potentially dangerous for use in patients with cancer.⁴

Effectiveness Not Established

Interventions for which data currently are insufficient or of inadequate quality

Cognitive-Behavioral Therapy

Therapy that involves changing negative thought processes and attitudes about one's ability to fall asleep, stay asleep, get enough sleep, and function during the day.⁵

Instruct the patient in the following.

. Go to bed only when sleepy and at approximately the same time each night.

. Get out of bed and go to another room whenever you are unable to fall asleep; return to bed only when sleepy again.

. Use the bedroom for sleep and sex only.

. Maintain a regular rising time each day.

. Avoid daytime napping. If needed, limit napping to 30-45 minutes.

Sleep hygiene techniques include behaviors to promote a good night's sleep and optimal functioning the next day.⁵

. Use a preferred relaxation technique, such as taking a warm bath or shower, reading, listening to soft music, or having a massage, within two hours of going to bed.

. Practice good sleep hygiene techniques (e.g., avoid caffeine after noon, complete dinner three hours before bedtime, do not go to bed hungry, keep the bedroom cool and the covers light, do not keep a television in the bedroom).

Four quasi-experimental studies were identified that had favorable sleep outcomes, except for the number and length of night awakenings; sample populations predominately had breast cancer, but mixed-cancer diagnoses also were included.^{6,7,8,9,10,11} One randomized, controlled trial with a wait-list control group of patients with breast cancer showed improved subjective sleep indexes and immune factors but more equivocal polysomnographic indexes.¹² One additional randomized, controlled trial used profile-based cognitive-behavioral therapy for patients with a variety of cancer diagnoses who were in chronic pain; however, results were inconclusive because of a high attrition rate (79%).¹³

Complementary Therapies, Including Expressive Therapy, Expressive Writing, Healing, Autogenic Training, Massage, Mindfulness-Based Stress Reduction (MBSR), Muscle Relaxation, and Yoga

. E ncourage patients to decrease stress by selecting relaxation techniques that they find suitable, such as massage, individual muscle relaxation, progressive muscle relaxation, meditation, mindfulness, yoga, and autogenic training.

. Encourage patients to keep a journal in which they document their deepest thoughts and feelings about 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 of the attention centered on the sensations of breathing, including the rhythm and rise and fall of chest .

. Provide referral to appropriate practitioner as needed.

Several small studies looking at a variety of complementary therapies were found that showed some improvement in sleep outcomes. One randomized, controlled trial and two quasi-experimental trials looked at MBSR, a combination therapy of relaxation techniques, meditative techniques, and yoga. ^14,15,16 Populations studied included women with stage 0-II breast cancer, men with early prostate cancer, and a group of patients with mixed cancer diagnoses. The randomized, controlled trial showed that sleep complaints are associated with psychological distress and provided preliminary evidence that sleep efficiency and sleep quality improved with MBSR. Carlson's quasi-experimental studies showed that MBSR significantly improved overall quality of life, stress symptoms, and sleep quality.^15,16 One study also documented increases in the interleukin-4 secretion and decreases in interferon gamma and interleukin-10, which characterizes healthier blood, reduced sleep disturbances, and improved sleep quality.¹⁶ Carlson's most recent randomized, controlled trial in a population with mixed cancer diagnoses demonstrated improvement in subjective sleep quality, sleep efficiency, and sleep duration.¹⁷ Two quasi-experimental studies looked at the use of autogenic training in populations with mixed cancer diagnoses. Data from the larger study (N = 229) showed improvement in sleep latency, sleep duration, sleep efficiency, and decreased need for sleeping medications as well as decreased daytime disruption.¹⁸ The second study showed autogenic training to be helpful for sleep induction.¹⁹ One quasi-experimental study of 38 subjects with lymphoma who were taught Tibetan yoga showed significant improvement in sleep quality, latency, and duration and less medication use.²⁰ One small study of 20 lesbian patients being treated for stage I-IIIA breast cancer showed significant improvement in minutes awake after sleep onset after a supportive-expressive group therapy intervention.²¹ One randomized, controlled trial with 42 male subjects with newly diagnosed stage IV metastatic renal cell cancer participating in a phase II vaccine trial showed improvement in four measured areas of sleep disturbance after an intervention using expressive writing.²² One randomized, controlled trial in adult patients with a variety of cancers at an inpatient and outpatient university hospital showed a reduction in sleep latency after using progressive muscle relaxation techniques.²³ A small study of 35 patients with a variety of cancers treated with healing touch 24 showed improvement on self-reported sleep disturbances. A study examining the use of massage in a group of patients with a variety of cancers undergoing therapy had unknown benefit.²⁵

Psychoeducation and Information

. Provide patients with information regarding the specifics of treatment and expected side effects, including sleep-wake disturbances.

. Repeat the information throughout the treatment.

. Teach patients the basic information about sleep hygiene (see Cognitive-Behavioral Therapy).

One randomized, controlled trial showed favorable sleep outcomes using an informational tape as an educational intervention in men receiving radiation for localized prostate cancer. Another randomized, controlled trial of the use of an informational tape by women with stage I or II breast cancer undergoing chemotherapy showed no change.^26,27

Exercise

. Nurses should rule out bone metastasis or exercise contraindications.

. Patients should complete moderate exercise (i.e., brisk walking for 20-30 minutes four to five times per week) at least three hours before bedtime.

. Encourage patients to perform strength and resistance training.

Two quasi-experimental studies relating to exercise and sleep were identified. Both were feasibility studies; one sample had breast cancer and the other included patients with a variety of cancers. Both studies showed favorable sleep outcomes with aerobic exercise.^28,29 A third study that evaluated exercise and sleep in patients with multiple myeloma was inconclusive because of a high attrition rate (42%).³⁰