Carter, P.A. (2006). A brief behavioral sleep intervention for family caregivers of persons with cancer. Cancer Nursing, 29, 95–103.

To (a) evaluate the feasibility (recruitment and retention, instrumentation, and intervention administration) and effectiveness of a brief behavioral Caregivers Sleep Intervention (CASI) that addressed the specific needs and sleep goals of family caregivers of persons with cancer, and (b) determine the effectiveness of  CASI in improving caregivers’ sleep quality, depressive symptoms, and quality of life

The Caregivers Sleep Intervention (CASI) had two sessions. The initial CASI session (week 2 of the study) lasted one hour and provided knowledge, guided participants in self-assessment of maladaptive habits affecting their sleep quality, and assisted participants to develop personal sleep and relaxation goals. In study week 5, a second one-hour CASI session (booster) reviewed the information provided in the initial session and rated personal sleep and relaxation goal achievement. Topics covered were (a) the importance of sleep and sleep \"myth busting,\" (b) stimulus control: environmental affects on sleep, (c) sleep hygiene: planning for sleep, and (d) relaxation techniques to promote sleep. Attention control participants were given the “back health” control condition at study weeks 2 and 5, with data collection at baseline, three and five weeks, and two, three, and four months postbaseline.

• The sample included 30 participants.
• Mean age of participants was 53 years, with a range of 21–85 years.
• The sample was 63% female and 37% male.
• To be included in the study, participants had to be age 21 or older, be identified as a family caregiver living with a person with advanced cancer, and have reported difficulty initiating and/or maintaining sleep or nonrestorative sleep for at least one month, with no major diagnosis of depressive disorder or preexisting sleep disorder other than insomnia.
• The sample was 80% Caucasian, 10% African American, and 10% Hispanic.
• The relationships of the caregiver to the patient were spouse/partner (57%), adult children (30%), and other (13%).
• Hours of caregiving ranged from 2 to 24 hours, with an average of 17 hours.

• Single site
• Outpatient setting
• Central Texas

End-of-life care

A repeated measures experimental design was used.

• Pittsburgh Sleep Quality Index (PSQI) was used to measure caregivers’ sleep quality.  
• An actigraph sleep watch was used to measure sleep patterns (latency, duration, efficacy, and wake after sleep onset).
• Sleep Center for Epidemiological Studies–Depression Scale (CES-D) was used to measure current and immediate past symptoms of depressions.CES-D has demonstrated good reliability at α 0.85 in previous studies.
• Caregivers Quality of Life Index–Cancer (CQOLC) was used to measure caregiver quality of life. Contextual factors, including caregiver demographic characteristics, patient demographic characteristics, and sleep arrangements, were collected on a demographic sheet.
   

Feasibility: In terms of recruitment, caregivers were difficult to identify and recruit from the community setting but were enthusiastic once identified. In terms of retention, 35 recruited caregivers who met the inclusion criteria were consented and remained in the study through the final data collection.

CASI effectiveness: Sleep duration and efficiency were consistently strongly negatively correlated with caregiver depressive symptoms and quality of life over time. Overall sleep quality and sleep latency were consistently strongly positively correlated with caregiver depressive symptoms over time.

Caregivers’ quality-of-life scores showed improvement across groups. No significant differences or patterns of change were seen between or within groups. All study participants showed improvement in self-reported sleep quality during the study. Caregivers in the CASI intervention group reported greater improvement in overall sleep quality than did the attention control group caregivers at each time point  (CASI group: baseline, M 7.9 [3]; week 5, M 7.2 [3]; month 2, M 6 [3]; month 3, M 5.5 [3]; and month 4, M 5.4 [3]. Control group: baseline, M 7.9 [5]; week 5, M 7.6 [5]; month 2, M 8.4 [5]; month 3, M 7 [5]; and month 4, M 10.3 [6]). Significant differences were seen in caregiver self-reported sleep latency at week 5 (t = 2.29, p = 0.02) and in overall sleep quality then did attention control caregivers at month 4 (t = 2.40, p = 0.03).  

Actigraph data comparisons between groups showed significant differences in sleep latency scores at two months (t = - 2.57, p = 0.02) and duration scores at four months (t = 2.0, p = 0.05).

The CASI intervention group was significantly different from the control group in sleep latency at the end of four months. Sleep latency is defined as the amount of time it takes to fall asleep. Although this is only one aspect of sleep difficulties, it does show that CASI can be effective.

• The sample was small, with less than 100 participants.
• Risk of bias existed because there was no random assignment.
• The researchers had difficulty identifying subjects for recruitment from the community setting. 
• The sample had limited ethnic diversity.

Sleeping difficulty for caregivers of patients with advanced cancer who are not currently receiving hospice care is an important focus for nursing research because the area is understudied. One-to-one attention from a nurse and goal setting are powerful strategies that healthcare providers can use with family caregivers that can impact sleep improvements and reduction of depressive symptoms. The feasibility of a CASI intervention study is promising with some needed changes to the attention control group that were outlined in this study. The steady improvement in overall sleep quality of caregivers in the CASI intervention group demonstrated the possibilities of success in a future study.