Indian Write-Ups

Insomnia In Patients with Advanced Cancer

- Santosh K. Chaturvedi, Prabha S. Chandra & G. Sateesh Kumar
Department of Psychiatry, National Institute of Mental Health & Neurosciences Bangalore.

Sleep disturbances, especially insomnia, are common in patients with advanced cancer, and become an important issue in palliative care. Sleep disturbances get ignored in advanced disease due to attention to other more obvious symptoms, like pain. Nevertheless, it should be understood that pain may be poorly tolerated in a person with sleeplessness. Similarly, a person with poor sleep is likely to suffer from continual fatigue, tiredness, tension and poor quality of life.

Sleeplessness may be a symptom of cancer itself, part of the stress reaction to having cancer, a sequel to some other symptom of advanced cancer such as pain, a side effect of cancer treatment or idiopathic. Insomnia is the more common sleep problem, although hypersomnia also occurs. Most insomnias are related either to pain or to psychophysiological factors.

Though sleep disturbances are common in cancer, their exact prevalence in the terminally ill cancer patients is not known (Chaturvedi & Chandra, 1996). Sleep problems are not considered as an important symptom for symptom control in palliative care. This could be because of two reasons. On one hand physicians consider sleep disturbances in cancer patients either as a normal reaction to cancer or as a manifestation of other psychiatric problems like depression or anxiety (Hu & Silberfarb, 1991). On the other hand, patients also have a tendency to keep these sleep problems to themselves. It has been found, in a study, that patients with lung cancer, rarely complained of sleep disturbance though most of them had a sleep architecture similar to that of insomniacs (Silberfarb et al, 1995).

A few studies undertaken in this area have found that sleep disturbance as a symptom is common in cancer patients and the prevalence of sleep disturbances in patients with advanced pancreatic cancer was found to be as high as 54% (DeSimone 1994). Another recent survey of symptoms of advanced cancer (Walsh et al, 2000), studied the relationship of symptoms to age, gender and performance status in 1,000 patients receiving palliative care. The prevalence of sleep problems was 49%. Sleep problems were more frequent among those younger than 65 years, and among male patients (Walsh et al, 2000). However, the gender differences disappeared on logistic regression analysis after excluding gender specific primary sites. In our experience with cancer patients, we have also found that a significant number of patients had insomnia as a major problem, both in the presence and absence of other emotional problems.

A few patients with insomnia reported that they were disturbed emotionally because of the sleep problems. In a study (Chaturvedi & Chandra, 2000) of 87 women with cervical cancers, 49 (56%) reported being concerned about their sleep. In 41% subjects sleep related concerns coexisted with a psychiatric disorder, predominantly in the form of depression, but 15% subjects had idiopathic sleep problem. Most were treated with tricyclic anti-depressants and some received hypnotics. There was no significant difference between the group with and without sleep concern on parameters such as age or duration of illness. However, more women in the group with sleep concern had co morbid psychiatric problems, especially depression. These observations in the Indian context reveal a high prevalence of sleep disorders among cancer patients. It is therefore important to detect and provide appropriate treatment for sleep disturbances in cancer.

Sleep disturbances seen in cancer patients can conveniently be classified in the following way:

A. Sleep disturbances occurring as a part of patients normal reaction to cancer

Diagnosis of cancer will evoke various emotional reactions in the patient. Common to most of the reactions is the physiological arousal. This physiological arousal will disrupt the sleep architecture. The usual ways in which it is manifested are initial insomnia (difficulty in getting sleep), intermittent awakening associated with nightmares and loss of the refreshing nature of sleep.

Usually after a reasonable period of time patients will be able to overcome the initial disturbances and achieve an equilibrium. When the physiological arousal subsides, the sleep will become normal. However, depending on personal resources and support system, the intensity and duration of the reaction may vary from person to person.