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B. Sleep disturbances due to the physical effects of cancer
C. Sleep disturbances as part of other psychiatric problems Anxiety, depression and delirium are the most common psychiatric diagnoses in cancer patients. In anxiety, patients will have difficulty in getting sleep and intermittent sleep awakenings. Nightmares are also common in this condition. Because of the disruption, sleep loses its refreshing quality. Patients with depression may have the characteristic sleep disturbance of early morning insomnia (loss of sleep towards morning). In addition to the initial and intermittent insomnia, delirious patients may have intermittent insomnia or total loss of sleep in the night and sleep in the day time (altered sleep wake schedule). As mentioned above, 41% of cancer patients had concerns about poor sleep. Of all patients with sleep concerns 74% had identifiable psychiatric disorder (Chaturvedi & Chandra, 2000). D. Sleep disturbances due to drugs In the treatment of the terminally ill, narcotic analgesics have important role. Since this group of drugs has a sedative effect, initially patients will have increased sleep. However, later as patients develop tolerance, sleep will be restored to normal and may even result in insomnia. So while using narcotic analgesics, one has to keep in mind possible complications such as day time sedation, tolerance and rebound insomnia. Medications which may contribute to insomnia are caffeine, bronchodilators, corticosteroids, some antihypertensives, SSRI antidepressants, and stimulants. Withdrawal of sedative-hypnotic medications can lead to insomnia (Sateia & Silberfarb, 1996). E. Specific sleep disorders (idiopathic sleep disorder) Some cancer patients have sleep disturbances which cannot be related to any of the above factors. We have seen several patients in whom insomnia preceded the onset of cancer by a few months. This, we feel is similar to depression occurring as an antecedent to certain cancers. In most of the patients with the primary insomnia, sleep was a major cause for concern and majority opted for medication (Sateesh Kumar et al, 1998). In study (Chaturvedi & Chandra 2000) on psychiatric morbidity among patients admitted to a cancer hospital, it was found that out of 294 patients, 44(15%) had a primary sleep disorder. Among these patients, the sleep disorder which was mainly in the form of insomnia could not be explained by anxiety or depression and was hence diagnosed as an idiopathic sleep disorder. Most of the patients with a sleep disorder had head and neck cancers (66%). 15% of women with cervical cancers also had idiopathic sleep disorders. Most patients with a sleep problem were prescribed benzodiazepines, while few were treated with anti depressants. Some patients refused treatment for the sleep problem and wanted to cope with it on their own. All patients were educated regarding healthy habits and sleep hygiene. F. Sleep disorders in advance stages of cancer : Sleep disturbances or disruption occur in advanced stages due to pain, distressing symptoms, fear of death/pain, and many other fears, well known during the terminal stages. Sometimes, patients with advanced disease are found to keep away or fight sleep, fearing that they would die during sleep, or if they slept off they may not be able to call people for help. Sometimes, such patients prefer to sleep during daytime, when caregivers are available and ‘keep watch at night’. MANAGEMENT OF SLEEP DISORDERS IN CANCER PATIENTS : Treatment of sleep disturbances should start with the identification of a specific cause of the problem and one should do a thorough medical and psychological evaluation of the patient; after that behavioral interventions, medications, or psychotherapy may be helpful. When using medication, keep in mind possible complications such as daytime sedation, tolerance, and rebound insomnia. A. Management of sleep disturbances occurring as part of patient’s normal reaction. Sleep disturbances occurring immediately after the disclosure of the diagnosis are transient and can be considered as part of the normal reaction. With reassurance and support from relatives and significant others, usually the patient will be able to overcome it. Intervention is required only if the sleep disturbance becomes severe enough to cause distress or persists for a long time. When the sleep disturbance becomes severe, a short course of sleep medications like zolpidem, zopiclone, or benzodiazepines like nitrazepam or lorazepam will be useful. In persistent sleep disturbances associated with other features of physiological arousal, behaviour therapy like relaxation training and biofeedback work better. B. Management of sleep disturbances due to the physical effects of cancer Mild degree of pain in the initial stages of cancer responds to behavioral therapy techniques like biofeedback. Analgesic drugs like paracetamol and diclofenac sodium may also be effective. When pain and insomnia are associated with depression, antidepressants such as amitriptyline are found to be effective. In severe cancer pain during the terminal stages, opiate analgesic drugs like morphine are preferred over other analgesics. Opiate analgesics, in addition to analgesia also produce sedation. The risk of dependence with opiates in terminal stages is negligible when compared with the benefits. The main problems are tolerance (loss of efficacy over continued use) and daytime sedation. When sleeplessness occurs, due to breathlessness, the specific cause should be found and treated. When the tumour obstructs the respiratory passage, endotracheal intubation should be done as early as possible. Pleural effusion should be tapped and patient should be put on a ventilator in severe pulmonary embolism. C. Management of sleep disturbances as part of other psychiatric problems In sleep disturbances associated with depression, sedative antidepressants like amitriptyline and dothiepin should be preferred over other drugs. In our experience amitriptyline when started at a low dose and increased with caution was found to be highly useful. When a patient has severe anxiety symptoms and insomnia, benzodiazepine anxiolytics, like diazepam or alprazolam are useful. In persistent low grade anxiety, relaxation training will be useful. The main stay of treatment of delirium is treatment of the specific cause. However, when the sleep disturbance is severe, a short acting benzodiazepine like lorazepam or a low dose of antipsychotic like resperidon (1 to 4 mg), haloperidol (1-5 mg) or thioridazine (25 mg –75 mg) can be used. D. Management of sleep disturbances due to drugs The narcotic analgesics, commonly used for the treatment of cancer pain can lead on to both insomnia (lack of sleep) and hypersomnia (increased sleep). Hypersomnia is produced in the initial stages which manifests as troublesome daytime drowsiness. This can be avoided by titrating the dose with the relief of pain. Only when this fails, stimulants like methylphenidate will have to be given. With continued use, most of the patients will develop tolerance to the sedative effect, at times resulting in insomnia. When a patient on a narcotic analgesic develops insomnia and pain an appropriate increase in the dose should be made. E. Management of idiopathic sleep disturbances Here, an evaluation of the sleep habits of the patient should be made and counseling regarding the sleep mechanism should be given. The essential points in counseling are, maintaining a regular timing of sleep, avoiding beverages and other food items which interfere with sleep in the evening and night, and keeping the other daily activities out of the bed room. These are called sleep hygiene measures. Lastly, an important point that should never be forgotten is that the patients quite often benefit from the presence of a counselor, doctor or any professional, who, gives them an adequate hearing even when all other treatment fails. F. Management of sleep disturbances in advanced stages of disease : If the cause of disruption of sleep disturbance is pain or other distressing symptoms, the underlying pain or symptoms relief should be managed first. If patient is resisting sleep, counseling should be attempted to understand the fears and concerns of the patient, and appropriate reassurance should be provided. Sleep disturbances in patients with advanced cancer are easy to detect, and are usually reported by the patients themselves or by their relatives. Uncorrected sleeplessness produces fatigue, tiredness, drowsiness, depression, irritability, tension and distress among cancer patients. Sleeplessness aggravates the experience of distressing symptoms, making them worse and diminishing quality of life. On the other hand, a good refreshed sleep makes the patient feel better, stronger, and with a good quality of life. Adequate amount of quality sleep is essential in order to feel alert, motivated and energized (Sateia & Silberfarb, 1996). Sleep is an important factor in promoting normal mood, cognitive function, healing, musculoskeletal restoration, immune function, and in pain thresholds (Roth et al, 1974; Johnson 1969; Oswald 1980). Good sleep may provide respite from pain, worry and hardship which can be associated with terminal illness (Sateia & Silberfarb, 1996). References
Reproduced after revision with permission from Editor and Publisher of Current Concepts in Psycho Oncology, NIMHANS, Bangalore. |
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Insomnia In Patients with Advanced Cancer
