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Sleep Difficulties

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Textbook of Palliative Care

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Abstract

Sleep disturbance is a prevalent and debilitating problem in palliative care that contributes to worse quality of life and adds to patient and caregiver suffering. Screening for this symptom in routine practice followed by a focused assessment and evaluation is essential given its consequences on daytime functioning and distress. The causes of disrupted sleep in palliative care populations are multifactorial and include disease physiology, uncontrolled physical symptoms, adverse effects of medications, and emotional distress or psychiatric disorders. Attention to reversible causative factors where possible, detection of specific sleep disorders to ensure appropriate treatment, and development of a treatment plan individualized to the patient that takes into consideration prognosis are essential. Simple approaches such as sleep hygiene education may be helpful, but usually a combination of psychological and pharmacological agents is necessary for effective management. Cognitive behavioral therapy for insomnia (CBT-I) is considered first-line treatment for insomnia that targets the cognitive and behavioral factors that perpetuate this symptom but may require adaptation in the context of palliative care. Common medications used to manage insomnia include the benzodiazepine receptor agonists, benzodiazepines, and sedating antidepressants, but there is a lack of information about adverse effects of these drugs. High-quality research is needed to establish efficacy of psychological therapies and pharmacological agents for management of insomnia and other sleep disorders in palliative care. This chapter provides an overview of sleep disturbance, causative factors, and management of common sleep disorders of insomnia, sleep-wake cycle reversal, hypersomnia, and nightmares in palliative care.

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References

  • Akechi T, Okuyama T, Akizuki N, Shimizu K, Inagaki M, et al. Associated and predictive factors of sleep disturbance in advanced cancer patients. Psycho-Oncology. 2007;16(10):888–94.

    Article  PubMed  Google Scholar 

  • American Academy of Sleep Medicine. International classification of sleep disorders. 3rd ed. Darien: American Academy of Sleep Medicine; 2014.

    Google Scholar 

  • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington: American Psychiatric Publishing; 2013.

    Book  Google Scholar 

  • Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011;135(1–3):10–9.

    Article  PubMed  Google Scholar 

  • Ballon JS, Feifel D. A systematic review of modafinil: potential clinical uses and mechanisms of action. J Clin Psychiatry. 2006;67(4):554–66.

    Article  CAS  PubMed  Google Scholar 

  • Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med. 2001;2:297–307.

    Article  PubMed  Google Scholar 

  • Beck SL, Dudley WN, Barsevick A. Pain, sleep disturbance, and fatigue in patients with cancer: using a mediation model to test a symptom cluster. Oncol Nurs Forum. 2005;32(3):542.

    Article  PubMed  Google Scholar 

  • Berger AM. Update on the state of the science: sleep-wake disturbances in adult patients with cancer. Oncol Nurs Forum. 2009;36:E165–77.

    Article  PubMed  Google Scholar 

  • Bliwise D. Normal aging. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. 4th ed. Philadelphia: Saunders; 2005. p. 24–38.

    Chapter  Google Scholar 

  • Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DL, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc. 2009;57:761–89.

    Article  PubMed  PubMed Central  Google Scholar 

  • Borbely AA. A two process model of sleep regulation. Hum Neurobiol. 1982;1:195–204.

    CAS  PubMed  Google Scholar 

  • Brincat JV, Macleod AD. Adverse effects of opioids on the central nervous system of palliative care patients. J Pain Palliat Care Pharmacother. 2007;21(1):15–25.

    Article  Google Scholar 

  • Buysse DJ. Insomnia. JAMA. 2013;309(7):706–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Buysse DJ. Sleep health: can we define it? Does it matter? Sleep. 2014;37(1):9–17.

    Article  PubMed  PubMed Central  Google Scholar 

  • Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.

    Article  CAS  PubMed  Google Scholar 

  • Buysse DJ, Yu L, Moul DE, Germain A, Stover A, et al. Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments. Sleep. 2010;33(6):781–92.

    Article  PubMed  PubMed Central  Google Scholar 

  • Campbell CL, Campbell LC. A systematic review of cognitive behavioural interventions in advanced cancer. Patient Educ Couns. 2012;89(1):15–24.

    Article  PubMed  PubMed Central  Google Scholar 

  • Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL, Morin CM. The consensus sleep diary: standardizing prospective sleep self- monitoring. Sleep. 2012;35(2):287–302.

    Article  PubMed  PubMed Central  Google Scholar 

  • Carskadon M, Dement W. Normal human sleep: an overview. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. 4th ed. Philadelphia: Elsevier Saunders; 2005. p. 13–23.

    Chapter  Google Scholar 

  • Davidson JR. Sleep disturbances in cancer patients. Soc Sci Med. 2002;54:1309–21.

    Article  PubMed  Google Scholar 

  • Davies AN, Patel SD, Gregory A, Lee B. Observational study of sleep disturbances in advanced cancer. BMJ Support Palliat Care. 2017;7(4):435–40.

    Article  PubMed  Google Scholar 

  • Davis MP, Goforth H. Fighting insomnia and battling lethargy: the yin and yang of palliative care. Curr Oncol Rep. 2014;16:377.

    Article  PubMed  Google Scholar 

  • Davis MP, Khoshknabi D, Walsh D, Lagman R, Platt A. Insomnia in patients with advanced cancer. Am J Hosp Palliat Care. 2014;31(4):365–73.

    Article  PubMed  Google Scholar 

  • De Crescenzo F, Foti F, Ciabattini M, Del Giovane C, Watanabe N, Sañé Schepisi M, Quested DJ, Cipriani A, Barbui C, Amato L. Comparative efficacy and acceptability of pharmacological treatments for insomnia in adults: a systematic review and network meta-analysis. Cochrane Database Syst Rev. 2016;(Issue 9):Art. No.: CD012364.

    Google Scholar 

  • DeCruz S, Espiritu JRD, Zelder M, Wang T. Sleep disorders in chronic liver disease. Semin Respir Crit Care Med. 2012;33:26–35.

    Article  Google Scholar 

  • Dietrich SK, Francis-Jimenez CM, Knibbs MD, Umali IL, Truglio-Londrigan M. Effectiveness of sleep education programs to improve sleep hygiene and/or sleep quality in college students: a systematic review. JBI Database System Rev Implement Rep. 2016;14(9):108–34.

    Article  PubMed  Google Scholar 

  • Dijk DJ, Duffy JF, Czeisler CA. Contribution of circadian physiology and sleep homeostasis to age-related changes in human sleep. Chronobiol Int. 2000;17(3):285–311.

    Article  CAS  PubMed  Google Scholar 

  • Doufas AG, Panagioutou OA, Panousis P, Wong SS, Ionnidis JPA. Insomnia from drug treatments-Mayo Clinic proceedings: evidence from meta-analysis of randomized controlled trials and concordance with prescribing information. Mayo Clin Proc. 2017;92(1):72–87.

    Article  PubMed  Google Scholar 

  • Espie CA. “Stepped care”: a health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep. 2009;32(12):1549–58.

    Article  PubMed  PubMed Central  Google Scholar 

  • Finan PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12):1539–52.

    Article  PubMed  PubMed Central  Google Scholar 

  • FitzGerald JM, O’Regan N, Adamis D, Timmons S, Dunne CP, Trzepacz PT, Meagher DJ. Sleep-wake cycle disturbances in elderly acute general medical inpatients: longitudinal relationship to delirium and dementia. Alzheimers Dement (Amst). 2017;7:61–8.

    Google Scholar 

  • Garbarino S, Lanteri P, Durando P, Magnavita N, Sannita WG. Co-morbidity, mortality, quality of life and the healthcare/welfare/social costs of disordered sleep: a rapid review. Int J Environ Res Public Health. 2016;13(8):E 831.

    Article  Google Scholar 

  • Garland SN, Carlson LE, Stephens AJ, Antle MC, Samuels C, Campbell TS. Mindfulness-based stress reduction compared with cognitive behavioural therapy for the treatment of insomnia comorbid with cancer: a randomized partially blinded, non-inferiority trial. J Clin Oncol. 2014;32(5):449–57.

    Article  PubMed  Google Scholar 

  • Gilbert JE, Howell D, King S, Sawka C, Hughes E, Angus H, Dudgeon D. Quality improvement in cancer symptom assessment and control: the provincial palliative care integration project (PPCIP). J Pain Symptom Manag. 2012;43(4):663–78.

    Article  Google Scholar 

  • Gillette M, Abbott S. Fundamentals of the circadian system. In: Sleep Research Society, editor. SRS basics of sleep guide. Westchester: Sleep Research Society; 2005. p. 131–8.

    Google Scholar 

  • Glynn J, Gale S, Tank S. Causes of sleep disturbance in a specialist palliative care unit. BMJ Support Palliat Care. 2014;4(Suppl 1):A56.

    Article  Google Scholar 

  • Hansen K, Höfling V, Kröner-Borowik T, Stangier U, Steil R. Efficacy of psychological interventions aiming to reduce chronic nightmares: a meta-analysis. Clin Psychol Rev. 2013;33(1):146–55.

    Article  PubMed  Google Scholar 

  • Howell D, Oliver TK, Keller-Olaman S, Davidson JR, Garland S, Samuels C, Savard J, Harris C, Aubin M, Olson K, Sussman J, MacFarlane J, Taylor C. Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice. Ann Oncol. 2011;25(4):791–800.

    Article  Google Scholar 

  • Howell D, Keller-Olaman S, Thomas O, Hack T, Broadfield L, Biggs K, Chung J, Gravelle D, Green E, Hamel M, Harth T, Johnston P, McLeod D, Swinton N, Syme A, Olsen KA. Pan-Canadian practice guideline and algorithm: screening, assessment and supportive care of adults with cancer-related fatigue. Curr Oncol. 2013;20(3):e233–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • Howell D, Molloy S, Wilkinson K, Green E, Orchard K, et al. Patient- reported outcomes in routine cancer clinical practice: a scoping review of use, impact on health outcomes, and implementation factors. Ann Oncol. 2015;26(9):1846–58.

    Article  CAS  PubMed  Google Scholar 

  • Hugel H, Ellershaw JE, Cook L, Skinner J, Irvine C. The prevalence, key causes and management of insomnia in palliative care patients. J Pain Symptom Manag. 2004;27(4):316–21.

    Article  Google Scholar 

  • Humbert M, Findley J, Hernandes-Con M, Chahine LM. Cognitive behavioural therapy for insomnia in Parkinson’s disease: a case series. NPJ Parkinsons Dis. 2017;3(25)

    Google Scholar 

  • Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540–5.

    Article  CAS  PubMed  Google Scholar 

  • Johnson JA, Rash JA, Campbell T, Savard J, Gehrman PR, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016;27:20–8.

    Article  PubMed  Google Scholar 

  • Khoo SY, Quinlan N. Mirtazapine: a drug with many palliative uses #314. J Palliat Med. 2016;19:1116.

    Article  PubMed  Google Scholar 

  • Klingman KJ, Jungquist CR, Perlis ML. Introducing the sleep disorders symptom checklist-25: a primary care friendly and comprehensive screener for sleep disorders. Sleep Med Res. 2017;8(1):17–25.

    Article  Google Scholar 

  • Krakow B, Zadra A. Clinical management of chronic nightmares: imagery rehearsal therapy. Behav Sleep Med. 2006;4(1):45–70.

    Article  PubMed  Google Scholar 

  • Kvale EA, Shuster JL. Sleep disturbance in supportive care of cancer: a review. J Palliat Med. 2006;9:437.

    Article  PubMed  Google Scholar 

  • Lee KA, Ward TM. Critical components of a sleep assessment for clinical practice settings. Issues Ment Health Nurs. 2005;26(7):739–50.

    Article  PubMed  Google Scholar 

  • Littner M, Kushida CA, Anderson WM, et al. Practice parameters for the role of actigraphy in the study of sleep and circadian rhythms: an update for 2002. Sleep. 2003;26:337–41.

    Article  PubMed  Google Scholar 

  • Maclean AW, Fekken GC, Saskin P, Knowles JB. Psychometric evaluation of the Stanford Sleepiness Scale. J Sleep Res. 1992;1(1):35–9.

    Article  CAS  PubMed  Google Scholar 

  • Majendie CMA, Dysch L, Carrigan N. Cognitive behavioral therapy for insomnia (CBT-I) for an adult with multiple sclerosis. Clin Case Stud. 2017;16(2):115–31.

    Article  Google Scholar 

  • Maltby KF, Sanderson CR, Lobb EA, Phillips JL. Sleep disturbances in caregivers of patients with advanced cancer: a systematic review. Palliat Support Care. 2017;15:125–40.

    Article  PubMed  Google Scholar 

  • Matheson E, Hainer BL. Insominia: pharmacological therapy. Am Fam Physician. 2017;96(1):29–35.

    PubMed  Google Scholar 

  • McSharry DG, Ryan S, Calverly P, Edwards JC, McNicholas WT. Sleep quality in chronic obstructive pulmonary disease. Respirology. 2012;17(7):1119–24.

    Article  PubMed  Google Scholar 

  • Mercadante S, Adile C, Ferrera P, Masedu F, Valenti M, Aielli F. Sleep disturbances in advanced cancer patients admitted to a supportive/palliative care unit. Support Care Cancer. 2017;25(4):1301–6.

    Article  PubMed  Google Scholar 

  • Moens K, Higginson IJ, Harding R, on behalf of EURO IMPACT. Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage. 2014;48(4):660–77.

    Article  PubMed  Google Scholar 

  • Montgomery P, Dennis JA. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database Syst Rev. 2003;(Issue 1):Art. No.: CD003161.

    Google Scholar 

  • Morin CM, Benca R. Chronic insomnia. Lancet. 2012;379:1129.

    Article  PubMed  Google Scholar 

  • Morin CM, Drake CL, Harvey AG, Krystal AD, Manber R, et al. Insomnia disorder. Nat Rev Dis Primers. 2015;1:15026.

    Article  PubMed  Google Scholar 

  • Mystakidou K, Parpa E, Tsilika E, Gennatas C, Galanos A, Vlahos L. How is sleep quality affected by the psychological and symptom distress of advanced cancer patients? Palliat Med. 2009;23(1):46–53.

    Article  CAS  PubMed  Google Scholar 

  • Neuendorf R, Wahbeh H, Chamine I, Yu J, Hutchinson K, Oken B. The effects of mind- body interventions on sleep quality: a systematic review. Evid Based Complement Alternat Med. 2015;2015:902708.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ohayon MM. Epidemiological overview of sleep disorders in the general population. Sleep Med Res. 2011;2(1):1–9.

    Article  Google Scholar 

  • Ouslander JG, Connell BR, Bliwise DL, Endeshay Y, Griffiths P, Schnelle JF. A non-pharmacological interventions to improve sleep in nursing home patients: results of a controlled clinical trial. J Am Geriatr Soc. 2006;54(1):38–47.

    Article  PubMed  Google Scholar 

  • Palesh OG, Roscoe JA, Mustian KM, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292–8.

    Article  PubMed  Google Scholar 

  • Pressman MR. Primer of polysomnogram interpretation. Boston: Butterworth–Heinemann; 2002.

    Google Scholar 

  • Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD. Management of chronic insomnia in older adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2016;165(2):125–33.

    Article  PubMed  Google Scholar 

  • Renom-Guiteras A, Planas J, Farriols C, Mojal S, Miralles R, Silvent MA, Ruiz-Ripoll AI. Insomnia among patients with advanced disease during admission in a palliative care unit: a prospective observational study on its frequency and association with psychological, physical and environmental factors. BMC Palliat Care. 2014;13:40.

    Article  PubMed  PubMed Central  Google Scholar 

  • Reynolds CF, O’Hara R. DSM-5 sleep-wake disorders classification: overview for use in clinical practice. Am J Psychiatry. 2013;170(10):1099–101.

    Article  PubMed  Google Scholar 

  • Roscoe JA, Kaufman ME, Matteson-Rusby SE, Palesh OG, Ryan JL, et al. Cancer related fatigue. Oncologist. 2007;12(Supplement 1):35–42.

    Article  PubMed  Google Scholar 

  • Rosenfeld B, Pessin H, Marziliano A, Jacobson C, Sorger B, et al. Does desire for hastened death change in terminally ill cancer patients? Soc Sci Med. 2014;111:35–40.

    Article  PubMed  PubMed Central  Google Scholar 

  • Ryan DJ, O’Regan NA, Caoimh RO, Clare J, O’Connor M, Leonard M, et al. Delirium in an adult acute hospital population: predictors, prevalence and detection. BMJ Open. 2013;3:1–10.

    Article  Google Scholar 

  • Sateia MJ, Pigeon WR. Identification and management of insomnia. Med Clin North Am. 2004;88(3):567–96.

    Article  PubMed  Google Scholar 

  • Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacological treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–49.

    Article  PubMed  PubMed Central  Google Scholar 

  • Savard MJ, Savard J. Cognitive-behavioral therapy for insomnia in cancer patients: an update of efficacy evidence and areas for future research. Curr Sleep Med Rep. 2017. Published online 18 April 2017.

    Google Scholar 

  • Savard J, Ivers H, Savard M-H. Capacity of the Edmonton Symptom Assessment System and the Canadian Problem Checklist to screen clinical insomnia in cancer patients. Support Care Cancer. 2016;24(10):4339–44.

    Article  PubMed  Google Scholar 

  • Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008;4(5):487–504.

    PubMed  PubMed Central  Google Scholar 

  • Seyffert M, Lagisetty P, Landgraf J, Chopra V, Pfeiffer PN, Conte ML, et al. Internet- delivered cognitive behavioral therapy to treat insomnia: a systematic review and meta-analysis. PLoS One. 2016;11(2):e0149139.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  • Spielman AJ, Nunes J, Glovinsky PB. Insomnia. Neurol Clin. 1996;14:513–43.

    Article  CAS  PubMed  Google Scholar 

  • Trauer JM, Quian MY, Doyle JS, Rajaratnam SM, Cunnington D. Cognitive behavioural therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(3):191–204.

    Article  PubMed  Google Scholar 

  • Waterhouse J, Fukudu Y, Morita T. Daily rhythms of the sleep-wake cycle. J Physiol Anthropol. 2012;31(1):5.

    Article  PubMed  PubMed Central  Google Scholar 

  • Weldemichael DA, Grossberg GT. Circadian rhythm disturbances in patients with Alzheimer’s disease: a review. Int J Alzheimers Dis. 2010;2010:716453.

    PubMed  PubMed Central  Google Scholar 

  • Wilson KG, Chochinov HM, Skirko MG, et al. Depression and anxiety disorders in palliative cancer care. J Pain Symptom Manag. 2007;33:118–29.

    Article  Google Scholar 

  • Woodward SC. Cognitive-behavioral therapy for insomnia in patients with cancer. Clin J Oncol Nurs. 2011;15(4):E42–52.

    Article  PubMed  Google Scholar 

  • Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, Berg EA, Chisholm GB, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care. 2017;7(3):274–80.

    PubMed  Google Scholar 

  • Zachariae R, Lyby MS, Ritterband LM, O’Toole MS. Efficacy of internet-delivered cognitive-behavioural therapy for insomnia: a systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev. 2016;30:1–10.

    Article  PubMed  Google Scholar 

  • Zepelin H, Siegel JM, Tobler I. Mammalian sleep. In: Kryger MH, Roth T, Dement WC, editors. Principles and practice of sleep medicine. 4th ed. Philadelphia: Elsevier/Saunders; 2005. p. 91–100.

    Chapter  Google Scholar 

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Authors and Affiliations

  1. Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

    Doris Howell

  2. Princess Margaret Cancer Center, University Health Network, Toronto, ON, Canada

    Doris Howell

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  1. Doris Howell
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Correspondence to Doris Howell .

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Editors and Affiliations

  1. School of Medicine,Palliative Care, HammondCare, The University of Sydney School of Medicine, Sydney, Australia

    Roderick Duncan MacLeod

  2. VUB-UGhent End-of-Life Care Research Group, Department of Family Medicine and Chronic Care and Department of Clinical Sciences, Vrije Universiteit Brussel (VUB), Brussels, Belgium

    Lieve Van den Block

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Howell, D. (2019). Sleep Difficulties. In: MacLeod, R., Van den Block, L. (eds) Textbook of Palliative Care. Springer, Cham. https://doi.org/10.1007/978-3-319-77740-5_20

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