Up All Night?

Insomnia is a serious sleep disorder experienced by 30 to 50 percent of people with cancer. It can involve difficulty falling or staying asleep, waking too early or not getting quality sleep. It can also cause distress or impaired functioning. But there are many ways to treat insomnia, and this is important because insomnia can negatively impact overall health and quality of life, especially for people who have cancer.

CAUSES > Situational factors that contribute to insomnia include cancer- and treatment-related symptoms, such as pain, nausea, hot flashes, diarrhea and incontinence. Poor sleep habits, daytime napping and negative thoughts about sleep can also contribute to and perpetuate insomnia. In addition, drugs that treat cancer or its side effects, such as steroids and anti-nausea agents, may cause insomnia. Anxiety about procedures and their side effects, as well as the side effects themselves, are also contributing factors.

SYMPTOMS AND CONSEQUENCES > Failure to get enough sleep or to obtain quality sleep can contribute to fatigue, daytime sleepiness, diminished concentration and memory, mood changes, depression, impaired immune function, pain and poorer quality of life. It can also affect performance at work, caring for dependents and social life. In severe cases, insomnia could even affect safety.

MANAGEMENT > The first step in treating insomnia is to identify and treat the underlying cause. This may involve drugs or other treatment strategies to control symptoms, such as pain or hot flashes, that might be disrupting sleep. It is also important to rule out other physical sleep disorders, such as obstructive sleep apnea, restless leg syndrome or periodic limb movement.

The most common treatment for insomnia involves the use of hypnotic drugs, but they generally should not be used for more than a few weeks. Possible limitations of some drugs include dependence and tolerance, as well as withdrawal or perhaps rebound insomnia when discontinued. Moreover, many hypnotics cause significant side effects, such as daytime drowsiness, light-headedness, headaches and memory impairment. Non-pharmacologic strategies include avoiding or minimizing intake of caffeine and alcohol, as well as regular physical activity during the day to help normalize sleep patterns.

The National Cancer Institute recommends patients use cognitive-behavioral therapy (CBT) before resorting to drug therapy. CBT helps patients change negative thoughts and quell anxiety about sleep and learn to change sleep habits that interfere with sleeping well.

Studies have shown that CBT is as effective as drug therapies and can improve sleep in up to 70 to 80 percent of cancer patients. CBT has also been shown to decrease fatigue, anxiety and depressive symptoms while increasing quality of life. There are many CBT methods, typically used in combination, to achieve these goals.

Behavioral strategies include stimulus control (which focuses on connecting the subconscious with getting ready for bed, and being in bed only with sleeping) and sleep restriction (which limits time spent in bed that does not involve sleeping to increase the likelihood of being sleepy at bedtime the next night). Relaxation therapy with guided imagery and breathing exercises also helps to relieve stress and tension before bedtime.

Sleep hygiene education can be used with other CBT strategies but is not effective alone. Sleep hygiene includes relaxing before bedtime (by taking a warm bath, for example), avoiding computer or television use in the bedroom, avoiding naps during the day, creating a dark and comfortable sleeping environment, and sleeping and waking at the same time each day.