Sleep

Improving sleep problems

Being tired and unable to sleep can make physical symptoms and difficult emotions harder to manage. Sleep problems can include difficulty in falling asleep or returning to sleep or frequent sleep disruptions.

Key points

• It is estimated that one-third to one-half of people with cancer or end-stage disease experience sleep disturbance and that this impacts on their quality of life and coping ability.
• Sleep disturbance should be assessed in relation to previous sleep problems - chronic insomnia is common in the general population.
• Physical symptoms, pain, hospitalisation, drugs and cancer treatments, and the psychological impact of a disease may all affect sleep.
• Sedative hypnotic medications have a significant potential for harm in the medium to long term (tolerance, withdrawal, increased risk of falls, drug interactions and delirium) and their ongoing use should be minimised. Non-pharmacological approaches must be considered. 
  
  

Assessment

• Review sleep hygiene - where and when the patient sleeps, the physical environment, and cues for sleeping.
• Identify and manage all potentially reversible causes of sleep disturbance as clinically appropriate:
  • Uncontrolled pain or other symptoms
  • Steroids
  • Depression leading to sleep fragmentation - ask about rumination, early morning wakening
  • Bladder or bowel discomfort
  • Anxiety / fears
  • obstructive sleep apnoea, restless legs, cramps.
• Sleep - wake cycle disturbances can be early symptoms of delirium, and of hepatic encephalopathy, and 'sundowning' is common in patients with dementia.
• Identify the impacts of sleep disturbance
  • Functional
  • Psychosocial
  • Safety - e.g. managing with medications, driving, etc
  • Interpersonal – others who are affected e.g. caregiver.
• Provide appropriate support - e.g. home nursing for medication management, respite and support for caregiver.
  
  

Approach to management

• Helpful strategies for managing tiredness include energy conservation, optimisation of physical activity around the most valued priorities, psychosocial interventions, and management of comorbidities (e.g. pain, insomnia, depression).
• Non-pharmacological approaches include relaxation, education about sleep hygiene, cognitive restructuring to reduce anxiety about sleep problems, and attention to any environmental factors that disrupt sleep patterns.
• Multicomponent approaches are more effective than single therapy.