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Sleep

Definition

Sleep disorders have been recognized for centuries as a frequent complication of medical illness. Human sleep is a complex and dynamic physiological function. It is an active condition affected by waking physiological and psychological states which, in turn, has significant effects on those waking conditions.

Presenting symptoms

Recognized symptoms of sleep disturbance include (Roscoe et al. [241]):

insomnia, a subjective complaint by the patient of poor sleep, insufficient sleep, difficulty initiating or maintaining sleep, interrupted sleep, poor quality or non‐restorative sleep, or sleep that occurs at the wrong time of the day‐night cycle
sleep deprivation resulting in a broad spectrum of physiological and psychological changes, including progressive fatigue, sleepiness, poor concentration, depression and irritability
excessive daytime sleepiness
disorders of the sleep‐wake schedule, having lengthy daytime naps, difficulty falling asleep.

Related theory

As relaxation focuses on enabling the patient to relax, it improves their quality of life, reduces stress and anxiety, and thus improves mood. Relaxation also aims to reduce the impact of fatigue and improve sleep and the global quality of life and physical functioning (Charalambous et al. [45], Greenlee et al. [118]).

Daytime fatigue and sleepiness may occur because of tumour effects (e.g. cytokines), chemotherapy, radiotherapy or surgery (Ancoli‐Israel et al. [7]). Cytokines are non‐antibody polypeptides secreted by inflammatory leukocytes and can be induced by cancer cells. They may play a role in the sleep disturbances of cancer patients due to cytokine‐based neuroimmunological mechanisms (Fiorentino and Ancoli‐Israel [104]).

There are strong correlations between fatigue and emotional distress (DH [187]), sleep disorder being amongst the causes. Sleep disturbances affect between 30 and 75% of newly diagnosed or recently treated cancer patients (Fiorentino and Ancoli‐Israel [104]). These vary from difficulties falling asleep to difficulty staying asleep with frequent awakenings. Anxiety over disease recurrence, persisting sleep disturbance and physical deconditioning after a prolonged illness have also been considered important in predicting fatigue (Courtier et al. [61]).

Stress management techniques and relaxation exercises (Box 27.11) may help the sleep pattern (Varvogli and Darviri [281]). Cognitive behavioural therapy has been shown to be an effective treatment with this patient population (Ritterband et al. [239]). CBT is a way of changing unhelpful ways of thinking that can result in anxiety and disturb the sleep pattern (The Royal College of Psychiatrists [267]).

Box 27.11

Breathing technique to assist in relaxation

Instructions:

Loosen any tight clothing. Position yourself comfortably, either lying or sitting, but ensuring that your back is supported.
Close your eyes if you wish.
Keep your shoulders and upper chest relaxed.
Place your hand flat on your stomach.
Inhale slowly (through your nose if possible).
As you breathe in, your stomach should gently swell underneath your hand (this should not be a forced movement using your abdominal muscles).
Remember to keep your shoulders and upper chest relaxed.
Exhale slowly through your mouth (your stomach will gently flatten beneath your hand).
Pause, then repeat steps 2–9.
During the exercise, think of a positive word or phrase such as ‘I am relaxed’ or ‘calm’.

Evidence‐based stress management techniques including progressive muscular relaxation, autogenic training, biofeedback, guided imagery, mindfulness and CBT may reduce sleep disturbance and daytime related fatigue (Vargas et al. [280]). These techniques need to be carried out by advanced expert clinicians. CBT, for example, is a treatment approach that encompasses assessment strategies, cognitive and behavioural treatment techniques. The clinician and patient work together to set goals and homework. By changing thought patterns, cognitive and behavioural changes can take place to enable the individual to substitute life‐enhancing thoughts and beliefs (Varvogli and Darviri, [281]).

Evidence‐based approaches

Rationale

Studies show that relaxation and guided imagery demonstrate a statistically significant reduction in anxiety (Leon‐Pizarro et al. [144]) and how instruction in progressive muscular relaxation may help in maintaining activities (Christman and Cain [49]). Patients also feel able to take control of their lives, setting goals and priorities by managing their anxiety levels (Cooper [53]).

As with fatigue management, the management of disturbed sleep requires a multiprofessional approach, including medical, nursing and allied healthcare professionals (e.g. occupational therapy and physiotherapy) to carry out holistic and accurate assessment and screening.

More complex coping strategies need to be tailored to the individual's needs so that they can develop a toolkit that can be used in their daily routine to manage this symptom. These needs can only be established following specific assessment and treatment programmes by skilled and experienced clinicians such as medical and nursing, occupational therapy and physiotherapy specialists in sleep management.

Multidimensional assessment should ideally include a clinical evaluation together with self‐report questionnaires and daily sleep diaries (Morin et al. [178]). One example of a sleep diary is shown in Figure 27.34 (National Sleep Foundation [189]).

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Figure 27.34 Sleep diary. Source: National Sleep Foundation ([189]). Reproduced with permission of the National Sleep Foundation.

This information will enable the clinician to analyse the patient's behavioural patterns and establish an appropriate treatment programme. The treatment programme should be reviewed with an outcome measure to enable the patient to gauge their progress (Barsevick et al. [12]).

Indications

Interventions and advice to help individuals with poor sleep are principally needed when sleep‐wake disturbances are a persistent problem linked to poor quality of life. Knowledge of the prevalence, severity and correlates of these disturbances provides useful information to healthcare providers during clinical evaluations for treatment of these disturbances in cancer survivors (Otte et al. [216]).

Contraindications

Although most people are aware of the common‐sense approach to sleep hygiene as shown in Procedure guideline 27.22, failure to adhere to these guidelines is extremely widespread. Engagement and compliance with this advice is a challenge with many sleep disorders.

The individual symptoms of, for example, insomnia are not a diagnosis in themselves. Single and multi‐symptom measurements in themselves are of limited usefulness in distinguishing fatigue, depression and insomnia (Donovan and Jacobsen [85]).

Relaxation and guided imagery techniques should not be used with patients known to have psychotic episodes as these techniques promote channelled thoughts and there is a risk of the patient experiencing hallucinations.

Principles of care

When addressing patients’ difficulties in sleeping, the following points should be considered (LCA [148]):

assessing for and treating physical symptoms (e.g. pain)
checking medication that affects sleep (e.g. steroids, chemotherapies, anticonvulsants and antihypertensives)
introducing principles of relaxation and anxiety management techniques
sleep hygiene including:
- limiting stimulants, caffeine or alcohol, removing the TV from the bedroom to avoid stimulation of flashing images and lights
- regulating room and body temperature
- a standard routine of sleep and rest
- regulating nutrition to avoid hunger or overeating before bedtime
the role of exercise.

Procedure guideline 27.22

Relaxation and anxiety management