Sleep

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 – eg, managing with medications, driving, etc
  • Interpersonal – others who are affected eg, caregiver.
• Provide appropriate support – eg, 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 (eg, 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 distrupt sleep patterns.
• Multicomponent approaches are more effective than single therapy.