"Nurse, I Can't Sleep!"

Approaches to Management of Insomnia in Oncology Patients

Nina Margaret Dambrosio, BSN, RN, OCN; Polly Mazanec, PhD, ACNP, AOCN, FPCN

Disclosures

Journal of Hospice and Palliative Nursing. 2013;15(5):267-275. 

In This Article

Treatment Modalities

Insomnia in oncology patients has multiple etiologies, often disease-related, but sometimes it is a symptom that the patient has struggled with prior to the cancer diagnosis. As a result, insomnia management requires multimodal treatment, including nonpharmacological and pharmacological components.[15]

In 2006, the American Academy of Sleep Medicine Task Force conducted a review of literature published since 1999 and graded the evidence regarding the available nonpharmacological insomnia treatments.[25] The task force concluded that chronic primary and secondary insomnia can be effectively treated with psychological and behavioral interventions. Chronic primary insomnia had the best treatment responses from stimulus control therapy, relaxation training, or cognitive behavior therapy. Each modality is individually effective. For secondary insomnia, sleep restriction therapy, multicomponent therapy (not including cognitive therapy), biofeedback, and paradoxical intention have effective evidence-based results when used individually. Sleep hygiene education, imagery training, and cognitive therapy had insufficient evidence-based support to recommend as single or complementary therapies.[25]

The National Institutes of Health holds conferences to produce consensus statements on valid and controversial topics in medicine, such as the recommendations for treatment of insomnia. The National Institutes of Health Consensus and the American Academy of Sleep Medicine Practice Parameters recommend Cognitive Behavioral Therapy for Insomnia (CBTi) to be standard treatment based on the high level of empirical support.[26] In the oncology population, it has been classified as "likely to be effective" by the ONS's Putting Evidence Into Practice. Cognitive-behavioral therapy, pioneered in the 1980s, is proven effective in treating insomnia, depression, generalized anxiety, obsessive-compulsive, and eating disorders. Cognitive therapy targets negative perceptions from prior experiences. Behavioral therapy uses positive and negative reinforcement to modify behaviors in the present. The goal of CBTi is to lessen high-risk behaviors and patterns below the insomnia threshold and incidentally unlearn the hyperarousal response. The most frequently used CBTi therapies utilized in oncology clinics include stimulus control therapy, sleep restriction therapy, relaxation therapies, paradoxical intention, and sleep hygiene education.[27] Additional evidence from meta-analyses and systematic reviews is required to classify CBTi as "recommended for practice" by ONS's Putting Evidence Into Practice.

In a randomized controlled trial by Espie et al,[14] CBTi was tested against treatment as usual in 150 patients recently treated for breast, prostate, colorectal, or gynecologic malignancies. Sleep was measured objectively (actigraphy, Pittsburgh Sleep Quality Index) and subjectively (self-report sleep diaries). Cognitive Behavioral Therapy for Insomnia was proven clinically effective with improvement in subjective report of time taken to fall asleep and nocturnal wake time. Actigraphy measurement showed a less significant, modest effect. The CBTi group reported less fatigue, anxiety, and depression, with increased physical and functional quality of life when compared with the treatment-as-usual group.[14]

A randomized controlled trial by Morin et al[28] showed when treating noncancer patients with persistent insomnia adding zolpidem during the first 6 weeks of CBTi resulted in increased sleep time. Discontinuing the medication after the acute period of treatment, however, produced the best long-term results.[28] Additional randomized controlled trials have repeated consistent results. Cognitive Behavioral Therapy for Insomnia has similar efficacy with more sustainability when compared with sleep medicines.[26]

In addition to CBTi, the other components of nonpharmacological treatment for insomnia include complementary therapies and environmental strategies. Recently, Sleep Medicine Reviews conducted a systematic review of randomized controlled trials to determine the effectiveness of complementary and alternative medicine in insomnia. Many of the studies regarding homoeopathy, massage, and aromatherapy did not meet inclusion criteria because of small sample size or lack of control. Acupressure, tai chi, and yoga had evidence-based results in treating insomnia, whereas acupuncture and L-tryptophan showed mixed results. Herbal medicines, specifically valerian, did not significantly treat insomnia.[29]

Environmental strategies focus on noise reduction, light reduction, and scheduling uninterrupted sleep time.[20] These factors are especially difficult to adjust in inpatient settings. In a study of 69 stem cell transplant recipients hospitalized in 2011, 87% of women and 67% of men reported insomnia, attributing the sleep disturbance to frequent toileting and staff interruptions for care.[7] Nurses can recommend changes to the hospital environment that may minimize sleep disturbances (Table 2).

When nonpharmacological treatment methods are not effective alone, practitioners must consider using them in conjunction with pharmacological treatment. Table 3 summarizes Food and Drug Administration (FDA)–approved medications for the treatment of insomnia, common dosages, duration of action, and nursing considerations for practice.[2] The benefit of these medications must be balanced against the risk of interaction among other medications (prescribed, over-the-counter, herbal supplements). Practitioners must educate patients that, despite the growing support for herbals and natural supplements, there is no guarantee of quality control without FDA regulation. Special consideration must be given to both short- and long-acting sleep aids. Short-acting medications pose the risk of patients waking during the night, whereas medications with longer half-lives may contribute to daytime sleepiness and affect daily activities.[4] The benefit versus risk must also be considered when safely administering sleep aids to elderly patients.

Patients and families frequently ask nurses about the effectiveness of melatonin. Melatonin is a hormone produced in the pineal gland, secreted through the bloodstream in the dark or often at nighttime to regulate the sleep cycle.[30] The FDA approved ramelteon, a melatonin receptor agonist, as a treatment option for insomnia. Liu and Wang's[31] 2012 systematic review with meta-analysis evaluated the efficacy and safety of this drug. Subjective and PMG sleep latency, total sleep time, and latency to REM were significantly improved with ramelteon. Subjective sleep latency, however, was reduced only in the 18- to 64-year-old subgroup. Although the response looks promising, well-designed, double-blind, randomized controlled trials are needed to investigate higher doses in geriatric patients, comparison to sedatives, and adverse effects[31] (Table 3).

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