Insomnia in Cancer Patients

• Introduction to insomnia
• Normal sleep
• Causes of insomnia
• Treatment of insomnia
• Treatment of sleep apnoea

Introduction to insomnia

Insomnia is a common problem in our society today, with up to half of the population experiencing some difficulties sleeping in any given year, and 25% of the population having problems getting enough sleep. Insomnia is important because it may be a symptom of some important problems such as depression, anxiety, drug abuse and obstructive sleep apnoea.
Insomnia is also a significant problem for cancer patients. Most people with cancer have trouble sleeping at some time during their illness. This may be because of general anxiety, worry about treatment or fears about the future. Insomnia is the most common disturbance but other associated problems are fatigue, narcolepsy and excessive sleepiness. This article will focus mainly on insomnia and obstructive sleep apnoea.

Normal sleep

The average adult requires 7-8 hours of sleep each day although normal sleep requirements vary greatly between individuals. In a fit young individual the ideal is 7.5-8 hours, but some people require more sleep and some will require less, depending on factors such as age, and amount of physical activity in a day – this is quite normal.

Causes of insomnia

There can be many causes of insomnia at night. More common reasons for lack of good sleep at night in people with cancer include sleeping or excessive napping during the day. Sleeping in a strange bed (such as during a visit to hospital), or in a noisy sleep environment can also reduce chances of getting good quality sleep. Insomnia is commonly associated with depression and anxiety. Most episodes of insomnia start with a stressful or emotional event, and not sleeping well then becomes a habit.
For people with advanced disease the fear of dying during the night can be very real. It is important to talk to family, friends or health professionals about any distressing emotional thoughts you may be having.
Many medical conditions can cause long-term insomnia. These include angina and other heart diseases, diseases of the liver or urinary system, chronic airway limitation, asthma or bronchitis, hyperthyroidism, gastric reflux or peptic ulceration disease. Physical symptoms are often the cause of wakeful nights, for example pain, breathlessness or frequent urination.
Many drugs can cause insomnia, such as caffeine or steroids. Some prescription medications can cause daytime sleepiness which then makes night sleep more difficult. If you suspect that any prescription medication you are taking are the cause of your insomnia, discuss the problem with your doctor. Do not stop taking them without your doctor’s advice.

Treatment of insomnia

Insomnia is generally defined as the inability to function well with the amount/quality of sleep experienced. It may consist of trouble getting to sleep, difficulty staying asleep, or waking too early. It is important that possible contributing factors – such as stress, traumatic events, drug use, illness and pain are excluded. It may be helpful for patients to keep a ‘sleep-diary’ to see how much sleep they are getting and when.
Underlying causes should be treated, such as depression and other mood disorders, excessive intake of coffee, alcohol or drugs, and it is important to exclude medical conditions such as thyroid disease and urinary infections which can be treated.
Patients are advised to keep good sleep ‘hygiene’. This may include:

• Avoiding day time naps
• Go to bed when tired
• Regular daytime exercise
• Waking at the same time each day
• Avoiding exercise close to bed time
• Avoiding coffee, tea and alcohol close to bed time
• Have a quiet and comfortable sleeping environment
• Having a drink of warm milk or listening to some soothing music before going to bed

In addition, techniques such as relaxation therapy, massage, meditation and stress management may be of help. In some cases, counselling may be useful in addressing underlying issues contributing to insomnia. Your body will still get some benefit from lying quietly in bed, resting, even if you are not actually asleep. Although you may feel as if you have been awake all night, you may well have managed to have several hours of good quality sleep. Medications to help people sleep may be helpful for short periods of time. They are not recommended for long term use as they are not addressing the underlying problem. In addition, patients may get rebound insomnia if taken for a significant length of time.

Treatment of sleep apnoea

Sleep apnoea refers to the brief interruptions of breathing lasting between 15-90 seconds that some patients experience during sleep. Typically the patient will wake up by themselves, breath normally, fall asleep again and repeat this cycle throughout the night. This results in poor quality sleep. In brief, sleep apnoea may be classified as obstructive (most common) – involving blockage of the upper airway, or central (less common) – due to nervous system or brain disease.
Treament:

• Patients will usually be referred to a ‘sleep clinic’ to assess their sleeping and breathing patterns
• In obstructive sleep apnoea (OSA), patients are often recommended to lose weight as this can significantly reduce symptoms
• Practising good sleep hygiene
• Avoid sedative medications
• Quit smoking
• Patients may be helped by use of a ‘CPAP’ (continuous positive airway pressure) machine, which helps to keep the upper airways open
• In severe cases of OSA, surgery may be recommended.

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