Insomnia: Identification and management

Insomnia: Identification and Management Cathy D. Thomas

NABILITY to fall asleep and other sleep-related disturbances are often viewed as expected problems by nurses and patients alike. Traditionally, the treatment most often used to manage this problem among cancer patients has been use of pharmacologic sleep inducers. Research today, however, is demonstrating that many patients only respond to pharmacologic sleep inducers for a short period of time and often experience effects more harmful than beneficial from use of such agents. 1,2 As a result of the many problems associated with the use of sleeping pills, there is a growing trend to manage insomnia with nonpharmacologic interventions. Oncology nurses are involved in symptom/problem identification and management. These nurses play a vital role in the recognition, prevention, and management of problems with insomnia among individuals with cancer.

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CLASSIFICATIONS OF INSOMNIA

Insomnia among individuals with cancer is believed to be a common complaint that is manifested in several ways. In general, problems with insomnia fall into three categories: sleep latency, sleep interruptions, and early-morning awakenings. Patients may experience problems in one or a combination of these categories. 3 Disturbances in sleep can be attributed to a variety of causes and may be either transient or chronic in nature. Factors known to interfere with normal sleep patterns include anxiety, depression, medications, caffeine and alcohol intake, and environmental factors. In addition, a number of physiologic conditions commonly found in the cancer patient population interfere with normal sleep patterns such as nocturnal myoclonus, pain, and dyspnea. 4-7 Transient insomnia is often caused by medical conditions or pharmacologic agents, s'l° In medical conditions associated with pain, physical discomfort, and anxiety or depression, disturbed sleep is often a complaint, s-l° Pharmacologic agents such as amphetamines, steroids, central adrenergic blockers, bronchodilators, and commonly used caffeine-containing beverages may also result in sleep disturbances, il In addition, a condition known as rebound insomnia is often associated

with the withdrawal of benzodiazepines used to treat insomnia, which have a short or intermediate half-life. 11.12 Chronic insomnia, on the other hand, is often seen in aging patients, as well as in association with medical conditions. When neither aging nor medical conditions are the cause, psychologic problems are often considered the etiologic factor. 8"H This form of insomnia usually develops during high stress periods of a patient's life and more often in patients who have less than adequate coping mechanisms. 11.13 EFFECTS OF SLEEP DISTURBANCES/DEPRIVATION

Sleep disturbances can result in a variety of physiologic and psychologic conditions. They appear to be related to mood changes, in addition to an increase in fatigability, irritability and aggressiveness. 14 Individuals deprived of sleep also report that it requires greater effort to perform tasks. 15 Neurologic changes can also occur and may be manifested as mild nystagmus, hand tremors, ptosis of the eyelids, poor coordination, alterations in word pronunciation, and a decreased tolerance for pain. ~5.16 Patients' activities of daily living and quality of life are frequently affected by these alterations. INCIDENCE

Among all forms of sleep disorders, insomnia is the most frequently encountered. 13 According to several national and regional surveys, the prevalence o f insomnia is e s t i m a t e d at 30% to 35%. 11"17"19 Persons with medical and psychologic illnesses are affected more frequently than the general population and, on a demographic basis, women and the elderly are more likely to be affected than other groups. 7,17,18 The incidence and extent of the problem among individuals with cancer has not yet been clearly defined. The statistics reoresent studies dealing From the Jefferson Oncology Clhfic, Metairie. LA. Address reprint reque.~ts to Cathy D. Thonlas, RN, MN. OCN, 13600 Colgate Way #636, Sih'er Springs, MD 20904. © 1987 by Grune & Stratton, Inc. 0749-2081/8710304-0004505.00/0

Seminars in Oncology Nursing, Vol 3, No 4 (November), 1987: pp 263-266

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with the general population and are not specific to cancer patients. The lack of studies specific to oncology patients could be, in part, due to the fact that insomnia is more subjective and less acute when compared to other symptoms associated with cancer and cancer therapies. In the past, research has focused on the more acute symptoms rather than those less acute. A recent publication, Guidelines for Cancer Nurshlg Practice, recognized insomnia as a potential problem among cancer patients by including a section on "Sleep Pattern Disturbance. ''2° These guidelines identify nursing management, including assessment, actions, and patient teaching, as well as expected outcomes. The population at risk are patients at time of diagnosis; those receiving chemotherapy, radiation therapy, and/or immunotherapy; patients experiencing insult secondary to tumor growth; and those experiencing end-stage symptomatology.2° INSOMNIA AMONG INDIVIDUALS WITH CANCER

Literature addressing insomnia among cancer patients is scarce. Two studies, however, specifically address this disturbance among groups of oncology patients. Beszterczey and Lipowski 21 studied the sleep habits of 47 radiotherapy patients and reported that 45% of the patients averaged less than 50 hours of sleep per week and 23% averaged less than 40 hours of sleep per week. This study also demonstrated that sleep is more disturbed in patients with cancer as compared with the general population. 2~ Sleep patterns of patients with malignant diseases, in comparison to those with nonmalignant diseases, was addressed by Lamb. 2z This study revealed that hospitalized oncology patients experienced significantly higher levels of anxiety and depression than those patients admitted with nonmalignant illnesses. However, there was no significant difference between sleep patterns of the two populations. Cancer patients may be prone to sleep disturbances as a result of several factors. First, the diagnosis of a malignant disease is known to cause stress and varying degrees of anxiety and depression. 23-z5 Research has demonstrated that anxiety and depression can have an adverse effect on one's sleep. As anxiety and depression increase, so does the lack of sleep, and vice versa, as sleep decreases, anxiety and depression increase.26ln ad-

CATHY D. THOMAS

dition, hospitalization also contributes to anxiety and sleep disturbances. 27 During routine assessments in an oncology clinic, this author noted frequent and recurring complaints of sleeping difficulties by cancer patients. Consequently, these patient concerns led to a oneyear study to determine the extent of insomnia among patients with cancer. 28 A survey of 300 outpatients revealed that 95% experienced transient or persistent insomnia. Some of the most frequently identified problems are listed in Table 1. In addition, the majority of the patients reported using pharmacologic sleep inducers on a regular basis. Although the study did not identify the sleep inducers used, Solomon et al I reported that the character of sleep inducers for the general population claanged significantly in the 1970s. In 1971, of the 41.7 million prescriptions written, 47% were for barbiturates. By 1977 the number of prescriptions for hypnotics had declined to 39%; only 17% were for barbiturates, and the majority were for flurazepam (Dalamane), which is less harmful but not, however, an innocuous drug. NURSING ASSESSMENT TOOLS

Assessment is critical to the identification and management of patient problems. Assessment tools that are specific to a particular problem have the capability of assisting the nurse in obtaining appropriate information specific to the identified problem. A few tools addressing sleep disturbances have been developed for nurses. 5,29,3° Brun 5 describes an insomnia history that consists of 25 questions with a major focus on the description of bed and bedroom. A patient-admin-

Table 1. Problems Frequently Identified Decrease in physical activity Profound daytime fatigue Increase in amount of time napping Increase in amount of time spent in bed Preference for sedentary activities Difficulty going to sleep associated with fear of pain upon awakening Lack of knowledge regarding foods/beverages containing caffeine and the importance of decreasing intake after 6 PM High percentage of sleep onset latency and frequent awakenings Inadequate knowledge of nonpharmacologic techniques Frequent and regular use of pharmacologic sleep inducers

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INSOMNIA: IDENTIFICATION AND MANAGEMENT

istered sleep questionnaire is described by McNeil et a129 in which questions specifically address identification of the problem, causes and remedies, and daytime/bedtime behaviors. Kramer et al 3° developed an insomnia history to elicit answers significant to sleep problems in each of eight categories: (1) previous sleep patterns and onset of insomnia, (2) daytime symptoms, (3) past or present treatment, (4) bedtime habits, (5) nature of the disturbance, (6) severity of the problem, (7) bedroom conditions, and (8) personality profile. Based on the findings of the study at the outpatient oncology clinic, 28 this author designed an assessment tool to be administered by the nurse. A nurse-administered questionnaire has the advantage of encouraging patients to expand on thoughts; at the same time it can enhance the nurse-patient relationship. In addition, a questionnaire administered by the nurse allows the patient and/or nurse to ask for clarification, and is useful with all patients, regardless of literacy. This assessment tool consists of ten categories, which are listed in Table 2. The time involved in completion of the assessment varies from eight to 13 minutes. Identification of the type of problem, causes, and intervention(s) needed are the desired outcome of this tool. MANAGEMENT OF INSOMNIA: NONPHARMACOLOGIC AND PHARMACOLOGIC

Management of insomnia varies with respect to the type and cause, the patient's perception of the problem, and the patient's willingness to participate in treatment. Strategies for management of insomnia are often classified as nonpharmacologic and pharmacologic. Nonpharmacologic techniques often provide equal effectiveness as pharmacologic interventions in the management of insomnia but with less poTable 2. 10 Categories of the Sleep Assessment Tool Pre-illness sleep habits Patterns of insomnia Present pre-sleep routine Present daily activities Environmental considerations (noise/light/temperature) Physiologic associations (pain/dyspnea/etc) Medications (including sleeping pills) Caffeine/alcohol intake Emotional considerations Patient's perception of the problem

tential complications. Page2° addressed the importance of patient teaching and nursing actions to minimize pharmacologic intervention for the management of sleep disturbances. Kaempfer31 developed a nursing protocol for the management of sleep problems in cancer patients. The nonpharmacologic techniques used for the management of insomnia are listed in Table 3. Though employed in outpatients, these interventions are applicable in the hospital setting as well. For a variety of reasons, nurses in the hospital setting often contribute to sleep disturbances among patients. Procedures, noises, vital signs, and early morning weights can frequently be altered or minimized so that sleep disturbances are kept to a minimum. Although not promoted as the first choice, hypnotic/sedative sleep inducers have a role in the management of sleep disturbances in some cases. Pharmacologic therapy should be tried following a thorough assessment and after pertinent nonpharmacologic strategies have failed. When sleeping pills are indicated, it is important to select the drug that offers the patient the most benefit with the fewest possible side effects. It is important to understand the onsets, peaks, and half-lives of sleep inducers so that the most appropriate agent can be selected. Kaempfer31 provides an excellent review of medications used to promote sleep. CONCLUSION

It is believed that cancer patients are at a significant risk for the development of some form of sleep disturbance during their illness.

Table 3. Nonpharmacologic Techniques in the Management of Insomnia Relaxation techniques (relaxation tapes, warm baths, back rubs) Daily routine of activities Decrease sedentary activities; increase activity and exercise Avoid caffeine containing foods and beverages in the late afternoon Avoid alcoholic beverages in the late afternoon Take diuretics before 6 PM, if possible Avoid strenuous exercises prior to bedtime Minimum disruption of established sleep routine Comfortable position for sleep Control environmental factors interfering with sleep (noise, temperature, light) Utilize bed for sleeping only, not resting

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CATHY D. THOMAS

Traditionally, sleeping pills have been the solution for the management of sleep disturbances. However, research has shown that pharmacologic sleep inducers are not needed in many cases and may result in more harm than benefitY 32 Prevention and management of symptoms are important issues in the care of cancer patients. In addition, there is a growing trend to manage problems, such as insomnia, by using nonpharmacologic interventions that involve patient participation. Utilizing a comprehensive approach, nurses

can prevent and/or minimize symptoms associated with cancer and cancer therapies. Further research addressing problems of insomnia in cancer patients is needed in order to validate the few existing studies. Research addressing percentages of sedative/hypnotic sleep inducers used on inpatient oncology units, as well as the rationale for their use instead of nonpharmacologic methods, might also reveal information needed to stimulate changes in bedtime routines in the hospital setting.

REFERENCES

1. Solomon F, White C, Parron D, et al: Sleeping pills, insomnia and medical practice. N Engl J Med 300:803-808, 1979 2. Turner R, Ascher L: Controlled comparison of progressive relaxation, stimulus control, and paradoxical intention therapies for insomnia. J Consult Clin Psychol 47:500-508, 1979 3. Gottfries LG: Pharmacological.treatment of sleep disorders, in Priest R, Pletscher A, Ward J (eds): Sleep Research. Proceedings at the Northem European Symposium on Sleep Research. Baltimore, University Park, 1979 4. Fass G: Sleep, drugs, and dreams. Am J Nurs 71:23162320, 1971 5. Bran S: Insomnia: The common sense approach. Occup Health Nurs 29:36-39, 1981 6. Williams R, Jackson D: Problems with sleep. Heart Lung 11:262-267, 1982 7. Roth T, Zorick F: Taking a rational approach to an everyday problem. Consultant 10:203-213, 1981 8. Kales A, Kales JD, Bixler E: Insomnia: An approach to management and treatment. Psychiatr Ann 4:28-44, 1974 9. Kales A, Soldatos CR, Kales JD: Sleep disorders: Evaluation and management in the office setting, in Arieti S, Brodie H (eds): American Handbook of Psychiatry. New York, Basic, 1981, pp 423-454 10. Soldatos CR, Kales A, Kales JD: Management of insomnia. Annu Rev/,,led 30:301-312, 1979 11. Kales A, Kales JD, Soldatos CR: Insomnia and other sleep disorders. Med Clin North Am 66:971-988, 1982 12. Kales A, Scharf MB, Kales JD, et ah Rebound insomnia: A potential hazard following withdrawal of certain benzodiazepines. JAMA 241:1692-1695, 1979 13. Haeley E, Kales A, Monroe L, et ah Onset of insomnia: Role of life stress events. Psychosom Meal 43:439-451, I981 14. Gerner RH, Post RM, Gillin JC, ctaI: Biological and behavioral effects on one night's sleep deprivation in depressed patients and normals. J Psychol Res 15:21-40, 1979 15. Chuman M: The neurological basis of sleep. Heart Lung 12:177-181, 1983 16. Ross J: Neurological findings after prolonged sleep deprivation. Arch Neurol 12:399-403, 1965 17. Bixler E, Kales A, Saldatos CR, et ah Prevalence of

sleep disorders in the Los Angeles metropolitan area. Am J Psychol 136:1257-1262, 1979 18. Baiter M, Bauer M: Patterns of prescribing and use of hypnotic drugs in the United States, in Clift A (ed): Sleep Disturbances and Hypnotic Drug Dependence. New York, Excerpta Medica, 1975, pp 261-293 19. Karacan I, Thornby J, Anch M, et al: Prevalence of sleep disturbance in a primarily urban Florida county. Soc Sci Med 10:239-244, 1976 20. Page M: Sleep pattern disturbance, in McNally J, Stair J, Somerville E (eds): Guidelines for Cancer Nursing Practice. Orlando, FL, Grune & Stratton, 1985, pp 89-95 21. Beszterczey A, Lipowski Z: Insomnia in cancer patients. Canad Med Assoc J 116:355, 1977 22. Lamb M: The sleeping patterns of patients with malignant and non-malignant diseases. Cancer Nurs 5:389-396, 1982 23. Huges R: Anxiety in the woman with genital cancer. South Med J 59:1055-1057, 1966 24. Buehler J: What contributes to hope in the cancer patient. Am J Nurs 75:1353-1356, 1975 25. Batelli T: Anxiety therapy in the neoplastic patient. Curr Med Res Opin 4:185-187, 1976 26. Warnock J: A controlled study of trancopal in the treatment of sleep disturbances due to anxiety. J Int Med Res 6:115-120, 1974 27. Lucente F: A study of hospitalization anxiety in 408 medical and surgical patients. Psychosom Med 34:304-312, 1972 28. Thomas CD: Insomnia among individuals with cancer. Proceedings of the Oncology Nursing Society 13:63, 1986 (abstr) 29. McNeil B, Padrick K, Wellman J: I didn't sleep a wink. Am J Nurs 86:26-27, 1986 30. Kramer M, Kupfer D, Pollak C: When the patterns of sleep go askew. Patient Care 14:t22-176, 1980 31. Kaempfer SH: Comfort: Sleep, in Johnson BL, Gross J (eds): Handbook of Oncology Nursing. New York, Wiley, 1985, pp 167-184 32. Pawlicki R, Heitkemper MA: Behavioral management of insomnia. J Psychosoc Nurs 23:15-17, 1985