Treating sleep problems may improve pain management in patients with cancer

Westchester, Ill. –A study in the April 15 issue of the Journal of Clinical Sleep Medicine suggests that sleep problems lead to increased pain and fatigue in cancer patients. The results indicate that interventions aimed at trouble sleeping would be expected to improve both pain and fatigue in this patient population.

Results show that more than half the sample reported having trouble sleeping, with 26 percent reporting moderate or severe trouble sleeping. Compared with patients who reported no trouble sleeping, patients with moderate to severe trouble sleeping reported significantly more fatigue, pain and depressed mood. Using structural equation modeling analysis to evaluate causal relations and directions of effect, the best-fitting model indicates that trouble sleeping led to increased ratings of pain.

According to the authors, the relationship between pain and sleep often has been assumed to be reciprocal. In the present study, however, a model of reciprocal causation could not be fit to the data, and models in which pain caused trouble sleeping did not fit as well as the model in which trouble sleeping caused pain.

“We believed we would find a bi-directional relationship between insomnia and pain, but instead found that trouble sleeping was more likely a cause, rather than a consequence, of pain in patients with cancer,” said lead author Edward J. Stepanski, chief operational officer at the Accelerated Community Oncology Research Network in Memphis, Tenn.

The study included demographic, clinical and patient-reported outcomes data from 11,445 cancer patients undergoing treatment at the West Clinic, a large community oncology practice in Memphis. Participants had an average age of 61.5 years, and 74 percent were female. Breast cancer was the most common form of cancer, and about 25 percent of study subjects had received chemotherapy in the last 30 days. Increases in depressed mood also led to increased ratings of pain.

Younger age and recent administration of chemotherapy were both associated with increased trouble sleeping. According to the authors, younger patients often receive more aggressive chemotherapy than older patients; therefore, younger patients may be exposed to more treatment-related toxicity.

Stepanski stated that several studies have shown that cognitive behavioral therapy (CBT) improves sleep in cancer patients who have insomnia. He believes that this type of intervention may decrease patients’ pain and fatigue by improving their sleep.

More information is available from the AASM about sleep and breast cancer at http://www.sleepeducation.com/Article.aspx?id=1076 and about cognitive behavioral therapy at http://www.sleepeducation.com/Treatment.aspx?id=5.

The Journal of Clinical Sleep Medicine (JCSM) contains published papers related to the clinical practice of sleep medicine, including original manuscripts such as clinical trials, clinical reviews, clinical commentary and debate, medical economic/practice perspectives, case series and novel/interesting case reports. In addition, the JCSM publishes proceedings from conferences, workshops and symposia sponsored by the American Academy of Sleep Medicine or other organizations related to improving the practice of sleep medicine

For a copy of the study, “The Relation of Trouble Sleeping, Depressed Mood, Pain, and Fatigue in Patients with Cancer,” or to arrange an interview with an AASM spokesperson, please contact Kelly Wagner, AASM public relations coordinator, at (708) 492-0930, ext. 9331, or kwagner@aasmnet.org.

AASM is a professional membership organization dedicated to the advancement of sleep medicine and sleep-related research. As the national accrediting body for sleep disorders centers and laboratories for sleep related breathing disorders, the AASM promotes the highest standards of patient care. The organization serves its members and advances the field of sleep health care by setting the clinical standards for the field of sleep medicine, advocating for recognition, diagnosis and treatment of sleep disorders, educating professionals dedicated to providing optimal sleep health care and fostering the development and application of scientific knowledge.

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By : KASMIAH MUSTAPHA

2009/03/23

Most of us would have experienced an inability to sleep at some point in our lives. KASMIAH MUSTAPHA talks to an expert to find out the causes.

IT’S 3am and Adam has been tossing and turning throughout the night. He has been trying hard to go to sleep but can’t seem to do it. Even if he does fall asleep, he will be awake 10 minutes later.

Adam has been suffering from this sleeping disorder for months. Insomnia is the most common sleeping disorder; most of us would have faced this problem at some point of our lives.

Some people only suffer from it for a short term and will be back to normal in no time, while others require professional help.

Symptoms include difficulty in falling asleep, waking up often during the night and having trouble going back to sleep, waking up too early in the morning and feeling tired upon waking.
Research has found that insomnia is a persistent condition for many people. About 75 per cent of those with insomnia experience the condition for at least a year, and almost half experience it for three years.

Darul Ehsan Medical Centre consultant physician and cardiologist Col (R) Dr Abd Rahman Mohd Ali said when insomnia leads to problems such as lethargy, fatigue, inability to concentrate and low quality of life, one has to seek treatment.

“For some people, worrying about their health, financial situation and work can result in them not being able to sleep for days, weeks or even months. Once they are deprived of sleep, they may face other problems.

“In Adam’s case, a family member had died of cancer. He began to worry that he too had cancer. Even a slight pain had him rushing to the doctor as he was convinced that he will die of cancer. The worry, stress and fear kept him awake.”

Dr Abd Rahman said disturbed sleeping patterns can also lead to insomnia.

“If the time you go to sleep is constantly changed, the body will find it difficult to adjust after a while and you will start having sleepless nights.

“We need to maintain a regular bedtime. If you usually go to sleep at 11pm and wake up at 6am, you need to keep to it. You shouldn’t sleep late or wake up late because your biological clock has been set. If you sleep late, you tend to oversleep, and this pattern can go on for days.”

A recent study in the United States found that almost a third of all Americans suffer from insomnia because they are worried about the economy, their jobs or finances.

The study also found that those whose sleep is affected are less likely to work efficiently, exercise and eat healthily.

In the study, 27 per cent of those surveyed said they had disturbed sleep in the past month due to money issues — including personal finances (16 per cent), the economy (15 per cent) or losing their jobs (10 per cent).

The study also revealed that insomnia is more common among females, especially menopausal women, due to hormonal changes.

People with a medical condition will also face difficulty in sleeping. Those who are suffering from asthma, diabetes, prostate problems, arthritis, depression and anxiety are prone to insomnia.

Dr Abd Rahman said if a person is sleep deprived, it will affect his concentration and work which, in turn, will have consequences on his social and economic life. Lack of sleep will also increase certain conditions such as hypertension, diabetes, stress, heart disease, headache and depression.

The treatment for insomnia usually begins with changing one’s lifestyle and behaviour. In many cases, doctors would not prescribe medication for treating it as it can lead to addiction, said Dr Abd Rahman.

“People who suffer from insomnia must maintain good hygiene and good sleeping habits including maintaining a conducive environment in their bedroom.

“Make sure your bedroom is purely for sleeping. For some people, their bedrooms also double up as their office with laptops, TV sets and such.”

There are also those who are not opposed to eating in bed. They make the bedrooms not conducive to a good night’s sleep.

Another no-no is taking long naps during the day.

“If you feel sleepy, take a short nap between 10 and 15 minutes after lunch. Do light exercises at least four hours before you go to bed and try not to have a heavy meal close to your bedtime.”

Caffeine, nicotine and alcohol should be avoided late in the day. Caffeine and nicotine are stimulants which will keep us from falling asleep while alcohol can cause waking in the night and interferes with sleep quality.

If you are not sleepy, have a warm bath or drink that will help you relax or read a book that you know will help you fall asleep.

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As we age, we take longer to fall asleep, spend less time in deep sleep and wake more frequently during the night – but that’s not all. If our rest is interrupted, we take longer to fall back to sleep.

These sleep changes, which are comparable to age-related changes in physical and mental skills, probably reflect the natural aging of the brain’s sleep system.

Other factors can magnify the problem, including common stressors among the aged. Loneliness, bereavement, worries about finances, health and death can all contribute to sleeplessness.

So what can you do? Anyone can take a few simple steps to improve what experts call “sleep hygiene.”

1. Avoid sleeping pills. New research indicates that non-drug approaches are clearly more effective than sleeping pills for chronic insomnia. Over-the-counter medications can have serious side effects, create a physical or psychological dependency and stop working over time.

2. Cut out alcohol, nicotine and caffeine. Alcohol may help you get to sleep initially, but will disturb sleep and affect the overall quality of your sleep. Both nicotine and caffeine hamper sleep by interfering with the brain chemical that promotes sleep, so you don’t get the deeper stages of sleep that promote physical and mental functioning. If you can’t give them up, limiting the use of these substances after noon to minimize their effects.

3. Maintain a consistent wake-up time. Forcing yourself into bed at a certain hour can actually make it harder to sleep; you may become anxious if you don’t fall asleep quickly. It’s recommended going to bed when you’re drowsy, and getting up around the same time each morning. Over time, this will better regulate your sleep rhythm.

4. Use your bed appropriately. By watching TV or reading in bed, many seniors are actually training their brains not to sleep. You’re sending a behavioral cue to your brain by doing this, so when you actually go to bed for the night, your body’s no longer sure if it’s bedtime or activity time.

5. If you can’t fall asleep after 30 minutes, go into another room and read or watch a fairly boring TV show until you feel drowsy. This will promote sleep better than worrying in bed.

6. Avoid long naps that can detract from nighttime sleep. A 10 to 20 minute nap between 2 p.m. and 4 p.m. is fine. This is when the body’s circadian rhythm, our 24-hour cycle, experiences a natural dip.

7. Work out. Insomniacs tend to lead more sedentary lives than good sleepers. Exercising three to six hours before bedtime is the optimum. It produces a significant rise in body temperature, followed by a compensatory drop that induces sleep. A hot bath two hours before bed is a great substitute on days when you can’t exercise.

8. Keep your room cool. Insomnia is related to your body’s ability to drop in temperature either at bedtime or during the night. Open a window or adjust your thermostat to avoid warm temperatures that can impede sleep.

9. Get outside. Sunlight is a natural sleep regulator. A brightly lit room has only 500 luxes of light (a lux supplies roughly the same amount of light as one burning candle), but a midsummer noon has 100,000. Spending your day indoors is like keeping your brain in the dark all day. If you have trouble falling asleep, catch some rays early in the day. If you have trouble staying asleep in the early morning hours, make sure you get sunlight in the late afternoon.
         

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