Cancer patients are at great risk for developing insomnia and disorders of the sleep-wake cycle. Insomnia is the most common sleep disturbance in this population and is most often secondary to physical and/or psychological factors related to cancer and/or cancer treatment.[1] Anxiety and depression, common psychological responses to the diagnosis of cancer, cancer treatment, and hospitalization, are highly correlated with insomnia.[2-6]

Sleep disturbances may be exacerbated by paraneoplastic syndromes associated with steroid production and by symptoms associated with tumor invasion, such as draining lesions, gastrointestinal (GI) and genitourinary (GU) alterations, pain, fever, cough, dyspnea, pruritus, and fatigue. Medications—including vitamins, corticosteroids, neuroleptics for nausea and vomiting, and sympathomimetics for the treatment of dyspnea—as well as other treatment factors can negatively impact sleep patterns.

Side effects of treatment that may affect the sleep-wake cycle include the following:[7]

• Pain.
• Anxiety.
• Night sweats/hot flashes (refer to the PDQ summary on Fever, Sweats, and Hot Flashes for more information).
• GI disturbances (e.g., incontinence, diarrhea, constipation, or nausea).
• GU disturbances (e.g., incontinence, retention, or GU irritation).
• Respiratory disturbances.

Medications commonly used in the treatment of cancer can cause insomnia. Sustained use of central nervous system (CNS) stimulants (e.g., amphetamines, caffeine, and diet pills, including some dietary supplements that promote weight loss and appetite suppression), sedatives and hypnotics (e.g., glutethimide, benzodiazepines, pentobarbital, chloral hydrate, secobarbital sodium, and amobarbital sodium), cancer chemotherapeutic agents (especially antimetabolites), anticonvulsants (e.g., phenytoin), adrenocorticotropin, oral contraceptives, monoamine oxidase inhibitors, methyldopa, propranolol, atenolol, alcohol, and thyroid preparations can cause insomnia. In addition, withdrawal from CNS depressants (e.g., barbiturates, opioids, glutethimide, chloral hydrate, methaqualone, ethchlorvynol, alcohol, and over-the-counter and prescription antihistamine sedatives), benzodiazepines, major tranquilizers, tricyclic and monamine oxidase inhibitor antidepressants, and illicit drugs (e.g., marijuana, cocaine, phencyclidine, and opioids) may cause insomnia. The most commonly prescribed hypnotics can interfere with rapid eye movement (REM) sleep, resulting in increased irritability, apathy, and diminished mental alertness. Abrupt withdrawal of hypnotics and sedatives may lead to many symptoms, including nervousness, jitteriness, seizures, and REM rebound. REM rebound has been defined as a “marked increase in REM sleep with increased frequency and intensity of dreaming, including nightmares.”[8] The increased physiologic arousal that occurs during REM rebound may be dangerous for patients with peptic ulcers or a history of cardiovascular problems.

The sleep of hospitalized patients is likely to be frequently interrupted by treatment schedules, hospital routines, and roommates, which singularly or collectively alter the sleep-wake cycle. Other factors influencing sleep-wake cycles in the hospital setting include patient age, comfort, pain, and anxiety; and environmental noise and temperature.[9]

Consequences of sleep disturbances can influence outcomes of therapeutic and supportive care measures. The patient with mild to moderate sleep disturbances may experience irritability and inability to concentrate, which may in turn affect the patient's compliance with treatment protocols, ability to make decisions, and relationships with significant others. Depression and anxiety can also be caused by sleep disturbances. Supportive care measures are directed toward promoting quality of life and adequate rest.

References

1. Savard J, Simard S, Hervouet S, et al.: Insomnia in men treated with radical prostatectomy for prostate cancer. Psychooncology 14 (2): 147-56, 2005.  [PUBMED Abstract]
   
   
2. Coursey RD: Personality measures and evoked responses in chronic insomniacs. J Abnorm Psychol 84 (3): 239-49, 1975.  [PUBMED Abstract]
   
   
3. Freemon FR: Sleep Research: A Critical Review. Springfield, Ill: Thomas Publishing, 1972. 
   
   
4. Johns MW, Bruce DW, Masterton JP: Psychological correlates of sleep habits reported by healthy young adults. Br J Med Psychol 47 (2): 181-7, 1974.  [PUBMED Abstract]
   
   
5. Engstrom CA, Strohl RA, Rose L, et al.: Sleep alterations in cancer patients. Cancer Nurs 22 (2): 143-8, 1999.  [PUBMED Abstract]
   
   
6. Berger AM, Farr L: The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue. Oncol Nurs Forum 26 (10): 1663-71, 1999 Nov-Dec.  [PUBMED Abstract]
   
   
7. Page M: Sleep pattern disturbance. In: McNally JC, Stair JC, Somerville ET, eds.: Guidelines for Cancer Nursing Practice. Orlando, Fla: Grune and Stratton, Inc., 1985, pp 89-95. 
   
   
8. Berlin RM: Management of insomnia in hospitalized patients. Ann Intern Med 100 (3): 398-404, 1984.  [PUBMED Abstract]
   
   
9. Webster RA, Thompson DR: Sleep in hospital. J Adv Nurs 11 (4): 447-57, 1986.  [PUBMED Abstract]
   
   

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