Sleep Disturbances in Patients With Advanced Cancer in Different Palliative Care Settings

Resource use in the last year of life of prostate cancer patients-A register-based analysis

BACKGROUND

Given the paucity of data on the end of life (EOL) of prostate-cancer (PC) patients, we investigated medication prescription patterns and hospitalizations during their final year of life.

METHODS

The data base of the Österreichische Gesundheitskasse Vienna (ÖGK-W) was used to identify all men who died with the diagnosis PC between 1.1.2015 and 31.12.2021 and who were under androgen deprivation and/or new hormonal therapies. Patient age, prescription patterns and hospitalizations during the last year of life were recorded, odds ratios for age groups were analyzed.

RESULTS

A total of 1.109 patients were included. ADT was given in 86.7% (n = 962) and NHT in 62.8% (n = 696). Overall, prescription of analgesics increased from 41% (n = 455) during the first to 65.1% (n = 722) in the last quarter of the final year of life. Prescription of NSAIDs was almost consistent (18-20%) whereas the number of patients receiving other non-opioids (paracetamol, metamizole) more than doubled (18 to 39%). Older men had lower prescription rates for NSAID (OR: 0.47, 95% CI: 0.35-0.64), non-opioids (OR: 0.43, 95% CI: 0.32-0.57), opioids (OR: 0.45, 95% CI: 0.34-0.6) and adjuvant analgesics (OR: 0.42, 95% CI: 0.28-0.65). Approximately 2/3 of patients (n = 733) died in the hospital with a median of four hospitalizations in the final year of life. The overall cumulative length of admission was less than 50d in 61.9%, 51-100d in 30.6% and >100d in 7.6%. Younger patients (<70 yrs) were more likely to die in the hospital (OR: 1.66, 95% CI: 1.15-2.39), had a higher median rate of hospitalizations (n = 6) and longer cumulative duration of admissions.

CONCLUSIONS

Resource use increased during the last year life of PC patients with highest rates in younger men. Hospitalization rates were high and 2/3 died in the hospital, both showed clear age dependency with higher rates, duration and death in the hospital for younger men.

The Drug-Drug Interaction between Erlotinib and OSI-930 Is Mediated through Aldehyde Oxidase Inhibition

The propensity for aldehyde oxidase (AO) substrates to be implicated in drug-drug interactions (DDIs) is not well understood due to the dearth of potent inhibitors that elicit in vivo inhibition of AO. Although there is only one reported instance of DDI that has been ascribed to the inhibition of AO to date, the supporting evidence for this clinical interaction is rather tenuous, and its veracity has been called into question. Our group recently reported that the epidermal growth factor receptor inhibitor erlotinib engendered potent time-dependent inhibition of AO with inactivation kinetic constants in the same order of magnitude as its free circulating plasma concentrations. At the same time, it was previously reported that the concomitant administration of erlotinib with the investigational drug OSI-930 culminated in a an approximately twofold increase in its systemic exposure. Although the basis underpinning this interaction remains unclear, the structure of OSI-930 contains a quinoline motif that is amenable to oxidation at the electrophilic carbon adjacent to the nitrogen atom by molybdenum-containing hydroxylases like AO. In this study, we conducted metabolite identification that revealed that OSI-930 undergoes AO metabolism to a mono-oxygenated 2-oxo metabolite and assessed its formation kinetics in human liver cytosol. Additionally, reaction phenotyping in human hepatocytes revealed that AO contributes nearly 50% to the overall metabolism of OSI-930. Finally, modeling the interaction between erlotinib and OSI-930 using a mechanistic static model projected an ∼1.85-fold increase in the systemic exposure of OSI-930, which accurately recapitulated clinical observations. SIGNIFICANCE STATEMENT: This study delineates an aldehyde oxidase (AO) metabolic pathway in the investigational drug OSI-930 for the first time and confirmed that it represented a major route of metabolism through reaction phenotyping in human hepatocytes. Our study provided compelling mechanistic and modeling evidence for the first instance of an AO-mediated clinical drug-drug interaction stemming from the in vivo inhibition of the AO-mediated quinoline 2-oxidation pathway in OSI-930 by erlotinib.

For the Long Haul: Management of Long-Term Survivors after Melanoma Systemic Therapy

PURPOSE OF REVIEW

This review summarizes the latest advancements in survivorship care for patients with advanced melanoma who received systemic therapy and emphasizes the areas where more research is needed.

RECENT FINDINGS

Over the last decade there have been remarkable advances in the treatment of advanced and metastatic melanoma. Due to these novel treatments, including several immune checkpoint inhibitors and tyrosine kinase inhibitors, there are and will continue to be increasing numbers of long-term melanoma survivors who have been treated with systemic therapy. These patients will navigate new challenges are they are essentially among the first long term survivors after these novel therapies. Survivorship care focuses on improving the health-related quality of life of patients including the physical, emotional, social and functional effects of cancer that begin at diagnosis and continue through the end of life. Survivorship also includes screening for cancer recurrence and second cancers. As the number of melanoma survivors who received systemic therapy continues to grow, the survivorship care plan will become increasingly important for optimal care of patients even after their cancer treatments. Understanding the many domains of survivorship care for this group of patients is imperative for their care now and to identify unmet needs for future research.

International consensus on sleep problems in pediatric palliative care: Paving the way

OBJECTIVE

Sleep problems constitute a common and heterogeneous complaint in pediatric palliative care (PPC), where they often contribute to disease morbidity and cause additional distress to children and adolescents and their families already facing the burden of life-threatening and life-limiting conditions. Despite the significant impact of sleep problems, clinical evidence is lacking. The application of general pediatric sleep recommendations appears insufficient to address the unique challenges of the PPC dimension in terms of disease variability, duration, comorbidities, complexity of needs, and particular features of sleep problems related to hospice care. Therefore, we initiated an international project aimed at establishing a multidisciplinary consensus.

METHODS

A two-round Delphi approach was adopted to develop recommendations in the areas of Definition, Assessment/Monitoring, and Treatment. After selecting a panel of 72 worldwide experts, consensus (defined as ≥75% agreement) was reached through an online survey.

RESULTS

At the end of the two voting sessions, we obtained 53 consensus recommendations based on expert opinion on sleep problems in PPC.

CONCLUSIONS

This study addresses the need to personalize sleep medicine's approach to the palliative care setting and its peculiarities. It provides the first international consensus on sleep problems in PPC and highlight the urgent need for global guidance to improve sleep-related distress in this vulnerable population and their caregivers. Our findings represent a crucial milestone that will hopefully enable the development of guidelines in the near future.

Assessment and Management of Sleep Disturbance in Palliative Care Settings

Background: Sleep disturbances, including insomnia, sleep-disordered breathing, and circadian rhythm disorders with potential consequences including excessive daytime somnolence and worsening fatigue, are prevalent yet largely under-measured and therefore under-managed problems in people receiving palliative care. This has the potential to negatively affect the person's functioning and quality of life. Objectives: We aimed to review the current practice of assessment and management of sleep disturbances in people with life-limiting illnesses in Australian and New Zealand palliative care settings, and to define areas for improvement in assessment and management of sleep disturbances and further research. Design: A cross-sectional, online survey was conducted with palliative care health professionals (PCHPs) to explore current approaches to routine assessment of sleep disturbances and PCHPs' awareness of, and perceived access to, evidence-based resources for assessing and managing sleep disturbances in their local settings. Results: Fifty-four PCHPs responded to the survey, including allied health professionals (44%), palliative care nurses (26%), and physicians (19%). Over 70% of PCHPs endorsed routine verbal screening of sleep symptoms, and >90% recommended management with basic behavioral strategies. However, none of PCHPs used validated patient-reported outcome measures for sleep, and <10% of PCHPs demonstrated awareness or use of sleep-specific interventions (including medications). Only 40% reported they had access to sleep specialist services for patients. Conclusion: Our findings provide a useful snapshot of current approaches to managing sleep disturbances in palliative care. Gaps in current practice are highlighted, including the lack of structured, clinical assessment, referral pathways, and PCHPs' perceived lack of access to targeted interventions for sleep disturbances.

A comparison of the prevalence of dry mouth and other symptoms using two different versions of the Edmonton Symptom Assessment System on an inpatient palliative care unit

BACKGROUND

Symptom assessment is key to effective symptom management and palliative care for patients with advanced cancer. Symptom prevalence and severity estimates vary widely, possibly dependent on the assessment tool used. Are symptoms specifically asked about or must the patients add them as additional symptoms? This study compared the prevalence and severity of patient-reported symptoms in two different versions of a multi-symptom assessment tool. In one version, three symptoms dry mouth, constipation, sleep problems were among those systematically assessed, while in the other, these symptoms had to be added as an "Other problem".

METHODS

This retrospective cross-sectional study included adult patients with advanced cancer at an inpatient palliative care unit. Data were collected from two versions of the Edmonton Symptom Assessment System (ESAS): modified (ESAS-m) listed 11 symptoms and revised (ESAS-r) listed 9 and allowed patients to add one "Other problem". Seven similar symptoms were listed in both versions.

RESULTS

In 2013, 184 patients completed ESAS-m, and in 2017, 156 completed ESAS-r. Prevalence and severity of symptoms listed in both versions did not differ. In ESAS-m, 83% reported dry mouth, 73% constipation, and 71% sleep problems, but on ESAS-r, these symptoms were reported by only 3%, 15% and < 1%, respectively. Although ESAS-r severity scores for these three symptoms were higher than on ESAS-m, differences did not reach statistical significance.

CONCLUSION

We identified significant differences in patient symptom reporting based on whether symptoms like dry mouth, obstipation and sleep problems were specifically assessed or had to be added by patients as an "Other problem".

iCare - a self-directed, interactive online program to improve health and wellbeing for people living with upper gastrointestinal or hepato-pancreato-biliary cancers, and their informal carers: the study protocol for a Phase II randomised controlled trial

BACKGROUND

Up to 70% of people diagnosed with upper gastrointestinal (GI) tract or hepato-pancreato-biliary (HPB) cancers experience substantial reductions in quality of life (QoL), including high distress levels, pain, fatigue, sleep disturbances, weight loss and difficulty swallowing. With few advocacy groups and support systems for adults with upper GI or HPB cancers (i.e. pancreas, liver, stomach, bile duct and oesophageal) and their carers, online supportive care programs may represent an alternate cost-effective mechanism to support this patient group and carers. iCare is a self-directed, interactive, online program that provides information, resources, and psychological packages to patients and their carers from the treatment phase of their condition. The inception and development of iCare has been driven by consumers, advocacy groups, government and health professionals. The aims of this study are to determine the feasibility and acceptability of iCare, examine preliminary efficacy on health-related QoL and carer burden at 3- and 6-months post enrolment, and the potential cost-effectiveness of iCare, from health and societal perspectives, for both patients and carers.

METHODS AND ANALYSIS

A Phase II randomised controlled trial. Overall, 162 people with newly diagnosed upper GI or HPB cancers and 162 carers will be recruited via the Upper GI Cancer Registry, online advertisements, or hospital clinics. Patients and carers will be randomly allocated (1:1) to the iCare program or usual care. Participant assessments will be at enrolment, 3- and 6-months later. The primary outcomes are i) feasibility, measured by eligibility, recruitment, response and attrition rates, and ii) acceptability, measured by engagement with iCare (frequency of logins, time spent using iCare, and use of features over the intervention period). Secondary outcomes are patient changes in QoL and unmet needs, and carer burden, unmet needs and QoL. Linear mixed models will be fitted to obtain preliminary estimates of efficacy and variability for secondary outcomes. The economic analysis will include a cost-consequences analysis where all outcomes will be compared with costs.

DISCUSSION

iCare provides a potential model of supportive care to improve QoL, unmet needs and burden of disease among people living with upper GI or HPB cancers and their carers.

AUSTRALIAN AND NEW ZEALAND CLINICAL TRIALS REGISTRY

ACTRN12623001185651. This protocol reflects Version #1 26 April 2023.

Trends in utilisation of palliative care services in COVID-19 patients and their impact on hospital resources in the USA: insights from the national inpatient sample

OBJECTIVES

Poor prognosis and lack of effective therapeutic options have made palliative care an integral part of the management of severe COVID-19. However, clinical studies on the role of palliative care in severe COVID-19 patients are lacking. The objective of our study was to evaluate the utility of palliative care in intubated COVID-19 patients and its impact on in-hospital outcomes.

METHODS

Rate of palliative care consult, patient-level variables (age, sex, race, income, insurance type), hospital-level variables (region, type, size) and in-hospital outcome variables (mortality, cost, disposition, complications) were recorded.

RESULTS

We retrospectively analysed 263 855 intubated COVID-19 patients using National Inpatient Sample database from 1 January 2020 to 31 December 2020. 65 325 (24.8%) patients received palliative care consult. Factors associated with an increased rate of palliative care consults included: female gender (p<0.001), older age (p<0.001), Caucasian race (p<0.001), high household income (p<0.001), Medicare insurance (p<0.001), admission to large-teaching hospitals (p<0.001), patients with underlying comorbidities, development of in-hospital complications and the need for intensive care procedures. Patients receiving palliative consults had shorter hospital length of stay (LOS) (p<0.001) and no difference in hospitalisation cost (p=0.15).

CONCLUSIONS

Palliative care utilisation rate in intubated COVID-19 patients was reflective of disease severity and disparities in healthcare access. Palliative care may help reduce hospital LOS. Our findings also highlight importance of improving access to palliative care services and its integration into the multidisciplinary management of severe COVID-19 patients.

Symptom Clusters in Patients With Advanced Cancer: A Prospective Longitudinal Cohort Study to Examine Their Stability and Prognostic Significance

This study's purpose was to assess symptom cluster (SC) stability during disease progression and determine their strength of association with survival in patients with advanced cancer . Consecutively eligible patients with advanced cancer not receiving cancer-specific treatment and referred to a Tertiary Palliative Care Clinic were enrolled in a prospective cohort study. At first consultation (D0) and in subsequent consultations at day 15 (D15) and day 30 (D30), patients rated 9 symptoms through the Edmonton Symptom Assessment System scale (0-10) and 10 others using a Likert scale (1-5). Principal components factor analysis with varimax rotation was used to determine SCs at each consultation. Of 318 patients with advanced cancer, 301 met eligibility criteria with a median age of 69 years (range 37-94). Three SCs were identified: neuro-psycho-metabolic (NPM), gastrointestinal, and sleep impairment, with some variations in their constitution over time. Exploratory factor analysis accounted for 40% of variance of observed variables in all SCs. Shorter median survival was observed continuously for NPM cluster (D0 23 vs. 58 days, P < .001; D15 41 vs. 104 days, P=.004; D30 46 vs. 114 days, P = .002), although the presence of 2 or more SCs on D0 and D15 also had prognostic significance (D0: 21 vs. 45 days, P = .005; D30: 50 vs. 96 days, P = .040). In a multivariable model, NPM cluster (D0 hazard ratio estimate: HR 1.64; 95%CI, 1.17-2.31; P = .005; D15 HR: 2.51; 95%CI, 1.25-5.05; P = .009; D30 HR: 3.9; 95%CI, 1.54-9.86; P = .004) and hospitalization (D0 HR: 2.27; 95%CI, 1.47-3.51; P < .001; D15 HR: 2.43; 95%CI, 1.18-5.01; P = .016; D30 HR: 3.41; 95%CI, 1.35-8.62; P = .009) were independently and significantly associated with worse survival. Three clinically relevant SCs were identified, and their constitution had small variations, maintaining a stable set of nuclear symptoms through disease progression. Presence of the NPM cluster and hospitalization maintained their prognostic value over time.

Prevalence, Severity, and Predictors of Insomnia in Advanced Colorectal Cancer

CONTEXT

Insomnia is an under-recognized and undertreated symptom in palliative care and advanced cancer cohorts. Insomnia in an advanced colorectal cancer cohort is yet to be investigated despite colorectal cancer being the third commonest cancer worldwide and one with a high symptom burden.

OBJECTIVES

To examine the prevalence of insomnia and its associations in a large advanced colorectal cancer cohort.

METHODS

A consecutive cohort study of 18,302 patients with colorectal cancer seen by palliative care services across various settings (inpatient, outpatient, and ambulatory) was conducted from an Australia-wide database (2013-2019). The Symptom Assessment Score (SAS) was used to assess the severity of insomnia. Clinically significant insomnia was defined as SAS score ≥3/10, and used to compare associations with other symptoms and functional scores from validated questionnaires.

RESULTS

The prevalence of any insomnia was 50.5%, and clinically significant insomnia 35.6%, particularly affecting people who were younger (<45-years-old), more mobile (AKPS score ≥70), or physically capable (RUG-ADL score ≤5). Outpatients and patients living at home had higher prevalence of insomnia. Nausea, anorexia and psychological distress were the commonest concurrent symptoms in patients with clinically significant insomnia.

CONCLUSIONS

To our knowledge, this study was the first to investigate the prevalence and associations of insomnia in an advanced colorectal cancer cohort. Our findings demonstrate several groups at greater risk of suffering from insomnia (younger, greater physical capacity, living at home, and those with greater psychological distress). This may guide earlier recognition and management of insomnia to improve overall quality of life in this population.

Efficacy of mind-body therapies for sleep disturbance in patients with early-stage cancer: A systematic review and network meta-analysis

OBJECTIVE

To evaluate and compare the efficacy of different mind-body therapies (MBTs) for sleep disturbance in patients with early-stage cancer.

METHODS

Randomised controlled trials that included patients (aged ≥18 years) with early stage cancer who underwent MBTs (mindfulness, hypnosis, relaxation, yoga, and qigong) were searched in the CINAHL via the EBSCO Host, Cochrane Library, Embase, MEDLINE, PsycINFO, PubMed, and Scopus databases, from the date of database inception to October 2022. The outcomes were subjective sleep disturbance and objective sleep efficiency. Network meta-analysis (NMA) and comparative effects ranking were performed using STATA (v14.0; STATACorp, College Station, TX, USA).

RESULTS

Forty-seven studies investigating five MBTs were included in the NMA. For cancer patients receiving active treatment, mindfulness demonstrated the largest effect size in reducing subjective sleep disturbance (standardised mean difference [SMD]: 0.85; 95% confidence intervals [CI]: 0.20-1.50; Grading of Recommendations Assessment, Development, and Evaluation assessment: moderate), and had the highest cumulative probability compared to usual care or waitlist. For cancer patients who had completed active treatment, qigong demonstrated the largest effect size in reducing subjective sleep disturbance (SMD: 0.99; 95% CI: 0.35-1.63; GRADE: low), followed by hypnosis (SMD: 0.87; 95% CI: 0.32-1.42; GRADE: moderate), and mindfulness (SMD: 0.42; 95% CI: 0.24-0.59; GRADE: moderate). Qigong also demonstrated the largest effect size in improving objective sleep efficiency (weighted mean differences: 10.76; 95% CI: 2.01-19.50; GRADE: low); however, the effect of qigong was tested in only one study in this NMA. Among the eight different treatment conditions, cognitive behavioral therapy (CBT) showed the highest cumulative probability (surface under the cumulative ranking curve: 96.3%) in reducing subjective sleep disturbance and the second highest cumulative probability (SUCRA: 83.3%) in improving objective sleep efficiency.

CONCLUSION

There is no evidence supporting the use of MBTs to replace or be comparable to CBT. Mindfulness can be recommended as an optional treatment for reducing sleep disturbance in patients with early-stage cancer. Some support was observed for qigong and hypnosis in reducing sleep disturbances in patients with early-stage cancer who had completed active treatment. More rigorous trials are warranted to confirm whether different forms of MBTs have different effects on sleep in patients with cancer.

Mind-Body Therapies for Sleep Disturbance among Patients with Cancer: A Systematic Review and Meta-analysis

OBJECTIVE

s: To assess whether mind-body therapies (MBTs) are effective for relieving sleep disturbance among patients with cancer.

DESIGN

Systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

Seven English electronic databases were searched from the date of inception to September 2022. All RCTs that included adults (≥18 years) who were treated with mindfulness, yoga, qigong, relaxation, and hypnosis were screened. The outcome was subjective and/or objective sleep disturbance.The revised Cochrane tool (RoB 2.0) was applied to evaluate the risk of bias. The RevMan software was applied to assessed each outcome according different control groups and assessment time points. Subgroup analyses were performed according to different categories of MBTs.

RESULTS

Sixty-eight RCTs (6339 participants) were identified. After requesting for missing data from corresponding authors of included RCTs, 56 studies (5051 participants) were included in the meta-analysis. The meta-analysis showed a significant immediate effect of mindfulness, yoga, relaxation, and hypnosis on subjective sleep disturbance, compared with usual care or wait list control, and the effect of mindfulness lasted at least 6 months. For objective sleep outcomes, we observed significant immediate effects of yoga on wake after sleep onset and of mindfulness on sleep onset latency and total sleep time. Compared with active control interventions, MBTs had no significant effect on sleep disturbance.

CONCLUSIONS

Mindfulness, yoga, relaxation, and hypnosis were effective in sleep disturbance severity reduction among patients with cancer at post-intervention, and the effect of mindfulness lasted at least 6 months. Future MBTs studies should apply both objective and subjective sleep measurement tools.

Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer-a double-blind, randomized placebo-controlled clinical multicenter phase IV trial

PURPOSE

Insomnia is frequent in patients with advanced cancer, and a variety of pharmacological agents is used to treat this condition. Still, few clinical trials have investigated the effectiveness of pharmacological sleep therapies in this patient group. We aimed to study the short-term effectiveness of zopiclone on sleep quality in patients with advanced cancer who report insomnia.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group, multicenter, phase IV clinical trial in adult patients with metastatic malignant disease and insomnia. Patients were treated with zopiclone or placebo for six subsequent nights. Primary end point was patient-reported sleep quality during the final study night (NRS 0-10). Secondary end points were patient-reported sleep onset latency (SOL) and total sleep time (TST).

RESULTS

Forty-one patients were randomized, with 18 being analyzed in the zopiclone group and 21 in the placebo group. Median age was 66, median Karnofsky performance score was 80, and 56% were male. Mean sleep quality at end of study was 2.9 (CI 2.3 to 3.8) in the zopiclone group and 4.5 (CI 3.6 to 5.4) in the placebo group (p = 0.021). At end of study, SOL was significantly different between the treatment groups: zopiclone 29 min (CI 13 to 51) and placebo 62 min (CI 40 to 87) (p = 0.045). TST was not significantly different across groups: zopiclone 449 min (403 to 496) and placebo 411 min (CI 380 to 440) (p = 0.167).

CONCLUSION

Zopiclone improved short-term patient-reported sleep quality in this cohort of patients with advanced cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02807922.

Effects of an Intrathecal Drug Delivery System Connected to a Subcutaneous Port on Pain, Mood and Quality of Life in End Stage Cancer Patients: An Observational Study

BACKGROUND

In cancer patients with limited life expectancy, an implant of an intrathecal (IT) drug delivery system connected to a subcutaneous port (IDDS-SP) has been proposed as a successful strategy, but conflicting results are reported on quality of life (QoL). The aim of this prospective observational study is to report the effects on pain, mood and QoL of an IT combination therapy delivered by an IDDS-SP in malignant refractory pain.

METHODS

Adult patients in which IT therapy was recommended were recruited. An IT therapy with morphine and levobupivacaine was started: VASPI score, depression and anxiety (evaluated by the Edmonton Symptom Assessment System -ESAS-), the Pittsburgh Sleep Quality Index (PSQI), the 5-level EuroQol 5D version (EQ-5D-5L) and the requirements of breakthrough cancer pain (BTcP) medications were registered, with adverse events rate and the satisfaction of patients scored as Patient Global Impression of Change (PGIC).

RESULTS

Fifty patients, (16 F/34 M) were enrolled (age 69 ± 12). All had advanced cancer with metastasis. The median daily VASPI score was 75, the median depression score was 6, and the median anxiety score was 4, median PSQI was 16. At 28 days, a significant reduction in VASPI score was registered as well as in depression and anxiety item. Also, PSQI decreased significantly. The EQ-5D-5 L showed a significant improvement in all components at 14 and 28 days. Patient Global Impression of Change scores showed high level of satisfaction. A low incidence of adverse events and a reduction in BTCP episodes were also registered.

CONCLUSION

Intrathecal combination therapy delivered by an IDDS-SP could ensure adequate control of cancer related symptoms, such as pain, depression, anxiety and sleep disturbances. These effects, with low rate of AEs and reduced BTcP episodes, could explain the improvement in QoL and the overall high levels of patients' satisfaction.

Underlying Music Mechanisms Influencing the Neurology of Pain: An Integrative Model

Pain is often debilitating, and is associated with many pathologies, as either a cause or consequence. Pharmacological interventions, such as opioids, to manage pain may lead to potential problems, such as addiction. When pain is controlled and managed, it can prevent negative associated outcomes affiliated with disease. Music is a low-cost option that shows promise in the management of painful circumstances. Music therapy has provided potent options for pain relief across a variety of ages and populations. As a nonpharmacological alternative or complement lacking side effects, music interventions are growing in clinical application and research protocols. This article considers the neurological implications of varying kinds of pain to provide working considerations that preempt the use of music and music-therapy applications in treating pain.

The effect of a combined treatment of foot soak and lavender oil inhalation therapy on the severity of insomnia of patients with cancer: Randomized interventional study

OBJECTIVES

This three-arm randomized intervention study was carried out with the aim to evaluate the effects of a combined foot soak and lavender oil inhalation therapy on the severity of insomnia of patients with cancer.

METHOD

This research was carried out in oncology and palliative services. Forty-five patients were randomly assigned to three groups. Throughout a 14-day period, 20 min of foot soak treatment was applied to the patients in the F group, patients in the L group were applied lavender oil inhalation therapy for 5 min and a combined treatment of foot soak and lavender oil inhalation therapy were applied to the patients in the FL group. Insomnia severity of the patients in all groups were evaluated twice using the Insomnia Severity Index at the baseline and on the fifteenth day.

RESULTS

The severity of the insomnia of the patients in all groups was found to be moderate. The severity of the insomnia in the second evaluation was found to be statistically significantly lower in the L and FL groups (p<0.05) compared to the baseline evaluation within the group, however no significant difference was found in the F group (p>0.05). The effect size of a combined treatment of foot soak and lavender oil inhalation therapy on the severity of insomnia of patients in the FL group was higher and moderate (d = 0.684) compared to merely foot soak and merely lavender oil inhalation therapy.

CONCLUSION

A combined treatment of foot soak and lavender oil inhalation therapy shall mitigate the severity of a moderate level of insomnia of patients with cancer.

The WHOQOL-BREF instrument: Psychometric evaluation of the Greek version in patients with advanced cancer and pain and associations with psychological distress

OBJECTIVES

Assessment of the psychometric characteristics of the Greek version of the brief World Health Organization Quality of Life Instrument (WHOQOL-BREF) in patients with advanced cancer and pain, and exploration of the association between psychological distress and quality of life (QoL).

METHOD

The sample consisted of 145 patients with advanced cancer and pain who completed the WHOQOL-BREF, the Symptom Checklist-90 (SCL-90), and the Pain Visual Analogue Scale (VAS). In analysis, the following methods were used: Cronbach's alpha, Item Response Theory (IRT), polychoric, Pearson and polyserial correlation, t-test, and Linear regression.

RESULTS

The internal consistency was high for all domains of the WHOQOL-BREF (Cronbach's α ≥ 0.731). Similarly, with the exception of three items, the WHOQOL-BREF items has large discrimination parameters suggesting that they have a high ability in differentiating subjects. On SCL-90, the three dimensions with the highest scores were Depression, Somatization, and Anxiety. The overall score for psychological distress, the Global Severity Index (GSI), showed significant negative association with all the WHOQOL-BREF factor scores (Physical Health: B = -1.488, p < 0.001, Psychological Health: B = -1.688, p < 0.001, Social Relationships: B = -0.910, p < 0.001, Environment: B = -1.064, p < 0.001). Male gender was associated with lower scores for Social Relationships (B = -0.358, p = 0.007) and Environment (B = -0.293, p = 0.026).

SIGNIFICANCE OF RESULTS

The Greek version of the WHOQOL-BREF showed good psychometric properties in patients with advanced cancer and can be used as a reliable instrument in clinical practice. The level of psychological distress can be considered a determinant of QoL in patients with advanced cancer and pain, independently of pain intensity or other clinical characteristics. In cancer, the disease process can activate multiple physiological and psychological mechanisms that lead to a wide range of symptoms of psychological distress. To improve their QoL, psychological intervention focused on the identification and alleviation of psychological distress in patients with advanced cancer, and help in finding meaning in their experience, should be provided.

An Update on Prevalence, Assessment, and Risk Factors for Sleep Disturbances in Patients with Advanced Cancer—Implications for Health Care Providers and Clinical Research

Simple Summary

This review focuses on sleep in patients with advanced cancer. Cancer patients experience multiple symptoms and they receive concomitant medications. These are all factors that may affect sleep. In this paper, we present recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that may contribute to insomnia. Sleep is an essential aspect of health-related quality of life; therefore, it is important for health care providers to focus on sleep to improve patient care.

Abstract

Patients with advanced cancer experience multiple symptoms, with fluctuating intensity and severity during the disease. They use several medications, including opioids, which may affect sleep. Sleep disturbance is common in cancer patients, decreases the tolerability of other symptoms, and impairs quality of life. Despite its high prevalence and negative impact, poor sleep quality often remains unrecognized and undertreated. Given that sleep is an essential aspect of health-related quality of life, it is important to extend both the knowledge base and awareness among health care providers in this field to improve patient care. In this narrative review, we provide recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that contribute to insomnia. We also present direct implications for health care providers working in palliative care and for future research.

Nationwide database analysis of insomnia, depression, and sleeping pill prescriptions in hepatocellular carcinoma patients

OBJECTIVE

To clarify the status of insomnia and depression and the prescription of sleeping pills in hepatocellular carcinoma (HCC) patients before and after HCC diagnosis and treatment.

METHODS

Patients' data from a Japanese health insurance claims database were analyzed retrospectively to determine the incidence of insomnia and depression and their association with sleeping pill prescriptions during the 6 months before and after HCC diagnosis and treatment.

RESULTS

A total of 9,109 HCC patients (median age at diagnosis = 71.5 years, 68.1% male) were analyzed. The incidences of insomnia and depression increased significantly after HCC diagnosis. Insomnia was reported in 15.0% of patients before diagnosis, and it increased to 27.6% after diagnosis. Similarly, depression was reported in 6.3% and 11.3% before and after diagnosis, respectively. The incidences of insomnia and depression before diagnosis were higher in patients with concomitant liver diseases including hepatitis, cirrhosis, and hepatic encephalopathy. However, the rate of sleeping pill prescription was significantly lower in patients with concomitant liver diseases after diagnosis. The incidence of fracture was higher in insomnia or depression patients than others and in patients treated with sleeping pills than without before and after diagnosis.

CONCLUSIONS

HCC patients had increased risks of insomnia and depression after diagnosis. The high risk of fracture in HCC patients with insomnia and depression and treated with sleeping pills suggests that it is difficult to optimize the management of HCC patients, especially those with concomitant liver diseases.

Prevalence of Sleep Disturbance in Patients With Cancer: A Systematic Review and Meta-Analysis

Sleep disturbance is one of the most common and troubling symptoms that harm the quality of life throughout all phases of treatment and stages of the illness among patients with cancer. The aim of this meta-analysis is to examine the present status of sleep disturbance prevalence in patients with cancer. The following databases were searched: PubMed, CINAHL, MEDLINE, EMBASE, PsycINFO, from inception to April 2021. Prevalence rates were pooled with meta-analysis using a random-effects model. A total of 160 studies (N = 46,279) published between 1998 and 2021 met the inclusion criteria. The overall prevalence of sleep disturbance was 60.7% (26,448/46,279 participants, 95% CI 58.1-63.3%) with significant heterogeneity between studies (p < .000, τ2 = .0000, I2 = 96.4%). This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce sleep disturbance and improve the quality of life of cancer patients.

Electroacupuncture for treating cancer-related insomnia: a multicenter, assessor-blinded, randomized controlled, pilot clinical trial

Background

Insomnia is one of the most frequent symptoms in people with cancer. Electroacupuncture has been widely used in people with cancer or insomnia. We explored the feasibility and preliminary effectiveness of electroacupuncture for cancer-related insomnia.

Methods

People with cancer and insomnia disorder were randomly allocated to electroacupuncture, sham-electroacupuncture, or usual care groups. Participants received either 10 sessions of electroacupuncture at real acupoints, sham-electroacupuncture at non-acupoints, or usual care in each group for 4 weeks. We calculated the recruitment, adherence, and completion rates of participants. The Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), sleep diary and actigraphy-derived sleep parameters, Functional Assessment of Cancer Therapy-Fatigue (FACT-F), Montreal Cognitive Assessment (MoCA), and salivary levels of cortisol and melatonin were evaluated as outcome measures.

Results

Twenty-two participants were enrolled (8, 6, and 8 respectively in the electroacupuncture, sham-electroacupuncture, and usual care groups) and 20 participants completed the trials (8, 4, and 8 respectively). The recruitment, adherence, and completion rates were 78.57% (22/28), 95.45% (21/22), and 90.91% (20/22), respectively. Most of the participants had previously received conventional treatment for insomnia, but few had received Korean medicine treatment, without any demographic or clinical differences between groups. In the electroacupuncture group, there was a statistically significant reduction of 10.13 (mean) ± 8.15 (standard deviation) and 5 ± 3.70 points in mean ISI and PSQI scores at 4 weeks post-treatment (P = .0098 and .0066), compared with sham-electroacupuncture (2.06 ± 7.15 and 1.61 ± 4.34; P = .4796 and .3632) and usual care (3.25 ± 2.60 and 1.38 ± 2.13; P = .0096 and .1112). Although there was no significant difference in ISI score between groups at 4 weeks post-treatment, the electroacupuncture group continued to improve significantly at 4 weeks’ follow-up, showing borderline and significant differences compared to the sham-electroacupuncture and usual care (P = .0614 and .0015). The FACT-F scores in electroacupuncture group showed a significant improvement compared with the sham-electroacupuncture group (P = .0305). No electroacupuncture-related adverse events were reported.

Conclusions

Electroacupuncture might be feasible for cancer-related insomnia, despite slow participant recruitment. Additional trials with adequately powered sample sizes and a substantial change to the recruitment procedure are needed.

Trial registration

Clinical Research Information Service, KCT0002162. Submitted 27 October 2016, Registered 2 December 2016 - Retrospectively registered (The first participant enrolment: 28 November 2016),

Supplementary Information

The online version contains supplementary material available at 10.1186/s12906-022-03561-w.

Sleep Disturbance in Older Adults With or Without Mild Cognitive Impairment and Its Associated Factors Residing in Rural Area, China

AIMS

To evaluate the prevalence of sleep disturbance in older adults with or without mild cognitive impairment (MCI) and associated factors among residents in rural central China.

METHODS

A cross-sectional survey was conducted in adults in rural areas of the Hunan province aged≥60 years. Study participants (N = 1213) included 479 individuals meeting the criteria for MCI and 734 with normal cognitive abilities. The participants completed the Athens Insomnia Scale, Stress Resilience Quotient Scale, Affect Balance Scale and Activities of Daily Living (ADL) Scale. Chi-square test, Wilcoxon rank sum analyses and multiple logistic regression were used in this study.

RESULTS

A total of 60.33% of participants with MCI demonstrated sleep disturbance (60.33%, 95% CI: 0.559-0.649), which was significantly higher than in the non-MCI group (43.73%, 95% CI: 0.759-0.838). Multiple logistic regression conducted separately in the populations of older adults with or without MCI showed that age, drinking habits, affect balance and activities of daily life were correlates of self-reported sleep disturbance in rural older adults with MCI (B = -5.469), whereas age, ADL, living arrangement and resilience were the main influencing factors in older adults without MCI (B = 2.991).

CONCLUSION

Sleep disturbance is more common in older adults with MCI than without MCI in rural areas of China. The factors influencing sleep disturbances vary between older adults with or without MCI, with age and ADL representing common factors influencing sleep disturbance in both groups. Interventions focusing on the age, drinking habits, affect balance and ADL may improve sleep quality in MCI older adults.

Auricular Acupressure Therapy for Patients with Cancer with Sleep Disturbance: A Systematic Review and Meta-Analysis

Aim

We aim to provide available synthesized evidence of the efficacy and safety of auricular acupressure for cancer patients with sleep disturbance.

Methods

Randomized controlled clinical trials (RCTs) were identified from PubMed, EMBASE, Web of Science, The Cochrane Library, PsycINFO, Chinese Biomedical Database, China National Knowledge Infrastructure, Chongqing VIP, and Wanfang Data, and the search date ranged from the inception of the databases to May 2021. Literature screening and data extraction were independently performed by three researchers. The Cochrane collaboration's tool for assessing the risk of bias was applied to evaluate the risk of bias of the RCTs included. The extracted data were analyzed using Rev-Man 5.4.1 software.

Results

Nine trials involving 688 participants met the inclusion criteria and were included in the qualitative analysis; 6 trials involving 485 participants were included in the meta-analysis. Synthesized results showed that auricular acupressure had a significant effect on reducing the total Pittsburgh Sleep Quality Index (PSQI) score (MD = −3.88, 95% CI (−5.24, −2.53), P < 0.00001), and the scores of five PSQI components, sleep latency (MD = −0.53, 95% CI (−0.73, −0.32), P < 0.00001), subjective sleep quality (MD = −0.79, 95% CI (−1.05, −0.53), P < 0.00001), sleep duration (MD = −0.50, 95% CI (−0.69, −0.31), P < 0.0001), daytime dysfunction (MD = −0.53, 95% CI (−0.77, −0.29), P < 0.0001), and sleep disturbances (MD = −0.54, 95% CI (−0.60, −0.49), P < 0.00001), were also obviously decreased after the intervention of auricular acupressure. Shenmen and heart were the most commonly selected auricular acupoints, the main intervention durations ranged from 10 to 42 days, and the pressing times of auricular acupoints were 1–6 times a day, 1–5 min each time. One trial reported slight and transient pain caused by auricular acupressure, while the remaining 8 trials did not report obvious side effects.

Conclusion

Auricular acupressure can significantly improve the sleep quality of cancer patients with sleep disturbance, with no obvious side effects. Rigorously designed clinical trials are necessary for the further support of the clinical application.

Insomnia in patients with advanced lung cancer admitted to palliative care services

AIM

To assess the prevalence of insomnia and possible associated factors in patients with advanced lung cancer admitted to different settings of palliative care.

METHODS

Secondary analysis of a consecutive sample of patients with advanced lung cancer receiving palliative care. Epidemiological and clinical data, treatments received in the last month, Karnofsky status, Edmonton Symptom Assessment System (ESAS), Athens Insomnia Scale and the Hospital Anxiety and Depression Scale (HADS), as well as concomitant medical treatment were recorded.

RESULTS

One-hundred-eight-two patients with advanced lung cancer were surveyed. The mean age was 69.9 years (SD 10.8), and 121 patients (66%) were men. The majority of patients showed consistent levels of insomnia. A poor Karnofsky level, pain, nausea, and drowsiness, time from diagnosis (1-3 years), HADS anxiety, and HADS depression, were positively associated with insomnia.

CONCLUSIONS

About 50% of patients with advanced lung cancer admitted to palliative care services had relevant insomnia. Several factors associated with insomnia have been identified and should prompt physicians for a careful examination and subsequent treatment.

Sleeping-related distress in a palliative care population: A national, prospective, consecutive cohort

BACKGROUND

Sleep, a multi-dimensional experience, is essential for optimal physical and mental wellbeing. Poor sleep is associated with worse wellbeing but data are scarce from multi-site studies on sleeping-related distress in palliative care populations.

AIM

To evaluate patient-reported distress related to sleep and explore key demographic and symptom distress related to pain, breathing or fatigue.

DESIGN

Australian national, consecutive cohort study with prospectively collected point-of-care data using symptoms from the Symptom Assessment Scale (SAS).

SETTING/PARTICIPANTS

People (n = 118,117; 475,298 phases of care) who died while being seen by specialist palliative care services (n = 152) 2013-2019. Settings: inpatient (direct care, consultative); community (outpatient clinics, home, residential aged care).

RESULTS

Moderate/severe levels of sleeping-related distress were reported in 11.9% of assessments, more frequently by males (12.7% vs 10.9% females); people aged <50 years (16.2% vs 11.5%); and people with cancer (12.3% vs 10.0% for other diagnoses). Sleeping-related distress peaked with mid-range Australia-modified Karnofsky Performance Status scores (40-60).Strong associations existed between pain-, breathing- and fatigue-related distress in people who identified moderate/severe sleeping-related distress, adjusted for age, sex and functional status. Those reporting moderate/severe sleeping-related distress were also more likely to experience severe pain-related distress (adjusted odds ratios [OR] 6.6; 95% confidence interval (CI) 6.3, 6.9); breathing-related distress (OR 6.2; 95% CI 5.8, 6.6); and fatigue-related distress (OR 10.4; 95% CI 9.99-10.8).

CONCLUSIONS

This large, representative study of palliative care patients shows high prevalence of sleeping-related distress, with strong associations shown to distress from other symptoms including pain, breathlessness and fatigue.

Palliative Care Nurse Perceptions of Nonpharmacological Sleep-Promoting Interventions

Poor quality of sleep is common among those with advanced serious illness. Several interventions have been demonstrated to improve sleep; however, the extent to which these are used is unknown. This study describes nurses' perceptions of 36 nonpharmacological sleep-promoting interventions as well as facilitators and barriers to implementing nonpharmacological interventions. A descriptive survey design was used to collect data via an online, anonymous survey from nurses throughout the United States that included demographic items and open-ended questions (barriers and facilitators). The 108 respondents were nurses working in either a hospital (33.3%) or home care/outpatient (54.6%) setting. Among 36 interventions presented, a mean (SD) total score of feasible interventions per respondent was 27.1 (6.5). There were no significant differences in the mean total feasibility score due to practice site, nurse type, or years of experience. Most thought individual belief in the efficacy of the nonpharmacological intervention was an important facilitator whereas perceived lack of value and institutional support were the major barriers. There was an overall appreciation and positive perception of nonpharmacological, sleep-promoting interventions by palliative care nurses. Increasing use will depend on overcoming barriers by identification of specific patient/caregiver and institutional factors in each setting or patient population.

Practice review: Evidence-based quality use of corticosteroids in the palliative care of patients with advanced cancer

BACKGROUND

It would be unusual for a patient with advanced cancer not to be prescribed corticosteroids at some stage of their disease course for a variety of specific and non-specific indications.

AIM

The aim of this practice review was to provide a pragmatic overview of the evidence supporting current practice and to identify areas in which further research is indicated.

DESIGN

A 'state-of-the-art' review approach was used to examine the evidence supporting the use of corticosteroids for the management of cancer-related complications and in symptom control, in the context of known risks and harms to inform quality use of this medicine. We developed 'Do', 'Do not', and 'Don't know' recommendations based on current literature and identified areas for future investigation and research.

DATA SOURCES

We searched MEDLINE, EMBASE and the Cochrane library from inception to 14th October 2020. Our initial search limited to reviews, reviews of reviews, randomised controlled trials (RCTs) and controlled trials was supplemented by supporting literature as appropriate.

RESULTS

Evidence to support common practice in the use of corticosteroids is lacking for most indications. This is in the context of strong evidence for the potential for significant toxicity and poor quality use of medicine.

CONCLUSION

Guidelines recommending the widespread use of corticosteroids should acknowledge the poor evidence base supporting much current dogma. Quality research is essential not only to define the role of corticosteroids in this context but to ensure good prescribing practice.

Sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos na assistência domiciliar: uma revisão integrativa

Resumo Objetivo identificar os principais sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos na assistência domiciliar. Método revisão integrativa nas bases LILACS, MEDLINE e CINAHL em janeiro de 2020. Perguntou-se: “Quais os principais sinais e sintomas manifestados por pacientes em cuidados paliativos oncológicos destacados nos estudos abrangendo o contexto do domicílio?”. Foram descritores/termos: Sinais e Sintomas/Signs and Symptoms; Assistência Domiciliar/Home Care Services; Cuidados Paliativos/Palliative Care e Neoplasias/Neoplasms. Elencaram-se como critérios de elegibilidade: texto completo; entre 2015 e 2019; em inglês, português ou espanhol e idade adulta. Para o mapeamento dos dados, consideraram-se: título; país; ano; objetivo; método; sinais e sintomas. Os resultados foram categorizados em subgrupos, considerando a classificação conceitual predeterminada (sinal e sintoma). O elemento contagem facilitou a análise e a comparação de dados. Resultados foram selecionados 35 artigos, sendo identificados 25 sinais e 23 sintomas. Os mais frequentes foram: dor, náusea/vômito, dispneia, fadiga, depressão, ansiedade, constipação, perda de apetite, sonolência, bem-estar e insônia. A maioria (39) relacionou-se ao domínio físico. Conclusão a identificação dos principais sinais e sintomas, neste contexto, direciona a prática dos profissionais de saúde para as intervenções mais adequadas e o mais precocemente possível, contribuindo para viabilizar a assistência domiciliar, e alerta para a necessidade de educação permanente sobre este tema.

Comparing the Effects of Melatonin and Zolpidem on Sleep Quality, Depression, and Anxiety in PatientsWithColorectalCancerUndergoingChemotherapy

Introduction:

Patients with cancer may have many complications involving their psychosomatic systems, such as sleep disturbance, depression, and anxiety. Thus, many research studies were conducted to reduce these complications. Zolpidem, as a short-term non-benzodiazepine treatment of insomnia, and melatonin as a chronobiological functionregulatory hormone, are commonly used for improving sleep quality. This randomized clinical trial aims to compare the effects of zolpidem and melatonin on sleep quality, depression, and anxiety in patients with colorectal cancer.

Methods:

In this single-blinded trial, 90 patients with colorectal cancer undergoing chemotherapy who had obtained a score of 5 or higher on the Pittsburgh Sleep Quality Index (PSQI) were randomly divided into two groups (n=45). One group was treated with 10 mg zolpidem at bedtime, and the other group received 6 mg melatonin at bedtime for 30 days. PSQI on weeks 0, 4, 8, Groningen sleep quality scale, Hamilton rating scale for depression, and Hamilton anxiety rating scale questionnaires were performed to assess patients on weeks 0, 4, and 8. The outcome was then analyzed, and P≤0.05 was considered statistically significant.

Results:

Both zolpidem and melatonin had significant impacts on sleep quality in week 4 (P<0.05). After stopping the treatments, the conditions were noticeably reversed on week 8 (P<0.05). Zolpidem and melatonin were relatively similar in affecting sleep duration, latency, efficiency, and disturbance. None of the two study medications had any considerable influence on anxiety and depression.

Conclusion:

Melatonin and zolpidem are promising agents for treating sleep complications and, to some extent, depression, and anxiety in cancer patients, according to the present study. However, further clinical trials are recommended to confirm the results of this study.

The short-term impact of methylprednisolone on patient-reported sleep in patients with advanced cancer in a randomized, placebo-controlled, double-blind trial

Purpose

Although corticosteroids are frequently used in patients with advanced cancer, few studies have examined the impact of these drugs on patient-reported sleep. We aimed to examine the short-term impact of methylprednisolone on patient-reported sleep in patients with advanced cancer.

Methods

Patient-reported sleep was a predefined secondary outcome in a prospective, randomized, placebo-controlled, double-blind trial that evaluated the analgesic efficacy of corticosteroids in advanced cancer patients (18+), using opioids, and having pain ≥ 4 past 24 h (NRS 0–10). Patients were randomized to the methylprednisolone group with methylprednisolone 16 mg × 2/day or placebo for 7 days. The EORTC QLQ-C30 (0–100) and the Pittsburgh Sleep Quality Index questionnaire (PSQI) (0–21) were used to assess the impact of corticosteroids on sleep at baseline and at day 7.

Results

Fifty patients were randomized of which 25 were analyzed in the intervention group and 22 in the control group. Mean age was 64 years, mean Karnofsky performance status was 67 (SD 13.3), 51% were female, and the mean oral daily morphine equivalent dose was 223 mg (SD 222.77). Mean QLQ-C30 sleep score at baseline was 29.0 (SD 36.7) in the methylprednisolone group and 24.2 (SD 27.6) in the placebo group. At day 7, there was no difference between the groups on QLQ-C30 sleep score (methylprednisolone 20.3 (SD 32.9); placebo 28.8 (SD 33.0), p = 0.173). PSQI showed similar results.

Conclusions

Methylprednisolone 16 mg twice daily for 7 days had no impact on patient-reported sleep in this cohort of patients with advanced cancer.

Trial registration

Clinical trial information NCT00676936 (13.05.2008)

Effect of Aromatherapy Massage on Quality of Sleep in the Palliative Care Ward: A Randomized Controlled Trial

CONTEXT

There is little evidence of the effectiveness of aromatherapy massage in palliative care despite its popularity.

OBJECTIVES

This study aimed to investigate the effects of a 30-minute single session of aromatherapy massage at night time on quality of sleep and fatigue in palliative care.

METHODS

A randomized controlled trial from January 2018 to March 2019. After being stratified by sex, participants were randomly assigned to an aromatherapy massage group and a control group. The effects of aromatherapy massage were evaluated on the massage day and the next day using the Richards-Campbell Sleep Questionnaire and the Brief Fatigue Inventory.

RESULTS

Of the 74 participants, data of 27 participants in the treatment group and 30 participants in the control group were analyzed. Analysis of covariance indicated that quality of sleep and fatigue did not improve owing to the aromatherapy massage, although usual fatigue in preceding 24 hours and enjoyment of life subscales of the Brief Fatigue Inventory showed signs of contribution (P = 0.07 and 0.09, respectively). Post hoc analyses indicated that higher age and performance status were factors with moderate correlation with better sleep (P = 0.03; r = 0.45 and P = 0.03; r = 0.40, respectively), and that older patients tended to experience greater improvement in fatigue (P = 0.02; r = -0.47).

CONCLUSION

A single aromatherapy massage session is no more effective than not having a massage in improving sleep quality in palliative care settings. However, older patients and those in poor health conditions may benefit from aromatherapy massage.

Somatic Acupoint Stimulation for Cancer-Related Sleep Disturbance: A Systematic Review of Randomized Controlled Trials

Aim

The aim of this systematic review was to analyze and synthesize available evidence for the effects of somatic acupoint stimulation (SAS) on cancer-related sleep disturbance in adults with cancer.

Methods

Nine databases and four clinical trial registries were searched from their inception to July 2019 to identify potential articles and registered trials. Two authors independently extracted data and appraised the methodological quality of the included studies. The included studies could not be subjected to meta-analysis due to the significant variations in SAS intervention protocols and outcome measurement instruments. This systematic review therefore reported the results of the included trials narratively.

Results

Seven studies were identified, which involved 906 cancer patients. SAS protocols varied across trials without an optimal evidence-based standard intervention protocol to manage cancer-related sleep disturbance. Sanyinjiao (SP6) was the most commonly selected acupoint. Manual acupuncture was typically 15–30 min in duration and was conducted once a day or once a week for a period of 1–5 weeks, whereas self-administered acupressure was typically 1–3 min in duration per point and was conducted once a day, such as during night time before going to bed, for a period of 1–5 months. The results indicated that SAS could potentially relieve cancer-related sleep disturbance and improve quality of life. Mild adverse effects were reported in three of the included studies, but none of them performed a causality analysis to clarify the association between the reported adverse events and the intervention.

Conclusions

This systematic review showed that SAS is a useful approach to relieving cancer-related sleep disturbance. However, research evidence on SAS for managing cancer-related sleep disturbance has not been fully conclusive due to the limited number of existing clinical studies with relatively small sample size and suboptimal methodological quality. Clinical trials with large sample size and robust methodology are warranted in future research.

Systematic Review of the Prevalence, Predictors, and Treatment of Insomnia in Palliative Care

Introduction:

The primary function of palliative care is to improve quality of life. The recognition and treatment of symptoms causing suffering is central to the achievement of this goal. Insomnia reduces quality of life of patients under palliative care. Knowledge about prevalence, associated factors, and treatment of insomnia in palliative care is scarce.

Methodology:

Literature review about the prevalence, predictors, and treatment options of insomnia in palliative care patients. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in identified articles and selected reviews. OpenGrey and Google Scholar were used for searching grey literature. Study quality analysis was based on the Newcastle-Ottawa Scale.

Results:

A total of 65 studies were included in the review. Most studies had acceptable /good quality. The prevalence of insomnia in the included studies ranged from 2.1% to 100%, with a median overall prevalence of 49.5%. Sociodemographic factors such as age; clinical characteristics such as functional status, disease stage, pain, and use of specific drugs, including opioids; psychological factors such as anxiety/depression; and spiritual factors such as feelings of well-being were identified as predictors. The treatment options identified were biological (pharmacological and nonpharmacological), psychological (visualization, relaxation), and spiritual (prayer).

Conclusions:

The systematic review showed that the prevalence of insomnia is high, with at least one in 3 patients affected in most studies. Insomnia’s risk factors and treatment in palliative care are both associated to physical, psychological, social, and spiritual factors, reflecting its true holistic nature.

A screening method for sleep disturbances at the end-of-life

OBJECTIVE

To evaluate sleep disturbances and to verify the accuracy of three screening tests to detect them in patients at the end-of-life admitted in a hospital palliative care unit.

METHOD

The level of sleep disturbances was evaluated through the Pittsburgh Sleep Quality Index (PSQI) in 150 palliative patients. This questionnaire was the criterion variable for testing the three screening tests used: Edmonton Symptom Assessment System (ESAS-Sleep subscale); the single question "How much do you worry about your sleep problems?" which is answered on a scale of 0-10 (Sleep-Worry-Q) and another single question: "Do you think you have sleep problems?" with two response categories, Yes/No (Sleep-Problem-Q).

RESULTS

According to the PSQI (cut-off point: 8), 87% of patients presented sleep disturbances. The ESAS-Sleep (cut-off point: 3) showed a sensitivity of 0.87, a specificity of 0.58, and an AUC of 0.729; the Sleep-Worry-Q (cut-off point: 4) showed a sensitivity of 0.95, a specificity of 0.68, and an AUC of 0.854; the Sleep-Problem-Q obtained a sensitivity of 0.92 and a specificity of 0.65.

SIGNIFICANCE OF RESULTS

Patients at the end-of-life, near the time of death, have high levels of sleep disturbances that can be detected early, with better diagnostic accuracy, with the Sleep-Worry-Q. Although from a clinical point of view, the application of the Sleep-Problem-Q may be more advantageous, as it presents good diagnostic accuracy, greater simplicity, and brevity.

Cebranopadol, a Novel First-in-Class Analgesic Drug Candidate: First Experience With Cancer-Related Pain for up to 26 Weeks

CONTEXT

Pain is one of the most prevalent symptoms associated with cancer. Strong opioids are commonly used in the analgesic management of the disease, but carry the risk of severe side effects. Cebranopadol is a first-in-class drug candidate, combining nociceptin/orphanin FQ peptide and opioid peptide receptor agonism. For cancer patients, frequently experiencing multimorbidities and often exposed to polypharmacy, cebranopadol is easy to handle given its once-daily dosing, the small tablet size that enables swallowing, and the option to flexibly titrate to an effective dose.

OBJECTIVES

We assessed the safety and tolerability of prolonged treatment with oral cebranopadol for up to 26 weeks in patients suffering from chronic moderate-to-severe cancer-related pain.

METHODS

This was a non-randomized, multi-site, open-label, single-arm clinical trial with patients who had completed a double-blind trial comparing morphine prolonged release with cebranopadol. In this extension trial, patients were treated with oral cebranopadol for up to 26 weeks.

RESULTS

Cebranopadol was safe and well tolerated in patients with chronic moderate-to-severe pain related to cancer in the dose range tested (200-1000 μg once daily). The median and mean pain levels remained in the range of mild pain during the treatment period.

CONCLUSION

Our data suggest that cebranopadol was safe and well tolerated when administered for up to 26 weeks in patients with chronic cancer-related pain who were previously treated with cebranopadol or morphine prolonged release.

Personalized goal for insomnia and clinical response in advanced cancer patients

AIM

The aim of this study was to assess the Personalized Insomnia Intensity Goal (PIIG), the achievement of Personalized Goal Response (PGR), and Patient Global Impression (PGI) after a comprehensive symptom management.

PATIENTS AND METHODS

Advanced cancer patients admitted to palliative care units rated pain and symptoms intensity and their PIIG by using the Edmonton Symptom Assessment Score (ESAS) (T0). In patients with significant levels of insomnia, the achievement of target expected (PIIG) was measured (patient goal response, PIGR), as well the patient global impression (PGI), by the minimal clinically important difference (MCID), after a comprehensive symptom management (T7).

RESULTS

Three hundred ninety-seven patients with a level of insomnia of ≥ 3 on ESAS were analyzed in this study. The mean values of PIIG at T0 and T7 were 1.2 (SD 1.5) and 0.9 (SD 1.4), respectively. Most patients (n = 406, 89.8%) indicated a PIIG of ≤ 3 as a target at T0. Such target was significantly lower at T7 (p = < 0.0005). PGI, expressed as MCID, was perceived with a mean decrease in insomnia intensity of - 2.3. In a minority of patients (n = 26; 5.8%) insomnia worsened, with a MCID of 0.50 (SD 2.8). Higher insomnia intensity at T0 and lower insomnia intensity at T7 were independently related to PGI. PIGR was achieved in 87.9% of patients. PIGR was associated with PIIG at T0, and inversely associated to insomnia intensity at T0 and T7, and PIIG at T7.

CONCLUSION

PGIR and PGI seem to be relevant for evaluating the effects of a comprehensive management of insomnia, suggesting therapeutic decisions according to PIIG. Some factors influencing the individual target and clinical response have been detected.

Sleep in Hospitalized Patients

Hospitalized patients frequently have disordered and poor-quality sleep due to a variety of both intrinsic and extrinsic factors. These include frequent nighttime intrusions, insomnia related to pain and unfamiliar environments, dark conditions during the day with loss of natural light, and disruption of the natural sleep cycle due to illness. Sleep wake disturbances can result in a deleterious consequence on physical, emotional, and cognitive status, which may impact patient satisfaction, clinical recovery, and hospital length of stay. Despite this, clinicians frequently fail to document sleep disturbances and are generally unaware of the best practices to improve sleep quality in the hospital. A PubMed search was conducted using the terms: ("sleep and hospitalized patients") and ("sleep and hospitalization") to review the published data on the topic of sleep in hospitalized medical patients. The search was limited to English-language articles published between 2000 and 2018. Subsequent PubMed searches were performed to clarify the data described in the initial search, including the terms "hospital sleep protocols," "hospitalized patients sleep documentation," and "hospitalized patients sleep quality". The purpose of this review is to discuss sleep disturbances in hospitalized patients with a focus on causes of sleep disturbance, the effect of poor-quality sleep, high risk populations, considerations for surveillance and prevention, and pharmacologic and non-pharmacologic options for treatment.

Problems sleeping with prostate cancer: exploring possible risk factors for sleep disturbance in a population-based sample of survivors

PURPOSE

This study aimed to investigate the prevalence of sleeping problems in prostate cancer survivors and to explore the role of predisposing, precipitating and perpetuating factors in this process.

METHODS

Using a cross-sectional design, 3348 prostate cancer survivors between 2 and 18 years post diagnosis reported experiences of insomnia using the QLQC30, along with their sociodemographic characteristics, health status and treatment(s) received. The EQ5D-5L and QLQPR25 assessed survivors' overall and prostate cancer-specific health-related quality of life. A hierarchical multiple regression analysis was constructed with three blocks: (1) predisposing (e.g. demographics at diagnosis), (2) precipitating (e.g. disease extent, treatment) and (3) perpetuating factors (e.g. side effects).

RESULTS

Nineteen percent of survivors reported significant problems sleeping. The final model accounted for 31% of the variance in insomnia scores (p < .001). In order of magnitude, associates of sleep disturbance were urinary symptoms (β = 0.22; p < .001), experiencing symptoms of depression/anxiety (β = 0.18; p < .001), hormone treatment-related symptoms (β = 0.12; p = .001), pain (β = 0.10; p < .001) and bowel symptoms (β = 0.06; p = .005). Having a lower education and more comorbidities at diagnosis also predicted sleep problems.

CONCLUSION

Results suggest that it is the ongoing adverse effects of prostate cancer and its treatment (e.g. urinary symptoms) that put survivors most at risk of sleep problems. Strong associations with symptoms of depression/anxiety were also observed. Findings highlight the need for health care practitioners to treat and manage adverse effects of prostate cancer treatment in order to mitigate sleep disturbance in survivors.

Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer: study protocol for a double-blind, randomized, placebo-controlled, clinical multicenter trial

BACKGROUND

Despite the high prevalence of insomnia in patients with advanced cancer, there are no randomized controlled trials on pharmacological interventions for insomnia in this group of patients. A variety of pharmacological agents is recommended to manage sleep disturbance for insomnia in the general population, but their efficacy and safety in adults with advanced cancer are not established. Thus, there is a need to evaluate the effectiveness of medications for insomnia in order to improve the evidence in patients with advanced cancer. One of the most used sleep medications at present in patients with cancer is zopiclone.

METHODS

This is a randomized, double-blind, placebo-controlled, parallel-group, multicenter trial. A total of 100 patients with metastatic cancer who report insomnia will be randomly allocated to zopiclone or placebo. The treatment duration with zopiclone/placebo is 6 consecutive nights. The primary endpoint is patient-reported sleep quality during the final study night (night 6) assessed on a numerical rating scale of 0-10, where 0 = Best sleep and 10 = Worst possible sleep. Secondary endpoints include the mean patient-reported total sleep time and sleep onset latency during the final study night (night 6).

DISCUSSION

Results from this study on treatment of insomnia in advanced cancer will contribute to clinical decision-making and improve the treatment of sleep disturbance in this patient cohort.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02807922 . Registered on 21 June 2016.

Pilot randomized controlled trial of a symptom cluster intervention in advanced cancer

OBJECTIVE

This study evaluated a three-session acceptance-based cognitive behavioral -acceptance and commitment therapy (CBT-ACT) intervention targeting a common symptom cluster in advanced cancer-worry-insomnia-depression-fatigue.

METHODS

Twenty-eight patients with advanced cancer were randomly assigned to the CBT-ACT intervention or waitlist. At preintervention, participants completed a psychodiagnostic interview, standardized questionnaires, and a sleep diary. Intervention and waitlist groups were reassessed after 6 weeks, at which point the waitlist group completed the intervention.

RESULTS

Participants receiving the intervention demonstrated improved sleep efficiency (P = 0.0062, d = 1.08), sleep latency (P = 0.028, d = -0.86), insomnia severity (P = 0.0047, d = -1.18), and worry (P = 0.026, d = -0.89) compared with waitlist controls. They also demonstrated a 7-point reduction on depression (P = 0.03, d = -0.88), reduced hyperarousal (P = 0.005, d = -1.51), and a decrease in distress (P = 0.032, d = -0.83). Effects were maintained for the whole sample in sensitivity analyses. Effects on uncertainty intolerance approached significance (P = 0.058). No effect was found on fatigue.

CONCLUSIONS

The CBT-ACT group performed significantly better than the waitlist control group. CBT-ACT yielded strong effects for worry, sleep, depression, emotional distress, total distress, and hyperarousal. Future studies will enhance the fatigue and uncertainty tolerance components of the intervention.

Palliative care in intensive care units: why, where, what, who, when, how

Palliative care is patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering when “curative” therapies are futile. In the Intensive Care Unit (ICU), critically ill patients receive life-sustaining therapies with the goal of restoring or maintaining organ function. Palliative Care in the ICU is a widely discussed topic and it is increasingly applied in clinics. It encompasses symptoms control and end-of-life management, communication with relatives and setting goals of care ensuring dignity in death and decision-making power. However, effective application of Palliative Care in ICU presupposes specific knowledge and training which anesthesiologists and critical care physicians may lack. Moreover, logistic issues such protocols for patients’ selection, application models and triggers for consultation of external experts are still matter of debate.

The aim of this review is to provide the anesthesiologists and intensivists an overview of the aims, current evidence and practical advices about the application of palliative care in ICU.

Sleep quality with WHO Step III opioid use for cancer pain

OBJECTIVE

Sleep is often disturbed in patients with advanced cancer. There is limited knowledge about sleep in patients with cancer treated with strong opioids. This study examines sleep quality in patients with advanced cancer who are treated with a WHO Step III opioid for pain.

METHODS

An international, multicentre, cross-sectional study with 604 adult patients with cancer pain using WHO Step III opioids. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) global score (range; 0-21; score >5 indicates poor sleep). PSQI includes sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of sleep medications and daytime dysfunction. Pain and quality of life were assessed by Brief Pain Inventory and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core30.

RESULTS

The median age was 62 years, 42% were female, mean Karnofsky performance score (KPS) was 62.5 (±14.2) and mean oral daily morphine equivalent dose was 303 mg/24 hours (±543.8 mg). The mean PSQI global score was 8.8 (±4.2) (range 0-20). Seventy-eight per cent were poor sleepers. All PSQI components were affected, and 44% reported trouble sleeping caused by pain. In the multiple regression model, predictors of PSQI global scores were pain intensity, emotional function, constipation, financial difficulties and KPS (adjusted R²=0.21).

CONCLUSION

The majority (78%) of these patients with cancer treated with Step III opioids experienced poor sleep quality. Pain intensity, emotional function, constipation, financial difficulties and KPS predicted poor PSQI global scores. The clinical implication is that healthcare personnel should routinely assess and treat sleep disturbance in patients with advanced cancer disease.

Correlates of disrupted sleep-wake variables in patients with advanced cancer

OBJECTIVES

High rates of sleep difficulties have been found in patients with advanced cancer. However, not much is known about factors that are associated with sleep impairments in this population and that could constitute their potential risk factors or consequences. This study conducted in patients with cancer receiving palliative care aimed to evaluate the relationships of subjective (sleep diary; Insomnia Severity Index, ISI) and objective (actigraphy) sleep-wake variables with several physical and psychological symptoms, maladaptive sleep behaviours, erroneous beliefs about sleep, quality of life, time to death and environmental factors.

METHODS

The sample was composed of 57 community-dwelling patients with cancer receiving palliative care and with an Eastern Cooperative Oncology Group Scale score of 2 or 3. Actigraphic, light and sound recording and a daily sleep and pain diary were completed for seven consecutive days. A battery of self-report scales was also administered.

RESULTS

Greater disruptions of subjective and objective sleep-wake variables were more consistently associated with worse physical symptoms than with psychological variables. Disrupted objective sleep-wake parameters were also associated with a greater frequency of maladaptive sleep behaviours. Finally, a greater nocturnal noise in the bedroom was correlated with more impairments in subjective and objective sleep-wake variables while a lower 24-hour light exposure was associated with more disruption of subjectively assessed sleep only.

CONCLUSIONS

Although longitudinal studies are needed to establish the etiology of sleep-wake difficulties in patients with advanced cancer, our findings suggest that physical symptoms, maladaptive sleep behaviours and environmental factors can contribute to their development or their persistence and need to be adequately addressed.