How is sleep quality affected by the psychological and symptom distress of advanced cancer patients?

Exploring the Link between Social Support and Patient-Reported Outcomes in Chronic Obstructive Pulmonary Disease Patients: A Cross-Sectional Study in Primary Care

We aimed to explore the link between social support and various patient-reported outcome measures (PROMs) in primary care patients with COPD. This was a cross-sectional study with 168 patients with COPD from six primary care centers in Crete, Greece. We collected data on sociodemographic characteristics, medical history, disease-specific quality of life, the COPD Assessment Test (CAT), fatigue, the Fatigue Severity Scale (FSS), phycological parameters, Patient Health Questionnaire-9, General Anxiety Disorder-7, sleep complaints, the Pittsburg Sleep Quality Index, the Athens Insomnia scale (AIS), and the Epworth Sleepiness Scale. Social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS). Out of 168 patients with COPD, 114 (68.9%) exhibited low levels of social support. Low social support (MSPSS total ≤ 5) was positively associated with COPD symptoms (CAT score ≥ 10) (OR = 3.97, 95%CI:1.86-8.44; p < 0.01), fatigue (FSS ≥ 36) (OR = 2.74, 95%CI:1.31-5.74; p = 0.01), and insomnia symptoms (AIS ≥ 6) (OR = 5.17 95%CI:2.23-12.01; p < 0.01), while the association with depressive symptoms (PHQ-9 ≥ 10) was marginally significant (OR = 3.1, 95%CI:0.93-10.36; p = 0.07). Our results suggest that lower levels of social support are positively associated with PROMs in patients with COPD. Therefore, our findings show an additional way to improve the overall health of patients with COPD in primary care by putting social support at the epicenter of actions.

Various types of stress and greater use of disengagement coping are associated with worse sleep disturbance in oncology patients undergoing chemotherapy

Various types of stress and the choice of coping strategies may be risk factors for higher levels of sleep disturbance in oncology patients. Purposes were to evaluate for differences in global, cancer-specific, and cumulative life stress, as well as resilience and the use of coping strategies among three subgroups of patients with distinct sleep disturbance profiles (i.e., Low, High, Very High). Oncology outpatients (n = 1331) completed measures of global (Perceived Stress Scale), cancer-specific (Impact of Event Scale-Revised), and cumulative life (Life Stressor Checklist-Revised) stress, resilience (Connor-Davidson Resilience Scale) and coping (Brief Cope) prior to their second or third cycle of chemotherapy. Sleep disturbance was assessed six times over two chemotherapy cycles. Differences were evaluated using parametric and non-parametric tests. All stress measures showed a dose response effect (i.e., as the sleep disturbance profile worsened, levels of all types of stress increased). Compared to Low class, the other two classes reported higher levels of global perceived stress and higher occurrence rates and effect from previous stressful life events. Impact of Event Scale-Revised scores for the Very High class indicated post-traumatic symptomatology. Patients in High and Very High classes had resilience scores below the normative score for the United States population and used a higher number of disengagement coping strategies. Our findings suggest that very high levels of sleep disturbance are associated with higher levels of various types of stress, lower levels of resilience, and higher use of disengagement coping strategies. Clinicians need to perform routine assessments and implement symptom management interventions to reduce stress and encourage the use of engagement coping strategies.

Investigation of the Relationships Between Beck Depression/Anxiety Scores and Neuropsychological Tests Scores with Lifestyle Behaviors in the Context of Neuroplasticity and Neurogenesis Approach

In this study, the relationships between lifestyle behaviors within the scope of neuroplasticity and neurogenesis approach and depression, anxiety and neuropsychological test scores were examined. As this study aimed to reveal the relationships between events or variables, it was designed using the "descriptive cross-sectional study" method, one of descriptive and relational research methods, was used. The data were collected from 117 students by the researchers using the Öktem Verbal Memory Test, WCST, Digit Span Test, Beck Depression Inventory, Beck Anxiety Scale and Lifestyle Behaviors Survey.According to the results, the quality of sport/exercise and the quality of life showed a significant difference in the depression model, while social support demonstrated a significant difference in the anxiety model. It was seen that those with high scores in life quality and in perceived social support had significantly lower depression and anxiety scores. Moreover, those with good levels of sleep quality, social interaction and nutrition had significantly lower depression scores.Both depression and anxiety scores of those who did sport/exercise, which was among the lifestyle behaviors, were found to be significantly lower. Lastly, the correlations between the neuropsychological test scores and the depression and anxiety scores were examined, and a significant positive correlation was found between both depression and anxiety scores and the "failure to maintain set" scores.

How Hospital Patients Experience Pain the Previous 24 Hours-A Prevalence Assessment of Pain in Five Hospitals in Sweden

BACKGROUND

Previous studies show that pain is common among hospital inpatients.

AIM

This study measures the prevalence of pain and the impact of pain on sleep in patients admitted to five hospitals in Sweden.

METHODS

The patients were admitted to a surgical or a medical ward. They answered on a self-reported questionnaire about their average pain intensity and how much their pain interfered with their sleep the previous 24 hours, on a 010 numerical rating scale (NRS).

RESULTS

Of the 500 patients, 308 experienced pain (62%), (NRS ≥ 3) and 111 (22%) rated their pain as NRS ≥ 7. We found no difference between surgical and medical specialty regarding pain prevalence. The results suggest that roughly the same proportion of patients with pain also experienced poor sleep due to pain265 patients (53%) reported pain interference on sleep, NRS ≥ 3.

CONCLUSIONS AND CLINICAL IMPLICATIONS

This study shows that there is still an unacceptable high pain prevalence in inpatients and that patients experience pain as negatively impacting their sleep. Future pain care is likely to include a more comprehensive implementation strategy for the dissemination of knowledge, especially related to the complex context of today's healthcare system. That is, the possibility that anchoring new knowledge also benefits the patient is probably associated with optimization of the structural context. Future research should take this question further by examining how the organizational structure should be optimized for the dissemination of knowledge in healthcare professionals about pain and pain interference with sleep.

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.

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.

The Association between Sleep Quality and Fatigue in Colorectal Cancer Survivors up until Two Years after Treatment: A Cross-Sectional and Longitudinal Analysis

Simple Summary

Fatigue is a distressing complaint with high detriment to quality of life that persists in one third of colorectal cancer survivors after cancer treatment. Surprisingly, the contribution of poor sleep quality to fatigue in colorectal cancer survivors is underinvestigated. We aimed to investigate the association between sleep quality and fatigue in colorectal cancer survivors up until two years post-treatment. Results showed worse sleep quality in colorectal cancer patients was associated with higher levels of fatigue during the first two years post-treatment. The results of this study suggest that more attention for sleep quality in colorectal cancer survivors and offering sleep health interventions may lead to less fatigue and better quality of life in this group.

Abstract

Fatigue is a distressing complaint with high detriment to quality of life that persists in one-third of colorectal cancer survivors after cancer treatment. Previous studies in mixed groups of cancer patients have suggested sleep quality is associated with fatigue. We aimed to investigate this association in colorectal cancer survivors up until two years post-treatment. Data on n = 388 stage I–III colorectal cancer patients were utilized from the EnCoRe study. Sleep quality and fatigue were measured at 6 weeks and 6, 12, and 24 months post-treatment. Sleep quality was measured using the Pittsburgh Sleep Quality Index (cross-sectional analysis only) and the single-item insomnia scale from the EORTC QLQ-C30. Fatigue was measured by the Checklist Individual Strength. Linear and mixed-model regression analyses analysed associations between sleep quality and fatigue cross-sectionally and longitudinally. Longitudinal analysis revealed worsening sleep quality over time was significantly associated with increased levels of fatigue over time (β per 0.5 SD increase in the EORTC-insomnia score = 2.56, 95% Cl: 1.91, 3.22). Significant cross-sectional associations were observed between worse sleep quality and higher levels of fatigue at all time points. Worse sleep quality in colorectal cancer patients was associated with higher levels of fatigue during the first two years post-treatment.

Post-traumatic stress symptomatology and adjustment of medical oncology practice during the COVID-19 pandemic among adult patients with cancer in a day care hospital

Background

The COVID‐19 pandemic may induce post‐traumatic stress disorder (PTSD) symptoms among patients with cancer, who also face adaptations to their treatment. The authors assessed the occurrence of PTSD symptoms, investigated pandemic‐induced adjustments in medical oncology practice in patients with cancer, and explored risk factors for PTSD and the association between PTSD symptoms, insomnia, and quality of life (QoL).

Methods

This prospective French study was conducted in patients with solid/hematologic tumors who were receiving medical treatment in the day care departments of 2 cancer centers during the lockdown. Adjustments to medical oncology practice were collected from medical records. PTSD (measured using the Impact of Event Scale‐Revised), insomnia (measured using the Insomnia Severity Index), QoL (measured using the Functional Assessment of Cancer Therapy‐General instrument), and cognitive complaints (measured using the Functional Assessment of Cancer Therapy–Cognitive Function instrument) were collected through validated questionnaires.

Results

Clinical data and questionnaires were available for 734 and 576 patients, respectively. The median patient age was 64 years, and 69% of patients were women. Twenty‐one percent of patients had PTSD. Twenty‐seven percent (95% CI, 23%‐30%) had an adjustment in their medical oncology program, including adjournments (29%), treatment interruptions (16%), modified treatment plans (27%), or adapted monitoring (27%). Women and patients experiencing an adjustment in oncology practice had a higher odds of PTSD (odds ratio= 2.10 [95% CI, 1.07‐4.14] and 1.65 [95% CI, 1.03‐2.63]; P < .05). PTSD symptoms were correlated with worse scores for QoL, cognition, and insomnia.

Conclusions

Twenty‐one percent of patients with cancer experienced PTSD symptoms associated with poor QoL during the first COVID‐19–induced lockdown. Medical oncology practice was adjusted in approximately one‐quarter of patients and was associated with the occurrence of PTSD symptoms. Psychosocial support should be offered in cancer centers to promote emotional resilience and avoid PTSD symptoms in patients.

Post‐traumatic stress disorder symptomatology occurred in 21% of patients with cancer during the first lockdown due to COVID‐19, was more frequent among women, and was associated with adjustment in medical oncology treatments. Caregivers should pay special attention to the psychological needs of patients with cancer to prevent or manage post‐traumatic stress disorder symptoms.

Are Sleep Complaints Related to Cognitive Functioning in Non-Central Nervous System Cancer? A Systematic Review

Patients with non-central nervous system (CNS) cancer frequently report cognitive complaints, that are recurrent and affect their quality of life. In order to improve supportive care of these cognitive difficulties, it is important to identify associated factors. Sleep disturbance is a good candidate to study, as patients with non-CNS cancer frequently report sleep disorders, and sleep plays a key role in cognitive functioning. The objective of the present systematic review was to summarize the results of studies evaluating the relationship between cognition and sleep in non-CNS cancer, and to highlight the need for further studies. PubMed [Medline] and Scopus databases were screened from April to November 2020 for studies published in English evaluating the association between cognition and sleep in adults with non-CNS cancer. The characteristics and risk of bias for each of the 30 included studies have been reported. Greater cognitive complaints in patients with non-CNS cancer were related to poorer self-reported sleep quality in almost all studies (n = 22/24). By contrast, around half of the studies reported a significant association between poorer neuropsychological performances and sleep complaints (n = 5/11). The studies were found to have several limitations, such as the lack of a control group, which would have shed the light on the period of occurrence of this association (e.g. after cancer diagnosis or after cancer treatments). Our review also identified factors that may influence the relationship between cognition and sleep. Recommendations are given for improving the methodology of future studies and extending the impact of their results.

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)

Newly diagnosed patients with advanced non-small cell lung cancer: A clinical description of those with moderate to severe depressive symptoms

OBJECTIVES

The aims of this observational study were to 1) accrue newly diagnosed patients with advanced-stage non-small cell lung cancer (NSCLC) awaiting the start of first-line treatment and identify those with moderate to severe depressive symptoms and, 2) provide a clinical description of the multiple, co-occurring psychological and behavioral difficulties and physical symptoms that potentially exacerbate and maintain depressive symptoms.

MATERIALS AND METHODS

Patients with stage IV NSCLC (N = 186) were enrolled in an observational study (ClinicalTrials.gov Identifier: NCT03199651) and completed the American Society of Clinical Oncology-recommended screening measure for depression (Patient Health Questionnaire-9 [PHQ-9]). Individuals with none/mild (n = 119; 64 %), moderate (n = 52; 28 %), and severe (n = 15; 8 %) depressive symptoms were identified. Patients also completed measures of hopelessness, generalized anxiety disorder (GAD) symptoms, stress, illness perceptions, functional status, and symptoms.

RESULTS

Patients with severe depressive symptoms reported concomitant feelings of hopelessness (elevating risk for suicidal behavior), anxiety symptoms suggestive of GAD, and traumatic, cancer-specific stress. They perceived lung cancer as consequential for their lives and not controllable with treatment. Pain and multiple severe symptoms were present along with substantial functional impairment. Patients with moderate depressive symptoms had generally lower levels of disturbance, though still substantial. The most salient differences were low GAD symptom severity and fewer functional impairments for those with moderate symptoms.

CONCLUSIONS

Depressive symptoms of moderate to severe levels co-occur in a matrix of clinical levels of anxiety symptoms, traumatic stress, impaired functional status, and pain and other physical symptoms. All of the latter factors have been shown, individually and collectively, to contribute to the maintenance or exacerbation of depressive symptoms. As life-extending targeted and immunotherapy use expands, prompt identification of patients with moderate to severe depressive symptoms, referral for evaluation, and psychological/behavioral treatment are key to maximizing treatment outcomes and quality of life for individuals with advanced NSCLC.

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.

Cancer-Specific Stress and Trajectories of Psychological and Physical Functioning in Patients With Relapsed/Refractory Chronic Lymphocytic Leukemia

Background

Chronic lymphocytic leukemia is the most prevalent adult leukemia. The disease is incurable with a cycling of treatment and relapse common. Little is known about the psychological and physical functioning of patients with relapsed/refractory chronic lymphocytic leukemia. Cancer-specific stress is an important individual difference variable that predicts psychological and physical outcomes.

Purpose

To examine cancer-specific stress at treatment initiation as a predictor of psychological and physical functioning trajectories in patients with relapsed/refractory chronic lymphocytic leukemia during the first 5 months of treatment.

Methods

Patients with relapsed/refractory chronic lymphocytic leukemia (N = 152) enrolled in a phase II clinical trial completed self-report measures at treatment initiation (baseline), 1, 2, and 5 months of treatment. Cancer-specific stress at baseline was examined as a predictor of psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems, physical health quality of life), controlling for demographic and treatment variables.

Results

Using multilevel modeling, higher baseline cancer-specific stress was related to worse psychological (cognitive-affective depressive symptoms, negative mood, mental health quality of life) and physical functioning (fatigue interference, sleep problems) at baseline and more rapid improvements during the next 5 months. Despite these improvements, higher baseline cancer-specific stress remained associated with poorer 5-month psychological, though not physical, functioning.

Conclusions

Findings suggest cancer-specific stress at treatment initiation may be a risk factor for poorer psychological functioning during treatment for patients with relapsed/refractory chronic lymphocytic leukemia.

Effects of a multidisciplinary quality of life intervention on sleep quality in patients with advanced cancer receiving radiation therapy

OBJECTIVES

Sleep disturbances are prevalent in cancer patients, especially those with advanced disease. There are few published intervention studies that address sleep issues in advanced cancer patients during the course of treatment. This study assesses the impact of a multidisciplinary quality of life (QOL) intervention on subjective sleep difficulties in patients with advanced cancer.

METHOD

This randomized trial investigated the comparative effects of a multidisciplinary QOL intervention (n = 54) vs. standard care (n = 63) on sleep quality in patients with advanced cancer receiving radiation therapy as a secondary endpoint. The intervention group attended six intervention sessions, while the standard care group received informational material only. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS), administered at baseline and weeks 4 (post-intervention), 27, and 52.

RESULTS

The intervention group had a statistically significant improvement in the PSQI total score and two components of sleep quality and daytime dysfunction than the control group at week 4. At week 27, although both groups showed improvements in sleep measures from baseline, there were no statistically significant differences between groups in any of the PSQI total and component scores, or ESS. At week 52, the intervention group used less sleep medication than control patients compared to baseline (p = 0.04) and had a lower ESS score (7.6 vs. 9.3, p = 0.03).

SIGNIFICANCE OF RESULTS

A multidisciplinary intervention to improve QOL can also improve sleep quality of advanced cancer patients undergoing radiation therapy. Those patients who completed the intervention also reported the use of less sleep medication.

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.

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.

La influencia del estrés y el optimismo sobre la calidad de sueño de mujeres con cáncer de mama

Objetivo: El objetivo de este estudio fue determinar la influencia del estrés y el optimismo sobre la calidad de sueño de mujeres con cáncer de mama. Método: Diseño trasversal correlacional. Los instrumentos utilizados fueron el Índice de Calidad del Sueño de Pittsburgh, la Escala de Estrés Percibido y la Escala de Orientación de Vida. Participaron 60 pacientes con cáncer de mama en estadios tempranos, sin metástasis, con una media de edad de 51,4 (±9,3) años. Resultados: Las pacientes obtuvieron una media de 7,5 (±4,4) del Índice de calidad de sueño global, en donde a mayor puntaje indica una mala calidad de sueño, una media de 24,5 (±9,5) para estrés y una media 37,6 (±5,5) para optimismo. Se obtuvo una correlación positiva y significativa entre el estrés y calidad de sueño global (r =0,349, p=0.006), y una correlación negativa y significativaentre optimismo y calidad de sueño (r =-0,524, p=0,001). El optimismo predice la calidad de sueño global en un 25,8%. Conclusión: En mujeres con cáncer de mama en estadios tempranos, la relación entre variables indica que a mayor estrés menor calidad de sueño, menor duración del dormir y más alteraciones de sueño. En cuanto a la variable de optimismo, indica que, a mayor optimismo, mayor calidad subjetiva de sueño, mayor duración, menor latencia de sueño y menos alteraciones del dormir. Por lo tanto, se concluye que, en mujeres con cáncer de mama, el estrés reduce la calidad de sueño mientras que el optimismo la beneficia directamente.

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.

Feasibility of a Cognitive-Behavioral and Environmental Intervention for Sleep-Wake Difficulties in Community-Dwelling Cancer Patients Receiving Palliative Care

BACKGROUND

High rates of sleep-wake difficulties have been found in patients with cancer receiving palliative care. Pharmacotherapy is the most frequently used treatment option to manage these difficulties despite numerous adverse effects and the absence of empirical evidence of its efficacy and innocuity in palliative care.

OBJECTIVE

This pilot study aimed to assess the feasibility and acceptability of a cognitive-behavioral and environmental intervention (CBT-E) to improve insomnia and hypersomnolence in patients with a poor functioning level and to collect preliminary data on its effects.

METHODS

Six patients with cancer receiving palliative care (Eastern Cooperative Oncology Group score 2-3), who had insomnia and/or hypersomnolence, received 1 CBT-E individual session at home. They applied the strategies for 3 weeks. Patients completed the Insomnia Severity Index, the Epworth Sleepiness Scale, a daily sleep diary, and a 24-hour actigraphic recording (7 days) at pretreatment and posttreatment, in addition to a semistructured interview (posttreatment).

RESULTS

Participants found strategies easy to apply most of the time, and none was rated as impossible to use because of their health condition. However, their adherence and satisfaction toward CBT-E were highly variable. Results on the effects of CBT-E were heterogeneous, but improvements were observed in patients with a persistent insomnia disorder.

CONCLUSIONS

The CBT-E protocol tested among this highly selected sample was fairly well received and suggested positive outcomes in some patients, particularly those with an insomnia complaint alone.

IMPLICATIONS

Efforts should be pursued to adapt CBT-E and develop other nonpharmacological interventions, in order to provide an alternative to pharmacotherapy for sleep-wake difficulties in this population.

Relationship between sleep and exercise as colorectal cancer survivors transition off treatment

PURPOSE

The primary objective of this study was to evaluate the relationship between exercise and sleep disturbance in a sample of individuals diagnosed with stage I, II, and III colorectal cancer (CRC) as patients transitioned off first-line treatment. We also sought to identify heterogeneity in the relationship between sleep disturbance and exercise.

METHODS

Data were obtained from the MY-Health study, a community-based observational study of adults diagnosed with cancer. Patient-Reported Outcomes Measurement Information System® (PROMIS) measures (e.g., PROMIS Sleep) were administered, and participants self-reported demographics, comorbidities, cancer treatment, and exercise. Regression mixture and multiple regression models were used to evaluate the relationship between sleep disturbance and exercise cross-sectionally at an average of 10 months after diagnosis, and the change in sleep disturbance over a 7-month period, from approximately 10 to 17 months post-diagnosis.

RESULTS

Patients whose exercise was categorized as likely at or above American College of Sports Medicine's guidelines did not report statistically better sleep quality compared to patients who were classified as not active. However, retirement (B = - 2.4), anxiety (B = 0.21), and fatigue (B = 0.24) had statistically significant relationships with sleep disturbance (p < 0.05). Increase in exercise was not significantly associated with a decrease in sleep disturbance. No statistical heterogeneity was revealed in the relationship between sleep and exercise.

CONCLUSIONS

Further prospective research using an objective measure of exercise is warranted to confirm or refute the nature of the relationship between exercise and sleep disturbance in individuals diagnosed with CRC transitioning off first-line treatment.

Sleep quality in individuals diagnosed with colorectal cancer: Factors associated with sleep disturbance as patients transition off treatment

OBJECTIVE

To identify patient characteristics associated with sleep disturbance and worsening of sleep in individuals diagnosed with localized colorectal cancer and assess heterogeneity in these relationships.

METHODS

Data were from the MY-Health study, a community-based observational study of adults diagnosed with cancer. Patient-Reported Outcomes Measurement Information System® Sleep Disturbance, Anxiety, Depression, Fatigue, and Pain Interference measures were administered. Participants self-reported demographics, comorbidities, and treatment information. Regression mixture and multiple regression models were used to evaluate the relationship between sleep disturbance and patient characteristics cross-sectionally at an average of 10 months after diagnosis (n = 613) as well as change in sleep disturbance over a 6-month period (n = 361).

RESULTS

Pain, anxiety, fatigue, and the existence of multiple comorbid conditions had statistically significant relationships with sleep disturbance (B = 0.09, 0.22, 0.29, and 1.53, respectively; P < 0.05). Retirement (B = -2.49) was associated with sleep quality in the cross-sectional model. Worsening anxiety (B = 0.14) and fatigue (B = 0.20) were associated with worsening sleep disturbance, and more severe sleep disturbance 10 months after diagnosis (B = -0.21) was associated with improvement in sleep quality after diagnosis (P < 0.05). No evidence of latent subgroups of patients (heterogeneity) was present.

CONCLUSIONS

Pain, anxiety, fatigue, employment, and comorbid conditions were associated with sleep disturbance, but regression coefficients were small (< |2.5|). Results suggest that screening for anxiety, depression, fatigue, or pain is not sufficient for identifying sleep disturbance. Given the negative consequences of sleep disturbance, sleep disturbance screening may be warranted.

Disruptions in sleep-wake cycles in community-dwelling cancer patients receiving palliative care and their correlates

Significant disruptions in sleep-wake cycles have been found in advanced cancer patients in prior research. However, much remains to be known about specific sleep-wake cycle variables that are impaired in patients with a significantly altered performance status. More studies are also needed to explore the extent to which disrupted sleep-wake cycles are related to physical and psychological symptoms, time to death, maladaptive sleep behaviors, quality of life and 24-h light exposure. This study conducted in palliative cancer patients was aimed at characterizing patients' sleep-wake cycles using various circadian parameters (i.e. amplitude, acrophase, mesor, up-mesor, down-mesor, rhythmicity coefficient). It also aimed to compare rest-activity rhythm variables of participants with a performance status of 2 vs. 3 on the Eastern Cooperative Oncology Group scale (ECOG) and to evaluate the relationships of sleep-wake cycle parameters with several possible correlates. The sample was composed of 55 community-dwelling cancer patients receiving palliative care with an ECOG of 2 or 3. Circadian parameters were assessed using an actigraphic device for seven consecutive 24-h periods. A light recording and a daily pain diary were completed for the same period. A battery of self-report scales was also administered. A dampened circadian rhythm, a low mean activity level, an early mean time of peak activity during the day, a late starting time of activity during the morning and an early time of decline of activity during the evening were observed. In addition, a less rhythmic sleep-wake cycle was associated with a shorter time to death (from the first home visit) and with a lower 24-h light exposure. Sleep-wake cycles are markedly disrupted in palliative cancer patients, especially, near the end of life. Effective non-pharmacological interventions are needed to improve patients' circadian rhythms, including perhaps bright light therapy.

Sleep Disturbance Mediates the Association of Post-Traumatic Stress Disorder Symptoms and Pain in Patients With Cancer

BACKGROUND

Sleep disturbance is a common complaint of patients with cancer and is well established in both pain conditions and post-traumatic stress disorder (PTSD). An estimated one-third of patients with cancer develop symptoms of PTSD at some point in their treatment. However, few studies have evaluated the contributions of PTSD and sleep disturbance to pain processes in cancer populations. The current study used mediation models to test the hypothesis that sleep disturbance would mediate the relationships between PTSD symptoms and pain intensity and PTSD symptoms and pain interference in a sample of patients with cancer.

METHODS

A cross-sectional, retrospective chart review was conducted of the electronic medical records of 85 adult patients with cancer (89.4% female; 59% white; 42% metastatic) who sought individual psychosocial support services at our institution.

RESULTS

Post-traumatic stress disorder symptoms, sleep disturbance, pain intensity, and pain interference were all positively correlated ( P < .01). Clinical levels of PTSD symptoms were reported by 30% to 60% of the sample. Even after controlling for metastatic disease, race, and cancer type, sleep disturbance mediated the relationships between PTSD symptoms and pain intensity ( B = 0.27; 95% CI: 0.10-0.44) and PTSD symptoms and pain-related interference ( B = 0.58; 95% CI: 0.28-0.87).

CONCLUSIONS

The relationships among PTSD symptoms, pain intensity, and pain interference could be explained by co-occurring sleep disturbance. Given the high frequency of PTSD symptoms among patients with cancer and PTSD's known links to sleep problems and pain, clinicians should be attentive to the role that traumatogenic processes may play in eliciting sleep and pain-related complaints among patients with cancer.

Sleep-wake difficulties in community-dwelling cancer patients receiving palliative care: subjective and objective assessment

OBJECTIVE

Prevalence rates of sleep difficulties in advanced cancer patients have varied widely across studies (12 to 96%), and none of these employed a diagnostic interview to distinguish different types of sleep-wake disorders. Moreover, very limited information is available on subjective and objective sleep parameters in this population. Our study was conducted in palliative cancer patients and aimed to assess rates of sleep-wake disorders and subsyndromal symptoms and to document subjective and objective sleep-wake parameters across various types of sleep-wake difficulties.

METHOD

The sample was composed of 51 community-dwelling cancer patients receiving palliative care and having an Eastern Cooperative Oncology Group score of 2 or 3. Relevant sections of the Duke Interview for Sleep Disorders were administered over the phone. An actigraphic recording and a daily sleep diary were completed for 7 consecutive days.

RESULTS

Overall, 68.6% of the sample had at least one type of sleep-wake difficulty (disorder or symptoms): 31.4% had insomnia and 29.4% had hypersomnolence as their main sleep-wake problem. Participants with insomnia as their main sleep difficulty had greater disruptions of subjective sleep parameters, while objectively-assessed sleep was more disrupted in patients with hypersomnolence comorbid with another sleep-wake difficulty.Significance of the Results:The high rates of sleep-wake difficulties found in this study indicate a need to screen more systematically for sleep-wake disorders, including insomnia and hypersomnolence, in both palliative care research and clinical practice, and to develop effective nonpharmacological interventions specifically adapted to this population.

Cognitive problems following hematopoietic stem cell transplant: relationships with sleep, depression and fatigue

Cognitive problems are a significant, persistent concern for patients undergoing hematopoietic stem cell transplant (HSCT). Sleep is important for many cognitive tasks; however, the relationship between sleep and cognitive problems for HSCT patients is unknown. This study examined the relationship between sleep and cognitive problems for HSCT patients from pre to post transplant. Patients undergoing HSCT (N=138) completed questionnaires at pre-transplant and during the 12 months following transplant. Questionnaires assessed sleep and cognitive problems as well as commonly co-occurring symptoms: depressive symptoms, fatigue and pain. Post hoc analyses examined the relationship of specific sleep problems with cognitive problems. Sleep problems covaried with cognitive problems even after controlling for depressive symptoms, fatigue and pain. Depressive symptoms and fatigue were also uniquely related to cognitive problems. Post hoc analyses suggest that sleep somnolence, shortness of breath, snoring and perceptions of inadequate sleep may contribute to the association found between sleep and cognitive problems. Findings suggest that sleep problems are associated with and may contribute to cognitive problems for HSCT patients. However, sleep problems are rarely screened for or discussed during clinic visits. Assessing and treating specific sleep problems in addition to depressive symptoms and fatigue may have implications for improving cognitive problems for HSCT patients.

Sleep quality in patients with chronic illness

AIMS AND OBJECTIVES

To explore sleep quality in patients with chronic illness in primary care.

BACKGROUND

Many people suffer from chronic illness with the numbers increasing. One common issue arises from problems that people have with their quality of sleep: a largely under-researched topic. This study exploring poor quality sleep allowed patients to describe their daily struggles with poor sleep in their own lives. This allowed the development of a deeper understanding of what it means to sleep poorly and find out how participants cope with not sleeping well.

DESIGN

A qualitative approach enabling a deep exploration of patient's experiences of sleep quality was used. Interviews were conducted with a purposive sample of nine participants from a primary care clinic. Analysis utilised an interpretative approach.

RESULTS

Data analysed produced four recurrent themes that were grouped into two categories. First, themes that identified the recognition by participants that 'something was wrong' were abrupt beginning and impact on their life. Second, themes that identified that the participants considered there was 'nothing wrong' were I am fine and I just carry on.

CONCLUSION

Data revealed that poor quality sleep can have a profound effect on quality of life. Participants lived without good quality sleep for years. They had come to accept two seemingly irreconcilable ideas that not being able to sleep is an enduring problem with a distinct starting point, and paradoxically, this is not a problem that deserves much professional attention.

RELEVANCE TO CLINICAL PRACTICE

Important original data were generated on the impact of poor quality sleep indicating that chronically disturbed sleep can increase the disease burden on patients with chronic illness. The results of this study suggest healthcare professionals need to understand how sleep quality issues impact on patient's experience of chronic illness. Data from this study will help nurses and other health professionals to deepen their understanding of the profound impact of poor quality sleep on patients with chronic illness. A programme of education highlighting the important role of sleep quality in chronic illness is suggested by the issues raised in this study. Nurses are ideally placed to assess sleep quality in patients and tailor intervention to positively affect the quality of life for this group.

Improving sleep-wake disturbances in patients with cancer

Patients with cancer tend to suffer sleep-wake disturbances at a higher rate than the general population. Insomnia and fatigue should be regarded as a significant patient safety issue, as poor sleep can elevate patients' risks of falls, motor vehicle accidents, and acute infectious illnesses. To alleviate those risks, oncology nurses should be familiar with effective evidence-based practices for assessing and improving patients' sleep quality.

Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained?

Although sleep is vital to all human functioning and poor sleep is a known problem in cancer, it is unclear whether the overall prevalence of the various types of sleep disorders in cancer is known. The purpose of this systematic literature review was to evaluate if the prevalence of sleep disorders could be ascertained from the current body of literature regarding sleep in cancer. This was a critical and systematic review of peer-reviewed, English-language, original articles published from 1980 through 15 October 2013, identified using electronic search engines, a set of key words, and prespecified inclusion and exclusion criteria. Information from 254 full-text, English-language articles was abstracted onto a paper checklist by one reviewer, with a second reviewer randomly verifying 50% (k = 99%). All abstracted data were entered into an electronic database, verified for accuracy, and analyzed using descriptive statistics and frequencies in SPSS (v.20) (North Castle, NY). Studies of sleep and cancer focus on specific types of symptoms of poor sleep, and there are no published prevalence studies that focus on underlying sleep disorders. Challenging the current paradigm of the way sleep is studied in cancer could produce better clinical screening tools for use in oncology clinics leading to better triaging of patients with sleep complaints to sleep specialists, and overall improvement in sleep quality.

Insomnia, hypnotic use, and health-related quality of life in a nationally representative sample

PURPOSE

To assess health-related quality of life (HRQoL) associated with insomnia and prescription hypnotic use.

METHODS

Primary outcomes were mental component summary (MCS) and physical component summary (PCS) scores from the 12-item Short-Form Health Survey. Using multiple regression, subjects in the 2005 through 2009 Medical Expenditure Panel Survey with diagnosed insomnia were compared against those without that diagnosis. Among subjects with diagnosed insomnia, users of prescription hypnotics were compared against nonusers.

RESULTS

Of 104,274 adults, 1.3 % (n = 1,401) had an insomnia diagnosis. Of those, 45.6 % (n = 639) used prescription hypnotics. For subjects with insomnia, mean PCS and MCS scores were 9.2 and 7.0 points lower (p < 0.001), respectively. After controlling for demographic and clinical covariates, differences remained significant (PCS:5.1;

MCS

6.2; p < 0.001). Among subjects with insomnia, HRQoL scores were not different between prescription hypnotic users (n = 639) and nonusers (n = 762). Analysis by drug class revealed lower PCS scores (difference: 7.5, p < 0.001) with benzodiazepine use (n = 129) versus benzodiazepine receptor agonist use (n = 493), but the adjusted difference was not significant (difference: 3.8, p = .018).

CONCLUSIONS

Diagnosed insomnia was associated with consistent decreases in both physical and mental HRQoL scores, regardless of whether prescription hypnotics were used. Benzodiazepine use may be associated with a further decrease in physical HRQoL scores. Although limited by its retrospective design, this study provides a first look at real-world hypnotic use outcomes at a national level. Important next steps include studies with patients serving as their own controls, and further evaluation of the sensitivity of HRQoL instruments to the effects of insomnia treatments.

[Health-related quality of life among patients with advanced cancer: an integrative review]

This integrative literature review aimed to characterize scientific articles on health-related quality of life - HRQoL - among patients with advanced cancer from national and international literature, and summarize those factors evidenced in the literature that contributed to the improvement or worsening of HRQoL among patients with advanced cancer. The search for materials was conducted in the following databases: CINAHL, EMBASE, PubMed, SciELO and LILACS. Among the 21 articles in the sample, 13 showed an improvement of HRQoL among patients with advanced cancer related to the development of physical, emotional and spiritual interventions. In eight studies, we identified predictive symptoms of low HRQoL, such as pain, fatigue, sleep disorders, depression, nutritional changes, and others. The results showed that clinical manifestations, which many times were inherent in cancer, such as factors that can lower patients' HRQoL, while physical, psychological and spiritual benefits resulting from therapeutic interventions may promote its improvement.

Sleep quality following hematopoietic stem cell transplantation: longitudinal trajectories and biobehavioral correlates

The present study examined changes in sleep quality following hematopoietic stem cell transplantation (HSCT) and investigated associations with biobehavioral factors. Individuals undergoing HSCT for hematologic malignancies (N=228) completed measures of sleep quality and psychological symptoms pre-transplant and 1, 3, 6, and 12 months post-transplant. Circulating inflammatory cytokines (IL-6, TNF-α) were also assessed. Sleep quality was poorest at one month post-transplant, improving and remaining relatively stable after 3 months post-transplant. However, approximately half of participants continued to experience significant sleep disturbance at 6 and 12 months post-transplant. Mixed-effects linear regression models indicated that depression and anxiety were associated with poorer sleep quality, while psychological well-being was associated with better sleep. Higher circulating levels of IL-6 were also linked with poorer sleep. Subject-level fixed effects models demonstrated that among individual participants, changes in depression, anxiety, and psychological well-being were associated with corresponding changes in sleep after covarying for the effects of time since transplant. Sleep disturbance was most severe when depression and anxiety were greatest, and psychological well-being was lowest. Findings indicate that sleep disturbance is a persistent problem during the year following HSCT. Patients experiencing depression or anxiety and those with elevated inflammation may be at particular risk for poor sleep.

Insomnia among patients with advanced disease during admission in a Palliative Care Unit: a prospective observational study on its frequency and association with psychological, physical and environmental factors

BACKGROUND

THE AIMS OF THIS STUDY WERE

1) to assess the frequency of insomnia among patients during admission in a Palliative Care Unit (PCU); 2) to study the association between emotional distress and insomnia, taking physical, environmental and other psychological factors into account.

METHODS

Prospective observational study including patients consecutively admitted to a PCU during eight months, excluding those with severe cognitive problems or too low performance status. Insomnia was assessed by asking a single question and by using the Sleep Disturbance Scale (SDS), and emotional distress using the Hospital Anxiety and Depression Scale (HADS). Physical, environmental and other psychological factors potentially interfering with sleep quality were evaluated. Association between insomnia and the factors evaluated was studied using univariate and multivariate regression analyses.

RESULTS

61 patients were included (mean age 71.5 years; 95% with oncological disease); 38 (62%) answered "yes" to the insomnia single question and 29 (47%) showed moderate to severe insomnia according to the SDS. 65% showed clinically significant emotional distress and 79% had nocturnal rumination. The physical symptoms most often mentioned as interfering with sleep quality were pain (69%) and dyspnoea (36%). 77% reported at least one environmental disturbance. In the univariate analysis, answering "yes" to the insomnia single question was significantly associated with higher HADS score, anxiety, nocturnal rumination, clear knowledge of the diagnosis, higher performance status and dyspnoea; moderate to severe insomnia was significantly associated with nocturnal rumination, higher performance status, environmental disturbances and daytime sleepiness. In the multivariate regression analysis, answering "yes" to the single question was associated with dyspnoea (OR 7.2 [1.65-31.27]; p = 0.009), nocturnal rumination (OR 5.5 [1.05-28.49]; p = 0.04) and higher performance status (OR 14.3 [1.62-125.43]; p = 0.017), and moderate to severe insomnia with nocturnal rumination (OR 5.6 [1.1-29.1]; p = 0.041), and inversely associated with daytime sleepiness (OR 0.25 [0.07-0.9]; p = 0.043).

CONCLUSIONS

Insomnia was highly frequent. Several physical, psychological and environmental factors seemed to influence insomnia. Within the multimodal management of insomnia, the assessment of nocturnal rumination may be of particular interest, irrespective of emotional distress. Further studies with larger sample sizes could confirm this result.

Clinical Usefulness of Hydromorphone-OROS in Improving Sleep Disturbances in Korean Cancer Patients: A Multicenter, Prospective, Open-Label Study

Purpose

To evaluate the efficacy of hydromorphone-OROS (HM-OROS) in reducing sleep disturbance and relieving cancer pain.

Materials and Methods

One hundred twenty cancer patients with pain (numeric rating scale [NRS] ≥ 4) and sleep disturbance (NRS ≥ 4) were evaluated. The initial HM-OROS dosing was based on previous opioid dose (HM-OROS:oral morphine=1:5). Dose adjustment of the study drug was permitted at the investigator’s discretion. Pain intensity, number of breakthrough pain episodes, and quality of sleep were evaluated.

Results

A total of 120 patients received at least one dose of HM-OROS; 74 of them completed the final assessment. Compared to the previous opioids, HM-OROS reduced the average pain NRS from 5.3 to 4.1 (p < 0.01), worst pain NRS from 6.7 to 5.4 (p < 0.01), sleep disturbance NRS from 5.9 to 4.1 (p < 0.01), incidence of breakthrough pain at night from 2.63 to 1.53 times (p < 0.001), and immediate-release opioids use for the management of breakthrough pain from 0.83 to 0.39 times per night (p = 0.001). Of the 74 patients who completed the treatment, 83.7% indicated that they preferred HM-OROS to the previous medication. The adverse events (AEs) were somnolence, asthenia, constipation, dizziness, and nausea.

Conclusion

HM-OROS was efficacious in reducing cancer pain and associated sleep disturbances. The AEs were manageable.

The complex associations among sleep quality, anxiety-depression, and quality of life in patients with extreme obesity

INTRODUCTION

Sleep duration and quality have been associated with obesity. Sleep disturbance has been reported to be associated with stress and depression among non-obese populations, but these relationships have not been previously examined in the obese population. The objective of the current study was to examine the complex associations among sleep disturbance, quality of life, anxiety, and depression in a patient sample with severe obesity.

METHODS

Two hundred seventy consecutively recruited patients with a mean body mass index (BMI) of 47.0 kg/m² were studied. The correlation coefficient, multiple linear regressions, and structural equation modeling (SEM) analysis were used to evaluate the association between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Impact of Weight on Quality of Life-Lite (IWQOL-Lite) and Hospital Anxiety and Depression Scale (HADS).

RESULTS

The mean (standard deviation; SD) PSQI score was 8.59 (5.11), and mean ESS score was 8.84 (5.79). After controlling for potential confounders, poor sleep quality and excessive daytime sleepiness were found to be significantly associated of all the components of IWQOL-Lite; physical function (β = -0.32, β = -0.27; P < 0.01), self-esteem (β = -0.23, β = -0.30; P < 0.05), sexual-life (β = -0.30, β = -0.35; P < 0.05), public distress (β = -0.39, β = -0.39; P < 0.01), and work (β = -0.26, β = -0.48; P < 0.01). We also found that the PSQI global score had a positive significant association with anxiety (β = 0.29; P = 0.01) and depression (β = 0.31; P = 0.01) components of HADS.

CONCLUSION

Poor sleep quality was strongly associated with mood disturbance and poor quality of life among extremely obese patients. Future interventions are needed to address sleep disturbance to prevent further development of psychological co-morbidity and potentially worsening of obesity among these individuals.

Self-reported sleep disturbance in patients with advanced cancer: Frequency, intensity, and factors associated with response to outpatient supportive care consultation — A preliminary report

Objectives:

Self-reported sleep disturbance (SD) is a distressing symptom in patients with advanced cancer. There are limited data on the treatment of SD and predictors to response of SD to outpatient supportive care clinic (OPC) consultation. The aims of our study was to determine the frequency, intensity, and correlates of SD as assessed with the Edmonton Symptom Assessment System (ESAS) sleep item at the time of initial consultation and identify the predictors of improvement in SD at follow-up.

Methods:

We reviewed the records of consecutive patients with advanced cancer presenting to the OPC. ESAS scores were obtained at the initial and subsequent visits between January 2008 and February 2010. All patients underwent screening for SD (0–10 scale: 0 = best sleep, presence of SD defined as ≥3) and interdisciplinary assessment and treatment, including drug review, counseling, sleep hygiene review, and drug therapy. A response was defined as a 1-point improvement at the follow-up visit on the Edmonton Symptom Assessment Scale (ESAS) sleep item score. Baseline patient characteristics, medication use, and ESAS scores were analyzed to determine their association with response.

Results:

The median age was 58 years, and 53% of patients were men. The most common cancer type was head and neck or lung (36%). Of the 442 patients, 330 had baseline SD (score ≥3/10, 75%). Median and mean (standard deviation) baseline SD scores were 5 and 5.1 (2.9). The multivariable regression model found the intensity of baseline ESAS sleep item scores to be associated with baseline sedative use, baseline ESAS pain scores, baseline ESAS fatigue scores, baseline ESAS feeling of well-being scores, and sedative use (R2 = 0.22). Sleep disturbance response at first follow-up was seen in 196 of 330 patients (59%). Moderate to high SD score and anxiety at initial visit with odds ratios (OR) of 2.53 (p = 0.0007) and 1.59 (p = 0.048), respectively, were associated with a response.

Significance of results:

Both the frequency and severity of SD were high. Response to supportive care consultation was substantial. The severity of SD and anxiety at the initial visit predicted a response at first follow-up. Further research is needed.

Post-traumatic stress disorder as a comorbidity: impact on disease outcomes

Post-traumatic stress disorder (PTSD) is associated with many psychiatric and nonpsychiatric comorbidities. Growing evidence suggests that PTSD as a comorbidity may impair drug adherence, quality of life and sleep quality, as well as increase rehospitalization rates, disease relapses, intensity of symptoms, morbidity and mortality. The aim of this article is to examine the literature regarding the effects of PTSD comorbidity on physical and mental health.

Stress, coping and cognitive deficits in women after surgery for breast cancer

Research on neuropsychological difficulties among cancer patients has focused on chemotherapy as a primary cause, yet several studies have now shown that some patients evidence cognitive weaknesses prior to chemotherapy. As an alternative to the 'chemo-brain' theory, this study examined the hypothesis that stress and coping style may be associated with observed neuropsychological difficulties among female cancer patients. Thirty-six women completed neuropsychological testing and psychological questionnaires following surgery for breast cancer and prior to any subsequent treatments. Twenty-seven percent of participants evidenced deficits on at least one measure of verbal fluency, and 14% of participants were impaired on at least one memory measure. Self-reported stress was correlated with deficits in memory, verbal fluency, and attention. Subsequent mediational analyses indicated that use of passive coping styles may underlie this relationship between stress and neuropsychological deficits. These findings highlight the potential relevance of psychological mechanisms, such as coping style, in cancer patients' experience of neuropsychological deficits.

Sleep quality and its association with delirium among veterans enrolled in hospice

OBJECTIVES

: The objectives of this study were to describe sleep quality and evaluate the association of sleep quality with delirium onset among patients enrolled in hospice.

DESIGN

: The study utilized secondary data from a prospective, observational, longitudinal study.

SETTING

: Veterans enrolled in hospice were recruited from the Portland Veterans Affairs Medical Center, Portland, Oregon.

PARTICIPANTS

: The cohort consisted of 105 patients, of whom 73% had at least one sleep measurement.

MEASUREMENTS

: Sleep quality was measured with the Pittsburgh Sleep Quality Index. Delirium was measured with the Confusion Assessment Method. Other important variables were recorded from the medical record and/or longitudinal interviews with patients and their caregivers. Cox regression was used to estimate hazard ratios (HRs) to measure the association between sleep quality and delirium onset.

RESULTS

: Of the patients who could be assessed, 44% had poor average sleep quality and 58% reported at least one episode of poor sleep. Overall, sleep quality did not appear to worsen as patients neared death although an increasing number of patients were unable to report on sleep quality. Poor sleep quality was associated with an increased risk of developing delirium, with an HR of 2.37 (95% CI: 1.50-3.74), for every one point worsening in the sleep quality score on a 4-point scale.

CONCLUSIONS

: Poor sleep quality was common among Veteran patients enrolled in hospice. These findings may help guide decision making between clinicians, patients, and families regarding the likely impact of sleep disturbance and may help identify patients at higher risk of developing delirium.

Poor sleep is associated with exaggerated cortisol response to the combined dexamethasone/CRH test in a non-clinical population

Although sleep disturbance has been shown to be associated with psychological distress and the hypothalamic-pituitary-adrenal (HPA) axis function, the simultaneous relationship between sleep, distress and HPA axis function is less clear. Here we examined the relationship between sleep quality as assessed with the Pittsburgh Sleep Quality Index, psychological distress as assessed with the Hopkins Symptom Checklist, and cortisol responses to the dexamethasone (DEX)/corticotropin-releasing hormone (CRH) test in 139 non-clinical volunteers. Poor sleep was significantly correlated with greater cortisol response to the combined DEX/CRH challenge, but not with the cortisol level just before CRH challenge. When subjects were divided into three groups based on the suppression pattern of cortisol (i.e., incomplete-, moderate-, and enhanced-suppressors), poor sleep was significantly associated with the incomplete suppression in women while no significant association was found between sleep and the enhanced suppression. The association between poor sleep and exaggerated cortisol response to the CRH challenge became more clear in the regression analysis where the confounding effect of psychological distress was taken into consideration. These results indicate that poor sleep would be associated with exaggerated cortisol reactivity. The observed association of poor sleep with reactive cortisol indices to the CRH challenge, but not with the cortisol level after DEX administration alone, might add to the well-established evidence demonstrating the role of CRH in the regulation of sleep. Our findings further suggest that the mediation model would work better than the bivariate approach in investigating the relationship between sleep, distress and HPA axis reactivity.

Self-reported rates of sleep disturbance in patients with symptomatic bone metastases attending an outpatient radiotherapy clinic

PURPOSE

To examine the reported rates and predictive factors for sleep disturbance in patients with bone metastases.

METHODS

Patients with symptomatic bone metastases treated with palliative radiotherapy (RT) were eligible. At initial consultation, demographic information, baseline Brief Pain Inventory (BPI) questionnaire, and analgesic consumption were recorded. The BPI functional interference sleep item was categorized into none (0), mild (1-3), moderate (4-6), and severe (7-10). Follow-up BPI was collected in person or via telephone post-RT at week 4, 8, and 12. Subgroup analysis for BPI between responders and nonresponders was performed. Ordinal logistic regression analysis was used to search for the relationship between sleep disturbance and other covariates.

RESULTS

Four hundred patients were enrolled between May 2003 and June 2007. Two hundred thirty-five males (59%) were accrued. The median age was 68 years old (range, 30-91). Within the study population, primary cancer sites included breast (25%), lung (25%), prostate (24%), bladder (4%), pancreas/gastric (3%), and other primaries (18%). In the BPI functional interference items, the mean baseline score for sleep disturbance was 4.8. When categorized in terms of severity, 99 (25%) patients had moderate sleep disturbance and 144 (36%) patients had severe sleep disturbance, respectively. There was an improvement in sleep scores for both responders and nonresponders at week 4 and 8, but scores worsened for nonresponders at week 12.

CONCLUSION

Age, Karnofsky Performance Scale (KPS), pain score, and lung primary were the significant variables associated with sleep disturbance. The scores for sleep disturbance improved significantly post-RT in responders at week 4 and 12.

Validation of the Taiwanese version of the Athens Insomnia Scale and assessment of insomnia in Taiwanese cancer patients

CONTEXT

It is well known that insomnia is highly prevalent in cancer patients. Although various studies have used the Athens Insomnia Scale (AIS) for insomnia assessment, it has never been applied to cancer patients with insomnia.

OBJECTIVES

The purpose of this study was to establish the reliability and validity of the Taiwanese AIS version (AIS-T) and evaluate the severity of insomnia among cancer patients in Taiwan.

METHODS

Using a cross-sectional research design, 195 cancer patients (n=195) were recruited from outpatient oncology clinics.

RESULTS

Cronbach's alpha for internal consistency was 0.83, and the test-retest reliability was 0.94 over an interval of three days, based on a sample of 30 patients. Moreover, concurrent validity could be evaluated by significant correlations of the AIS-T with the Pittsburgh Sleep Quality Index-Taiwan form (PSQI-T) (r=0.82, P<0.001) and sleep efficiency measured by Actiwatch parameters (r=-0.54, P<0.001). Construct validity could be established by the Brief Fatigue Inventory-Taiwan form (r=0.56, P<0.001) and Medical Outcomes Study Short Form-36-Taiwanese version (physical component summary: r=-0.52, P<0.001; mental component summary: r=-0.53, P<0.001). The AIS-T could detect significant known-group validity from sleep quality (PSQI-T ≥ 5 or <5, respectively). The Actiwatch parameters are consistent with the results of the AIS-T, and both data sets indicate that patients experienced sleep disturbances. The prevalence of insomnia, as defined by the criteria of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th ed., was 22.56%; 49.2% subjects had significant insomnia at the score ≥ 6 at AIS-T.

CONCLUSION

This study concludes that the AIS-T is a reliable and valid instrument for assessing insomnia among cancer patients in Taiwan.

Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer

CONTEXT

Sleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.

OBJECTIVES

In this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.

METHODS

We reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥ 5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.

RESULTS

The median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r=0.27, P=0.006), dyspnea (r=0.25, P<0.001), well-being (r=0.35, P<0.0001), and sleep (r=0.44, P<0.0001). Compared with patients without SD, those with SD were more likely to report pain (P=0.0132), depression (P=0.019), anxiety (P=0.01), and a poorer sense of well-being (P=0.035). An ESAS-Sleep item cutoff score of ≥ 3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.

CONCLUSION

SD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥ 3. More research is needed to better characterize this frequent and distressing syndrome.

Circadian effects in cancer-relevant psychoneuroendocrine and immune pathways

Human biology is deeply integrated with the rotation of the Earth: healthy physiology is synchronized with circadian cycles, while unhealthy states are often marked by poor circadian coordination. In certain cancers including breast cancer, striking circadian rhythm dysregulation extends to endocrine, immune, metabolic, and cellular function. Disruption resulting from biological and behavioral influences has been linked with higher incidence and faster tumor progression in humans and animals. The hypothalamic SCN coordinates circadian events at the tissue and cellular level, partly via glucocorticoids that regulate genes involved in tumor growth, cell proliferation, apoptosis, immune cell trafficking, and cytotoxicity. We present a revision of our previously published model of circadian effects in cancer (Sephton and Spiegel, 2003) based on evaluation of new data from divergent lines of investigation. Human clinical studies show circadian endocrine disruption may be accompanied by suppressed functional cellular immunity and overactive inflammatory responses that could promote tumor growth, angiogenesis, and metastasis. Animal data provide strong evidence of clock gene regulation of tumor cell growth. Tissue culture research demonstrates that biologically or behaviorally mediated down-regulation of clock gene expression can accelerate tumor growth. An integrated view suggests mechanisms by which circadian effects on tumor growth may be mediated. These include psychoneuroendocrine and psychoneuroimmune pathways, the relevance of which we highlight in the context of breast cancer. Taken together, data from clinical, systemic, cellular, and molecular research suggest the circadian clock is a tumor suppressor under both biological and behavioral control.

Translating the Pittsburgh Sleep Quality Index into Arabic

This descriptive correlational study describes the translation process and the psychometric testing of the Pittsburgh Sleep Quality Index (PSQI). The PSQI has been successfully translated into Arabic and back-translated into English by 10 Arabic bilingual translators. Then the PSQI is tested in a sample of 35 healthy Arabic bilinguals.The internal consistency reliability for the Global PSQI demonstrates borderline acceptability (Cronbach's alpha = .65). The reliability is further supported by moderate to high correlations between five PSQI components and the global PSQI score (r = .53 to .82, p < .01). Convergent validity is supported by the global PSQI correlating strongly with the Insomnia Severity Index (r = .76) and moderately with the related construct of the Medical Outcome Study Short Form-36 vitality subscale (r = -.33). Further testing of the PSQI is needed in a larger Arabic population, both clinical and healthy populations, living in their native countries.