How can patients improve sleep quality during chemotherapy?

Improving Sleep Quality During Chemotherapy

Cognitive Behavioral Therapy for insomnia (CBT-I) is the most effective intervention for improving sleep quality in cancer patients undergoing chemotherapy, showing significant improvements in sleep efficiency, sleep onset latency, and overall sleep quality. 1

Evidence-Based Sleep Interventions

Behavioral Interventions

• CBT-I components have shown significant improvements in overall insomnia severity (p<0.001), sleep efficiency (p=0.002), sleep onset latency (p=0.03), and restorative sleep (p=0.002) in cancer patients 1
• Internet-delivered CBT programs are effective alternatives, with significant improvements in self-reported insomnia severity and sleep quality 1
• Brief Behavioral Therapy for Cancer-Related Insomnia (BBT-CI) improved Insomnia Severity Index scores by 6.3 points compared to 2.5 points in control groups, and can be delivered by trained oncology staff in community settings 2
• Sleep efficiency can increase from 69% to 84% with CBT interventions, with improvements maintained at 12-month follow-up 1

Exercise Interventions

• Home-based walking/exercise programs significantly improve subjective sleep quality in cancer patients undergoing treatment 1
• Exercise interventions show significantly shorter actual wake time and less movement during sleep (p=0.02 and p=0.05, respectively) 1
• Tibetan yoga has demonstrated significantly lower sleep disturbance scores compared to control groups (5.8 versus 8.1; p<0.004), with improvements in sleep quality, latency, duration, and reduced sleep medication use 1

Sleep Hygiene Practices

• Poor sleep hygiene behaviors are frequent in cancer patients and should be addressed 1
• Key sleep hygiene recommendations include:
  • Maintaining a regular sleep schedule 1
  • Avoiding daytime napping 1
  • Limiting caffeine, alcohol, and high-sugar foods before bedtime 1
  • Creating a sleep environment that is dark, quiet, and comfortable 1
  • Engaging in stress-reducing activities before bedtime (reading, journaling, meditation, listening to quiet music) 1
  • Limiting electronic device use (phones, computers, TV) in the hours before sleep 1

Addressing Contributing Factors

• Assess and treat psychological factors:

  • Anxiety is significantly associated with poor sleep quality (OR 1.17 [95% CI, 1.01-1.35]) in cancer patients undergoing chemotherapy 3
  • Stress symptoms partially mediate the relationship between sleep quality and fatigue (p=0.030) 3
  • Depression is an independent predictor of fatigue and poor sleep 4

• Evaluate and manage physical symptoms:

  • Pain, nausea, and other treatment-related symptoms can disrupt sleep 1
  • Nutritional deficiencies and electrolyte imbalances can contribute to fatigue and sleep disturbances 1
  • Anemia should be assessed and treated as it can exacerbate fatigue and sleep problems 4

Pharmacological Considerations

• No RCT data specifically evaluating pharmacological interventions for insomnia in cancer patients is available 1
• When considering pharmacotherapy:
  • It should be considered an adjunctive therapy to cognitive and behavioral interventions 1
  • Short-term use is preferred due to potential for dependence 1
  • Dosage should be kept to the minimum effective amount 1
  • Consider potential interactions with cancer treatments 1

Implementation Challenges

• Sleep disturbances are prevalent in 30-75% of cancer patients but often neglected in oncology care 1
• 65% of women with breast cancer report poor sleep in the month preceding chemotherapy 5
• The first night after chemotherapy is typically the worst for sleep quality 5
• Sleep during chemotherapy is characterized by fragmentation with an average of 10 awakenings and 61 minutes of wake time after sleep onset 5

Clinical Recommendations

• Screen all patients undergoing chemotherapy for sleep disturbances using validated tools like the Pittsburgh Sleep Quality Index or Insomnia Severity Index 1, 2
• Implement CBT-I as first-line treatment, which can be delivered in various formats (individual, group, internet-based) 1
• Incorporate daily exercise when possible, tailored to the patient's condition and energy level 1
• Address psychological symptoms concurrently, as they significantly impact sleep quality 3
• Evaluate and treat underlying physical symptoms that may disrupt sleep 1
• Consider pharmacotherapy only as an adjunct to behavioral interventions and for short-term use 1