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Life After Cancer A Roadmap for Cancer Survivors

The Role of Sleep in Health, Disease, and Therapy
David Claman, MD and Ernest H. Rosenbaum, MD

The More Common Sleep Disorders
Sleep Hygiene
Sleep Issues Specific to Cancer

Our knowledge about sleep and sleep disorders has increased dramatically since the 1950's, which is when REM (rapid eye movement) sleep was first described in the medical literature. Sleep is now viewed as an active state, with highly regulated physiologic processes. Compared to 100 years ago, the average person today probably sleeps about one hour less per night, which makes sleep deprivation a common issue.

Cancer survivors have many potential physical and psychological issues which may disturb sleep.

The More Common Sleep Disorders
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Purposeful Sleep Deprivation
- Many of us undervalue sleep and make shortcuts about when we go to bed and when we get up, so that we're not getting a full 7.5-8 hours of sleep per night. The most common cause of sleepiness during the daytime is purposeful sleep deprivation.

- Insomnia is far and away the most common sleep disorder reported in the population. Approximately 36% of the population has experienced either occasional insomnia or chronic insomnia, and 9% of people currently report chronic insomnia.

- The first step in evaluating insomnia is asking whether the trouble is getting to sleep at bedtime or waking up frequently as the night goes on, or waking up at 3 a.m. and being unable to get back to sleep. The insomnia can be a combination of these different issues. If you can't get to sleep at bedtime, it may be that caffeine is keeping you awake. Perhaps you're worried or tense about different issues related to work, family, or your health that usually come up at bedtime. If you're waking up frequently at night, there may be physical issues or emotional issues behind this. Waking up early in the morning could be related to stress or depression. Emotional causes are less common than physical problems, but those really depend on the individual person, the issues involved, and the medications being prescribed.

There are four main categories of causes of insomnia: medical causes, psychiatric, situational and pharmacologic.
- The more medical problems that a person has, the more frequently they complain of insomnia. Survivors may be waking up with shortness of breath from lung problems, waking up with ulcer pain or with chronic arthritis in the hips or knees or hands.

- Psychiatric issues are common causes of insomnia, especially in patients with depression, anxiety or schizophrenia. It is estimated that about 1/3 of the patients with chronic insomnia may have some problem with depression or anxiety.

- Situational issues, such as tests, lectures, job changes, can also cause insomnia. It is hoped that when the situation resolves, their sleeping will improve.

- Pharmacologic causes of insomnia may occur because many medications, both prescription and non-prescription, have sleep-related side effects. The two most common ones are caffeine and alcohol. If you drink caffeine in the evening it may keep you awake at bedtime and be a cause of insomnia. If you drink alcohol at bedtime to get to sleep, and the alcohol wears off two or three hours later, you may find yourself waking up and not being able to get back to sleep. Prescription drugs also have sleep-related side effects and substances.

Sleep Hygiene
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The best intervention for insomnia is a behavioral approach called sleep hygiene, a term that refers to good and bad sleeping habits. The goal is trying to practice good sleeping habits so you sleep better and trying to avoid bad sleeping habits.

For good sleep hygiene:
- Maintain a regular schedule for going to bed and waking up, regardless of your weekend vs. weekday schedules.
- Avoid excessive time in bed.
- Avoid taking naps during the day.
- Use the bed and bedroom for sleeping and sex only.
- Do not watch the clock while in bed, because this reinforces how much time has gone by and how much worry there is about not sleeping.
- Do something relaxing before going to bed.
- Make the bedroom quiet and comfortable.
- Avoid taking the troubles of the day to bed with you.
- Avoid alcohol and caffeinated beverages.
- Try to get regular exercise, but not within two hours of bedtime.

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Medication options are available including hypnotics, sedatives and antidepressants. It would be important to discuss with your physician which these of medications might be most helpful for your situation.

Avoid using sleeping medications, if at all possible, unless it Ôs really and truly necessary. Most people can make significant improvement by focusing on their sleep hygiene.

Sleep Issues Specific to Cancer
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Cancer survivors may develop insomnia for a myriad of reasons related to their cancer. Some of these are:
- Pain, due to the underlying cancer, surgery, radiation treatment, or other treatments can disrupt sleep. Effective pain control can improve overall sleep quality.
- Breathing may be more difficult because of the underlying cancer or the side effects treating other conditions such as asthma, emphysema, or congestive heart failure.
- Emotional issues, anxiety and depression can seriously disturb sleep. Fear of dying during sleep prevents many survivors from getting adequate sleep. Issues that cause depression can be treated by medications and/or psychological therapy, but improved sleeping habits may improve sleep without a need for medications or psychological support.
- Many drugs cause side effects that can disturb sleep. Specifically, chemotherapy has been shown to disrupt brain chemistry which in turn may interfere with sleep and other mental functions. Pain medications, caffeine, and alcohol may also disturb sleep quality. It is important to review the need for sleep medicines with your physician.

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