Management of sleep disturbances should focus on treatment of problems with falling asleep, staying asleep, or early morning awakenings. Other areas to manage include symptoms from cancer and its treatment, and the identification and management of environmental and psychological factors. When sleep disturbances are caused by symptoms of cancer or treatment, measures that control or alleviate symptoms are often the key to resolving sleep disturbances. Management of sleep disturbances combines nonpharmacologic and pharmacologic approaches individualized for the patient.
Nonpharmacologic Management of Sleep Disturbances
Several large, randomized trials and meta-analyses provide the evidence base for the efficacy of cognitive behavioral therapy (CBT) for insomnia (CBT-I).[1,2,3] Almost all of these trials have been in populations of patients without cancer. Components of CBT-I include the following:
- Cognitive restructuring.
- Behavioral strategies.
- Basic sleep hygiene education.
Cognitive strategies include restructuring negative thoughts, beliefs, and attitudes related to sleep and preventing excessive monitoring or worrying about getting enough sleep. Behavioral strategies include stimulus control and sleep restriction. Both of these strategies seek to limit time spent in bed that does not involve sleeping.[1,4,5]
Relaxation therapy can be used to achieve both behavioral and cognitive outcomes, particularly when it is combined with imagery. Educational objectives around sleep hygiene are also used to treat insomnia and include content on the following:
- Sleeping and waking up at regular times.
- Relaxing before bedtime.
- Creating a dark, comfortable sleep environment.
- Avoiding watching television or working in the bedroom.
- Getting ample daylight during nonsleep hours.
- Avoiding naps.
- Limiting caffeine.
- Getting regular exercise but no closer than 3 hours before bedtime.
Practice guidelines from the American Academy of Sleep Medicine clearly state that multicomponent therapy is recommended over single therapies. Because of insufficient evidence about its efficacy, sleep hygiene education should not be recommended as a single-modality management approach; other reviews state that sleep hygiene by itself is not effective.[2,6] Information about sleep hygiene, although not sufficient alone to combat sleep disturbances, should be included as a foundation of education related to sleep issues.
Several trials and meta-analyses have shown CBT-I to be at least as effective as conventional pharmacological therapies in treating primary chronic insomnia, but without side effects.[2,3,7,8,9]
A four-arm study that evaluated zolpidem (Ambien) versus CBT versus zolpidem and CBT versus placebo reported a greater effect (P = .05) on sleep-onset latency for both groups involving CBT (change of 44%) versus the group receiving zolpidem alone (change of 29%). Another study evaluated CBT with temazepam alone versus a combination of CBT and temazepam versus placebo and found that all active treatments were significantly better than placebo and that there was a trend for the most improvement in the combined arm of CBT and temazepam. Both arms with CBT demonstrated greater reductions in time to sleep onset than did the pharmacotherapy-alone arm (64% combined arm, 55% CBT arm, and 47% temazepam arm). A meta-analysis examining pharmacologic and behavioral studies for persistent insomnia found that pharmacologic and behavioral treatments did not differ in magnitude of benefit except for latency to sleep onset, in which greater reductions were found with behavioral therapy.