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The Secrets to Better Sleep for Cancer Patients

February 15, 2021

Deb Walker, APRN
Survivorship Program
Hartford Health Care Cancer Institute
Hartford Hospital

It’s 1 a.m. and you’re wide awake. You’ve been struggling to fall asleep since 10:00 p.m. Your mind is racing with a list of things you need to do as you keep watching the clock anxiously waiting to fall asleep.

Most of us are no strangers to an occasional restless night of sleep, but what differentiates this from insomnia?

Many cancer patients face sleep problems, such as difficulty fall­ing asleep, staying asleep or early morning awakenings. These symptoms, according to research, can occur in up to 80 percent of people with can­cer. After treatment, fewer people report sleeping problems. Nonetheless, surveys have revealed sleep issues continue to affect approximately 40 percent of cancer survivors for several years after diagnosis.

The number of cancer survivors continues to grow each year. For many survivors, impaired sleep significantly affects quality of life and health.

The American Psychiatric Association’s DSM-5 standards define insomnia as dissatisfaction with sleep quantity or quality, associated with one or more of the following symptoms: difficulty initiating sleep, difficulty maintaining sleep or early morning awakenings. The sleep disturbances occur at least three nights per week and are present for at least three months.

Common causes of insomnia:

• Poor sleep habits.
• Depression.
• Anxiety.
• Medical conditions.
• Pain.
• Medications, caffeine, nicotine, alcohol.
• Changes in sleep patterns.
• Lack of exercise or decreased activity.

Potential complications due to insomnia:

• High blood pressure.
• Diabetes.
• Obesity.
• Irritability.
• Poor concentration.
• Anxiety.
• Depression.
• Weakened immune system.
• Accidents.
• Higher rates of work absenteeism.
• Diminished job performance.

It’s clear that quality of life and health can suffer significantly due to insomnia. So it’s important to receive a medical evaluation to rule out treatable contributing factors of insomnia as well as treatment options. There are many ways patients can enhance sleep and help alleviate symptoms of insomnia.

The recommended goal for adults is to get seven or more hours of sleep per night to avoid the health risks of chronic inadequate sleep. Unfortunately, time spent in bed is not the same as time spent asleep.

Insufficient sleep and insomnia can be addressed with behavioral interventions. Several research studies on insomnia treatment have compared cognitive behavioral therapy for insomnia (CBT-I), medication alone and combination therapy that includes CBT-I with medication. The research shows that CBT-I is superior to medication alone and is equivalent to the combination of CBT-I with medication.

So CBT-I without medication has an advantage, as it does not expose patients to medication side effects, as well as potential drug interactions. And the American Academy of Sleep Medicine and the American College of Physicians endorses CBT-I as the initial therapy for insomnia. CBT-I addresses common thoughts and behaviors that interfere with optimal sleep.

CBT-I Strategies to Improve Sleep

Sleep hygiene

Good sleep hygiene is about creating basic lifestyle habits to help promote sleep. These recommendations include avoiding caffeine and alcohol close to bedtime, maintaining a comfortable room temperature, using the bed only for sleep and sex, and avoiding both exercise and eating close to bedtime.

Also, it includes activities that help promote sleep such as exercising during the day, shutting off electronics one hour before bedtime, and finding some relaxing activities that help you wind down before sleep.

Stimulus Control

Stimulus control strengthens the bed as a cue for sleep and weakens it as a cue for wakefulness. Also, it can improve and regulate the circadian rhythm. One strategy includes establishing a consistent daily bedtime and wake time. A regular sleep schedule can help your body maintain a rhythm and make it easier to fall asleep each night.

And going to bed only when sleepy will increase the likelihood that you will fall asleep quickly. If you cannot fall asleep within 15-20 minutes, try getting out of bed and find something relaxing to do until you feel sleepy and then return to bed.

Lastly, avoid excessive napping. A brief midday nap for 15 -30 minutes can be refreshing and is unlikely to negatively impact nighttime sleep.

Sleep Restriction

Lying in bed when you are awake can become a habit that leads to poor sleep. Sleep restriction is designed to eliminate prolonged middle-of-the night awakenings. Sleep restriction is a CBT-I strategy that focuses on reducing the time in bed to approximate the total hours of estimated sleep. This goal can be identified and met by creating a sleep diary.

The time spent in bed and time asleep are recorded in the diary. For example, if you’re in bed from 9 p.m. until 6 a.m. and only spend six hours sleeping, then the initial therapy goal would be to stay in bed for about six hours.

The aim is not to restrict actual sleep time, but to initially restrict the time spent in bed. But the time allowed in bed should not be less than 5.5 hours. The next step is to gradually extend the time spent in bed by 15 to 30 minutes. This technique works by getting more consolidated sleep and over time improves sleep quality.  In addition, it eliminates negative sleep cues and associations.

Cognitive Therapy

Cognitive therapy identifies and alters unhelpful thoughts associated with sleep. These anxious and catastrophic thoughts are often associated with sleeplessness. For example, thoughts such as, “I’ll never be able to function in my meeting tomorrow if I don’t fall asleep right now” increase anxiety and disrupt sleep.

In cognitive therapy, the goal is to modify these thoughts and create a more positive thought such as, “I may be tired, but I’m well prepared for my meeting and will do fine.”

This can help reduce anxiety and promote sleep. Also, worrying that you cannot sleep can actually keep you awake. Changing negative thoughts can help you relax and make it easier to fall asleep.

Relaxation Techniques

Relaxation training helps calm the mind and body to promote sleep. Techniques such as relaxation through mindfulness, imagery, breathing exercises, progressive muscle relaxation and meditation are useful. Research has shown these techniques improve the ability to fall asleep. It is important to set aside 30 minutes to wind down before bedtime each night with behaviors that can calm you.

Good examples would be listening to soft music, reading and relaxation exercises. Today, a variety of online applications are available to help promote relaxation. It is important to consult with your healthcare provider to assist with sleep issues.

The free, downloadable CBT-i Coach App (iOS and Android) is a helpful application used to improve sleep. The app can help users through the process of learning about sleep, developing positive sleep routines and improving their sleep environments. CBT-i Coach augments face-to-face care with a healthcare professional. It can be used on its own, but it is not intended to replace therapy for those who need it.