Assessment is the initial step in management strategies. Assessment data should include documentation of predisposing factors, sleep patterns, emotional status, exercise and activity levels, diet, symptoms, medications, and caregiver routines. The sections below outline recommendations for a sleep history and physical examination. Data can be retrieved from multiple sources: the patient’s subjective report of sleep difficulty, objective observations of behavioral and physiologic manifestations of sleep disturbances, and reports from the patient's significant others regarding the patient's quality of sleep. Use of the Insomnia Severity Index is suggested to screen for insomnia in clinical settings.[3,4]
The diagnosis of insomnia is primarily based on a careful, detailed medical and psychiatric history. The American Academy of Sleep Medicine has produced guidelines for the use of polysomnography as an objective tool in evaluating insomnia. The routine polysomnogram includes the monitoring of electroencephalography, electro-oculography, electromyography, effort of breathing and air flow, oxygen saturation, electrocardiography, and body position. Polysomnography is the major diagnostic tool in sleep disorders and is indicated in the evaluation of suspected sleep-related breathing disorders and periodic limb movement disorder, and when the cause of insomnia is uncertain or when behavioral or pharmacologic therapy is unsuccessful.[Level of evidence: IV]
Sleep disturbance has been shown to change throughout the cancer trajectory, which supports the need to assess sleep throughout the patient’s cancer experience. One descriptive study [Level of evidence: II] involving 398 women with breast cancer used the General Sleep Disturbance Scale (GSDS) to identify three different sleep trajectories when self-reported sleep was evaluated beginning before surgery and continuing for 6 months. One group (55% of the sample) had a high level of sleep disturbance throughout the study, defined as scores on the GSDS of around 58 to 60 at all data points. A second group (40% of the sample) was considered to have a low level of sleep disturbance throughout, defined as scores on the GSDS in the low 30s at each data point. The final group (5% of the sample) started out high with scores around 62, but their scores decreased to below 30 over the first 4 months and remained there through month 6. Characteristics of women in the group who were identified as having a more severe sleep disorder were significantly younger, had more comorbidities, had a lower performance status, and experienced hot flashes.
Risk Factors for Sleep Disorders
- Disease factors, including paraneoplastic syndromes with increased steroid production; and symptoms associated with tumor invasion (e.g., obstruction, pain, fever, shortness of breath, pruritus, and fatigue).
- Treatment factors, including symptoms related to surgery (e.g., pain, frequent monitoring, and use of opioids); chemotherapy (e.g., exogenous corticosteroids); and symptoms related to chemotherapy.
- Medications such as opioids, sedatives/hypnotics, steroids, caffeine/nicotine, some antidepressants, and dietary supplements, including some vitamins, diet pills, and other products promoting weight loss and appetite suppression.
- Environmental factors.
- Physical and/or psychological stressors.
- Depression (refer to the PDQ summary on Depression for more information).
- Anxiety (refer to the Anxiety Disorders: Description and Etiology section in the PDQ summary on Adjustment to Cancer: Anxiety and Distress for more information).
- Delirium (refer to the PDQ summary on Delirium for more information).
- Daytime seizures, snoring, and headaches.
Characterization of Sleep
- Usual patterns of sleep, including usual bedtime, routine before retiring (e.g., food, bath, and medications), length of time before onset of sleep, and duration of sleep (awaking episodes during night, ability to resume sleep, and usual time of awakening).
- Characteristics of disturbed sleep (changes following diagnosis, treatment, and/or hospitalization).
- Perception of significant others as to quantity and quality of patient's sleep.
- Family history of sleep disorders.
- American Academy of Sleep Medicine: The International Classification of Sleep Disorders: Diagnostic & Coding Manual. 2nd ed. Westchester, Ill: American Academy of Sleep Medicine, 2005.
- Perlis ML, Jungquist C, Smith MT, et al.: Cognitive Behavioral Treatment of Insomnia: A Session-by-Session Guide. New York, NY: Springer Science+Business Media LLC, 2008.
- Bastien CH, Vallières A, Morin CM: Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2 (4): 297-307, 2001. [PUBMED Abstract]
- Savard MH, Savard J, Simard S, et al.: Empirical validation of the Insomnia Severity Index in cancer patients. Psychooncology 14 (6): 429-41, 2005. [PUBMED Abstract]
- Littner M, Hirshkowitz M, Kramer M, et al.: Practice parameters for using polysomnography to evaluate insomnia: an update. Sleep 26 (6): 754-60, 2003. [PUBMED Abstract]
- Van Onselen C, Cooper BA, Lee K, et al.: Identification of distinct subgroups of breast cancer patients based on self-reported changes in sleep disturbance. Support Care Cancer 20 (10): 2611-9, 2012. [PUBMED Abstract]