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Insomnia and Fatigue

Insomnia and Fatigue. Andrea Richtel Branas, MSE, MPT, CLT Lead Therapist Good Shepherd Penn Partners Abramson Cancer Center. Cancer Related Fatigue (CRF).

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Insomnia and Fatigue

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  1. Insomnia and Fatigue Andrea Richtel Branas, MSE, MPT, CLT Lead Therapist Good Shepherd Penn Partners Abramson Cancer Center

  2. Cancer Related Fatigue (CRF) Distressing, persistent, subjective sense physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. NCCN Guidelines V 1.2013, Cancer-Related Fatigue

  3. Cancer Related Fatigue • Reported as the most common and distressing side effect of cancer treatment • Affects 70-100% of the cancer population • Can make it hard to: • Be with friends and family • Do daily activities • Follow treatment plan

  4. What does fatigue feel like? • No energy • Need more sleep • Sleeping is not restful • Normal activities are difficult to do • Difficulty focusing your attention

  5. What causes Fatigue? Cancer and it’s treatment

  6. What causes Fatigue • Cancer • Cancer treatments (surgery, chemo, radiation) • Anemia • Insomnia/sleep disturbance • Nutrition • Depression and anxiety • Medications • Too much activity • Lack of exercise

  7. Symptom Cluster • Fatigue is commonly clustered with symptoms of: • Pain • Sleep disturbance • Emotional distress

  8. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  9. Energy Conservation • Finding easier ways to perform tasks • Saving your energy • Avoiding fatigue, by balancing work and rest • Changing how you do activities • So you can do more without as much fatigue

  10. Energy Conservation • Pacing • Planning • Posture • Organization

  11. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  12. Non-Pharmacologic • Activity Enhancement • Exercise • Rehabilitation • Psychsocial Intervention • Nutrition

  13. “Activity Enhancement” “It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment”

  14. ACSM Guidelines • ACSM Roundtable on Exercise Guidelines for Cancer Survivors • Medicine & Science in Sports and Exercise, June 2010 • ***Avoid Inactivity*** • Exercise should be individualized • Exercise is safe both during and after most types of cancer treatment

  15. Exercise with lymphedema • Weight Lifting in Women with Breast-Cancer-Related Lymphedema • In breast cancer survivors with stable lymphedema, slowly progressive weight lifting did not significantly increase limb swelling. • Decreased incidence of flares • Decreased lymph symptoms • Increased strength Schmitz KH, et al. Weight Lifting in Women with Breast-Cancer-Related Lymphedema. N Engl J Med 2009;361:664-73.

  16. Physical Activity • American Cancer Society guidelines • Adopt a physically active lifestyle.     • Adults: • Moderate or greater activity for 30 minutes or more on five or more days of the week. • Always talk to your doctor/nurse first! • Special precautions • Low blood counts • Bone metastases Byers et al. (2002). American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention. CA: A Cancer Journal for Clinicians 52: 92-119.

  17. How do you get started with exercise? Vs. Vs.

  18. Physical Therapy • Not sure what to do • Recent surgery • Medically complex • Lymphedema • Very deconditioned

  19. Exercise Specialist • ACSM/ACS Certified Cancer Exercise Trainer • No specific muscle/joint pains • Need guidance • No lymphedema

  20. Exercise at Home • Experienced exerciser • Know how to slowly progress • Know how to come back after a holiday • Know how to monitor how hard you are working

  21. Bare minimum • Walk • Walk • Walk • Walk • Something is more than nothing! • Start Low and Progress Slow!

  22. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue

  23. Pharmacologic • Medications for: • Pain • Insomnia • stimulants

  24. Sleep Distrubance • Hypersomnia –sleeping too much • Insomnia – not enough sleep • 30%-75% of patients with cancer

  25. Why is sleep disrupted? • Pain • Anxiety • Night sweats • Upset stomach • Frequent urination • Difficulty breathing • Poor sleep habits • Medication www.cancer.gov

  26. Look closely at your sleep Issues • Sleep history • Impact of insomnia on daily activities • Sleep diary • Mood evaluation – check for depression & anxiety • Apnea/snoring ADL = activity of daily living Fleishman. Journal of the National Cancer Institute Monographs No. 32. 2004; Bennett, Cameron, Brown, et al. Oncology Nursing Forum. 2010.

  27. Help for Insomnia • Behavioral therapy • Stimulus control therapy • Sleep restriction therapy • Sleep hygiene education • Regular exercise • Medications Mills, Graci. Cancer Symptom Management. 2004; Savard, Simard, Ivers, et al. JCO. 2005.

  28. Medical Treatments • CLASSIC THERAPIES • Benzodiazepines (temazepam) • Imidazopyridines (zolpidem) • Pyrazolopyrimidine (zaleplon) • Pyrrolopyrazine (eszopiclone) • Behavior Therapy (sleep restriction, stimulus control) • Antidepressants (amitriptyline , trazodone, doxepin) } benzodiazepine receptor agonists BZRAs Savard, Simerd, Ivers, et al. JCO. 2005.

  29. Other Pharmacologic strategies • Psychostimulants • Corticosteroids • Antidepressants • Treatment of depression related fatigue • Herbals • Promising • Drug-drug interactions possible NCCN Practice Guidelines in Oncology v1.2011: Cancer-Related Fatigue. Downloaded from http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf.

  30. Controlling your fatigue

  31. How do you gain control? • Know your symptoms • Monitor symptoms regularly • Share your symptoms with • Care team • Family and friends • Try new treatments • But only 1 at a time

  32. Getting to know your fatigue • Rate your fatigue

  33. On your calendar • Fatigue • Mood • Activity • Medication • Stressors • Sleep

  34. Symptoms Calendar F= Fatigue P = Pain M= mood S= hours of sleep Exercise

  35. Share symptoms with care team • Discuss: • Medications • Activity • Sleep • Mood • Pain

  36. Exercise

  37. Eliminate caffeine, nicotine, & alcohol Check meds with MD Keep bedtime and wake-time same Exercise Avoid late afternoon naps Eliminate big bedtime snacks Limit night-time fluids Avoid noise Keep correct temperature Get outside Get up if not sleeping Reserve bed for sleep Sleep Hygiene Mills, Graci. Cancer Symptom Management. 2003; Savard, Simerd, Ivers, et al. JCO. 2005.

  38. Eat Well

  39. Managing Side Effects from the Psycho/Social Point of View • Side effects are no fun! • How you respond to side effects is completely up to you

  40. Managing Side Effects • Relationship to Self • Acceptance • Emotional Release • Not over-identifying with the body • Relationship to Others • Communicating Feelings • Educating Others • Getting help!

  41. Moving On What is the most loving thing you can do for yourself?

  42. Questions and Discussion

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