Sleep Problems & Insomnia During Cancer Treatment

As many as half of people with cancer have problems sleeping. Insomnia — being unable to fall asleep and stay asleep — and abnormal sleep-wake cycles are the most common. If your sleep has fallen apart since treatment started, you are in the majority, not the exception.

Sleep problems during treatment usually have several causes stacked on top of each other.

Medicines. Corticosteroids are on the list of drugs that can disturb sleep, alongside hormone therapy, sedatives and tranquilizers, antidepressants, and anticonvulsants. If you take dexamethasone with chemotherapy, the wakefulness on those nights is a known drug effect. See side effects from steroids and premedications.

Physical symptoms. Pain, fever, nausea, constipation or diarrhea, bladder problems, cough, trouble breathing, itching, and fatigue all interrupt sleep. Medicines can also cause sleep-disrupting effects indirectly, through pain, anxiety, night sweats, hot flashes, digestive problems, bladder problems, and breathing problems.

Worry and mood. The stress of a cancer diagnosis, anxiety, and depression are all listed causes. So is loss of social support.

Where you sleep. In hospital, an uncomfortable bed, noise, room temperature, sharing a room, and routine interruptions all get in the way.

Other conditions. Restless legs syndrome, sleep apnea — a breathing disorder in which breathing stops for 10 seconds or more during sleep — and age-related sleep changes may already be present. Alcohol use is also listed.

Your team will take a medical history covering cancer side effects, all your medicines including vitamins and over-the-counter drugs, emotional effects, diet, exercise, and daily routines, along with a physical exam and a picture of your sleep pattern from you and your family. If a specific cause needs identifying, a polysomnogram records brain wave changes, eye movements, breathing rate, blood pressure, heart rate, and electrical activity of the heart and other muscles during sleep.

Non-drug approaches come first, and the evidence behind them is the strongest part of this picture.

Cognitive behavioral therapy helps reduce anxiety about getting enough sleep by teaching you to change negative thoughts and beliefs about sleep into positive thoughts and images. It has three parts:

• Stimulus control. Go to bed only when sleepy, and get out of bed if you do not fall asleep after a short time. Use the bed and bedroom only for sleeping, not for other activities.
• Sleep restriction. Deliberately decrease the time you spend in bed, which increases sleepiness the next night; the time is increased again gradually as sleep improves.
• Relaxation therapy. Tensing and relaxing muscles, guided imagery, and meditation relieve muscle tension and stress, lower blood pressure, and help control pain. Self-hypnosis at bedtime can also help you feel relaxed and sleepy.

Sleep habits. Go to sleep and wake up at the same hours every day, no matter how little you slept. Avoid naps. Stay active during the day, and get regular exercise, but not within three hours of bedtime. Avoid watching TV or working in the bedroom. Relax before bedtime.

Food and drink. Eat a high-protein snack, such as milk or turkey, two hours before bedtime. Avoid heavy, spicy, or sugary foods before bed. Avoid alcohol and smoking before bedtime, and avoid caffeine, including dietary supplements used to control appetite.

Bowel and bladder. Drink more fluids and eat more high-fiber foods during the day, avoid drinking a lot right before bed, and empty your bowel and bladder before going to bed.

The room. Keep it quiet, dim or turn off lights, and keep the temperature comfortable. Keep skin clean and dry, dress in loose, soft clothing, and keep bedding and pillows clean, dry, and smooth, without wrinkles.

Sleep medicines are considered if treatment without drugs does not help. The choice depends on whether the problem is falling asleep or staying asleep, and on how the drug interacts with your other medicines. Some sleep drugs should not be stopped suddenly, because stopping can cause nervousness, seizures, and a change in the REM phase of sleep. If pain is the reason you are awake, pain relief is treated first, before a sleep medicine is prescribed. For older adults, non-drug treatments are tried first — regular mealtimes, avoiding daytime naps, and being more active during the day.

Call your health care team if you sleep very little or cannot sleep at all during the night, if you have trouble staying awake during the day, or if you think you might have sleep apnea or restless legs syndrome.

Bring the specifics: which nights are worst, what time you wake, what wakes you, and which medicines you took that day. That is what lets your team tell the difference between a steroid night, uncontrolled pain, night sweats, and anxiety — because each one is treated differently.

Side Effects From Steroids & Premedications, Fatigue During Cancer Treatment, Anxiety and Distress During Cancer, Hot Flashes During Cancer Treatment, and Side Effects Overview.

• National Cancer Institute, Sleep Disorders (PDQ) — Patient Version
• American Cancer Society, Sleep Problems