Sleep Disturbances in Palliative Care
Dmitriy Kogan, MD, FCCPAssistant Professor of Medicine
Program Director for Sleep Medicine at Zablocki VA Medical CenterAssociate Program Director for Sleep Medicine Fellowship at
Medical College of Wisconsin
Conflict of Interest• I have no relevant financial conflicts of
interest and nothing to disclose for this educational activity
Goals• Outline different types of sleep disorders
and their prevalence in palliative care patients
• Describe the effects of specific chronic medical conditions on sleep
• Explore the sleep disturbances of caregivers
• Introduce treatment options for common sleep disorders
Sleep Disorders• Insomnia• Hypersomnia• Sleep Disordered Breathing• Restless Legs• Parasomnias
– Periodic Limb Movements of Sleep– REM Behavioral Disorder
Predictive factors• Poor Karnofsky score• Cancer type (Breast, gastrointestinal, head
and neck, lung, and prostate)• Lower level of education• Younger age• Hormone therapy, opioids, corticosteroids• Comorbid anxiety and depression
Mercadante et al. J Pain Symptom Manage. 2015 Dec;50(6):786-92.
Effect of Chronic Pain on Sleep• 50-90% report poor sleep quality1
• Difficulty falling/staying asleep, lack of restful sleep, daytime somnolence
• Disruption in sleep architecture2
– Decreased REM and deep sleep• Sleep deprivation can increase pain3
1. Mystakidou et al. Oxford Textbook of Palliative Medicine (5 ed.). March 2015.2. Branco et al. J Rheumatol. 1994;21:1113-1117.3. Roehrs et al. Sleep. 2006 Feb;29(2):145-51.4. Mystakidou et al. Pain Practice . 2011;3:282-289.
4
Effects of Opioids on Sleep• Can cause sleep disturbance even in
absence of pain• Disruption in sleep architecture
– Decreased REM sleep– Inconsistent effect on deep sleep
• Sleep disordered breathing– Increased obstructive and central events
• Poor sleep leads to increased opioid intake the following day
Mystakidou et al. Pain Practice . 2011;3:282-289.
Effect of Antidepressants on Sleep
Wichniak et al. Curr Psychiatry Rep (2017) 19: 63
Cancer
and
Sleep
Cancer Patients• Sleep disturbance due to
– Direct effect of neoplasm– Cancer surgery– Chemotherapy – Radiation– Pain / other symptoms
Davidson et al. Social Science & Medicine. 2002;54:1309-1321.
Prevalence of Insomnia • Large observational study of cancer patients in
palliative care settings (n=820)• >60% with major sleep disturbances (insomnia)
Mercadante et al. J Pain Symptom Manage. 2015 Dec;50(6):786-92.
Cancer and Insomnia
• 823 patients– 597 female– Mean age 58– Prospective study
using patient questionnaires
Palesh et al. Journal of Clinical Oncology. 2010;28:292-298.
Cancer and Insomnia
Palesh et al. Journal of Clinical Oncology. 2010;28:292-298.
Cancer and Insomnia
Palesh et al. Journal of Clinical Oncology. 2010;28:292-298.
Cancer and Insomnia
Palesh et al. Journal of Clinical Oncology. 2010;28:292-298.
Sleep Disordered Breathing• High prevalence of obstructive and central
sleep apnea• Small study of cancer patients receiving
palliative care (n=28)– 61% with increased obstructive events– 32% with increased central events
• Most subjects with daily use of opioids
Good et al. J Pain Symptom Manage. 2018 Mar;55(3):962-967
COPD
andSleep
COPD and Sleep • Increased sleep disturbances due to
– Hypoxia – Hypercapnia– Dyspnea– Chronic cough– Anxiety / Depression
Budhiraja et al. J Clin Sleep Med. 2015 Mar 15; 11(3): 259–270.
Factors Contributing to Hypoxemia during Sleep in COPD
Budhiraja et al. J Clin Sleep Med. 2015 Mar 15; 11(3): 259–270.
COPD and Insomnia• Cross-sectional study • 192 pts with COPD• Questionnaire data in
insomnia
Woo Ho Ban et al. International Journal of COPD. 2018(13): 2049-2055
Chronic Heart Failure and Sleep
Sleep Apnea in CHF• Prevalent
– 72.8% with moderate to severe• Predominantly obstructive events• Frequently asymptomatic• Sometimes without typical risk factors
Ferreira et al. BMC Pulm Med. 2010 Mar 3;10:9.
Cardiac Event Rates: Cardiac Death and CHF Exacerbation
Kanno et al. Circ J. 2016 Jun 24;80(7):1571-7.
• Insomnia is an independent predictor of cardiac events in HF pts
• HF pts with insomnia have activated renin-angiotensin-aldosterone system and lower exercise capacity
Chronic Liver Disease
and
Sleep
Cirrhosis and Sleep• Sleep Disorders
– Circadian Rhythm Disorders– Restless Legs Syndrome– Insomnia– Sleep disordered breathing
• Bidirectional relationship
De Cruz et al. Seminars in Resp and Crit Care Med. 2012;33:26-35.
Cirrhosis and Sleep• High prevalence of
– Insomnia– Daytime sleepiness– Daytime napping– Nocturnal awakenings
• Liver transplantation not shown to improve sleep symptoms
De Cruz et al. Seminars in Resp and Crit Care Med. 2012;33:26-35.
Cirrhosis and Sleep Architecture
Teodoro et al. World J Gastroenterol. 2013;19(22):3433-8.
Alzheimer’s Disease
andSleep
Sleep Disturbances in AD
• Prevalence of 45%1
• Early occurrence in AD• Correlates with severity of dementia• Risk factor for early institutionalization2
1. Moran et al. Sleep Med (2005) 6: 347-3522. Singer at al. Sleep (2003) 26: 893-901
Sleep Disorders in AD• Sleep–wake cycle alteration
– Sundowning• Sleep Disordered Breathing
– Increased risk from neurodegeneration
Peter-Derex et al. Sleep Med Rev (2015) 19: 29-38
Alzheimer’s Disease
Sleep Disruptions
Degeneration of neural pathwaysSomatic/Psychiatric co-morbidities
Impairment in memory consolidation
Peter-Derex et al. Sleep Med Rev (2015) 19: 29-38
and
Parkinson’sDisease
Sleep
Parkinson’s Disease• Sleep disturbances are common (up to
98%)1
• Sleep disturbance contributes to poor patient quality of life1
• Sleep disturbances often worsen with disease progression2
1. Swick et al. Park Dis, 2012 (2012), Article ID 205471.2. Goetz et al. Neurology, 2010;75(20):1773-1779.
Types of Sleep Disorders• Insomnia• REM Behavior Disorder (RBD)
– Can be a prodrome• Obstructive Sleep Apnea (OSA)• Periodic Limb Movement Disorder (PLMD)• Restless Legs Syndrome (RLS)• Nocturia
Kutscher et al. Curr Treat Options Neurol. 2014;16(8):304
Albers et al. Sleep Medicine 2017;35:41-48.
ALS
and
Sleep
Sleep Disorders in ALS• Sleep Disordered Breathing
– Weakness of respiratory muscles– Decreased central respiratory drive
• Restless Legs– Prevalence of 13.8% in cohort of 69 pts1
1. Limousin et al. Amyotrophic Lateral Sclerosis. 2011;12(4):303-306
Hypoventilation in ALS
Ahmed et al. Sleep Medicine Reviews. 2016;26:33-42
Degeneraton
Central Dysregulation
Sleep Disorders in ALS• Insomnia
– Anxiety– Immobility, cramps– Excess saliva, cough1
• Circadian Disorders– Thalamic and Hypothalamic involvement2
1. Ahmed et al. Sleep Medicine Reviews. 2016;26:33-422. Turek et al. Arch Neurol. 2001;58(11):1781-1787
Treatment Options to Improve Sleep in ALS
• Riluzole– Excitatory (Glutamate) regulator– Survival benefit– Increased sleep duration1
• Non-invasive Ventilation• Secretion management
1. Stutzmann et al. Neurosci Lett. 1988;88:195-200
What
about
the caregiver?
Caregivers of CHF Patients• Over 90% report sleep disturbances
– Difficulty with sleep onset– Disrupted sleep– Daytime sleepiness
• Negative impact on quality of life• Negative impact on patient outcomes
Rausch et al. Prog Cardiovasc Nurs. 2007;22:38–40
Caregivers of CHF Patients• Poor predictors of caregiver well-being
– Female gender– Closer relationship
• Spouse– Younger age
• Patient symptoms / Functional class (NYHA) not predictive of caregiver well-being
Molloy et al. European Journal of Heart Failure. 2005;7:592-603.
Lerdal et al. BMJ Open. 2016; 6(1): e009345. .
Age
Relationship
Lerdal et al. BMJ Open. 2016; 6(1): e009345. .
A quick word about treatment…
Sleep Apnea
• Weight loss• PAP therapy• Dental devices• Positional therapy• Nasal preclusion
cpapstoreusa.com entto
day.
org
medicaldepartmentstore.com proventtherapy.com
Insomnia
• Cognitive Behavioral Therapy for Insomnia (CBT-I)
• Pharmacologic therapy
CBT-I in CancerInsomnia Severity
Johnson et al. Sleep Medicine Reviews. 2016; 27: 20e28.
CBT-I in Cancer
Sleep Efficiency
Johnson et al. Sleep Medicine Reviews. 2016; 27: 20e28.
Medications• Effective short term• Lose effectiveness over long term• Side effects• Dependence
Summary• Patients with chronic illnesses are at
increased risk for various sleep disorders including Insomnia, Sleep Disordered Breathing, Circardian Disorders, Restless Legs, and parasomnias
• Chronic pain and medications can exacerbate these problems
Summary• Caregivers of patients in palliative care are
also at increased risk for insomnia and disrupted sleep
• Female gender, closer relationship, and younger age are poor predictive factors
• Variety of treatment options available for sleep disorders in palliative care patients
Thank you
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