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