Medicines, good sleep habits can help insomnia
By DR. V. UPENDER RAO
Published February 21, 2005
Treatment of insomnia in cancer patients includes CBT (Cognitive Behavioral Therapy) and pharmacotherapy.
CBT includes several techniques that alter the patient's thought process and the environment in a manner that is conducive to sleep. Some components of CBT are difficult to practice, especially in the hospital setting.
Most cancer patients have associated depression, anxiety, pain and other problems related to cancer or its treatment, owing to which some drug therapy becomes necessary. Because the drugs available for the treatment of insomnia, depression, anxiety, and so on are ever-increasing in numbers and complexity, especially with regard to their undesirable side effects, it is beneficial for the patients to be evaluated and treated by a psychiatrist for the problems mentioned above.
Pharmacotherapy includes benzodiazepine and non-benzodiazepines. The long-acting benzodiazepines Klonapin, Ativan and Serax - while effective - can cause daytime drowsiness, dizziness and cognitive impairment. The short-acting ProSom, Dalmane, Restoril and Halcion induce tolerance, dependence, rebound insomnia and daytime anxiety.
The non-benzodiazepine hypnotic Ambien is more selective and does not cause tolerance, dependence, alteration in sleep architecture or rebound insomnia. A long-acting variety of Ambien, which would facilitate less frequent than nightly administration, is under development.
Other non hypnotics include Sinequan, Amitriptyline and Pamelor. These work well for the depressed and non depressed insomniac patients, especially for those with neuropathic pain. The second generation antidepressant Desyrel works well for the depressed insomniacs, but there is limited data for the non depressed patients.
Remeron induces sleep, stimulates appetite and decreases nausea when given in low doses at bed time. Antihistamines, because of their many side effects, are generally not considered safe for elderly cancer patients.
Atypical antipsychotic Danzapine induces sleep, relieves opiate (morphine) induced nausea and improves appetite. Psychostimulant Provigil is a non amphetamine stimulant that is effective in reducing daytime sleepiness in primary insomnia. Concerta relieves daytime sleepiness as well as morphine induced nausea.
Tips on sleep hygiene:
--Establish regular bedtime and wake up time.
--Estimate the number of hours you sleep with the alarm clock turned off. Use this as a rough estimate of the amount of sleep you need each day.
--Use the bed for sleep and sex only. Do not watch TV, pay bills or have telephone conversations that can induce or increase anxiety.
--Avoid heavy meals late in the evening. A warm bath and a light bedtime snack, especially dairy products, help induce sleep.
--Do not consume alcohol, caffeine or nicotine for at least four to six hours before bedtime.
--Regular exercise for 20 minutes three times a week induces sleep.
--Do not nap for more than 30 minutes after 3 p.m.
--Take sleeping pills and other prescribed medication according to instructions only.
--Keep the bedroom clean, cool, quiet and dark.
--Dr. V Upender Rao, FACP, practices at the Cancer and Blood Disease Center in Lecanto.