[2023-11-23] Better sleep

Today, I rewatched another of the sessions from Ovarian Cancer Canada's National Symposium in November: Getting your ZZZZs - How to improve your sleep with ovarian cancer. While the session touched on sleep challenges faced by cancer patients generally and ovarian cancer patients in particular, the majority of the advice was applicable to anyone who experiences sleep difficulties.

The session featured expert advice from Dr. Josée Savard and lived experience from ovarian cancer survivor Kaylie Rooke. Dr. Savard is a professor of psychology at Université Laval and a researcher at the university's Cancer Research Centre. She is also a clinical psychologist who specializes in cognitive behavioural therapy and psycho-oncology and is recognized as an international leader in cancer-related insomnia. She has been studying the topic of sleep and cancer for 25 years.

Dr. Savard identified four types of insomnia that people may experience:
  • Difficulty falling asleep at bedtime
  • Difficulty staying asleep during the night
  • Awakening too early in the morning
  • Mixed, which is a combination of difficulties, and is very common
She defined insomnia as having one of the four types of sleep disturbance at least three nights per week for at least one month. If the insomnia lasts between one and three months, it's called episodic. If it lasts for more than three months, it's called chronic. Dr. Savard noted that chronic insomnia is not a trivial problem because there are many negative consequences of having insomnia in the long term. She said that it can be associated with fatigue, concentration and memory difficulties, impaired daytime functioning, psychological disorders (e.g., depression, anxiety, substance use), impaired quality of life, other medical conditions, increased risk of infection, and greater use of healthcare resources. So it's important to address insomnia, especially chronic insomnia.

Among the factors that increase the risk of insomnia are unfit sleep behaviours—spending too much time in bed while awake, having an irregular sleep schedule, napping during the day, doing activities in bed that are incompatible with sleep (e.g., reading, watching TV)—and erroneous beliefs about sleep, such as "I need 8 hours of sleep to function well during the day" and "If I don't sleep well, my cancer will come back."

Dr. Savard noted that good sleepers fall asleep readily because their brains interpret their head hitting the pillow as a clear signal that it's time to go to sleep. People who experience insomnia spend more time in their beds while they're awake and therefore the signal to their brain to go to sleep when their head hits the pillow is not as clear. "The brain is not too sure whether it's time for sleep or it's time for insomnia," she said. "So this is something that needs to be corrected in the intervention."

Dr. Savard discussed the pros and cons of various medications used to treat insomnia, but mentioned that cognitive behavioural therapy is the treatment of choice. It includes four components:
  1. Stimulus control
  2. Sleep restriction
  3. Cognitive restructuring
  4. Sleep hygiene
She added that cognitive behavioural therapy for insomnia was found to help cancer patients by improving sleep, decreasing psychological distress (e.g., anxiety and depressive symptoms), decreasing fatigue and increasing quality of life.

STIMULUS CONTROL

The aims of stimulus control are to reinforce the association between the bed environment (bed, bedroom, bedtime) and sleep and to establish a regular sleep-wake rhythm. Here's Dr. Savard's advice.

Keep at least one hour before going to bed to relax, reduce activation and induce sleepiness
  • Do activities that prepare for sleep (e.g., read, watch TV, listen to music).
  • Exercise caution with cell phones and electronic tablets; at minimum, lower their light intensity.
  • Follow a routine that's repeated every night.
Go to bed only when you feel sleepy
  • Look for signs of sleepiness before going to bed. Sleepiness is an irrepressible desire to close your eyes, lie down and yawn, and it is often characterized by nodding off, heavy eyelids and watery eyes. By comparison, fatigue is a lack of energy to do activities, such as after intense exercise or a busy work day.
  • Just as we don't eat before we feel hungry, we don't go to bed until we feel sleepy; otherwise it will take longer to fall asleep.
When unable to fall asleep or go back to sleep within 20-30 minutes, leave the bedroom and return to bed only when you feel sleepy again to reinforce the association between the bed and sleep
  • Do activities that induce sleepiness (e.g., reading, watching TV).
  • Do not return to bed too soon; wait for sleepiness to occur.
  • Repeat this step as often as necessary. In the first few weeks of treatment, you may have to do this more than once a night.
Get up at the same time every morning even on weekends and even after a poor night of sleep
  • This is difficult, but it's important to resynchronize your biological clock to have a regular sleep schedule.
  • Use an alarm to ensure you wake up at the same time every morning.
Use the bedroom for sleep (and sexual activities) only
  • Do not eat, watch TV, work, use your cell phone or electronic tablet or read in your bedroom.
  • In the initial stage of the intervention, you want to reassociate the bed with sleep.
  • It's important not to do any activities that are incompatible with sleep, even reading, in the first stage of the intervention, though you may reintroduce some of these habits later.
Avoid napping in order to re-establish a regular sleep schedule
  • For cancer patients going through treatment, if a nap is necessary, Dr. Savard recommends that it occur before 3:00 PM, be for no more than one hour, and occur in the bedroom to associate the bed with sleep.
  • When you nap later in the afternoon or in the evening, you will experience a lot of deep sleep; the sleep you have in the night will be lighter and more interrupted by wake episodes.
  • To avoid napping during the day, do stimulating activities when you feel sleepy, such as going for a walk.
Dr. Savard then moved on to sleep restriction.

SLEEP RESTRICTION

The goal of sleep restriction is to reduce the time in bed to the actual sleep time. For example, if you spent 9 hours in bed but slept only 6 hours, your sleep efficiency (the number of hours you sleep divided by the number of hours in bed) would be only 67% (6 ÷ 9 = 67%). Your sleep schedule would initially be adjusted to 6 hours. This would create mild sleep deprivation (which facilitates falling asleep) and result in more consolidated and more efficient sleep. You would spend 6 hours in bed for at least a week until your sleep efficiency increased to 85%, which you would reach if you slept 5.1 hours for every 6 hours in bed (5.1 ÷ 6 = 85%).

COGNITIVE RESTRUCTURING

Dr. Savard tackled two misconceptions about sleep, with the goal of reducing the performance anxiety associated with sleep.

The first misconception is "If I don't sleep 8 hours, I will not function well tomorrow." Patients are encouraged to look at the evidence to determine whether or not this is true, and are asked "What is the worst thing that could happen if you don't sleep?" More realistic thoughts would be: "If I stop worrying about the impact of insomnia, I might sleep well. Not everybody needs 8 hours of sleep each night to function well. Even if I don't sleep 8 hours, I will still be able to function, as I do most of the time. I'll just feel sleepy at times during the day, which will help me sleep well tomorrow night."

The second misconception is "If I don't sleep well, my cancer will come back." Again, patients are encouraged to look at the evidence: Do all insomniacs have cancer recurrence? Do all good sleepers have no cancer recurrence? More realistic thoughts would be: "There is no scientific evidence that insomnia could cause a cancer recurrence. Cancer is a complex disease and its recurrence is influenced by an array of often unknown factors. It is very unlikely that insomnia alone could cause a recurrence. Worrying about the consequences of insomnia only makes my problem worse."

SLEEP HYGIENE

The goal of sleep hygiene is to understand the effects of environmental factors and health behaviours on sleep. People struggling to get adequate sleep should:
  • Avoid caffeine 4-6 hours before bedtime.
  • Avoid smoking before bedtime and during nocturnal awakenings.
  • Avoid drinking alcohol before bedtime.
  • Avoid heavy meals before bedtime.
  • Exercise regularly but not too late in the evening.
  • Make the sleep environment (temperature, noise, light) comfortable.
  • Avoid using sleep medications.
Given how many of us struggle to get to sleep and stay asleep, these tips are helpful.

In addition to checking out Ovarian Cancer Canada's recording of this presentation, you may wish to read previous Jenesis posts on sleep:
  • [2020-08-20] Sleep - sleep influences our effectiveness in waking life more than any other behaviour
  • [2020-09-18] More on sleep - observations on the link between sleep dysfunction and cancer, and tips for achieving better sleep
  • [2020-10-16] The Sleep Solution - observations on sleeping and tips for a good night's sleep from The Sleep Solution by W. Chris Winter, MD
Sleep well.