INSOMNIA AND RELATED FACTORS IN A PALLIATIVE CARE UNIT

INSOMNIA AND RELATED FACTORS IN A PALLIATIVE CARE UNIT A. Renom 1, C. Farriols 2, M.A. Silvent 2, A. Arocas 2, S. Arias 2, J. Planas 2, A.I. Ruiz 3 Institute(s): 1 Institut Municipal d'assistència Sanitària (IMAS), Department of Geriatrics, Barcelona, Spain, 2 Institut Municipal d'assistència Sanitària (IMAS), Palliative Care Unit, Department of Medical Oncology, Hospital de l'esperança, Hospital del Mar, Barcelona, Spain, 3 Institut Municipal d'assistència Sanitària (IMAS), Department of Psychiatry, Barcelona, Spain

INTRODUCTION Insomnia Insomnia is more prevalent in cancer patients than community subjects It is prevalent in patients hospitalized in Palliative Care Units It is likely to be underreported It contributes to the burden of suffering for this population Several demographical and clinical factors have been found associated with insomnia

AIMS To evaluate the prevalence and characteristics of insomnia in our Palliative Care Unit To determine the factors associated with insomnia

METHODS Patients consecutively admitted to the PCU INCLUSION CRITERIA: Pfeiffer Questionnaire score 4 Karnofsky Index 30 3 days hospitalization Demographical, disease and treatment data TRAINED NURSE-ADMINISTERED QUESTIONNAIRE (3rd-5th day) Evaluation of insomnia Evaluation of factors potentially related to insomnia: -Physical factors -Environmental factors -Psychological factors

METHODS Patients consecutively admitted to the PCU INCLUSION CRITERIA: Pfeiffer Questionnaire score 4 Karnofsky Index 30 3 days hospitalization Demographical, disease and treatment data TRAINED NURSE-ADMINISTERED QUESTIONNAIRE (3rd-5th day) Evaluation of insomnia Evaluation of factors potentially related to insomnia: -Physical factors -Environmental factors -Psychological factors

METHODS Evaluation of insomnia SIMPLE QUESTION: Have you been suffering from insomnia since you have been admitted? (yes/no/sometimes) SLEEP DISTURBANCE SCALE 1 : During the time you have been hospitalized have you suffered from...? a. Difficulty in falling asleep (0-10) b. Waking up during the night (0-10) c. Waking up too early in the morning (0-10) SLEEP DISTURBANCE SCORE (SDS): a + b + c 3 5: moderate to severe insomnia 1- Anderson KO et al. Fatigue and sleep disturbance in patients with cancer, patients with clinical depression, and community-dwelling adults. J Pain Symptom Manage. 2003 Apr;25(4):307-18.

METHODS Evaluation of insomnia Is insomnia a worry for you? (0-5) Do you suffer from diurnal somnolence? (yes/no) Do you have the feeling of non-restorative sleep? (yes/no)

METHODS Patients consecutively admitted to the PCU INCLUSION CRITERIA: Pfeiffer Questionnaire score 4 Karnofsky Index 30 3 days hospitalization Demographical, disease and treatment data TRAINED NURSE-ADMINISTERED QUESTIONNAIRE (3rd-5th day) Evaluation of insomnia Evaluation of factors potentially related to insomnia: -Physical factors -Environmental factors -Psychological factors

METHODS Physical factors: Does interfere with your sleep quality? - Dyspnea - Functional incontinence - Fever - Sweating - Nausea, vomiting - Itch - Pain - Drug/tobacco abstinence - Nycturia - Cough - Restless-legs syndrome - Other Environmental factors: Does any environmental factor from the unit such as noise or light bother you when sleeping? (yes/no)

METHODS Psychological factors: Emotional distress measured by Hospital Anxiety and Depression Scale (HADS): 19 clinically significant emotional distress Do you suffer from nightmares / nocturnal ruminations / feeling of fear or loneliness? (yes/no)

METHODS What kind of factor is the one most interferring with your sleep quality? Physical Environmental Psychological

RESULTS 138 patients INCLUSION CRITERIA: Pfeiffer Questionnaire score 4 Karnofsky Index 30 3 days hospitalization 45 included (32%) 46.7% women / 53.3% men 72.16±11.05 years old [40-89] 35.6% coming from home / 62.2% acute care 93.3% oncological patients 20% lung, 17.8% colon, 15.6% gynecological, 11.1% urinary tract 37.8% with local or regional extension, 55.6% disseminated

RESULTS Evaluation of insomnia SIMPLE QUESTION:

RESULTS Evaluation of insomnia Difficulty in falling asleep (0-10) Waking up during the night (0-10) Waking up too early in the morning a + b + c / 3 mean

RESULTS Evaluation of insomnia Moderate to severe insomnia (SDS 5) 29 16 64.5% 35.5% no yes no yes

RESULTS Evaluation of insomnia Mean: 2.58±1.67

RESULTS Physical factors Does interfere with your sleep quality? Yes No Pain 31 (68.9%) 14 (31.1%) Dyspnea 18 (40%) 27 (60%) Cough 16 (35.6%) 29 (64.4%) Nausea, vomiting 15 (33.3%) 30 (66.7%) Sweating 13 (28.9%) 32 (71.1%) Nycturia 11 (24.4%) 34 (75.6%) Functional Incontinence 8 (17.8%) 37 (82.2%) Itch 7 (15.6%) 38 (84.4%) Restless-legs syndrome 5 (11.1%) 40 (88.9%) Drug/tobacco abstinence 3 (6.7%) 42 (93.3%) Fever 1 (2.2%) 44 (88.9%)

RESULTS Environmental factors

RESULTS Psychological factors HAD score: 20.33 ±7.46 [6-34] Clinically significant emotional distress (HAD score 19) 28 62% 8 9 0-13 14-18 19

RESULTS Psychological factors yes no Nightmares 11 (24%) 34 (75.6%) Rumiations 32 (71.1%) 13 (28.9%) Fear or loneliness 19 (42.2%) 26 (57.8%)

RESULTS

RESULTS Univariant analysis Which factors were associated with insomnia?

RESULTS Univariant analysis Answering yes to the question: Have you been suffering from insomnia since you have been admitted? Associated factors Yes (n=23) No/Sometimes (n=22) N(%) N(%) p Diurnal somnolence 62.2 37.8 <0.05 Feeling of non-restorative sleep 70.8 29.2 <0.05 Coming from acute care (vs. home) 64.3 35.7 <0.05 Dyspnea 77.8 22.2 <0.05 Ruminations 59.4 40.6 0.08 Mean Mean HAD score 22.26±6.73 18.32±7.79 p=0.076

RESULTS Univariant analysis Moderate to severe insomnia (SDS 5) Associated factors Degree of worry about insomnia SDS 5 <5 Mean Mean p 3.56±1.46 1.92±1.5 p<0.05 SDS Tumor extension 5 <5 p Locoregional 3 (17.6%) 14 (82.4%) Disseminated 12 (48%) 13 (52.0%) <0.05

CONCLUSIONS Insomnia was a frequent and multifactorial symptom in our PCU Patients atributed insomnia mostly to physical factors Patients presented a high level of emotional distress The Sleep Disturbance Scale can be a useful tool for initial evaluation and follow-up of insomnia in PCU

CONCLUSIONS Moderate to severe insomnia was frequent and it was associated with a higher degree of worry about insomnia and with disseminated cancer. Organic changes or treatment associated with advanced disease may contribute to sleep cycle disruption

CONCLUSIONS More prospective studies are needed to determine the factors associated with insomnia and to understand the possible relationship between them

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