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Insomnia and Fatigue Andrea Richtel Branas, MSE, MPT, CLT Lead Therapist Good Shepherd Penn Partners Abramson Cancer Center
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Cancer Related Fatigue (CRF) Distressing, persistent, subjective sense physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and interferes with usual functioning. NCCN Guidelines V 1.2013, Cancer-Related Fatigue
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Cancer Related Fatigue Reported as the most common and distressing side effect of cancer treatment Affects 70-100% of the cancer population Can make it hard to: – Be with friends and family – Do daily activities – Follow treatment plan
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What does fatigue feel like? No energy Need more sleep Sleeping is not restful Normal activities are difficult to do Difficulty focusing your attention
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What causes Fatigue? Cancer and it’s treatment
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What causes Fatigue – Cancer – Cancer treatments (surgery, chemo, radiation) – Anemia – Insomnia/sleep disturbance – Nutrition – Depression and anxiety – Medications – Too much activity – Lack of exercise
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Symptom Cluster Fatigue is commonly clustered with symptoms of: – Pain – Sleep disturbance – Emotional distress
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How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic Patient Education
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Energy Conservation Finding easier ways to perform tasks Saving your energy Avoiding fatigue, by balancing work and rest Changing how you do activities – So you can do more without as much fatigue
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Energy Conservation Pacing Planning Posture Organization
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How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic
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Non-Pharmacologic Activity Enhancement – Exercise – Rehabilitation Psychsocial Intervention Nutrition
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“Activity Enhancement” “It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment”
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ACSM Guidelines ACSM Roundtable on Exercise Guidelines for Cancer Survivors – Medicine & Science in Sports and Exercise, June 2010 ***Avoid Inactivity*** Exercise should be individualized Exercise is safe both during and after most types of cancer treatment
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Exercise with lymphedema Weight Lifting in Women with Breast-Cancer- Related Lymphedema In breast cancer survivors with stable lymphedema, slowly progressive weight lifting did not significantly increase limb swelling. – Decreased incidence of flares – Decreased lymph symptoms – Increased strength Schmitz KH, et al. Weight Lifting in Women with Breast-Cancer-Related Lymphedema. N Engl J Med 2009;361:664-73.
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Physical Activity American Cancer Society guidelines – Adopt a physically active lifestyle. Adults: – Moderate or greater activity for 30 minutes or more on five or more days of the week. – Always talk to your doctor/nurse first! Special precautions – Low blood counts – Bone metastases Byers et al. (2002). American Cancer Society Guidelines on Nutrition and Physical Activity for Cancer Prevention. CA: A Cancer Journal for Clinicians 52: 92-119.
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How do you get started with exercise? Physical Therapy Cancer Certified Trainer Home Vs.
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Physical Therapy – Not sure what to do – Recent surgery – Medically complex – Lymphedema – Very deconditioned
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Exercise Specialist ACSM/ACS Certified Cancer Exercise Trainer – No specific muscle/joint pains – Need guidance – No lymphedema
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Exercise at Home Experienced exerciser Know how to slowly progress Know how to come back after a holiday Know how to monitor how hard you are working
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Bare minimum Walk Something is more than nothing! Start Low and Progress Slow!
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How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic
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Medications for: – Pain – Insomnia – stimulants
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Sleep Distrubance Hypersomnia –sleeping too much Insomnia – not enough sleep 30%-75% of patients with cancer
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Why is sleep disrupted? Pain Anxiety Night sweats Upset stomach Frequent urination Difficulty breathing Poor sleep habits Medication www.cancer.gov
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ADL = activity of daily living Fleishman. Journal of the National Cancer Institute Monographs No. 32. 2004; Bennett, Cameron, Brown, et al. Oncology Nursing Forum. 2010. Look closely at your sleep Issues – Sleep history – Impact of insomnia on daily activities – Sleep diary – Mood evaluation – check for depression & anxiety – Apnea/snoring
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Help for Insomnia – Behavioral therapy – Stimulus control therapy – Sleep restriction therapy – Sleep hygiene education – Regular exercise – Medications Mills, Graci. Cancer Symptom Management. 2004; Savard, Simard, Ivers, et al. JCO. 2005.
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Medical Treatments CLASSIC THERAPIES Benzodiazepines (temazepam) Imidazopyridines (zolpidem) Pyrazolopyrimidine (zaleplon) Pyrrolopyrazine (eszopiclone) Behavior Therapy (sleep restriction, stimulus control) Antidepressants (amitriptyline, trazodone, doxepin) } benzodiazepine receptor agonists BZRAs Savard, Simerd, Ivers, et al. JCO. 2005.
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Other Pharmacologic strategies Psychostimulants Corticosteroids Antidepressants – Treatment of depression related fatigue Herbals – Promising – Drug-drug interactions possible NCCN Practice Guidelines in Oncology v1.2011: Cancer-Related Fatigue. Downloaded from http://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdfhttp://www.nccn.org/professionals/physician_gls/PDF/fatigue.pdf.
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Controlling your fatigue In your control Out of your control
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How do you gain control? 1.Know your symptoms – Monitor symptoms regularly 2.Share your symptoms with – Care team – Family and friends 3.Try new treatments – But only 1 at a time
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Getting to know your fatigue Rate your fatigue 012345678910 No fatigue Worst fatigue you can imagine
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On your calendar Fatigue Mood Activity Medication Stressors Sleep
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Symptoms Calendar SundayMondayTuesdayWednesday F=3 P=2 Walk = 1 mile Party S= 8 F=5 P=4 No exercise S = 7 F=3 P=3 Walk 2 miles S=9 F=3 P=2 Lift weights F= Fatigue P = Pain M= mood S= hours of sleep Exercise
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Share symptoms with care team Discuss: – Medications – Activity – Sleep – Mood – Pain
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Exercise
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Sleep Hygiene – Eliminate caffeine, nicotine, & alcohol – Check meds with MD – Keep bedtime and wake- time same – Exercise – Avoid late afternoon naps – Eliminate big bedtime snacks – Limit night-time fluids – Avoid noise – Keep correct temperature – Get outside – Get up if not sleeping – Reserve bed for sleep Mills, Graci. Cancer Symptom Management. 2003; Savard, Simerd, Ivers, et al. JCO. 2005.
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Eat Well
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Managing Side Effects from the Psycho/Social Point of View – Side effects are no fun! – How you respond to side effects is completely up to you
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Managing Side Effects Relationship to Self Acceptance Emotional Release Not over-identifying with the body Relationship to Others Communicating Feelings Educating Others Getting help!
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Moving On What is the most loving thing you can do for yourself?
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Questions and Discussion
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