https://doi.org/10.33698/NRF0228 Rajwant Kaur, Karobi Das, Sunita Sharma, Gaurav Parkash
Abstract : Background: Sleep disturbances occur in about 10% to 15% of the general population and 35 to 50% of people with cancer. These are often associated with situational stress, physical illness, aging, drug treatment, pain and hospitalization. Sound assessment of sleep difficulties helps to identify sources of sleep disruption. Objective: To identify the sleep difficulties among Hemato-Oncological patients. Material and Methods: A descriptive study was conducted among hospitalised Hemato-Oncological patients and 60 patients were studied. A standardised tool ‘Insomnia severity’ index was used to assess the sleep difficulties. Result: It was found that almost all the subjects had one or another sleep difficulty and 40% were having very severe difficulty in falling asleep. Similarly 30% patients were having very severe problem in staying asleep. Problem of waking too early was faced by 28% of the study subjects. Majority of patients were very dissatisfied with their sleep and maximum patients were having impact of sleep disturbance on their daily functions. Recommendations: Nursing professional should acknowledge the need and importance of quality sleep and to take care of this utmost important need assessment of sleep difficulties and contributing factors should be kept under consideration to promote sleep to patients.
Keywords
Insomnia, Sleep disturbances, Sleep difficulties in cancer patients
Correspondence at
Dr. Karobi Das
Lecturer
National Institute of Nursing Education (NINE), PGIMER, Chandigarh
Introduction
Sleep comprises one third of our adult life. According to the National Sleep Foundation, sound sleep is essential for a person’s health and wellbeing.1 As per Maslow’s Hierarchy Needs, sleep is one of the important basic physiological need of all individuals. It plays a vital role in good health and well-being throughout the life.2 Getting enough and quality sleep at the right times can help to protect mental health, physical health, quality of life, and safety. So, good and enough sleep is essential for normal nausea and vomiting. All these factors put an individual at higher prospect of developing sleep disorder. Other supplementary factors, which can be functioning.3 Without it an individual can customized are comprise, an unbalanced experience memory lapse, mood alteration and can have difficulty with concentration.4 A sleep disorder is the disturbance of the sleep pattern of a person, in which an individual fails to have adequate and good sleep. The American Academy of Sleep Medicine defines sleep disorder as unsatisfactory sleep that impacts daytime sleep schedule, extreme total of time spent in bed, napping, engaging in sleep intrusive actions, odd working hours.9 Sleeping difficulties influences individual physically as well as psychologically as it is always associated with fatigue, mood disturbances such as irritability, dysphoria, low concentration and functioning.5
According to American depressed mood. Many longitudinal studies Psychiatric Association, typical two symptoms of insomnia are difficulty in initiating and maintaining sleep by individual.6 In general population incidence of sleep disturbances is 10% to 15% which is usually associated with stress, co-morbid conditions like other medical, surgical and psychiatric disorders.
Sleep disturbances affect between 30% to 50% of recently diagnosed or treated cancer patients. Physical illness, pain, frequent hospitalization, drugs, other treatments for cancer (chemo- therapy, radiotherapy) and the psychological impact of a malignant disease may disrupt the suggest that untreated persistent sleep disturbance may be a risk for depression (Fora and Kamerod, 1989). It also affects professional and social functioning which further shows poor quality of life. The impact of sleeplessness on physical health is that individual reports somatic complaints, headache, non-specific pains and aches.10 It is very important to acknowledge the sleep problems among patients as it is equally important for patients to sustain a good health as sound sleep decrease severity of many physical and psychological symptoms among patients. sleeping pattern.8 There are several other Nurses are spending maximum time prospective causes of insomnia, as individual having family history of insomnia, the existence of depression or an nervousness disorder, hospitalization, certain drugs (chemo drugs, radiation and hormonal therapy), pain, hot flashes, with patients and play a major role in providing a comprehensive care to cancer patients by assessing their needs and plan the inter vention based on their requirements. Incidence of sleep difficulties among cancer patients is more than general population so knowledge of the nature, severity and cause of sleep problems, can provide the basis for new approaches to treat the problem of patients. According to the type of sleep difficulty effective pharmacological and non-pharmacological measures can be provided to them to improve sleep quality and sleep satisfaction. Managing sleep difficulties will help patients in improving daily functioning. Keeping in mind this study was under taken.
Objectives
To assess the Sleep disturbances among Hemato-Oncological patients admitted in selected wards of Nehru Hospital, PGIMER, Chandigarh.
Material and Method
Research approach was quantitative and descriptive research design was employed to assess sleep difficulties among hospitalised Hemato-Oncological patients. Study was carried out in selected wards of Nehru hospital, Post Graduate Institute of Education and Research , Chandigarh. Sampling technique used was purposive and 60 patients were enrolled in the study. Interview schedule were used to collect data which comprised of part 1: Socio- demographic profile of study subjects,Part 2: Clinical data sheet which included diagnosis of patient, duration of illness and duration of hospitalization. Part 3: Insomnia severity index, a standardized tool designed to assess the nature, severity, impact of Insomnia and monitor treatment response.
It is comprises of 7 items which includes, severity of sleep onset, sleep maintenance and early morning awakening problems, sleep dissatisfaction, interference of sleep difficulties with day time functioning, notice-ability of sleep problems by others, distress caused by the sleep difficulties. Each item has five options (0-4). Total score is 28.To get the result Score of all items to be add. Total score categories: 0–7 = No clinically significant insomnia 8–14 = Sub threshold insomnia 15–21 = Clinical insomnia (moderate severity) 22–28 = Clinical insomnia (severe). This tool was available free in open domain.
Ethical clearance was obtained from Institutes Ethics committee of Post graduate institute of education and research (PGIMER), Chandigarh and written permission was taken from Head, Department of Hematology. Data was collected from 6th July 2016 to 30th September, 2016 from selected wards of Nehru Hospital, PGIMER, Chandigarh.
Data was collected by visiting selected wards daily. Daily census record checked with the permission of sister- in charge to find out newly admitted patients, they were approached individually and self introduction was given to them. After making the patients comfortable, they were informed about purpose, objectives and benefits of the study. Patients were assured that all information will be kept confidential and will be used for study only. Thereafter, with their written consent all information regarding Socio-demographic and clinical profile of the patients was filled as per interview scheduled. The sleep difficulties were assessed with the standardized tool (Insomnia Severity Index).It took 10-15 minutes to interview each patient. After the assessment patients were referred to sleep counsellor for intervention. Data was analyzed by Descriptive statistic such as mean, standard deviation, and percentage was calculated in accordance with objective of study. Tables and figures were used to depict the findings.
Results:
Socio-demographic characteristics of study subjects’
Table1 depicts the socio-demographic data of the subjects. Nearly half of the subjects were in the age range of 41-60 yrs. More than half (63.3%) were male and majority of study subjects (86.6%) were married,24% subjects had studied up to secondary level, whereas 18% subjects’ were graduate and above and 5% were illiterate.As per occupation more than half of study subjects’ (53.3%) were employed .Majority of subjects'(70%) were from nuclear families andnearly half of the subjects (46.7%) have monthly income >Rs. 40,000. Majority of subjects’ were from Hindu religion and more than half subjects’ (56.7%) were from rural background.
Table 1 : Socio-demographic characteristics of study subjects
|
N=60
Table 2 shows that all the subjects had some or other difficulty related to sleep according to Insomnia Severity Index. Very severe and severe difficulty in falling asleep was reported by 40% and 15% subjects respectively. 30% patients were having very severe problem in staying asleep and 21% did not have any problem regarding staying sleep.20% and 18.3% subjects indicated severe and very severe problem respectively of waking up too early.
Table 2: Sleep difficulties among study subjects according to Insomnia Severity Index
(N=60)
| Items | None n (%) | Mild n (%) | Moderate n (%) | Severe n (%) | Very Severe n (%) |
| Difficulty in falling asleep | 12 (20.0) | 07 (11.6) | 08 (13.4) | 09 (15.0) | 24 (40.0) |
| Difficulty in Stay asleep | 13 (21.8) | 10 (16.6) | 10 (16.6) | 09 (15.0) | 18 (30.0) |
| Waking up too early | 06 (10.0) | 14 (23.3) | 17 (28.3) | 12 (20.0) | 11 (18.3) |
Figure 1 reveals that number of subjects who were very dissatisfied with their sleep was 33.3% and 36.7% subjects were dissatisfied with their sleep.
Figure1: Sleep satisfaction among study subjects according to Insomnia Severity
Table 3 depict that 25% subjects reported that their sleep disturbance is very much noticeable to others and according to 11% respondents it was much noticeable to others . 25% subjects were Very much worried about their sleep where as 36.7% subjects were worried much about their sleep .Interference of disturbed sleep with daily function of life was reported by almost by all subjects ,as 28.4% and 23.3% patients reported much and very much impact of disturbed sleep with their daily life respectively. Only 10% patients had a little influence of their sleep on functioning of their daily life.
Table 3: Sleep difficulties among study subjects according to Insomnia Severity Index
(N=60)
| Variables related to sleep difficulties | Not at all n(%) | A little n(%) | Somewhat n(%) | Much n(%) | Very much n(%) |
| How much noticeable to others | 05 (8.3) | 12(20.0) | 17(28.3) | 11 (18.3) | 15(25.0) |
| Worried about Sleep | 01(1.6) | 08 (13.3) | 14 (23.3) | 22 (36.7) | 15 (25.0) |
| Interference with daily functions | 04(6.7) | 10 (16.6) | 15(25.0) | 17 (28.4) | 14 (23.3) |
Table 4 reveals the factors contributing to sleeping difficulties among patients. More than half of the subjects reported disturbed sleeping pattern due to fever (57%), odd time medication administration (60%), medical procedures(63%) and sleep behavior problems(60%). Some of them were having pain (33%), body ache (35%), nausea/vomiting (40%), environmental disturbances(47%) and these symptoms were associated with sleep difficulty, 47% patients were emotionally disturbed and 32% patients had reported financial burden as a cause of sleep difficulty. Very few patients indicated some other factors like disturbed body image(13%), disease relapse (22%),night sweats(17%) and frequent urination during night influenced their sleep pattern. Hospitalization was also a contributing factor for sleep difficulty among 25% of study subjects.
Discussion
Sleep plays a vital role in good health and well-being throughout the life. Getting good quality sleep at the right time can help to protect mental health, physical health, quality of life and safety. Sleep difficulty is a main concern of cancer patients as research shows that 30 to 50% of cancer patients
Table 4 : Factors associated with sleep difficulties among study subjects
|
N=60
suffering from different type of cancer suffer from sleep difficulties. Difficulties which are commonly faced by cancer patients are difficulty in initiating sleep , maintaining study it is found that there are many factors which were the causes of impaired sleep of patients. Common factors were serious symptoms of disease,(pain, body aches, sleep and waking up too early.8 It seems fever),side effect of chemotherapy and likely that the emotional and physical distress like pain, physiological changes in body because of disease or its treatment regimen also affect sleep quality of patients, simultaneously emotional disturbances like anxiety and fear related to cancer, its prognosis, family support, financial burden , frequent hospitalization also have a great impact on patients sleep. Knowledge of the nature of sleep difficulty can provide the basis for management of problems related to sleep and supportive care can be provided to treat it effectively.
The present study was conducted to study sleep difficulties among hospitalized Hemato-Oncological patients especially, as while working in Hemato- Oncological unit researcher has observed that majority of patients were complaining to have inadequate and unsatisfactory sleep. Need was felt to find out the difficulties of sleep and contributory factors for poor sleep among patients. To assess the problems regarding sleep Insomnia severity tool was used. This tool is easily applicable and it helps to assess sleep difficulty as well as the severity level of that particular problem. With the use of same tool impact of disrupted sleep and level of sleep satisfaction also can be measured.
It was found that 40% subjects were having very severe difficulty in falling asleep. Oxman, and Schnurr (1993) found polysomnographic evidence of prolonged sleep latency and night-time wakefulness among 32 cancer patients.11 In present other drugslike( fever, nausea ,vomiting, body aches, general weakness) which are being used for treating cancer also were cause of sleep difficulty in patients. Many patients showed emotional imbalance related to their prognosis of disease, certain complication related to disease and tension related to side effect of chemotherapy (nausea vomiting, changes in physical appearance) , had a negative effect on their sleep. Fear of death also found to be cause of sleep disturbance. It was observed hospitalization as adaptation to a new environment, and disruption of the usual sleep pattern contribute to poor and disturbed sleep. Park et al. (2014) were mentioned in his study that, most of patients had difficulty in sleeping after hospitalization .12 Another common sleep problem was difficulty in staying asleep. Result of our study revealed that 30% patients had severe problem in staying asleep.Difficulty to maintain sleep was related to treatment protocol as many patients were getting chemotherapy infusion for 24 hours, so for them it was very difficult to sleep with intravenous devices. Many patients reported that they are being disturbed by health professionals in between to assess their status like blood pressure recording, blood sugar monitoring and for administering medicines and some time for various procedures like blood transfusion, X-Ray, ECG etc. Environment disturbance was another cause of problem of staying asleep such as alarms (ventilator, monitoring equipments, telephones), which disturb their sleep and they find it to difficult to sleep again. Hospital environment in regard to noise, lightening and temperature was also found to be associated factor for sleep disturbances among patients. Cicek et al. (2014) have found that, administration of medication, collecting blood sample and diagnostic tests had a negative effect on sleep quality.12
- Davidsona et al(2002) found that the most commonly identified factors for sleep difficulties were pain or discomfort (45%),thoughts (52%), concern about health (38.7%),cancer diagnosis(32%), physical effects of cancer (27.7%), concern about family (33.3%).11 Hata et al. (2014) had revealed in his study that, physical illness, emotional stress, environmental change, non-optimal lighting, and high environmental noise are factors that can cause sleep deprivation in hospitalized patients. Creating a quiet hospital environment is one component to promote and improve the quality of sleep.12 In present study problem of waking too early was faced by 28% of the study subjects. It was observed that up to some extent early awakening was associated with poor sleep hygiene as many patients were spending their maximum time in bed , sleeping too early , unit routines also had impact on their sleep pattern.Majority of patients were very dissatisfied with their sleep and maximum patients were having impact of sleep disturbance on their daily functions as they complained that insufficient and disturbed sleep make them sleepy ,drowsy, fatigued as well as irritable in day time. Study done by Lavinia (2011) oncancer patients found that 72% patients were not feeling rested in the morning because of their disturbed and inadequate sleep in the night.13
It can be concluded that, sleep disruption are a common problem among cancer patients and they have enormous adverse impact on their quality of life. This problem is related to many factors include patient’s related factors as physical, psychological, behavioural environmental factors such as alarms, lightning, telephone and patient’s sound contribute to sleep disruption.
Therefore adequate assessment of sleep pattern in imperative and should identify factors influencing or causing disturbance in sleep in order to manage these sleep difficulties. There are many ways to control anxiety, fear and fatigue related to disease as relaxation therapies can be given to patient, according to the responsible factor care can be provided to patient. To provide appropriate care one should have knowledge about the nature of sleep difficulty and influencing factors. It is only possible by studying the problems patients are facing. This study can help the nurses to know about various type of sleep difficulties and their common causes. It will help them to plan nursing intervention and will be able to minimise the complications faced by patients because of poor sleep quality. Educational programs for health professionals about the difficulties in sleep, importance of sleep factors responsible for disturbed sleep, ill effect of sleep disturbance on patients’ health , management of sleep disorder should be organised . Procedures and care plan must be organized as possible at the day time to eliminate the interruption for patients at night so that their sleep quality can be enhanced.
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