Sleep quality in hospitalized patients with advanced cancer: an observational study using self-reports of sleep and actigraphy

  • Gunnhild JakobsenEmail author
  • Morten Engstrøm
  • Morten Thronæs
  • Erik Torbjørn Løhre
  • Stein Kaasa
  • Peter Fayers
  • Marianne Jensen Hjermstad
  • Pål Klepstad
Original Article



Although patients with advanced cancer report poor sleep quality, few studies have assessed sleep quality with a combination of subjective and objective measures. We aimed to examine sleep quality in hospitalized patients with advanced cancer by combining patient-reported outcome-measures (PROMs) and polysomnography (PSG) or actigraphy.


A one-night prospective observational study of sleep in hospitalized patients with metastatic cancer using WHO step III opioids was conducted. Total sleep time, sleep onset latency, number of awakenings, and wake after sleep onset were assessed by PROMs and actigraphy. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) (range; 0–21), where higher scores indicate worse sleep quality.


Forty patients were monitored. Median age was 70, median oral morphine equivalent dose was 80 mg/24 h (10–1725), median Karnofsky Performance Score was 50 (20–90), and median time to death from inclusion was 38 days (4–319). Mean PSQI score was 6.5 (SD ± 3.4). PROMs and actigraphy of mean (SD) sleep onset latency were 46 (± 64) and 35 min (± 61), respectively, while mean time awake at night was 37 (± 35) and 40 min (± 21). PROMs and actigraphy differed on number of awakenings (mean 2 (± 1) vs. 24 (± 15), p ˂ 0.001). Bland-Altman plots showed large individual differences between PROMs and actigraphy. PSG was not feasible.


PROMs and actigraphy documented poor sleep quality, but a lack of agreement across methods. The study demonstrates a need to improve assessment of sleep quality and treatment of sleep disturbance in hospitalized patients with advanced cancer near end of life.


Sleep Advanced cancer Sleep diary Actigraphy Polysomnography 



We would like to thank all participating patients. In addition, we would like to thank the Department of Palliative Medicine, Cancer Clinic, St. Olav’s hospital, Trondheim University Hospital, Trondheim, Norway, for important contribution to patient recruitment and completion of the study. We thank Ragnhild Green Helgås for language editing.

Funding information

This work was funded by grants from the Central Norway Regional Health Authority awarded by the Liaison Committee for Central Norway (Project number 46083200, year 2015). The funder had no role in the trial design, collection, analysis and interpretation of data, or writing.

Compliance with ethical standards

Conflict of interest

Gunnhild Jakobsen, Morten Engstrøm, Morten Thronæs, Erik Torbjørn Løhre, Peter Fayers, Marianne Jensen Hjermstad, and Pål Klepstad have nothing to disclosure. Stein Kaasa is one of the shareholders in Eir Solution A/S and has research funding from Nutricia for other studies. He declares no income, dividend, or financial benefits from the work presented here.

Ethical standards

The study was conducted in accordance with ethical principles in the Declaration of Helsinki and was consistent with ICH/Good Clinical Practice and applicable regulatory requirements. The Regional Committee for Medical and Health Research Ethics, Rec North, approved the study (approval number 2015/1631).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

520_2019_4998_MOESM1_ESM.docx (14 kb)
ESM 1 (DOCX 13 kb)
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Supplementary Fig. 1 Illustrations of the clinical set-up of polysomnography equipment. Illustration photo (NTNU). Used with permission (JPG 373 kb)
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Supplementary Fig. 2 Illustrations of the clinical set-up of actigraphy. Illustration photo (NTNU). Used with permission (JPG 141 kb)
520_2019_4998_MOESM5_ESM.jpg (235 kb)
Supplementary Fig. 3 Actogram for two patients where the software was not able to generate sleep parameters for total sleep time, sleep onset latency, number of awakenings, wake after sleep onset and sleep efficiency. The black lines indicate activity. (JPG 234 kb)
520_2019_4998_MOESM6_ESM.jpg (410 kb)
Supplementary Fig. 4 Bland-Altman plots for total sleep time (TST) (A), sleep onset latency (SOL) (B), number of awakenings (NWAK) (C), wake after sleep onset (WASO) (D) ad sleep efficiency (SE) (E). On the plots, the y-axis represents the difference between actigraphy and patient-reported outcome measures (PROMs). The x-axis shows the average of the two methods. The red line represents the mean difference between actigraphy and PROMs, and the green lines demonstrate the 95% limits of agreement (mean difference ± 1.96 standard deviation). (JPG 409 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Gunnhild Jakobsen
    • 1
    • 2
    Email author
  • Morten Engstrøm
    • 3
    • 4
  • Morten Thronæs
    • 1
    • 2
  • Erik Torbjørn Løhre
    • 1
    • 2
  • Stein Kaasa
    • 1
    • 5
  • Peter Fayers
    • 7
  • Marianne Jensen Hjermstad
    • 5
    • 6
  • Pål Klepstad
    • 1
    • 8
    • 9
  1. 1.European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNTNU - Norwegian University of Science and TechnologyTrondheimNorway
  2. 2.Cancer Clinic, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
  3. 3.Department of Neuromedicine and Movement ScienceNorwegian University of Science and TechnologyTrondheimNorway
  4. 4.Department of Neurology and Clinical Neurophysiology, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
  5. 5.European Palliative Care Research Centre, Department of OncologyOslo University Hospital and Institute of Clinical Medicine, University of OsloOsloNorway
  6. 6.Regional Advisory Unit of Palliative Care, Department of OncologyOslo University HospitalOsloNorway
  7. 7.Division of Applied Health SciencesUniversity of AberdeenAberdeenUK
  8. 8.Department of Anaesthesiology and Intensive Care Medicine, St. Olavs HospitalTrondheim University HospitalTrondheimNorway
  9. 9.Department of Circulation and Medical Imaging, Faculty of Medicine and Health SciencesNorwegian University of Science and Technology NTNUTrondheimNorway

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