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

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Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusions

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.

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Acknowledgments

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

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.

Author information

Authors and Affiliations

  1. European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU - Norwegian University of Science and Technology, Postbox 8905, NO-7491, Trondheim, Norway

    Gunnhild Jakobsen, Morten Thronæs, Erik Torbjørn Løhre, Stein Kaasa & Pål Klepstad

  2. Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway

    Gunnhild Jakobsen, Morten Thronæs & Erik Torbjørn Løhre

  3. Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway

    Morten Engstrøm

  4. Department of Neurology and Clinical Neurophysiology, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway

    Morten Engstrøm

  5. European Palliative Care Research Centre, Department of Oncology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Stein Kaasa & Marianne Jensen Hjermstad

  6. Regional Advisory Unit of Palliative Care, Department of Oncology, Oslo University Hospital, Oslo, Norway

    Marianne Jensen Hjermstad

  7. Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK

    Peter Fayers

  8. Department of Anaesthesiology and Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway

    Pål Klepstad

  9. Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology NTNU, Trondheim, Norway

    Pål Klepstad

Authors
  1. Gunnhild Jakobsen
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  2. Morten Engstrøm
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  4. Erik Torbjørn Løhre
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  5. Stein Kaasa
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  8. Pål Klepstad
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Corresponding author

Correspondence to Gunnhild Jakobsen.

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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).

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

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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)

Supplementary Fig. 2

Illustrations of the clinical set-up of actigraphy. Illustration photo (NTNU). Used with permission (JPG 141 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)

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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Jakobsen, G., Engstrøm, M., Thronæs, M. et al. Sleep quality in hospitalized patients with advanced cancer: an observational study using self-reports of sleep and actigraphy. Support Care Cancer 28, 2015–2023 (2020). https://doi.org/10.1007/s00520-019-04998-5

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  • DOI: https://doi.org/10.1007/s00520-019-04998-5

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