A conversation with Dr. Douglas E. Guggenheim, MD

Q: What are the first steps someone with cancer can take if they aren’t sleeping well? 
A: There have been lots of anecdotal conversations with regard to how to manage insomnia and sleep problems throughout the cancer continuum. The problem with insomnia is that it can be multifactorial, treatment related, social, or psychological in nature. With that, the approaches and strategies with which we must employ must first start with conversations regarding what triggers may be contributing to the specific sleeping issue. Probably the best strategy to begin assessing one’s sleep problems would be to start with a sleep diary, assessing and looking for specific trends that may be contributing. For example, medication used at a certain time of the day, such as the timing of steroids, or identifying fractured sleep hygiene in the sense that one’s schedule is very off with regard to a consistent bedtime or sleep routine. With regard to specific concerns about steroids, the general strategy is to take these medications early in the day to ease the side effects at bedtime. For example, a specific routine incorporating a set time for bed and a “winding down” process may help alleviate insomnia.

Q: What if those first steps don't help? Suppose cancer-related anxiety or depression is contributing to insomnia. 
A: Strategies for correcting sleep problems in people with colorectal cancer can certainly be considered at home by the patient or family looking for specific triggers. There is evidence to suggest that one cause of insomnia could be stress and anxiety, and there may be a potential role for cognitive behaviour therapy (CBT) from a talk therapy approach. Oftentimes, discussing one’s problems and concerns can relieve significant anxiety and assist a patient with developing tools with which they can address some of the specific concerns, leading to improved sleep hygiene.  For a certain cohort of patients, support groups can assist with recommendations and strategies for improving sleep; however, from a more formal psychological perspective, literature supports the role of CBT as noted above.

Q: If those steps don’t address the sleep problems in people with colorectal cancer, what do you recommend next? What are your thoughts on complementary and alternative treatments?
A: If the above-noted strategies are not particularly helpful in alleviating sleep problems, employing alternate treatment strategies are appropriate – whether that be aromatherapy, acupuncture, nontraditional medication, and supplements, such as melatonin. The problem, however, is once the above-noted issues have been exhausted, where does one go? Typically the goal would be to exhaust treatment options with less potential side effects, as some of the more aggressive strategies can lead to dependence and addiction. If you are receiving palliative care, be sure to include your oncology team so they can help your palliative care team and you manage and maintain the best possible quality of life. 

Q: Finally, is there a point where a patient needs doctor-prescribed medicines or perhaps other legal alternatives to help with their sleep problems? 
A: It’s very clear that there can be many contributing factors to sleep problems in people with colorectal cancer. Using a troubleshooting approach at first can yield very successful results; however, there are potentially many other strategies with which we can employ to improve causes and symptoms of insomnia. From my perspective, an “all hands on deck“ strategy in cooperation with a team approach with your physician yields the most successful results for patients working through the issues and challenges of treatment and recovery from cancer.

5 Tips for Managing Sleep Problems

Create an optimal sleep environment. Keep your bedroom cool, but not cold. It’s hard to sleep when your feet are freezing. You can lower your thermostat or use a ceiling fan. 

Get rid of distractions and step away from the blue light. Charge electronics each night, but turn off notifications and sound. If you can’t turn off your electronics, put them on “Do Not Disturb” mode. Try to place them farther than arm’s reach, so you can avoid the temptation to pick them up if you awaken in the middle of the night. Your phone, table, and laptop all emit blue light, which stops melatonin production. Melatonin is key in getting you ready to fall asleep and can help prevent sleep issues.

Cut the caffeine and sugar. Try to avoid all things caffeine and sugar after 6pm. Both caffeine and sugar interfere with your ability to fall asleep and may cause sleep issues. Some people believe alcohol helps them sleep better, and while it may make you feel ready to nod off, alcohol often causes your body to wake up, which may mean a restless night’s sleep. 

Find your peace, however that looks. There are multiple ways that people find peace. Warm water can help your body and mind begin to distress as you wind down, so some prefer to take a warm bath or shower at night. Others may take deep breaths, meditate, or pray to help them feel at peace. Some people appreciate the essential oil lavender in a diffuser, lotion, or spray to bring them a natural calm. Whatever it is that helps you calm your mind and body, consider doing that to help prepare for bed. 

How Physical Activity Can Help You Sleep If you have sleep issues, don’t get enough sleep, or a good night’s sleep, try to incorporate exercise, if possible, into your day. Daylight tells your body to wake up and get moving. Fresh air and activity are great ways to energise your body. According to the National Cancer Institute, benefits of exercise include:

• Improved sleep, which helps your body rest and recover.
• Boosted mental health, which may reduce anxiety and depression. 
• Just be sure to get your light and movement early in the day rather than later at night. If you exercise earlier in the day, you can feel refreshed throughout your daily activities while also tiring yourself out enough to sleep well at night. Fresh air and activity are great ways to increase your energy, so try to make them both a consistent routine in your day.

Finally, know that you are not alone. Be sure to speak with your medical team if you are struggling with sleep problems. Together, you can work to figure out a sleep solution that works for you.