1. Insomnia and Fatigue Andrea Richtel Branas, MSE, MPT, CLT Lead Therapist Good Shepherd Penn Partners Abramson Cancer Center

2. 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

3. 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

4. What does fatigue feel like? No energy Need more sleep Sleeping is not restful Normal activities are difficult to do Difficulty focusing your attention

5. What causes Fatigue? Cancer and it’s treatment

6. What causes Fatigue – Cancer – Cancer treatments (surgery, chemo, radiation) – Anemia – Insomnia/sleep disturbance – Nutrition – Depression and anxiety – Medications – Too much activity – Lack of exercise

7. Symptom Cluster Fatigue is commonly clustered with symptoms of: – Pain – Sleep disturbance – Emotional distress

8. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic Patient Education

9. 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

10. Energy Conservation Pacing Planning Posture Organization

11. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic

12. Non-Pharmacologic Activity Enhancement – Exercise – Rehabilitation Psychsocial Intervention Nutrition

13. “Activity Enhancement” “It is reasonable to encourage all patients to engage in a moderate level of physical activity during and after cancer treatment”

14. 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

15. 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.

16. 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.

17. How do you get started with exercise? Physical Therapy Cancer Certified Trainer Home Vs.

18. Physical Therapy – Not sure what to do – Recent surgery – Medically complex – Lymphedema – Very deconditioned

19. Exercise Specialist ACSM/ACS Certified Cancer Exercise Trainer – No specific muscle/joint pains – Need guidance – No lymphedema

20. 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

21. Bare minimum Walk Something is more than nothing! Start Low and Progress Slow!

22. How do we treat fatigue? Adapted from NCCN Guidelines 1.2013 Cancer-Related Fatigue Patient Education Energy conservation Non-pharmacologic Pharmacologic

23. Medications for: – Pain – Insomnia – stimulants

24. Sleep Distrubance Hypersomnia –sleeping too much Insomnia – not enough sleep 30%-75% of patients with cancer

25. Why is sleep disrupted? Pain Anxiety Night sweats Upset stomach Frequent urination Difficulty breathing Poor sleep habits Medication www.cancer.gov

26. 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

27. 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.

28. 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.

29. 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.

30. Controlling your fatigue In your control Out of your control

31. 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

32. Getting to know your fatigue Rate your fatigue 012345678910 No fatigue Worst fatigue you can imagine

33. On your calendar Fatigue Mood Activity Medication Stressors Sleep

34. 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

35. Share symptoms with care team Discuss: – Medications – Activity – Sleep – Mood – Pain

36. Exercise

37. 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.

38. Eat Well

39. 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

40. Managing Side Effects Relationship to Self Acceptance Emotional Release Not over-identifying with the body Relationship to Others Communicating Feelings Educating Others Getting help!

41. Moving On What is the most loving thing you can do for yourself?

42. Questions and Discussion