The CNS taught TB how to document each morning her adherence to the techniques on her plan. The CNS also instructed TB to wear a wrist actigraph on her nondominant wrist (see Figure 1). Wrist actigraphs are portable devices the size of a large wristwatch that record movement over time in the form of activity counts. Actigraphs have gained acceptance as a sensitive tool for evaluating sleep–wake and activity–rest patterns.
TB was also shown how to fill out a daily sleep diary that includes items such as time she went to bed, number and length of time of awakenings, and time spent awake at the end of the sleep period. Based on TB's adherence and diary, the CNS helped TB identify barriers and reinforced adherence to the plan weekly. This occurred in person after the first, fourth, and fifth weeks and by telephone consultation after the second and third weeks. Her plan was revised to include the sleep hygiene technique of wearing ear plugs, because she heard sounds from dogs and television noise when she woke during the day. TB wore the actigraph for an entire week (9:00 AM on Saturday to 9:00 AM the following Saturday) during the first and sixth weeks and repeated the ISI on the last day of the sixth week.
The desired outcomes were improved subjective sleep (per ISI score) and improved objective sleep parameters (per actigraph) (Table 1). The ISI score on the first day of Week 1 was 14; when TB was assessed 6 weeks later it was 19, reflecting clinical insomnia. Despite coaching, all her sleep parameters reflected poorer sleep during TB's sixth week of paclitaxel(Drug information on paclitaxel) treatments. The most remarkable finding was that TB only scheduled herself to sleep six times per week and she only slept 6 hours on those nights. The time she spent awake while she was in bed was excessive, and her sleep efficiency was 10% to 15 % lower than normal.
This case illustrates poor sleep during chemotherapy in a young wife and mother who is employed in a physically demanding job full-time on a night shift. When assessed, the patient reported that her sleeping problems were very noticeable to others in terms of impairing her quality of life. More than 50% of shift workers have reported severely reduced sleep or alertness. Likewise, approximately 50% of cancer patients with a variety of diagnoses have reported sleep problems; insomnia is the most common disorder.[10,11] Sleep–wake disturbances are under-reported and under-treated in cancer patients during and after treatment. TB had not volunteered to report problems sleeping during the dose-dense chemotherapy treatments despite a high likelihood that she was experiencing problems.