Ask an Expert: Chemotherapy and insomnia

Q: I'm undergoing chemo, and though I am experiencing heavy-duty fatigue, I am also suffering from insomnia! Sometimes it's hard to fall asleep; other nights I wake up around 3 a.m. for an hour or two. My medical oncologist said chemo can disrupt the sleep-wake cycle and prescribed Ambien. I don't like the idea of relying on a sleeping pill. Anything else I can do?

Answer from Miles Hassell, M.D., director of Providence Integrative Medicine at Providence Cancer Center:  

Doctors who specialize in sleep disorders are fans of Ambien because it induces a deep, high quality sleep for about seven or eight hours. A different drug, Sonata, is shorter-acting and intended to help you get back to sleep in the middle of the night.

But you're right: All sleep agents are short-term solutions and tend to lose their effectiveness over time. It's smart to look at the whole picture. The first step is to deal with any other factors that might be interfering with sleep. Here's a checklist: 

  • Pain? If you're in pain, better control of your pain may help you sleep better. Make sure your doctor is aware of your symptoms because there are lots of alternatives for controlling them. Also, chemo can cause upset stomachs and mouth sores that are painful enough to keep you up. Talk with your oncologist about treating those.
  • Nausea? Take an anti-emetic at bedtime. Many anti-nausea medicines are sedatives, so it's a bonus side effect when you have sleep problems.
  • Alcohol? Drinking too much alcohol which can mean any alcohol at all for some people in the afternoon or evening can mess up sleep. If you drink alcohol regularly, try doing without for a few days and see if your sleep improves.
  • Caffeine? In battling fatigue, make sure you're not overdoing the caffeine, especially late in the day. As with alcohol, some people need to skip caffeine entirely.
  • Restless leg syndrome? If you have that syndrome, you may sleep fine after it's treated.
  • Anxiety? Healthy measures to calm your anxiety can improve sleep. This can involve any number of steps you personally find helpful for relieving anxiety, such as massage, meditation, prayer, talking to a friend or taking a walk.
  • Napping? If a big chunk of your overall sleep need is being met with daytime naps, you might need to scoot back your bedtime. Turn off the lights at 11 p.m. instead of 10 p.m. Fill in the extra hour with a positive, gentle pastime such as crafts, letter writing, playing an instrument, reading.
  • Menopause? If surgical or chemo-induced menopause is creating problems with hot flashes and night sweats, talk to your doctor about treatments to relieve your symptoms.

If you are still up with the owls, other strategies can help you sleep. Note, these are suggestions, not sure-fire solutions. Some may help, some may do nothing, and some may even worsen your sleep. So, you need to be ready for some trial and error.

Exercise. To help with disturbed sleep, I especially recommend exercising outdoors, in the morning. Many patients don't exercise at all during chemo, but almost everyone has the ability to walk for 10 minutes, three times a day. The target is a total of 30-60 minutes of daily activity. Studies show that patients who exercise during chemotherapy have less trouble with anemia, better white cell counts and improved mood.

Exercise also improves sleep. Moving fast enough to work up a sweat is ideal but not critical. Just keep moving at whatever pace you can. One warning: For some people, exercising in the late evening upsets their sleep. Others feel great after a late evening walk. Experiment.

Calms Forte. This is a homeopathic sleep aid that does the trick for many people, though not everyone. I don’t know how it works, but it is inexpensive and dead safe. It's available at natural foods stores.

Melatonin. In my experience, melatonin – a hormone involved in the sleep/wake cycle is particularly useful for patients age 60 and older. Studies suggest taking anywhere from 3 mg to 20 mg of melatonin at bedtime. Start with 3 mg. a dose, two or three hours before bedtime. If it's going to work for you, you should feel the effect within a few days.

If you find you're sleeping better, you might get by on a smaller dose. If you're not sleeping better, try doubling the dose for a few days. Warning: As with Ambien, a small group of people can feel wired on melatonin.

Valerian. Valerian, a plant with sedative effects, is available in pills, tinctures and ground root. Taking 160 mg-600 mg one hour before bedtime appears safe and effective. Check the label for "standardized extract"; you'll have a greater chance of being a good quality herb. I recommend the 600 mg dose; you can experiment with a lower dose if it works. You can also make a tea using 15-20 drops of a 1:5 tincture or with one teaspoon of the ground root. By using capsules, you avoid valerian's peculiar smell that may be noticeable in the tincture or ground root. It is an ingredient in Sleepytime Extra tea, but its 25 mg is a very small amount.

A little nip. While alcohol can mess up sleep, for some people, a tiny amount at bedtime sends them to dreamland. Try a ¼-½ serving of wine or sherry.

Bedtime snack. I haven't seen research on this, but I often see it work with my patients. Food in your tummy seems to have a calming effect. Sip a cup of warm milk; warm milk contains calcium, proteins and tryptophan, an essential amino acid that plays a role in relaxation and sleep. Some people make a hot milk nightcap by adding a quarter-shot of their favorite liqueur. Sprinkle nutritional yeast on popcorn; the yeast is rich in B vitamins and proteins, which also have a hand in drowsiness. Try peanut or almond butter on whole-grain bread, or a handful of almonds with a piece of fruit: The combination of carbohydrate and fat evens out the blood sugar. Cancer patients particularly benefit from a power yogurt sundae: plain yogurt high in beneficial bacteria (I recommend Nancy's brand) mixed with quality blueberry or raspberry jam and two tablespoons of ground flaxseed.

You may wonder about products such as Tylenol PM, Excedrin PM or Sominex. The "PM" part is diphenyhydramine, which you may know as Benadryl. Diphenyhydramine is an antihistamine that also has a sedating effect on the central nervous system. When sleep experts measure brain waves of patients using these products, they are not having good quality sleep; yet I talk with many people for whom it works well. I don’t recommend it, but practice still beats theory. Another caution: For the elderly, diphenyhydramine can cause bowel problems, increase risk of falls and cause confusion and difficulty with urination.

If you do wake up, shake off any agitation about not being able to sleep. Get up, keep the lights low, tell yourself, "This, too, shall pass," and do something pleasant and relaxing. Read a book, make a snack, knit – and after 45 minutes or an hour, give bed another try.

May 2004  

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