Fatigue/Sleep Flashcards
1
Q
Preventative rehabilitation - goal, example
A
Goal:
- Reduce burden of morbidity or disease treatment
Examples:
- Pre-op education re: maintaining strength and ROM following breast surgery
- Education for caregivers re: skin ulcers
- Methods to preserve social function and ADLs
2
Q
Restorative care - goal, examples
A
Goal:
- Return individual with **minimal functional impairment to pre-morbid state
- May include psychological and social approaches
- Attention to symptom control, management of pain, sleep, and hygiene, and evaluation of treatment effects
Examples:
- Re-establishment of ROM and upper extremity strength following mastectomy
3
Q
Supportive care - goal, eamples
A
Goal:
- Reduce functional difficulties and compensate for permanent deficits
- Program to restore mobility and manage symptoms occurring as a result of treatment
Example:
- Multimodal techniques to rehabilitate a patient after amputation
4
Q
Palliative Treatment - goal, examples
A
Goal:
- Maintain or restore (perhaps only for a time) functional capacity to care for oneself and maintain mobility
- Includes emotional support and symptom control
- Strategy often includes energy conservation strategies, assistive devices, and treatment of symptoms
5
Q
Rehabilitation Team Members
A
Nurse
- Primary point of contact between patient and team
- Triages and screens for impairments
- During team evaluation, assess for main symptoms and concerns
- Regular follow up and assistance with healthcare navigation
- May function as counsellors and assist with advocacy
PT
- Evaluates strength, mobility, endurance, and ROM
- Interventions include therapeutic exercise to maintain or improve ROM, endurance, and mobility
OT
- Assess self-care, household chores, leisure activities in the patient’s environment
- Interventions include:
1. Energy conservation/activity management
2. Goal setting/support/counselling
3. Cognitive retraining/stimulation
4. Communication with community agencies
5. Teaching of joint and bone protection techniques
6. Management of neuropathies
7. Education re: scar management
Dietician
- Evaluate nutritional status and provide recommendations for specific dietary needs
- Measurements of weight, BMI, and regular use of a screening tool to evaluate fatigue
- Use of dietary supplements or alternative foods
Social Worker
- Trained to assess psych needs of cancer patients and families, which may aggravate or cause symptoms
6
Q
Role of energy conservation in cancer rehab
A
Goals:
- Decrease impact of fatigue
- Promote physical activity
- Build up endurance
- Prevent deconditioning
- Develop new, balanced activity routines
7
Q
Role of goal setting, support, and counselling in cancer rehab
A
- Recognition of specific symptom patterns and appropriate organization of activities
- Goal is to avoid prolonged periods of bed rest and to encourage meaningful, rewarding activities and to reduce the sense of fatigue
8
Q
Role of cognitive training/stimulation in cancer rehab
A
- Strategies to improve cognitive abilities
- May include mental rehearsal, activities aimed at cognitive stimulation (e.g. Scrabble, crosswords, Sudoku), or compensatory strategies (using an agenda, writing things down)
9
Q
Members of a rehab team in the context of cancer
A
- OT
- PT
- RN
- SW
- Dietician
10
Q
Role of the Nurse in the rehab team
A
Nurse
- Primary point of contact between patient and team
- Triages and screens for impairments
- During team evaluation, assess for main symptoms and concerns
- Regular follow up and assistance with healthcare navigation
- May function as counsellors and assist with advocacy
11
Q
Role of the PT in the rehab team
A
PT
- Evaluates strength, mobility, endurance, and ROM
- Interventions include therapeutic exercise to maintain or improve ROM, endurance, and mobility
12
Q
Role of the OT in the rehab team
A
OT
- Assess self-care, household chores, leisure activities in the patient’s environment
- Interventions include:
1. Energy conservation/activity management
2. Goal setting/support/counselling
3. Cognitive retraining/stimulation
4. Communication with community agencies
5. Teaching of joint and bone protection techniques
6. Management of neuropathies
7. Education re: scar management
13
Q
Role of the dietician in the rehab team
A
Dietician
- Evaluate nutritional status and provide recommendations for specific dietary needs
- Measurements of weight, BMI, and regular use of a screening tool to evaluate fatigue
- Use of dietary supplements or alternative foods
14
Q
Role of the social worker in the rehab team
A
Social Worker
- Trained to assess psych needs of cancer patients and families, which may aggravate or cause symptoms
15
Q
Cancer-related fatigue (asthenia)
A
Definition
- Distressing, persistent, subjective sense of tiredness or exhaustion related to cancer or cancer treatments that is not proportional to recent activity and interferes with usual functions
- > 70% of cancer patients
- Differs from regular fatigue from lack of rest or overexertion as it may not be relieved by rest
- Often stem from chemo or rads, but persistent beyond the treatment period and may continue to interfere with function for months or years
- Fatigue may then limit behavioural activities that would normally mitigate stressors
Components
- General fatigue
- Physical fatigue
- Emotional fatigue
- Mental fatigue
Components as per Oxford:
- Easy tiring and reduced capacity to maintain performance
- Generalised weakness (anticipatory sensation of difficulty in initiating a certain activity)
- Mental fatigue (Impaired mental concentration, loss of memory, emotional lability)
16
Q
Changes associated with asthenia
A
- Decreased cognitive function
- Decreased muscle endurance
- Decreased sleep quality
- Decreased control over body processes
- Social withdrawal
- Increased emotional reactivity
17
Q
Components contributing to asthenia (multi dimensional model)
A
- Sleep (insomnia, disrupted sleep secondary to symptoms, etc.)
- Cancer
- Treatment (surgery, chemo, rads)
- Nutrition
- Symptoms (pain, nausea, constipation, dyspnea)
- Activities (stimulation, type, duration, position, accumulation - may result in loss of normal, healthy behavioural activation that would mitigate the impact of stressors, or may be fatiguing in and of themselves)
- Emotions
18
Q
Pathophysiology of asthenia
A
- Pain
- Energy imbalance
- Anemia, cachexia, infection, metabolic disorders, chronic inflammatory state
- Seem to cause most prominent symptoms, especially anemia
- Impaired muscle function due to cytokine production and other fatigue-inducing substances produced by the tumour
- Overexertion in patients attempting to maintain all previous activities while undergoing cancer treatment - Treatments
- Stress, mood changes, fatigue due to cancer treatment or treatments for pain/nausea etc. - Chronic physiological stress
- Activates HPA axis, hyperactivity of which can lead to depression and enhance fatigue - Deconditioning
- CNS abnormalities
- Disturbed cognitive functioning, particularly in brain tumours or tumours that produce hormones or neurotransmitters
- Inflammatory cytokines
- Treatments - Infection
- Inflammatory cytokines may mediate both fatigue and cachexia - Autonomic dysfunction
- Paraneoplastic syndromes
19
Q
Assessment of fatigue
A
- Self-report measures are most effective
- Numerical rating scale of 0-10 (0-3 no to mild fatigue, 4-6 moderate fatigue, 7-10 severe fatigue)
- Multi-dimensional scales (Multi-dimensional Fatigue Inventory) - validated in cancer and focusses on general, mental, and physical dimensions fatigue as well as motivation and activity
20
Q
Management of asthenia
A
Multi-dimensional approach
- Nutritional counselling
- Exercise (especially a structured exercise program)
- Ergonomic advice
- Correction of hormonal or metabolic abnormalities
- Pharmacologic interventions
21
Q
Structured exercise program for asthenia
A
Structured exercise program
- Demonstrated in several studies to reduce fatigue and emotional distress, improve physical and cardiopulmonary functioning, and quality of life (Cochrane review)
- Exercise may counteract negative impact of tumour and toxic treatments
22
Q
Impact of decreased exercise on patients with cancer
A
- Deconditioning
- Poorer symptom control
- Poorer clinical outcome after diagnosis
23
Q
Exercise guidelines for patients with cancer
A
- Evaluation for MSK morbidities secondary to treatment and peripheral neuropathy (regardless of time since treatment)
- Evaluation of fracture risk if patient has had hormonal tx
- Medical assessment of exercise safety if patient has a known cariac condition
24
Q
Components of an exercise prescription
A
- Frequency (number of sessions per week)
- Intensity
- Time (duration of session)
- Type (exercise modality)
Recommendations:
- 150 minutes per week of moderate exercise (brisk walking, light swimming)
- 75 minutes per week of vigorous exericse (jogging, running, swimming)
25
Pharmacologic therapies for asthenia
1. Review drugs that may cause or increase fatigue
- Benzos
- Antihistamines
- Barbiturates
- Beta blockers
- Opioids
2. Consider management of anemia
- EPO if caused exclusively by chemo - caution with use, speak with med onc as there is some evidence suggesting it can increase risk of progression)
- Blood transfusion for Hb <80
- Iron studies in case supplementation may be helpful
3. Treatment of depression
- Note paroxetine has been found to ameliorate depressive symptoms, but has not been demonstrated to improve fatigue
4. Methylphenidate
- May improve asthenia, depressive symptoms, somnolence, and cognitive abnormalities
- Caution if history of cardiac issues
- Limited evidence
5. Modafinil
- Used for norcolepsy, shift work sleep disorder, and daytime sleepiness secondary to OSA
- May be beneficial in severe fatigue, but not mile to moderate
- Very limited evidence
6. Steroids
- May decrease fatigue, likely due to anti-inflammatory effects
- Steroid effects typically last only 2-4 weeks and are approorpiate as short term treatments only
26
Group interventions for asthenia
Covers:
- What is cancer rehab?
- Recognising and managing cancer related fatigue
- Recognising and managing anxiety
- Complementary therapies and activities
- Nutrition
- Exercise and cancer
- Life after cancer
- Massage therapy
- Answering any questions
27
Epidemiology of sleep disorders in cancer
- 36-47% of patients with cancer
- 50% of CHF patients
- 50-90% of patients with chronic pain
28
Normal physiology of sleep
- Cyclic and dynamic state with alternation between REM and non-REM phases
- Phases vary in length, typical adult sleep period has 4-6 successive cycles
- Architecture varies with age
1. Sleep induction
- Decrease in skeletal muscle activity and cardiac/respiratory rhythm
- Lowering of core body temperature
- Lowered arterial pressure
2. non-REM phase
- Four phases: Phase 1 & 2 is lighter sleep, Phase 3 & 4 is deeper sleep accompanied by minimal mental activity
3. REM phase sleep
- 'Active' sleep where dreaming occurs
- Skeletal muscles remain inactive, but cardiac and respiratory rhythms/arterial pressure may vary
29
Impact of sleep disruption in cancer
- Alteration of mood and cognitive abilities (memory, concentration, anxiety, fatigue, physical discomfort)
- May impact treatment compliance, treatment outcomes, survival, and pain control
- Immune and metabolic functions may beimpacted
- QoL impacts
- May also impact caregivers (lack of opportunity for caregivers to sleep may lead to hospitalization)
30
Assessment of sleep disorder
1. Sleep hygiene (bed for sex and sleep only, not laying in bed for long periods of time, limiting screen time, routine bed time and wake time, etc.)
2. Symptoms that may disrupt sleep (pain, nausea, OSA, anxiety, dyspnea)
3. Difficulty falling (sleep initiation) or staying asleep (maintainence)
4. Daytime sleepiness
5. Alcohol and caffeine use
6. Cognitions around sleep (e.g. I can never sleep, catastrophizations, etc.)
31
Types of sleep disorders
1. Insomnia (difficulty initiating or maintaining sleep, despite adequate opportunity and circumstances)
Acute = < 3 months
Chronic = > 3 months at least 3 nights/week and is either primary or secondary
- Primary (may be due to hyperarousal and HPA dysfunction)
- Secondary (e.g. due to pain, anxiety, pulmonary disease, etc. )
2. Sleep-related breathing disorders
- OSA or OHS
3. Movement disorders
- RLS
- Periodic limb moveent secondary to sedative-hypnotic withdrawal, TCAs, anemia, uremia, leukemia, DM, or peripheral neuropathy
32
Factors contributing to insomnia in terminal illness
1. Environmental
- Light, noise, heating, cold, uncomfortable mattress
2. Psychological
- Anxiety
- Fear for self, family, or others
3. Physical
- Unrelieved pain
- GI symptoms (N/V, reflux, etc.)
- Urinary (frequency - consider that this may be related to diuretics)
- Pruritis
- Respiratory symptoms (dyspnea, apnea, hypoxia)
- Myoclonus
- Dementia
- Delirium
- Excessive daytime sleep
4. Pharmacological
- Med side effects
- Caffeine, smoking, alcohol, or withdrawal
- Prescription drug withdrawal (benzos, hypnotics, antidepressants, antipsychotics)
- Use of steroids, psychostimulants, bronchodilators, or others
33
Effect of opioids on sleep
- May result in fragmented sleep
| - May suppress both REM and non-REM sleep
34
Medical conditions associated with sleep disorders
- COPD
- Asthma
- Renal disease
- Endocrine disease
- Infectios
35
Non-pharm management of sleep disorders
- In cases of poor sleep hygiene, non-pharm management most likely to be effective with cognitive or behavioural interventions
1. Relaxation therapy
- Helpful to promote sleep initiation, also helpful with sleep maintenance but to a much lesser extent
2. Sleep restriction
- Restrict amount of time spent in bed while awake as this may improve the onset, duration, and quality of nighttime sleep
- Reinforces the normal sleep-wake cycle
3. Stimulus control
- Behavioural measure intended to help patients associate bed with sleep
- Patients instructed to go to bed only when they are sleepy
- If not asleep within 20 minutes, they should get up and engage in a minimally stimulating activity until they are sleeping again
- May induce a mild state of sleep deprivation and is most helpful with sleep onset
4. Cognitive therapy
- changing negative thoughts and attitudes about ability to fall asleep, stay asleep, get enough sleep, and function through the day
36
Pharmacologic management of insomnia
- No systematic studies of hypnotic meds in palliative care settings - rather extrapolated from other populations
1. Benzos
- Used for short term insomnia
- May prompt symptom relief in decreasing time to sleep onset and promote a sense of restful sleep
- Start low, go slow
- Long term use may disrupt sleep architecture
- Risks: cognitive impairment, risk of alls, worsening of opioid-associated delirium, associated with depression in longer-term use
- Use a shorter duration of action for patients with difficulty with sleep onset (e.g. alprazolam)
- Use a longer duration of action for patients with high daytime anxiety or early morning awakening (e.g. lorazepam)
- Caution with clonazepam - variability in its metabolism
2. Anti-depressants
- E.g. Trazodone 50mg HS, Side effects: Restlessness, dizziness, depression, GI symptoms
- Mirtazapine 15 - 45mg HS (SE: Somnolence, constipation, weight gain, increased appetite)
3. Non-benzo hyponotics
- Zopiclone 3.75 - 7.5mg HS
- Side effects: Palps, agitation, anterograde anemias, asthenia, GI symptoms
- Hepatically metabolised
4. Melatonin
- 0.5-6mg HS (SE: Vivid dreams)
5. Anti-psychotics
- Quetiapine 25mg - 200mg HS (SE: Drowsiness, dizziness, ataxia, tremor, EPS)
- Olanzapine 5mg - 10mg HS (SE: Drowsiness, dizziness, ataxia, EPS, tremor)
37
Sleep hygiene for palliative care patients
1. Personal habits
- Maintain regular bedtime and wake time
- Increase exposure to bright light through the day
- Avoid daytime naps
- Avoid alcohol within 3 hours of bedtime
- Avoid stimulants (nicotine, chocolate, tea, soda), especially 4-6 hours prior to bedtime
- Remain active and take as much exercise as possible but not immediately prior to sleep
2. Sleep environment
- Comfortable bedding
- Avoid bright light during the night
- Block distracting noise or light
- Keep room at a comfortable, cool temp
- Reserve bed for sleep and sex
3. Before going to bed
- Light snack with warm milk
- Relaxation technique
- Avoid mentally or emotionally stimulating activities prior to bedtime
- Maintain adequate pain relief through the night with long-acting analgesics
