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
Q
Pharmacologic therapies for asthenia
A
- Review drugs that may cause or increase fatigue
- Benzos
- Antihistamines
- Barbiturates
- Beta blockers
- Opioids - 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 - Treatment of depression
- Note paroxetine has been found to ameliorate depressive symptoms, but has not been demonstrated to improve fatigue - Methylphenidate
- May improve asthenia, depressive symptoms, somnolence, and cognitive abnormalities
- Caution if history of cardiac issues
- Limited evidence - 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 - 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
Q
Group interventions for asthenia
A
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
Q
Epidemiology of sleep disorders in cancer
A
- 36-47% of patients with cancer
- 50% of CHF patients
- 50-90% of patients with chronic pain
28
Q
Normal physiology of sleep
A
- 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
- Sleep induction
- Decrease in skeletal muscle activity and cardiac/respiratory rhythm
- Lowering of core body temperature
- Lowered arterial pressure - non-REM phase
- Four phases: Phase 1 & 2 is lighter sleep, Phase 3 & 4 is deeper sleep accompanied by minimal mental activity - REM phase sleep
- ‘Active’ sleep where dreaming occurs
- Skeletal muscles remain inactive, but cardiac and respiratory rhythms/arterial pressure may vary
29
Q
Impact of sleep disruption in cancer
A
- 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
Q
Assessment of sleep disorder
A
- 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.)
- Symptoms that may disrupt sleep (pain, nausea, OSA, anxiety, dyspnea)
- Difficulty falling (sleep initiation) or staying asleep (maintainence)
- Daytime sleepiness
- Alcohol and caffeine use
- Cognitions around sleep (e.g. I can never sleep, catastrophizations, etc.)
31
Q
Types of sleep disorders
A
- 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. ) - Sleep-related breathing disorders
- OSA or OHS - Movement disorders
- RLS
- Periodic limb moveent secondary to sedative-hypnotic withdrawal, TCAs, anemia, uremia, leukemia, DM, or peripheral neuropathy
32
Q
Factors contributing to insomnia in terminal illness
A
- Environmental
- Light, noise, heating, cold, uncomfortable mattress - Psychological
- Anxiety
- Fear for self, family, or others - 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 - Pharmacological
- Med side effects
- Caffeine, smoking, alcohol, or withdrawal
- Prescription drug withdrawal (benzos, hypnotics, antidepressants, antipsychotics)
- Use of steroids, psychostimulants, bronchodilators, or others
33
Q
Effect of opioids on sleep
A
- May result in fragmented sleep
- May suppress both REM and non-REM sleep
34
Q
Medical conditions associated with sleep disorders
A
- COPD
- Asthma
- Renal disease
- Endocrine disease
- Infectios
35
Q
Non-pharm management of sleep disorders
A
- In cases of poor sleep hygiene, non-pharm management most likely to be effective with cognitive or behavioural interventions
- Relaxation therapy
- Helpful to promote sleep initiation, also helpful with sleep maintenance but to a much lesser extent - 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 - 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 - Cognitive therapy
- changing negative thoughts and attitudes about ability to fall asleep, stay asleep, get enough sleep, and function through the day
36
Q
Pharmacologic management of insomnia
A
- No systematic studies of hypnotic meds in palliative care settings - rather extrapolated from other populations
- 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 - 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) - Non-benzo hyponotics
- Zopiclone 3.75 - 7.5mg HS
- Side effects: Palps, agitation, anterograde anemias, asthenia, GI symptoms
- Hepatically metabolised - Melatonin
- 0.5-6mg HS (SE: Vivid dreams) - Anti-psychotics
- Quetiapine 25mg - 200mg HS (SE: Drowsiness, dizziness, ataxia, tremor, EPS)
- Olanzapine 5mg - 10mg HS (SE: Drowsiness, dizziness, ataxia, EPS, tremor)
37
Q
Sleep hygiene for palliative care patients
A
- 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 - 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 - 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
