Sleep in Patients Who Have Undergone a Bone-Marrow Transplant: Ways to Help By Josh Tal, RPSGTResearch Assistant at Stanford’s Behavioral Sleep Research Center First Year PhD Student at Palo Alto University
The Bone Marrow TransplantExperience During the transplant: Patients undergo intensive monitoring and supportive care, yet their requirements for deep uninterrupted sleep often go unrecognized. Noises of monitors/pumps Need to use the bathroom Agitation/Stress Even healthy individuals could develop sleep difficulties if they were woken up so frequently.
After the Transplant One study in Nature found that nearly 50% of bone marrow transplant patients had sleeping issues and fatigue one year after the transplant. • Additionally, this study showed that sleeping issues do not decrease over time, indicating it was no longer an acute effect of the transplant.
The Evolution of Insomnia Insomnia Insomnia Threshold No Insomnia Premorbid Acute Chronic Insomnia Insomnia Predisposing Factors Precipitating Factors Adapted from Spielman et al., 2000. Perpetuating Factors
Cognitive IronyWorry about falling asleep leads to worse sleep. It takes longer to fall asleep if you tell yourself to fall asleep as fast as possible
Additional Issues: Facing a life-threatening illness. What happens next? Anxiety Depression Nightmares Avoidance of things that remind you of your past illness Relationships The whole experience before the transplant, during and after is scary and it affects you.
Sleeping Pills? • How many of you take sleeping pills? • How do you feel before you take them? • How do you feel the next morning? • How do/would you feel after years of taking them? • How would you feel if you decided not to take them? Adapted from Morin CM et al. JAMA 1999;281.
Cognitive Behavioral Therapy
Nonpharmacologic Treatment TECHNIQUE AIMSleep hygiene Promote habits that help sleep; provide rationale for subsequent instructions.Stimulus control** Strengthen bed & bedroom as sleep stimulusSleep restriction Restrict time in bed to improve sleep depth & consolidationRelaxation training* Reduce arousal & decrease anxietyCognitive therapy Address thoughts and beliefs that interfere with sleep.Circadian rhythm Reset or reinforce biological rhythmentrainment
Sleep Hygiene Regularize sleep / wake schedule Avoid stimulants and stimulating behavior Establish relaxing bedtime routine Provide a conducive sleep environment Limit daytime naps Reduce or eliminate alcohol and caffeine Obtain regular exercise earlier in the day Avoid clock watching
Clock Monitoring In both poor and good sleepers, compared to non- monitoring, clock-monitoring leads to more pre-sleep worry and longer sleep onset latency in good and poor sleepers more pre sleep worry For insomniacs, compared with digit monitoring, clock monitoring leads to longer time to fall asleep more pre sleep worry (Tang et al. 2007)
Stimulus Control Use bed for sleep, sex, and sickness Go to bed only when sleepy Get out of bed when unable to sleep Wake up at a consistent time Do not take daytime naps
Stimulus Control Stimulus control reduces sleep anticipatory anxiety (Bootzin et al. 1999). What do you think about using electronics in bed?
Sleep Restriction Determine average time asleep Set time in bed = time asleep Consistent wake-up time No daytime naps If time asleep > 90% (85%) of time in bed then increase time in bed (15-30 minutes) If time asleep < 80% of time in bed then decrease time in bed (15-30 minutes) Spielman AJ et al. SLEEP 1987;10.
Cognitive Therapy Adapted from Morin CM. J Psychosom Res 1999;46.
Circadian Rhythm Entrainment Light Therapy Morning light exposure for delayed sleep phase Evening light exposure for advanced sleep phase Behavioral Methods Establish regular wake-up time
Nightmares: Coping with bad dreams can be difficult. Some people don’t like relaxation before going to sleep, or are scared of letting go. If that is you, try these preparation techniques instead: Prepare yourself in case you have bad dreams by thinking of a bad dream then think of a different ending for it. Practice this new ending many times before going to sleep. Before going to sleep prepare to re-orient yourself when you wake from a bad dream. Remind yourself that you are at home, that you are safe. Imagine your street, buses, local shops. Put a damp towel or a bowl of water by the bed to splash your face, place a special object by the bed, such as a photograph, or a small soft toy. Practice imagining yourself waking up from a bad dream and reorienting yourself to the present, to safety by splashing your face, touching special object, having a bottle of rose or lavender essential oil to sniff, going to window to see surroundings. When you wake up from a bad dream- move your body if you can and reorient yourself immediately (touching object, wetting face, going to the window, talk to yourself in a reassuring way)
Thank you for having me! If you have any questions or concerns, email me at email@example.com. If you feel that you would like to see a behavior sleep specialist, email me for a referral. Any last questions?