bone marrow sleep
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Sleep in Patients Who Have Undergone a Bone-Marrow Transplant: Ways
to Help
By Josh Tal, RPSGTResearch Assistant at Stanford’s
Behavioral Sleep Research CenterFirst Year PhD Student at Palo Alto
University
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The Bone Marrow Transplant ExperienceDuring 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.
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After the TransplantOne 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.
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The Evolution of Insomnia
Adapted from Spielman et al., 2000.
Predisposing Factors
Precipitating FactorsPerpetuating Factors
Insomnia Threshold
Premorbid AcuteInsomnia
ChronicInsomnia
Insomnia
No Insomnia
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Cognitive Irony
Worry about falling asleep leads to worse sleep. It takes longer to fall asleep if you tell yourself to fall
asleep as fast as possible
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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.
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Treatments
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Sleeping Pills?
Adapted from Morin CM et al. JAMA 1999;281.
• 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?
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Cognitive Behavioral Therapy
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Nonpharmacologic Treatment
Reset or reinforce biological rhythm Circadian rhythm entrainment
Reduce arousal & decrease anxietyRelaxation training*
Address thoughts and beliefs that interfere with sleep.
Cognitive therapy
Restrict time in bed to improve sleep depth & consolidation
Sleep restriction
Strengthen bed & bedroom as sleep stimulusStimulus control**
Promote habits that help sleep; provide rationale for subsequent instructions.
Sleep hygiene
AIMTECHNIQUE
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Sleep HygieneRegularize sleep / wake scheduleAvoid stimulants and stimulating behavior Establish relaxing bedtime routineProvide a conducive sleep environmentLimit daytime napsReduce or eliminate alcohol and caffeineObtain regular exercise earlier in the dayAvoid clock watching
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Clock MonitoringIn 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 asleepmore pre sleep worry
(Tang et al. 2007)
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Stimulus ControlUse 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
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Stimulus ControlStimulus control reduces sleep anticipatory
anxiety (Bootzin et al. 1999).
What do you think about using electronics in bed?
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Sleep RestrictionDetermine average time asleep Set time in bed = time asleepConsistent wake-up timeNo daytime napsIf 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.
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Sleep Restriction
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Cognitive Therapy
Adapted from Morin CM. J Psychosom Res 1999;46.
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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
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Relaxation
Progressive muscle relaxationDiaphragmatic breathingMeditation and guided imageryBiofeedback (EMG)
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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)
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Thank you for having me!If you have any questions or concerns, email me
at [email protected] you feel that you would like to see a behavior
sleep specialist, email me for a referral.
Any last questions?