SLEEP QUALI TY OF W OMEN W I TH GYNECOLOGI CAL AND BREAST CANCER
1Renat a Furlani2 Maria Filom ena Ceolim3
Furlani R, Ceolim MF. Sleep qualit y of wom en wit h gynecological and breast cancer. Rev Lat ino-am Enferm agem 2006 nov em br o- dezem br o; 14( 6) : 872- 8.
Subj ect ive sleep qualit y has been recognized as a valuable indicat or of healt h and qualit y of life. This exploratory and descriptive study aim ed at describing habitual sleep quality of wom en suffering from gynecological and br east cancer and com par ing habit ual v er sus sleep qualit y dur ing hospit alizat ion. Tw ent y - fiv e w om en adm itted in hospital for clinical treatm ent of cancer com pleted the Pittsburgh Sleep Quality I ndex ( PSQI ) within 72 hours aft er adm ission and again j ust before discharge. Fift y- t wo percent of subj ect s report ed habit ual bad sleep qualit y, and t his proport ion increased t o 80% of subj ect s during hospit al st ay. Subj ect s indicat ed t he follow ing m ost fr equent causes of night sleep dist ur bance: need t o go t o t he t oilet , w ak ing up ear ly and receiving nursing care during the night. Results point to the im portance of including careful assessm ent of sleep qualit y and environm ent in nursing care planning for oncology pat ient s, m ainly during hospit alizat ion.
DESCRI PTORS: sleep; neoplasm s; nursing; hospit alizat ion
CALI DAD DEL SUEÑO EN MUJERES CON CÁNCER GI NECÓLOGO E MAMARI O
Act ualm ent e, la calidad de sueño referida por el propio individuo es reconocida com o un indicador de salud y calidad de v ida. Est o est udio ex plor at or io y descr ipt iv o descr ibe la calidad habit ual del sueño de m uj eres con cáncer ginecológico y m am ario y la confronta con la hospitalización. Se desarrolló con 25 m uj eres hospitalizadas para tratam iento clínico del cáncer ginecológico. Se colectaron inform aciones m ediante el Pittsburgh Sleep Quality I ndex ( PSQI ) y se verifico que el 52% de los suj etos poseía m ala calidad del sueño habitualm ente, m ient r as el 80% hubier a m ala calidad en la hospit alización. Las or ígenes de las per t ur baciones del sueño noct urno apunt adas m ás frecuent em ent e fueron: usar el baño, despert arse t em prano y ser cuidado por las enferm eras durant e la noche. Los result ados m uest ran la necesidad de que el planeam ient o de cuidados de enferm ería para m uj eres con cáncer ginecólogo incluya la evaluación de la calidad del sueño de las pacient es, inclusive en la hospit alización.
DESCRI PTORES: sueño; neoplasm as; enferm ería; hospit alización
QUALI DADE DO SONO DE MULHERES PORTADORAS
DE CÂNCER GI NECOLÓGI CO E MAMÁRI O
A qualidade de sono referida pelo próprio indivíduo é reconhecida at ualm ent e com o um indicador de saúde e de qualidade de vida. Est e est udo explorat ório e descrit ivo t eve por obj et ivo descrever a qualidade habit ual do sono de m ulher es com câncer ginecológico e m am ár io e com par á- la à qualidade do sono das m esm as na hospit alização. Par t icipar am 25 m ulher es hospit alizadas par a t r at am ent o clínico do câncer que responderam ao Í ndice de Qualidade de Sono de Pit t sburgh ( PSQI ) at é 72 horas após a adm issão e quando previst a a alt a hospit alar. Verificou- se que 52% das m ulheres apresent avam m á qualidade de sono habit ual e que, na hospit alização, esse percent ual elevou- se para 80% . Com o causas m ais freqüent es de pert urbação do sono na hospit alização dest acaram - se: necessidade de usar o banheiro; despert ar precoce; cuidados prest ados pela equipe de enferm agem . Os resultados apontam para a necessidade de cuidados oncológicos que englobem a qualidade de sono dest es pacient es, sobret udo na hospit alização.
DESCRI TORES: sono; neoplasias; enferm agem ; hospit alização
1 Paper ext ract ed from t he Mast er ’s Thesis; 2 M.Sc. in Nursing, e- m ail: [email protected] .br; 3 PhD, Assist ant Professor, e- m ail: fceolim @fcm .unicam p.br.
Cam pinas St at e Universit y Facult y of Medical Sciences
I NTRODUCTI ON
S
elf- report ed sleep qualit y and it s im pact int he daily lives of healt hy or sick people has becom e one of t he m ain foci of concer n for r esear cher s, as sleep is an essen t ial p h y siolog ical an d b eh av ior al process for the adequate functioning of the organism . Knowledge about sleep quality started to be considered an im portant clinical tool to identify health problem s(1),
as sleep disorders can be associated with fatigue, m ood alt erat ions and reduced pain t olerance( 2).
People af f ect ed by on cology pr oblem s ar e particularly subject to sleep disorder experiences, m ainly when they have to be hospitalized for treatm ent(3). I t is
believed that these patients present greater difficulties to catch sleep and continue sleeping than other clinical or surgical pat ient s, due t o t he sym pt om s associat ed with the disease or the very often aggressive therapeutics used for cancer treatm ent(2). Therefore, hospitalization
and ot her changes in t he sleep place can precipit at e sleep disorders am ong these patients(3) and exacerbate the dam age caused by chronic diseases.
Am on g n eoplast ic disor der s, gy n ecological and breast cancer diagnoses represent a real t hreat t o co u n t l e ss w o m e n ’ s l i v e s, w i t h n e g a t i v e repercussions on t heir qualit y of life. Alt hough sleep disorders are an im port ant t hem e for pat ient s affect ed by neoplasm s, coping w it h t hem st ill seem s t o be inadequat e in t he field of cancer care( 4).
Alt hough few st udies addr ess sleep- r elat ed aspect s in gynecological cancer pat ient s, t he healt h t eam is recom m ended t o priorit ize bot h t he qualit y of specific cancer t reat m ent and t he im pact t he disease and it s t reat m ent provoke in t he pat ient s’ qualit y of life( 5), im plying sleep qualit y.
As w om en w it h g y n ecolog ical an d b r east cancer are subj ect t o a wide range of problem s, it is int erest ing for t he hospit al environm ent t o be able t o favor a rest oring sleep. This art icle aim s t o describe t he habit ual sleep qualit y of wom en wit h gynecological and breast cancer and com pare it wit h sleep qualit y during hospit alizat ion, in order t o support t he planning of nursing care t hat at t em pt s t o prom ot e good sleep qualit y for t hese wom en, especially during t his period.
SUBJECTS AND METHODS
We carried out an explorat ory and descript ive st udy, wit h a quant it at ive approach. The research was
developed at t he Cancer Ward of t he I nt egral Wom en’s Healt h Car e Cent r e ( CAI SM) of t he Cam pinas St at e Un iv er sit y Facu lt y of Medical Scien ces ( UNI CAMP) bet ween March and August 2004.
Th e st u d y su b j ect s w er e 2 5 w om en w it h gynecological or breast cancer, whose ages ranged from 25.9 t o 77.8 years ( m ean 51.1 years, ± 12.7 years, m edian 47.4 y ear s) , w ho at t ended t o t he follow ing inclusion crit eria: hospit alizat ion for clinical t reat m ent during the data collection period; if subm itted to previous hospitalizations, having been discharged for 15 days or m or e* ; ov er 1 8 y ear s old; in t er est an d v olu n t ar y participation in the study; capable and in physical and em otional conditions to answer the research instrum ents. We ad op t ed cr it er ia t o su sp en d su b j ect s’ part icipat ion: negat ive evolut ion of clinical sit uat ion, m aking it im possible t o part icipat e in dat a collect ion; subm ission t o sur gical or sim ilar t r eat m ent , w hich r equir ed t he use of gener al anest het ics t hat w ould int er fer e in t he sleep cy cles and qualit y ; subj ect ’s refusal t o cont inue part icipat ing.
Dat a w er e collect ed t h r ou gh t h e f ollow in g inst rum ent s: I dent ificat ion Card ( I C) , elaborat ed for t he st udy; t he Pit t sburgh Sleep Qualit y I ndex ( PSQI )( 1),
in t he version used by ot her aut hors in Brazil( 6). Bot h
inst r um ent s w er e filled out by t he r esear cher, w ho filled out t he subj ect s’ answers.
Th e I C aim ed t o r ecor d sociodem ogr aph ic dat a, housing char act er ist ics and fact or s r elat ed t o t he disease and t o t r eat m ent s r ealized ear lier and during t he current hospit alizat ion. I t was applied wit hin 72 hours aft er t he subj ect s’ hospit al adm ission.
The PSQI was used to assess subjective sleep q u a l i t y, sl e e p h a b i t s r e l a t e d t o q u a l i t y a n d t h e occu r r en ce of sleep d ist u r b an ces. Th e in st r u m en t con sist s of sev en com pon en t s ( su bj ect iv e qu alit y, lat ency, durat ion, efficiency and sleep dist ur bances, sleep m edication use and daytim e sleepiness), resulting in a scor e t h at cor r espon ds t o g lob a l su b j e ct iv e
sle e p qua lit y. A score of up t o five indicat es good
sleep qualit y while a score of m ore than five m arks
bad sleep quality(1)
. Data collected through the PSQI
were ret rospect ive, corresponding t o a t im e int erval before t he dat e when it was filled out . I n t his st udy, each subject answered the instrum ent twice: within 72 hours after hospitalization, to provide data about sleep quality in the last 15 days, i.e. while they were at hom e ( indicat ed in t his st udy as ha bit ua l sle e p qua lit y) ; and as soon as hospital discharge had been scheduled, to supply data about sleep quality during hospitalization
( r efer r ed t o in t his st udy as sle e p qu a lit y du r in g
h osp it a liz a t ion) . Cr onbach’s alpha coefficient w as
used t o assess t he inst rum ent ’s int ernal consist ency, observing an int erm ediary consist ency wit h an alpha coefficient of 0.60 to assess habitual sleep quality, and 0.69 to assess sleep quality during hospitalization.
Dat a were subm it t ed t o descript ive analysis. Nex t , PSQI d at a f o r al l su b j ect s w er e co m p ar ed bet ween t he t wo st udy phases. Subj ect s were grouped according t o sleep qualit y ( good or bad) , and t he t wo groups were com pared in each st udy phase. Subj ect s were also grouped according t o t he clinical evolut ion of t heir disease, in t w o cat egor ies: subj ect s w hose
clinica l st a t e w a s m a int a ine d and subj ect s whose
clinical st at e w orsened, according t o dat a collect ed
in Oct ober 2 0 0 4 . Th ese gr ou ps w er e com par ed in t erm s of t heir sleep qualit y in t he t wo st udy phases. Non- param et rical st at ist ical t est s were used for int er-p h ase ( McNem ar an d Wi l co x o n ) an d i n t er - g r o u er-p ( Ma n n - W h i t n e y, Ch i - sq u a r e a n d Fi sh e r ’s Ex a ct ) com parisons, at a crit ical level of 5% .
The research was approved by t he Research Com m ission at CAI SM at b y t h e Resear ch Et h ics Com m it t ee at FCM/ UNI CAMP. Subj ect s who com plied wit h t he st udy inclusion crit eria signed t he Free and I nform ed Consent Term , elaborat ed according t o t he st andards of Resolut ion 196/ 96 by t he Nat ional Healt h Cou n cil.
RESULTS
Twent y- five subj ect s part icipat ed in t he st udy, 48% of whom present ed good habit ual sleep qualit y a n d 5 2 % b a d h a b i t u a l sl e e p q u a l i t y. D u r i n g hospit alizat ion, t he pr opor t ion of subj ect s w it h bad sleep qualit y increased t o 80% of t he t ot al.
Tw e l v e su b j e ct s w e r e cl a ssi f i e d a s g o o d habit ual sleep quality, t hree of whom m aint ained t his classificat ion for sleep qualit y during hospit alizat ion, while nine subj ect s st art ed t o present bad sleep qualit y during t his period. Am ong t he 13 subj ect s classified as b ad h ab it u al sleep q u alit y, 1 1 m ain t ain ed t h is classificat ion during hospit alizat ion, while t wo subj ect s st art ed t o present good sleep qualit y in t hat phase. I n su m , 2 0 su bj ect s pr esen t ed bad an d f iv e good sleep qualit y during hospit alizat ion. The proport ion of subj ect s wit h good habit ual sleep qualit y who st art ed t o present bad sleep qualit y during hospit alizat ion was st at ist ically significant ( p = 0 .0 4 in McNem ar’s t est ) . Subj ect s w it h good and bad habit ual sleep q u a l i t y w e r e h o m o g e n e o u sl y d i st r i b u t e d a cr o ss
d i f f e r e n t a g e r a n g e s i n t h i s st u d y a n d w e r e predom inant ly bet ween 41 and 60 years old ( 66.7% of subj ect s wit h good and 61.5% of t hose wit h bad habit ual sleep qualit y) . Educat ion levels were sim ilar am on g su bj ect s w it h good an d bad h abit u al sleep qualit y ( m edian of 4.5 and 5.0 years, respect ively) , as well as fam ily incom e, predom inant ly bet ween one and five m inim um wages ( 91.7% of t hose wit h good and 84.6% of t hose wit h bad habit ual sleep qualit y) . Median diagn osis t im e w as sim ilar am on g subj ect s w it h good and bad habit ual sleep qualit y, r anging bet w een zer o and eight y ear s ( m edian 4.0 years) and bet ween zero and 16 years ( m edian 4.5 y ear s) r espect ively.
Ta b l e 1 sh o w s t h e su b j e ct s’ d i st r i b u t i o n accor ding t o w hy t hey w er e hospit alized and t heir habit ual sleep qualit y.
Table 1 - Subjects’ distribution in term s of hospitalization m otive and habitual sleep quality. Cam pinas, 2004
Tab le 2 sh ow s t h e d ist r ib u t ion of d isease charact er ist ics ( locat ion of pr im ar y t um or, pr esence o r ab sen ce o f m et ast ases, d i sease st ag i n g ) an d habit ual sleep qualit y.
Table 2 - Subj ect s’ dist r ibut ion in t er m s of disease characteristics and habitual sleep quality. Campinas, 2004
n o i t a z il a t i p s o H e v i t o m I Q S P o t g n i d r o c c a y t il a u q p e e l s l a u t i b a H ) 2 1 = n ( y t il a u q d o o
G Badquailty(n=13)
n % N %
n i s n o it a c il p m o C n o it i d n o c l a c i n il
c 4 33.3% 5 38.5%
y p a r e h t o m e h C t n e m t a e r
t 4 33.3% 6 46.1%
o t n e m a t a r T o c i p á r e t o i d a
r 1 6,4% 0 0%
o ã ç a g it s e v n
I 3 25% 2 15,4%
l a t o
T 12 100% 13 100%
n o i t a z il a t i p s o H e v i t o m I Q S P o t g n i d r o c c a y t il a u q p e e l s l a u t i b a H ) 2 1 = n ( y t il a u q d o o
G Badquailty(n=13)
N % n %
r o m u t y r a m i r p f o n o i t a c o L r o m u t n o l o
C 4 33.4% 5 38.5%
r o m u t t s a e r
B 6 50.0% 5 38.5%
l a ir t e m o d n E r o m u
t 1 8.3% 3 23.0%
s i s o n g a i d o
N 1 8.3% 0 0%
l a t o
T 12 100% 13 100%
* s i s a t s a t e m f o e c n e s e r P s e
Y 3 25% 4 30.8%
o
N 9 75% 9 69.2%
l a t o
T 12 100% 13 100%
g n i g a t S I e g a t
S 2 16.7% 1 7.7%
II e g a t
S 2 16.7% 3 23.1%
II I e g a t
S 7 58.3% 8 61.5%
g n i g a t s o
N 1 8.3% 1 7.7%
l a t o
T 12 100% 13 100%
The r ecor ds of subj ect s w it h good habit ual sl e e p q u a l i t y w h o h a d b e e n h o sp i t a l i ze d a t t h e Oncology War d ear lier show ed t hat t his ev ent had occurred 19.5 ( ± 31.9) m ont hs ago, on t he average, again st 1 5 . 3 ( ± 2 8 . 9 ) m on t h s f or t h ose w it h bad habit ual sleep qualit y.
The sleep pat t erns im plied in habit ual sleep q u a l i t y ( n o ct u r n a l sl e e p l a t e n cy, d u r a t i o n a n d efficiency) are present ed in Table 3.
Table 3 - Habit ual noct urnal sleep pat t erns according t o PSQI . Cam pinas, 2004
Fort y percent of subj ect s wit h good and 30% of t hose wit h bad sleep qualit y during hospit alizat ion indicat ed m oderat e or int ense indisposit ion t o develop d a i l y a ct i v i t i es. I n t en se d a y t i m e sl eep i n ess w a s m ent ioned by 40% of subj ect s wit h good and 55% of pat ient s wit h bad sleep qualit y during hospit alizat ion. None of t he subj ect s wit h good sleep qualit y during hospit alizat ion used m edicat ion t o sleep, against 50% in t he bad qualit y gr oup, w her e pat ient s used t his kind of m edicat ion bet ween one and t hree t im es per week during t heir st ay in hospit al.
Th e f o l l o w i n g ca u se s o f n o ct u r n a l sl e e p dist ur bances st ood out dur ing hospit alizat ion: need t o use t he bat hroom ( 60% of subj ect s wit h good and 65% of t hose wit h bad sleep qualit y) ; care delivered by t he nursing t eam , m ent ioned by 60% of subj ect s wit h good sleep qualit y and 55% of t hose wit h bad sleep qualit y. Noise at t he nursing ward was indicat ed by 8.3% of pat ient s wit h good and 10% of subj ect s wit h bad sleep qualit y during hospit alizat ion. Am ong subj ect s wit h good sleep qualit y during hospit alizat ion, 8 . 3 % m en t ion ed ex cessiv e ligh t at t h e w ar d as a noct urnal sleep dist urbance fact or. Am ong t hose wit h bad sleep qualit y during hospit alizat ion, 75% indicat ed ear ly aw ak ening; 45% pain episodes; 30% feeling h ot du r in g t h e n igh t an d 2 0 % sleep dist u r ban ces p r ov ok ed b y ot h er h osp it alized p at ien t s in a b ad general st at e or who were agit at ed at t he ward.
Unt il Oct ober 2004, 64% of t he st udy subj ect s rem ained under out pat ient follow- up at CAI SM wit hout and worsening in t heir clinical condit ion, while 24% at t ended per iodical consult at ions and 40% r eceived ch em ot h er ap y or r ad iot h er ap y t r eat m en t . Tw en t y p e r ce n t o f t h e o t h e r p a t i e n t s n e e d e d a n o t h e r hospit alizat ion due t o worsening in t heir clinical st at us com pat ible w it h t he disease, and 8% passed away. Eight per cent of t he subj ect s did not r et ur n t o t he ser v ice unt il t he dat e under analy sis and w er e not considered in t he analysis below.
Alt hough bot h gr oups pr esent ed bad sleep qualit y, subj ect s whose clinical st at e worsened ( 28% , including pat ient s w ho passed aw ay ) had obt ained global PSQI scores t hat suggest ed worse habit ual sleep qualit y ( 10.3 ± 3.8 point s, m edian 11.0 point s) , in com parison wit h pat ient s ( 64% ) who m aint ained t heir clinical condit ion ( 7.2 ± 4.4 point s, m edian 7.0 point s) . These result s t end t ow ards a st at ist ically significant difference ( p = 0.06 on t he Mann- Whit ney t est ) .
As t o PSQI scores during hospit alizat ion, we found t hat dat a behav ed sim ilar ly : subj ect s w it h a
l a u ti b a H l a n r u t c o n p e e l s s n r e t t a p I Q S P o t g n i d r o c c a y ti l a u q p e e l s l a u ti b a
H Mann
-y e n ti h W t s e T y ti l a u q p e e l s d o o G ) 2 1 = n ( ti l a u q p e e l s d a B ) 3 1 = n ( n a e
M sd*(±)Median Mean sd*(±)Medianp-value**
y c n e t a
L 1min 4.3min 0min 60min 47.2min35min 0.0001 n o it a r u
D 8h 70min 8h 5h28min137min 6h 0.0046 y c n e i c if f
E 96.9% 6.2% 100% 68.8% 27.4% 71.4% 0.0011
* sd ( ± ) : st andard deviat ion * * : significance level < 0.05
Twent y- five percent of subj ect s wit h good and 46.2% of t hose wit h bad habit ual sleep qualit y indicat ed m oderat e or int ense indisposit ion t o develop t heir daily act iv it ies. Day t im e sleepiness and sleep m edicat ion use were m ent ioned m ore frequent ly by subj ect s wit h bad sleep qualit y ( 46.2% and 23.1% , respect ively) in com parison wit h pat ient s wit h good sleep qualit y ( 25% and 16.7% , respect ively) .
Subj ect s w it h good sleep qualit y m ent ioned t he need t o use t he bat hroom ( 75% ) and pain ( 41.7% ) as t he m ain causes of dist urbances in t heir habit ual noct urnal sleep. The m ain causes am ong pat ient s wit h b ad h ab it u al sleep q u alit y w er e ear ly aw ak en in g ( 92% ) and need t o use t he bat hroom ( 92% ) , followed by pain episodes ( 69.3% ) and feeling hot during t he night ( 46.2% ) .
Table 4 shows t he sleep pat t erns im plied in sleep qualit y dur ing hospit alizat ion ( noct ur nal sleep lat ency, durat ion and efficiency) .
Ta b l e 4 - No ct u r n a l sl e e p p a t t e r n s d u r i n g hospit alizat ion according t o PSQI . Cam pinas, 2004
l a n r u t c o N s n r e tt a p p e e l s g n ir u d n o it a z il a ti p s o h I Q S P o t g n i d r o c c a n o it a z il a ti p s o h g n ir u d y ti l a u q p e e l
S Mann
-y e n ti h W t s e T y t il a u q p e e l s d o o G ) 5 = n ( y t il a u q p e e l s d a B ) 0 2 = n ( n a e
M sd*(±)Median Mean sd*(±) Median p-value**
y c n e t a
L 9min 13min 0min 49min 48min 60min 0.14 n o it a r u
D 8h12min27min 8h 5h14min115min 5h 0.006 y c n e i c if f
E 98.8% 2.6% 100% 70.1% 23.0% 70.0% 0.006
worse clinical evolut ion present ed scores t hat indicat ed worse sleep qualit y ( 11.3 ± 4.8 point s, m edian 14.0 point s) , in com par ison w it h pat ient s w hose clinical con dit ion r em ain ed u n ch an ged ( 8 . 7 ± 4 . 5 poin t s, m edian 8. 0 point s) . The com par ison bet w een bot h groups during t his phase did not reveal st at ist ically significant differ ences.
DI SCUSSI ON
Th e p r e se n ce o f n e o p l a sm s ca n ca u se pr ofou n d ch an ges in people’s h abit u al w ay of life. Sleep habit s and qualit y ar e a fundam ent al par t of t his life rout ine( 3). Bad sleep qualit y was predom inant
a m o n g p a r t i ci p a n t s b o t h b e f o r e a n d d u r i n g hospit alizat ion, w hich highlight s t he im por t ance of charact erizing t hese subj ect s’ habit ual sleep qualit y, wit h a view t o neit her at t ribut ing t he occurred changes t o hospit alizat ion- relat ed event s only, nor m inim izing t he effect s of hospit alizat ion on sleep qualit y. The pr opor t ion of w om en w hose sleep qualit y w or sened during hospit alizat ion was st at ist ically significant , which seem s t o indicat e t hat t heir st ay in hospit al cont ribut ed t o t he decrease in t heir sleep qualit y.
Hospit alizat ion or ot her changes in people’s habit ual environm ent can precipit at e t he occurrence of sleep disor der s( 3), per haps because t hey inv olv e
adapt ing t o a new env ir onm ent and br eak ing w it h h ab it u al sleep r ou t in es( 7 ). Rem ain in g h osp it alized
im plies long per iods of bed r est . Hence, r est r ict ed act iv it ies du r in g t h e day an d r edu ced ex posu r e t o n at u r al illu m in at ion can r esu lt in ch an g es in t h e r egular it y of t he hum an or ganism ’s r hy t hm s, w hich ca n n e g a t i v e l y a f f e ct n o ct u r n a l sl e e p q u a l i t y( 8 ).
Nev er t h eless, som e par t icipan t s w it h bad h abit u al sleep qualit y st ar t ed t o pr esent good sleep qualit y during hospit alizat ion. This m ay be due t o t he cont rol of som e cancer - r elat ed com plicat ions.
D u r i n g h o sp i t al i zat i o n , m o st p ar t i ci p an t s r ecei v ed ch em o t h er a p y t r ea t m en t . Acco r d i n g t o l i t er at u r e, p at i en t s w h o r ecei v ed sp eci f i c can cer treatm ents during the last six m onths are m ore subject to excessive sleepiness and fatigue(7). Fatigue, in turn,
seem s to be related with reduced sleep duration(4). We
f o u n d h i g h e r l e v e l s o f sl e e p i n e ss a n d d a y t i m e indisposition am ong subj ects with bad sleep quality in com parison with the good habitual quality group.
Fin din gs f r om an ot h er st u dy in dicat e t h at breast and lung cancer pat ient s were m ost affect ed
by sleep dist urbances when com pared wit h ot her t ypes of cancer, such as gy necological and sk in cancer( 7).
Our findings did not show a significant predom inance of sleep dist urbances in pat ient s wit h any specific t ype of t um or.
We found higher incidence levels of diffuse bone m et ast ases in pat ient s wit h bad habit ual sleep qualit y, in line w it h anot her st udy( 4), w hich r epor t s
short er noct urnal sleep am ong pat ient s wit h t his t ype of m et ast asis, possibly due t o t he int erference of pain episodes.
The t im e bet ween t he previous hospit alizat ion and t he current one was short er am ong subj ect s wit h b ad sleep q u alit y, w h ich m ay su g g est t h at t h ese pat ient s need t o be hospit alized m ore frequent ly t han t hose wit h good sleep qualit y.
Wit h r espect t o habit ual sleep pat t er ns, w e found longer lat ency, lower efficiency and durat ion of sleep am ong par t icipant s w it h bad sleep qualit y in com parison w it h w om en w it h good sleep qualit y. I n anot her st udy, t he aut hors refer difficult ies t o cat ch sleep and reduced noct urnal sleep efficiency in cancer pat ient s( 9).
Cancer pat ient s ident ify w ak ing up sev er al t im es during t he night as t he m ost com m on t ype of insom nia( 2,7). Our findings were sim ilar, showing early
awakening and need t o use t he bat hroom as t he m ost frequent causes of noct urnal sleep dist urbance am ong wom en wit h bad habit ual sleep qualit y. Pat ient s wit h good habit ual sleep qualit y, on t he ot her hand, m ainly m ent ioned t he need t o use t he bat hroom and pain.
Across t he t wo st udy phases, t he need t o use t he bat hroom during t he night appears as t he m ost fr equent noct ur nal sleep dist ur bance fact or am ong part icipant s wit h good and bad sleep qualit y. A st udy w it h cer v ical can cer p at ien t s sh ow ed u r od y n am ic alt er at ion s, su ch as r ed u ced st or ag e an d b lad d er em p t y in g cap acit y an d u r in ar y in con t in en ce af t er su r g i ca l t r e a t m e n t ( h y st e r e ct o m y ) a n d r adiot her apy( 10). Pain dur ing t he night can pr ov ok e
noct ur nal aw ak ening, alt hough difficult ies t o cat ch sleep again m ay be relat ed t o how t he individual deals wit h t his event( 2). However, cancer pain assessm ent
is an im por t an t aspect of car e plan n in g f or t h ese subj ect s( 11).
r ecom m ended abandonm ent of hor m one t her apy or fr om t he suppor t t r eat m ent under t ak en in t r eat ing t he neoplasm( 12).
A con sider able n u m ber of can cer pat ien t s t ake m edicat ion t o sleep( 7). I n our st udy, t he proport ion
of wom en using t his kind of drug was sim ilar t o ot her lit er at ur e findings and pr edom inant am ong subj ect s wit h bad habit ual sleep qualit y.
Sleep habit s dur ing hospit alizat ion follow ed t he sam e t endency found before t his event . However, we found a st at ist ically significant difference bet ween su b j ect s w it h g ood an d b ad sleep q u alit y d u r in g hospit alizat ion for sleep durat ion and efficiency, which were reduced am ong subj ect s wit h bad sleep qualit y. Being ill is a st ressing fact or, m ainly if hospit alizat ion is needed. I t is believ ed t hat t he pr edom inance of bad- qualit y sleep par am et er s dur ing hospit alizat ion, negat iv ely affect ing noct ur nal sleep st ages, lead t o t he inadequat e recovery of hospit alized subj ect s( 13).
Dur ing hospit alizat ion, t he need t o use t he bat hroom and healt h care delivery st ood out as t he origin of noct urnal sleep dist urbance in bot h pat ient g r o u p s. Pa i n co n t r o l t o r e d u ce n o ct u r n a l sl e e p int errupt ions; cont rol of illum inat ion levels t o m aint ain a cl o se- t o - n o r m al l i g h t an d d ar k cy cl e an d car e deliv er y com pat ible w it h noct ur nal sleep pr om ot ion ar e som e pr act ices t hat need t o be consolidat ed t o obt ain bet t er noct urnal sleep qualit y. We found a st udy in which researchers ident ified a negat ive correlat ion bet ween sleep qualit y and t he num ber of dist urbances, t ot al t im e spent in t he pat ient ’s room and pat ient s’ par t icipat ion in t h eir car e( 1 4 ). Sleep f r agm en t at ion
deriving from such int ervent ions can negat ively affect su b j ect s’ p er cep t ion of t h eir sleep q u alit y, w h ich reinforces t he need for noct urnal care planning, wit h a view t o at t ending t o noct urnal rest needs. Nursing car e p l an n i n g an d p r act i ce f o r t h i s sak e can b e considered in fut ure st udies.
I n t his st udy, 20% of wom en wit h bad sleep qualit y indicat ed sleep dist urbances provoked by ot her p a t i en t s i n b a d g en er a l co n d i t i o n s o r w h o w er e agit at ed. Sharing t he room wit h ot her persons in t he hospit al environm ent can represent a sleep qualit y-im pair ing fact or. Cont r olling t he illum inat ion in t he r o o m a n d d e f i n i n g t i m e s t o sl e e p d e p e n d o n a consensus wit h ot her people; sleep habit s, t im es t o sleep and wake up can be different and healt h care needs pr obably v ar y am ong t hese subj ect s. These variat ions am ong people w ho share t he sam e room co u l d co n t r i b u t e t o i n cr ea sed sl eep l a t en cy a n d reduced durat ion during hospit alizat ion.
D a y t i m e sl e e p i n e ss w a s m o r e f r e q u e n t am on g w om en w it h bad sleep qu alit y, an d u se of m ed icat ion t o sleep w as id en t if ied in h alf of t h e subj ect s wit h bad sleep qualit y during hospit alizat ion. I t is believ ed t h at su bj ect s w it h bad sleep qu alit y co n ce n t r a t e f a ct o r s t h a t co r r o b o r a t e w i t h sl e e p dist urbances and, during hospit alizat ion, culm inat e in t he need t o use m edicat ion t o sleep. Part icipant s wit h bad sleep qualit y also highlight ed ear ly aw ak ening and feeling hot as noct urnal sleep dist urbance fact ors. W h e n g r o u p e d a cco r d i n g t o t h e cl i n i ca l evolut ion of t he disease, t he analysis of part icipant s’ sleep qualit y showed t hat t he PSQI scores of subj ect s whose clinical condit ion worsened had indicat ed bad sleep qualit y in bot h st udy phases, in com parison wit h pat ien t s w h ose clin ical st at e did n ot ch an ge. I t is believed t hat noct ur nal sleep condit ions int er fer e in p e o p l e ’s se n sa t i o n s t h r o u g h o u t t h e d a y, w h i ch h igh ligh t s t h e im por t an ce of good n oct u r n al sleep qualit y for sick pat ient s, so t hat t hey can feel well-disposed during the day and recover from the disease’s harm ful effect s, from t reat m ent or even from som e situations that occurred during hospitalization. However, patients m ay not m ention their sleep disorders during hospit alizat ion, which m akes it essent ial t hat nurses inquire about t hese difficult ies and get t o know t heir habit ual sleep pat t erns.
Th e bad clin ical con dit ion s in w h ich som e wom en are hospit alized or t he rapid evolut ion of t he disease im pede t he dev elopm ent of longer st udies wit h a larger num ber of subj ect s. This difficult y was t he m ain st udy lim it at ion.
FI NAL CONSI DERATI ONS
People affect ed by cancer can be vulnerable and depend on t he suppor t of r elat iv es or par t ner s during t he different st ages of coping wit h t he disease. During hospit alizat ion, t he nursing t eam is one of t he responsibles for support ing pat ient s in living wit h t he disease.
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