Circadian rhythms, symptoms, physical functioning, and body mass index in breast cancer survivors.

INTRODUCTION: Research has been limited in circadian activity rhythms and their relationship with health status in early-stage breast cancer survivors. Maintaining strong circadian parameters may reduce symptoms and improve physical functioning and disease-free survival. METHODS: This is a descriptive, correlational, secondary analysis of data from a randomized controlled trial collected 1 year after the first chemotherapy treatment; n = 156 cases with 7 days of wrist actigraph data of six circadian activity rhythm parameters; measures of function, fatigue, sleep, and anxiety/depression; and demographic/medical data including body mass index (BMI). RESULTS: In the total sample and three BMI categories, acrophase was the only circadian parameter that reached means established in healthy adults. In the total sample, phase-delayed acrophase was associated with higher depression (r = 0.180, p = 0.025) and lower morning energy (r = -0.194, p = 0.016) and trended for higher fatigue (r = 0.153, p = 0.057). Lower morning energy was also associated with a lower circadian quotient (r = 0.158, p = 0.05). As BMI increased, weaker circadian parameters were recorded consistently. When compared with women in normal BMI categories, obese women's amplitude and 24-h autocorrelation coefficient were significantly weaker (p = 0.011-0.015). In obese women, phase-delayed acrophase was correlated with higher fatigue and anxiety and with lower morning energy and physical functioning. DISCUSSION/CONCLUSIONS: Amplitude and 24-h autocorrelation parameters were significantly weaker, and phase-delayed acrophase was linked to several more intense symptoms and lower physical functioning in obese women. IMPLICATIONS FOR CANCER SURVIVORS: Clinicians need to target high-risk women with phase-delayed rhythms, higher symptoms, and lower physical functioning for intervention.

Patterns of circadian activity rhythms and their relationships with fatigue and anxiety/depression in women treated with breast cancer adjuvant chemotherapy.

PURPOSE: The purpose of this study was to examine patterns of circadian activity rhythms and their relationship with fatigue, anxiety/depression, and demographic/medical variables in women receiving breast cancer adjuvant therapy treatments (Tx) at three times within a randomized clinical trial (RCT) designed to improve sleep and modify fatigue. METHODS: A RCT enrolled 219 women with stage I-IIIA breast cancer who were randomized 2 days prior to starting chemotherapy to a behavioral therapy sleep intervention or healthy eating control group. All cases with available data (n = 190) were included in a descriptive, correlational, repeated measures analysis. Activity data were collected continuously by wrist actigraphy for 7 days at three times: the start (Tx 1), continuation (Tx 3), and recovery (30 days after last Tx) of chemotherapy. Circadian activity rhythm parameters were generated using Action4 software (Ambulatory Monitoring, Inc.). Measures collected simultaneously included Piper Fatigue Scale, Hospital Anxiety and Depression Scale, and demographic/medical variables. RESULTS: Circadian activity rhythm parameters at three times in both groups were disrupted compared to healthy adults, but similar to values of cancer patients. Significant changes in mesor, amplitude, peak activity, and 24 h autocorrelation values were found over time in both groups. The intervention group's amplitude and circadian quotient values were significantly more robust. More robust activity rhythms were associated with lower fatigue, depressive symptoms, body mass index, and higher performance status in both groups. CONCLUSIONS: Disrupted patterns of circadian activity rhythms were prevalent and associated with distressing fatigue and depressive symptoms during chemotherapy and at recovery. The intervention resulted in more robust rhythms.

One-year outcomes of a behavioral therapy intervention trial on sleep quality and cancer-related fatigue.

PURPOSE: To determine 1-year outcomes of a four-component behavioral therapy (BT) sleep intervention (Individualized Sleep Promotion Plan [ISPP]) versus a healthy eating control (HEC) on cancer-related fatigue in women receiving breast cancer adjuvant chemotherapy treatment (CTX). PATIENTS AND METHODS: A total of 219 participants from 12 oncology clinics were randomly assigned in a clinical trial. Before CTX, research nurses coached intervention participants to develop a BT plan including stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene. BT plans were revised before each CTX and 30, 60, and 90 days after the last CTX and reinforced 7 to 9 days later. HEC participants received nutritional information and equal attention. Pittsburgh Sleep Quality Index (PSQI), Daily Diary, Wrist Actigraph, and Piper Fatigue Scale measures and Repeated Linear Mixed Model analysis following the Intent to Treat paradigm were used. RESULTS: Sleep quality differed over 1 years time (F [4,162] = 7.7, P < .001; by group, F [1,173] = 4.8, P = .029; and over time by group, F [4,162] = 3.3, P = .013). Pairwise comparisons revealed significant differences between groups at 90 days (P = .002) but not at 1 year (P = .052). Seven days of diary and actigraphy data did not corroborate with monthly reflections (PSQI). The night awakenings (Actigraph) pattern was significantly different by group over time (P = .046), with no differences between groups at 90 days or at 1 year. Fatigue was lower at 1 year than before CTX; no group effects were found. CONCLUSION: The BT group, on average, experienced significant improvement on global sleep quality compared with the HEC group, but not on objective sleep or fatigue outcomes.

Beta-endorphin response to an acute pain stimulus.

The timing of the measurement of biological samples (e.g. biomarkers) is not always standardized. Biomarkers are the focus of many recent studies and treatments. The purpose of this study was to determine the timing of the release of beta-endorphin (BE), a possible biomarker, after exposure to pain and/or handling stress in order to standardize measurements. Mouse plasma was collected for BE analysis following handling i.e. being picked up by the investigator, exposure to a painful (55 degrees C hot-plate), or exposure to a nonpainful stimulus (room temperature hot-plate). The groups exposed to either a painful or nonpainful stimulus released BE in response to the stimulus, but the duration of the response was longer in mice exposed to a painful stimulus than in mice exposed to a nonpainful stimulus. The BE in the mice exposed to a nonpainful stimulus peaked at 1 min and returned to baseline levels by 5 min while the BE response of the mice exposed to a painful stimulus peaked at 10 min and remained elevated for 25 min. The results of this study indicate that BE can be a biomarker for pain and handling stress, however, the timing of the measurement should differ.

Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue.

BACKGROUND: To determine whether sleep quality and fatigue associated with breast cancer adjuvant chemotherapy treatments can be improved with behavioral therapy (BT) [Individualized Sleep Promotion Plan (ISPP)] including modified stimulus control, modified sleep restriction, relaxation therapy, and sleep hygiene. METHODS: Randomized-controlled trial based on Piper Integrated Fatigue Model, 219 stages I-IIIA breast cancer patients. Prior to the initial chemotherapy treatment, BT participants developed an ISPP plan that was regularly reinforced and revised. Controls received healthy eating information and attention. Pittsburgh Sleep Quality Index (PSQI), daily diary, actigraph, and Piper Fatigue Scale (PFS) data were collected 2 days prior, during the 7 days after each treatment, and 30 days after the last treatment. Repeated measures analysis of variance was used. RESULTS: Prior to chemotherapy, participants reported mild fatigue and fairly poor sleep quality. All variables changed over time. A group by time interaction was found for sleep quality (PSQI) improving in the BT group. Diary revealed group differences on number of awakenings, minutes awake after sleep onset, and sleep efficiency. Fatigue (PFS) was similar between groups. CONCLUSIONS: The BT group showed improved sleep quality over time and better sleep (diary). Perceptions of improved sleep quality over time are not consistently associated with diary or actigraph, or result in lower fatigue.

Methodological challenges when using actigraphy in research.

Actigraphy has become a valuable clinical and research tool to objectively evaluate sleep, daytime activity, and circadian activity rhythms in healthy individuals as well as persons with primary and comorbid insomnia. However, procedures used for sampling, data processing, and analysis are not consistently reported in the literature. The wide variability in how actigraphy is reported makes it difficult to compare findings across studies. The procedures and reporting methods from 21 studies that used actigraphs to assess sleep and wake in adult patients with cancer are reviewed to highlight the differences in reporting strategies. Patients with cancer were chosen to illustrate the methodological challenges related to procedures and reporting in one population. The aim of this article was to advance standards of information presented in publications to enable comparisons across research studies that use actigraphy. Specific methodological challenges when using actigraphy in research include instrumentation, selection of pertinent variables, sampling, and data processing and analysis. Procedural decisions are outlined and discussed, and suggestions are made for standardized actigraphy information to include in research reports. More consistent procedures and reporting will advance the science of sleep, daytime activity, and circadian activity rhythms and their association with other health-related variables.

Gender differences in sleep, fatigue, and daytime activity in a pediatric oncology sample receiving dexamethasone.

OBJECTIVE: To examine gender differences in sleep, fatigue, and daytime activity in a sample of children with acute lymphoblastic leukemia (ALL). METHODS: Participants included 88 children in maintenance treatment for ALL (34 girls; 54 boys). Participants wore an actigraph for 10 consecutive days (5 days pre-dexamethasone and 5 days during dexamethasone administration). Fatigue instruments were also administered. RESULTS: Girls napped more and had less fragmented night sleep than boys did. Wake time after sleep onset was sensitive to dexamethasone administration, revealing a differential direction of response for girls and boys. No gender differences were observed for subjective fatigue or daytime activity in the total sample. CONCLUSIONS: Our preliminary findings support gender differences in the sleep of children with cancer after controlling for differences in age, treatment, and risk group. Future research that focuses on the etiology of gender differences and developing interventions will help clarify the clinical application of our findings.

Sleep disturbance of residents in a continuing care retirement community.

The purpose of this pilot study was to examine the differences in temperature rhythms, rest/activity rhythms, melatonin rhythms, sleep percentages, and daytime sleepiness between two cohort-matched older adult groups in a continuing care retirement residence. Ten nursing home residents experienced disrupted rhythms, slept more, and experienced more daytime sleepiness compared with 10 apartment-dwelling residents. Nighttime light exposure was small in both groups but significantly greater in the nursing home. Gerontological nursing practice implications are to improve older residents' sleep by eliminating nighttime light and sleep-disrupting routines in all care settings for older adults.

Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy.

Fatigue is the most prevalent and distressing symptom experienced by patients receiving adjuvant chemotherapy for early stage breast cancer. Higher fatigue levels have been related to sleep maintenance problems and low daytime activity in patients who have received chemotherapy, but knowledge describing these relationships prior to chemotherapy is sparse. The Piper Integrated Fatigue Model guided this study, which describes sleep/wake, activity/rest, circadian rhythms, and fatigue and how they interrelate in women with Stage I, II, or IIIA breast cancer during the 48 hours prior to the first adjuvant chemotherapy treatment. The present report describes these variables in 130 females, mean age=51.4 years; the majority were married and employed. Subjective sleep was measured by the Pittsburgh Sleep Quality Index and fatigue was measured by the Piper Fatigue Scale. Wrist actigraphy was used to objectively measure sleep/wake, activity/rest, and circadian rhythms. Mean Pittsburgh Sleep Quality Index score was 6.73+/-3.4, indicating poor sleep. Objective sleep/wake results were within normal limits established for healthy individuals, except for the number and length of night awakenings. Objective activity/rest results were within normal limits except for low mean daytime activity. Circadian rhythm mesor was 132.3 (24.6) and amplitude was 97.2 (22.8). Mean Piper Fatigue Scale score was 2.56+/-2, with 72% reporting mild fatigue. There were significant relationships between subjective and objective sleep, but no consistent patterns. Higher total and subscale fatigue scores were correlated with most components of poorer subjective sleep quality (r=0.25-0.42, P< or =0.005).

Sleep wake disturbances in people with cancer and their caregivers: state of the science.

PURPOSE/OBJECTIVES: To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers. DATA SOURCES: Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases. DATA SYNTHESIS: Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent. CONCLUSIONS: Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies. IMPLICATIONS FOR NURSING: All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.

Fatigue and depression in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation.

PURPOSE/OBJECTIVES: To describe the patterns of depression and fatigue, including its dimensions, and the relationship between these two variables in patients with lymphoma undergoing autologous peripheral blood stem cell transplantation (PBSCT). DESIGN: Prospective, descriptive, correlational, repeated measures. SETTING: Midwestern university National Cancer Institute-designated clinical cancer center. SAMPLE: 27 patients with lymphoma aged 19 to 71 undergoing autologous PBSCT. METHODS: The revised Piper Fatigue Scale was used to measure fatigue and its dimensions. The Center for Epidemiologic Studies' Depression Scale was used to measure depression on selected days at baseline and during chemotherapy and recovery. MAIN RESEARCH VARIABLES: Fatigue and its four dimensions (behavioral/severity, sensory, cognitive/mood, and affective meaning) and depression. FINDINGS: Total fatigue, fatigues four dimension scores, and depression scores changed significantly over time, with the highest scores at day + 7 after transplant. Total fatigue and the four dimension scores were highly and positively correlated with depression, with the highest correlation reported between the affective fatigue dimension and depression. CONCLUSIONS: The findings support the importance of assessing fatigue and depression in patients undergoing autologous PBSCT at baseline, during chemotherapy, and throughout recovery. IMPLICATIONS FOR NURSING: Routine clinical assessment with close observation around day +7 after transplant and patient education about the patterns of fatigue and depression will help the healthcare team to intervene at the appropriate time and may help patients to better manage these symptoms.

Assessing internet survey data collection methods with ethnic nurse shift workers.

An increasing number of ethnic minorities are expected to enter the United States workforce based on projected demographic changes. This includes American Indian/Alaskan Native (AI/AN) nurses. Sociocultural influences on sleep disturbances, sleepiness, and other aspects related to shift-work tolerance are of unrecognized importance. More minority nurses are needed to provide culturally congruent care; however, AI/AN nurses represent less than 1% of nurses located throughout the American workforce. This article aims to verify the feasibility of Internet data collection (Web-based survey) methods and instrument stability as the first part of a two-phase study comparing individual differences and shift-work-related sleep disturbances between AI/AN and White non-Hispanic (WNH) nurses. In the first phase, an Internet survey was used to reach a cross-section of AI/AN and WNH nurses. The on-line survey was composed of accepted shift-work-related instruments. Items estimating sleep disturbances, sociocultural choices, time awareness, polychronicity, morningness/ eveningness, ethnic identity, and demographic questions were asked. The survey was linked to a series of Web pages describing the study purpose, inclusion and exclusion criteria, consent form, Web survey, and the second phase of the study in which subjects were invited to participate in actigraphy measurements. The survey was pilot-tested for error codes, item confusion, length, and completion time. Forced-answer questions were added asking ethnicity, age group, license type, state where licensed, and legal name on nursing license before accessing the survey. Data were saved periodically, cued by the word "continue." The database was located on a secure server and password protected. Nurses were recruited using published articles and printed advertisements, hospital e-mail systems, national nursing organization Web sites (minoritynurse.com; NANAINA.org), nursing Web site discussion groups, snow-balling, and word of mouth. The site was accessed 656 times with the Internet survey being completed by 138 WNH and 56 AI/AN nurses meeting the inclusion criteria. Except for the polychronicity measure (PAI3), instruments measuring time awareness, chronotype, and situational sleepiness achieved acceptable reliability coefficients with Internet data collection. Using pull-down menus would improve questions asking specific times. Internet data collection with different ethnic groups is possible; however, accessing the target population may be difficult. Despite extensive recruitment efforts, few AI/AN nurses participated. Computer literacy and failing to relate to the study's purpose may have limited the interest of the AI/AN nurses. It is possible to recruit nurse shift workers and collect individual difference and sleep disturbance data through the Internet; however, the researcher must remain vigilant throughout the process.

Effects of morphine and time of day on pain and beta-endorphin.

Clients report more pain at some times of day than at others due, in part, to the temporal variation of the body's inhibitory pain response. The analgesic effectiveness of morphine varies with the time of day, perhaps due to the inhibiting or enhancing effects of the drug on plasma beta-endorphin (BE). This experiment was designed to examine the timed effects of morphine on the pain-induced BE response. Six groups of treatment mice (injected with morphine sulfate) and 6 groups of control mice (injected with saline) were exposed to an acute pain stimulus at 4-h intervals, and blood was collected. Plasma BE was analyzed using radioimmunoassay. Control mice showed a robust circadian BE-response rhythm with a peak at 0000 and a nadir at 1200, whereas the BE response of mice that received morphine was arrhythmic. Animals that received morphine tolerated the noxious stimulus longer, but the analgesia varied with time of day. These results indicate that morphine abolishes the rhythmic BE response to pain and does not inhibit pain equally at all times of day. Morphine doses should be titrated to maximize the endogenous pain control system while achieving analgesia with decreased dosages.

Feasibilty of a sleep intervention during adjuvant breast cancer chemotherapy.

PURPOSE/OBJECTIVES: To evaluate the feasibility of an intervention designed to promote sleep and modify fatigue during four cycles of adjuvant breast cancer chemotherapy. DESIGN: Prospective, repeated measures, quasi-experimental feasibility study. SETTING: Midwestern urban oncology clinics. SAMPLE: 25 women between the ages of 40-65 (mean = 54.3) with stage I-II breast cancer receiving doxorubicin-based chemotherapy. METHODS: Each woman developed, reinforced, and revised an individualized sleep promotion plan (ISPP) with four components: sleep hygiene, relaxation therapy, stimulus control, and sleep restriction techniques. A daily diary, the Pittsburgh Sleep Quality Index, a wrist actigraph, and the Piper Fatigue Scale were used to collect data two days before and seven days after each treatment. MAIN RESEARCH VARIABLES: Adherence, sleep and wake outcomes, and fatigue. FINDINGS: Adherence rates with the components of the ISPP varied during treatments one through four: sleep hygiene (68%-78%), relaxation therapy (57%-67%), stimulus control (46%-67%), and sleep restriction (76%-80%). Mean sleep and wake outcomes at baseline, peak, and rebound times were that (a) sleep latency remained brief (less than 30 minutes per night), (b) time awake after sleep onset exceeded the desired less than 30 minutes per night, (c) sleep efficiency scores remained stable at 85%-90%, (d) total rest time remained stable at 8-10 hours per night, (e) subjective ratings of feelings on arising were stable, and (f) nighttime awakenings were 8-10 per night. Fatigue outcomes were that fatigue was stable two days after each treatment and mean daily fatigue intensity was lower at treatment three than at treatment one but rebounded at treatment four. CONCLUSIONS: The intervention was feasible, adherence rates improved over time, and most sleep and wake patterns were consistent with normal values. Revisions will focus on decreasing nighttime awakenings. IMPLICATIONS FOR NURSING: Adopting behaviors to promote sleep may assist in maintaining sleep and managing fatigue during chemotherapy.