The patient, “TB,” is a 44-year-old Caucasian, married woman with three daughters, 21, 18, and 10 years of age. The family lives in a small rural town. TB works full-time on a night shift (10:00 PM–6:30 AM) unloading trucks and restocking shelves at a store. She has been a 1 pack/day smoker for 20 years and was premenopausal at diagnosis. Diagnosed with hypothyroidism in 2006, TB takes Synthroid (levothyroxine) at 100 mcg daily. Her husband, a self-employed construction worker, recently had a heart attack and is at home during the day.
In summer 2009, TB noted a lump in the upper outer quadrant of her right breast and was diagnosed with stage II infiltrating ductal carcinoma (T2, N0, M0, ER positive, PR positive, HER2/neu negative). Three weeks after lumpectomy surgery, she began four cycles of dose-dense chemotherapy with Adriamycin (doxorubicin)/Cytoxan (cyclophosphamide) and her menstrual periods stopped. She started Taxol (paclitaxel) chemotherapy shortly thereafter and developed severe hand-and-foot syndrome after the first dose, which led to both dose reduction and delay. She is currently taking Neurontin (gabapentin) at a dosage of 300 mg twice a day for neuropathic pain. Her paclitaxel treatments were switched to weekly doses and she resumed her treatments 3 weeks after the first dose.
At the clinic appointment before her first weekly paclitaxel treatment, the nurse practitioner screened TB for sleep disturbances, and she screened positive. The nurse practitioner referred TB to the Oncology Clinical Nurse Specialist (CNS), who assessed TB's sleep using the Insomnia Severity Index (ISI). TB's ISI score of 14 indicated that she was experiencing subthreshold insomnia (normal value, 7) and could benefit from treatment. TB agreed to have the CNS, who had been trained by a sleep psychologist, assist her to improve her sleep over a 6-week period.
During their first session at the infusion center before her treatment, the CNS interviewed TB regarding her current sleep using the Brief Sleep History. TB's sleep history was complicated by her schedule of working Monday through Friday from late in the evening through early morning, and sleeping during the day. She sleeps until noon on Saturday and then sleeps on Saturday and Sunday nights. When she gets out of bed on Monday morning, she does not return to bed until she returns home from work on Tuesday morning, 25 hours later. TB scheduled her paclitaxel treatments for Saturday mornings.
After TB drives 12 miles home from work, she or her daughter drives 30 miles to the infusion center. She stated that she hopes to nap while waiting for laboratory results and during her scheduled infusions. TB reported no problem falling asleep in the morning, but stated that she wakes up two to three times during the day, usually to go to the bathroom. She said that she usually spends 7 hours in bed but reported that she believes her body needs 7½ hours of sleep. Her biggest issue was that she feels her sleeping problems are “very noticeable” to others in terms of impairing her quality of life.
After obtaining TB's sleep history, the CNS coached TB to develop an individual behavioral therapy plan.[3,4] Her plan included techniques that have been demonstrated to improve sleep in adults with chronic insomnia: sleep restriction, stimulus control, relaxation therapy, and sleep hygiene.[5,6] These techniques have been found to improve sleep in cancer survivors who have completed treatment.[7,8] TB chose the sleep hygiene strategies of stopping ingestion of liquids by 6:00 AM, using the bathroom before going to bed, and taking her Synthroid and Neurontin medications as prescribed.
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