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Subjective Sleep Quality, Objective Sleep Characteristics, Insomnia Symptom Severity, and Daytime Sleepiness in Women Aged 50 and Older With Nonmetastatic Breast Cancer

Carol A. Enderlin

Elizabeth Ann Coleman

Catherine Cole

Kathy C. Richards

Robert L. Kennedy

Julia A. Goodwin

Laura F. Hutchins

Karen Mack

sleep, sleep disturbance, quality, breast neoplasms
ONF 2011, 38(4), E314-E325. DOI: 10.1188/11.ONF.E314-E325

Purpose/Objectives: To examine subjective sleep quality in women aged 50 and older as predicted by cancer status, age, number of comorbidities, and symptoms of depressed mood; and to describe objective sleep characteristics, insomnia symptom severity, and daytime sleepiness.

Design: Descriptive.

Setting: Urban university and private oncology clinics in the southern United States.

Sample: 32 women with and 35 without nonmetastatic breast cancer, aged 50-90 years (X = 64.9, SD = 4.67).

Methods: Two telephone interviews, the Pittsburgh Sleep Quality Index, Profile of Mood States, three days of home actigraphy, Insomnia Severity Index, Epworth Sleepiness Scale, and medical records review.

Main Research Variables: Subjective quality of sleep; secondary objectives were sleep characteristics, insomnia symptoms, and daytime sleepiness.

Findings: Poor subjective sleep quality was predicted by depressed mood (p < 0.00005). All mean objective sleep characteristics were similar for the breast cancer and comparison groups. Nocturnal awakenings were excessive (9.2 versus 7.3). Mean sleep onset latency was longer for the breast cancer group than for the comparison group (34.8 versus 15.6 minutes). Mean insomnia severity scores for the breast cancer group indicated subthreshold insomnia symptoms, and no clinically significant insomnia for the comparison group (8.9 versus 6.4). Mean daytime sleepiness scores were normal for both groups (7 versus 6).

Conclusions: Subjective sleep quality was predicted by depressed mood only. Sleep in the breast cancer group was characterized by poor sleep quality, frequent nocturnal awakenings, and insomnia symptoms.

Implications for Nursing: Screening and monitoring in women aged 50 and older with breast cancer may help promote early sleep intervention; however, additional collaborative research regarding the underlying causes of sleep disruption is needed.

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    American Cancer Society. (2009). What causes breast cancer? Retrieved from
    Ancoli-Israel, S., Liu, L., Marler, M.R., Parker, B.A., Jones, V., Sadler, G.R., … Florentino, L. (2006). Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Supportive Care of Cancer, 14, 201-209.
    Andrykowski, M.A., Curran, S.L., & Lightner, R. (1998). Off-treatment fatigue in breast cancer survivors: A controlled comparison. Journal of Behavioral Medicine, 21, 1-18. doi:10.1023/A:1018700303959
    Asplund, R. (1996). Daytime sleepiness and napping amongst the elderly in relation to somatic health and medical treatment. Journal of Internal Medicine, 239, 261-267. doi:10.1046/j.1365-2796.1996.453806000.x
    Backhaus, J., Jughanns, K., Broocks, A., Riemann, D., & Hohagen, F. (2002). Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. Journal of Psychosomatic Research, 53, 737-740. doi:10.1016/S0022-3999(02)00330-6
    Banthia, R., Malcarne, V.A., Ko, C.M., Varni, J.W., & Sadler, G.R. (2009). Fatigued breast cancer survivors: The role of sleep quality, depressed mood, stage, and age. Psychology and Health, 24, 965-980. doi:10.1080/08870440802110831
    Bardwell, W.A., Profant, J., Casden, D.R., Dimsdale, J.E., Ancoli-Israel, S., Natarajan, L., … Pierce, J.P. (2008). The relative importance of specific risk factors for insomnia in women treated for early-stage breast cancer. Psycho-Oncology, 17, 9-18. doi:10.1002/pon.1192
    Beck, S.L., Schwartz, A.L., Towsley, G., Dudley, W., & Barsevick, A. (2004). Psychometric evaluation of the Pittsburgh Sleep Quality Index in cancer patients. Journal of Pain and Symptom Management, 27, 140-148. doi:10.1016/j.jpainsymman.2003.12.002
    Berger, A.M. (1998). Patterns of fatigue and activity and rest during adjuvant breast cancer chemotherapy. Oncology Nursing Forum, 25, 51-62.
    Berger, A.M., Farr, L.A., Kuhn, B.R., Fischer, P., & Agrawal, S. (2007). Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy. Journal of Pain and Symptom Management, 33, 398-409. doi:10.1016/j.jpainsymman.2006.09.022
    Berger, A.M., Kuhn, B.R., Farr, L.A., Lynch, J.C., Agrawal, S., Chamberlain, J., & Von Essen, S.G. (2009). Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. Psycho-Oncology, 18, 634-646. doi:10.1002/pon.1438
    Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research and practice. Psychiatry Research, 28, 193-213. doi:10.1016/0165-1781(89)90047-4
    Byar, K.L., Berger, A.M., Bakken, S.L., & Cetak, M.A. (2006). Impact of adjuvant breast cancer chemotherapy on fatigue, other symptoms, and quality of life [Online exclusive]. Oncology Nursing Forum, 33, E18-E26. doi:10.1188/06.ONF.E18-E26
    Carpenter, J.S., & Andrykowski, M.A. (2004). Psychometric evaluation of the Pittsburgh Sleep Quality Index. Journal of Psychosomatic Research, 45, 5-13. doi:10.1016/S0022-3999(97)00298-5
    Carpenter, J.S., Elam, J.L., Ridner, S.H., Carney, P.H., Cherry, J., & Cucullu, H.L. (2004). Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncology Nursing Forum, 31, 591-598. doi:10.1188/04.ONF.591-598
    Davidson, J.R., MacLean, A.W., Brundage, M.D., & Schulze, K. (2002). Sleep disturbance in cancer patients. Social Science and Medicine, 54, 1309-1321. doi:10.1016/S0277-9536(01)00043-0
    Enderlin, C.A., Coleman, E.A., Cole, C., Richards, K.C., Hutchins, L.F., & Sherman, A. (2010). Sleep: A growing concern for women 50 and older with breast cancer. Oncology Nursing Forum, 37, 461-468. doi:10.1188/10.ONF.461-468
    Faul, F., Erdfelder, E., Lang, A.G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavioral Research Methods, 39, 175-191. doi:10.3758/BF03193146
    Foley, D., Ancoli-Israel, S., Britz, P., & Walsh, J. (2004). Sleep disturbances and chronic disease in older adults: Results of the 2003 National Sleep Foundation Sleep in America Survey. Journal of Psychosomatic Research, 56, 497-502. doi:10.1016/j.jpsychores.2004.02.010
    Fortner, B.V., Stepanski, E.J., Kasprowicz, S., & Durrence, H.H. (2002). Sleep and quality of life in breast cancer patients. Journal of Pain and Symptom Management, 24, 471-480. doi:10.1016/S0885-3924 (02)00500-6
    Haghighat, S., Akbari, M., Holakouei, K., Rahimi, A., & Montazeri, A. (2003). Factors predicting fatigue in breast cancer patients. Supportive Care in Cancer, 11, 533-538. doi:10.1007/s00520-003-0473-5
    Huang, Y.L., Liu, R.Y., Wang, Q.S., Eus, J.W., Someran, V., Xu, H., & Zhou, J.N. (2002). Age-associated difference in circadian sleep-wake and rest-activity rhythms. Physiology and Behavior, 76(4-5), 597-603. doi:10.1016/S0031-9384(02)00733-3
    Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep, 14, 540-545.
    Johns, M.W. (1992). Reliability and factor analysis of the Epworth Sleepiness Scale. Sleep, 15, 376-381.
    Kuo, H.H., Chiu, M.J., Liao, W.C., & Hwang, S.L. (2006). Quality of sleep and related factors during chemotherapy in patients with stage I/II breast cancer. Journal of the Formosan Medical Association, 105, 64-69. doi:10.1016/S0929-6646(09)60110-8
    Lee, K.A. (2003). Impaired sleep. In V. Carrieri-Kohlman, A. Lindsey, & C. West (Eds.), Pathophysiological phenomena in nursing (3rd ed., pp. 363-385). St. Louis, MO: Saunders.
    Lichstein, K.L. (2006). Secondary insomnia: A myth dismissed. Sleep Medicine Reviews, 10, 3-5. doi:10.1016/j.smrv.2005.10.001
    Littner, M., Kushida, C.A., Anderson, W.M., Bailey, D., Berry R.B., Davila, D.G., … Johnson, S.F. (2003). Practice parameters for the role of actigraphy in the study of sleep and circadian rhythms: An update for 2002. Sleep, 26, 337-341.
    Liu, L., Fiorentino, L., Natarajan, L., Parker, B.A., Mills, P.J., & Sadler, G.R. (2009). Pretreatment symptom cluster in breast cancer patients is associated with worse sleep, fatigue and depression during chemotherapy. Psycho-Oncology, 18, 187-194. doi:10.1002/pon.1412
    Maggi, S., Langlois, J.A., Minicuci, N., Grigoletto, F., Pavan, M., Foley, D.J., & Enzi, G. (1998). Sleep complaints in community-dwelling older persons: Prevalence, associated factors, and reported causes. Journal of the American Geriatrics Society, 46, 161-168.
    McNair, C., & Heuchert, J.W. (2005). Profile of Mood States technical update. North Tonawanda, NY: Multi-Health Systems, Inc.
    McNair, C., Lorr, M., & Droppleman, L.M. (1992). EITS manual for the Profile of Mood States. San Diego, CA: Educational and Industrial Testing Service.
    McNair, D.M., Heuchert, J.W., & Shiloney, E. (2003). Research with the Profile of Mood States (POMS) 1964-2002: A comprehensive bibliography. Toronto, Canada: Multi-Health Systems.
    Monk, T.H., Reynolds, C.F., III, Kupfer, D.J., Buysse, D.J., Coble, P.A., Hayes, A.J., … Ritenour, A.M. (1994). The Pittsburgh Sleep Diary. Journal of Sleep Research, 3, 111-120. doi:10.1111/j.1365-2869.1994.tb00114.x
    Morin, C.M. (1993). Insomnia: Psychological assessment and management. New York, NY: Guilford Press.
    National Sleep Foundation. (2003). Sleep in America poll. Retrieved from
    Nyenhuis, D.L., Yamamota, C., Luchetta, T., Terrien, A., & Parmentier, A. (1999). Adult and geriatric normative data and validation of the Profile of Mood States. Journal of Clinical Psychology, 55, 79-86. doi:10.1002/(SICI)1097-4679(199901)55:179::AID-JCLP8>3.0.CO;2-7
    Ohayon, M.M., Carskadon, M.A., Gulleminault, C., & Vitello, M.V. (2004). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep, 27, 1255-1273.
    Ohayon, M.M., Zulley, J., Guilleminault, C., Smirne, S., & Priest, R.G. (2001). How age and daytime activities are related to insomnia in the general population: Consequences for older people. Journal of the American Geriatric Society, 49, 360-366. doi:10.1046/j.1532-5415.2001.49077.x
    Otte, J., Carpenter, J., Russell, K., Bigatti, S., & Champion, V. (2010). Prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors. Journal of Pain and Symptom Management, 39, 535-547. doi:10.1016/j.jpainsymman.2009.07.004
    Pack, A.I., Dinges, D.F., Gehrman, P.R., Staley, B., Pack, F.M., & Maislin, G. (2006). Risk factors for excessive sleepiness in older adults. Annals of Neurology, 59, 893-904. doi:10.1002/ana.20863
    Park, Y.M., Matsumoto, K., Seo, Y.J., Kang, M.J., & Nagashima, H. (2002). Effects of age and gender on sleep habits and sleep trouble for aged people. Biological Rhythm Research, 33, 39-51. doi:10.1076/brhm.
    Payne, J., Piper, B., Rabinowitz, I., & Zimmerman, B. (2006). Biomarkers, fatigue, sleep, and depressive symptoms in women with breast cancer: A pilot study. Oncology Nursing Forum, 33, 775-783. doi:10.1188/06.ONF.775-783
    Reid, K., Martinovich, Z., Finkel, S., Statsinger, J., Goldern, R., Harter, K., & Zee, P.C. (2006). Sleep: A marker of physical and mental health in the elderly. American Journal of Geriatric Psychiatry, 14, 860-866. doi:10.1097/
    Restless Legs Syndrome Foundation. (2007). Sleep diary. Retrieved from
    Roberts, R.E., Shema, S.J., Kaplan, G.A., & Strawbridge, W.J. (2000). Sleep complaints and depression in an aging cohort: A prospective perspective. American Journal of Psychiatry, 157, 81-88.
    Sadeh, A., Sharkey, K.M., & Carskadon, M.A. (1994). Activity-based sleep-wake identification: An empirical test of methodological issues. Sleep, 17, 201-207.
    Savard, J., Simard, S., Blanchet, J., Ivers, H., & Morin, C.M. (2001). Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep, 24, 583-590.
    Schubert, C.R., Cruickshanks, K.J., Dalton, D.S., Klein, B.E.K., Klein, R., & Nondahl, D.M. (2002). Prevalence of sleep problems and quality of life in an older population, Journal of Sleep Research and Sleep Medicine, 25, 889-893.
    Su, T.P., Huang, S.R., & Chou, P. (2004). Prevalence and risk factors of insomnia in community-dwelling Chinese elderly: A Taiwanese urban area survey. Australian and New Zealand Journal of Psychiatry, 38, 706-713.
    Vargas, S., Wohlgemuth, W.K., Antoni, M.H., Lechner, S.C., Holley, H.A., & Carver, C.S. (2010). Sleep dysfunction and psychosocial adaptation among women undergoing treatment for non-metastatic breast cancer. Psycho-Oncology, 19, 669-673. doi:10.1002/pon.1603
    Vitiello, M.V., Larsen, L.H., & Moe, K.E. (2004). Age-related sleep change: Gender and estrogen effects on the subjective-objective sleep quality relationships of healthy, non-complaining older men and women. Journal of Psychosomatic Research, 56, 503-510.
    Yancik, R., Wesley, M.N., Ries, L.A.G., Havlik, R.J., Edwards, B.K., & Yates, J.W. (2001). Effect of age and comorbidity in postmenopausal breast cancer patients aged 55 years and older. JAMA, 285, 885-892. doi:10.1001/jama.285.7.885
    Yoon, I.Y., Kripke, D.F., Youngstedt, S.D. & Elliott, J.A. (2003). Actigraphy suggests age-related differences in napping and nocturnal sleep. Journal of Sleep Research, 12, 87-93. doi:10.1046/j.1365-2869.2003.00345.x