This is the first cross-sectional study to examine predictors of sleep disturbance in patients newly diagnosed with meningiomas prior to surgery and effects on quality of life. Sleep disturbance has been described in the literature as a frequent occurrence in patients with brain tumors[14, 28–30]. Our results are consistent with those findings, based upon PSQI score, 43% of the meningioma patients included in this study suffered from sleep disturbance. Fatigue and headache are predictors of sleep disturbance in meningioma patients. In addition, meningioma patients with sleep disturbance have worse quality of life than meningioma patients without sleep disturbance.
Social demographic and clinical variables are closely related to sleep quality in patients with brain tumors. Pickering et al. indicated that high BMI was associated with increased daytime sleepiness and daytime dysfunction by evaluating sleep quality, fatigue, and quality of life in 15 craniopharyngioma patients, in comparison to 15 healthy controls. Furthermore, they found that the degree of hypothalamic injury was significantly correlated to higher BMI. However, no obvious correlation was found between BMI and sleep disturbance in our study, which may be explained by the differences in the types or diagnosis and locations of brain tumors included, and the hypothalamic region may not be damaged by some tumors. Some studies explored whether brain tumor location, laterality and size had a particular association with sleep disturbance[28, 32]. One study conducted in BT patients before surgery in Finland reported that poorer sleep was described by patients with anterior than posterior, but there was no difference in sleep between tumor size groups. However, Mainio et al. suggested that no statistically significant difference between brain tumor laterality groups was found in sleep quality before surgery. Our study failed to show any statistically significant correlation between sleep disturbances and size or site of tumor. These results could be attributed to the population heterogeneity and by the small size of the subgroups.
Only a limited number of studies have focused on the relationship between psychological disorders and sleep quality in brain tumor patients[28, 33, 34]. The presence of psychological disorders such as anxiety and depression is common in patients affected by primary brain tumors before surgery. Furthermore, some of the existing literature argues that meningioma, over other types of tumors, can lead to greater levels of anxiety and depression, resulting in the aggravation of health-related complications. In our study, patients with sleep disturbance had significantly higher levels of HADS-A and HADS-D scores compared with patients without sleep disturbance. The data indicated that it is necessary to systematically screen and manage patients with psychological disorders, and the importance of targeted interventions to help meningioma patients get rid of sleep problems[34, 37].
Our study found that sleep disturbances correlated significantly with fatigue. This finding is in accordance with previous studies[34, 38, 39]. Fatigue is described as a subjective feeling of tiredness and a lack of vitality, and is a complexity of symptoms modulated by multiple associated factors. In neurological patients, fatigue can be a persisting and/or recurrent symptom, which is not adequately alleviated by rest. Importantly, fatigue causes the greatest symptom distress and often occurs in symptom clusters with sleep disturbance, significantly lowering patients’ quality of life, as reported by people with BT.In our study, the risk for sleep disturbance was greater for patients with more severe fatigue, and logistic regression analysis indicated that fatigue was a significant predictor of sleep disturbance in meningioma patients. Although fatigue symptoms have a significant impact on patients’ sleep quality, the diagnosis and treatment of fatigue symptoms are often insufficient. There is some evidence that patients experiencing fatigue may benefit from exercise interventions or psychological interventions to help patients manage fatigue symptoms[40, 41]. Health care providers should take active intervention to alleviate fatigue and improve sleep quality.
Moreover, we also found that headache and functional status (KPS score) were strongly correlated with sleep disturbance, consistent with the literature[34, 42]. In addition, logistic regression analysis indicated that headache was a major contributor to sleep disturbance, while functional status was not. Headache is the most frequent symptom and occurs in about two thirds of meningioma patients. Meningioma causes a headache may depend on compression of specific structures or an increase in intracranial pressure. Meningioma patients with headache may wake up frequently at night, making it difficult to fall asleep again. The relationship between sleep and headache seems to be bidirectional; in fact, headache may be a predictor of sleep disturbance and, in turn, sleep disturbance aggravates headache. Previous studies have shown that sleep disturbance may damage vital physiological processes, such as dopaminergic signal, opioid signal and emotional regulation, which contribute to the development of hyperalgesia and maintenance of chronic pain. Longitudinal data involving a larger sample are required to adequately understand the direction and magnitude of the relationship between sleep and headache. One study exploring sleep disturbance among adults with primary or secondary malignant brain tumors indicated that KPS was a significant risk factors for sleep disturbance. Our study found that meningioma patients with sleep disturbance had lower KPS score than meningioma patients without sleep disturbance. If sleep disturbance was present, these patients should be screened for functional impairment.
Considering the importance of quality of life in evaluating the prognosis of patients, this study also explored the impact of sleep disturbances on the quality of life of meningioma patients. Previous studies have found that meningioma patients had significantly lower quality of life than healthy controls before surgery[45, 46]. A recent systematic review highlights a picture emerging from studies reporting the results of HRQoL that sleep disturbance is a highly common and severe symptom in patients with brain tumors, leading to distress. Furthermore, our study shows that meningioma patients with sleep disturbance score worse both in the domains of the PCS and MCS of SF-36, which indicated that the quality of life of these patients decreased in many aspects, as it was previously reported. Nassiri et al. have proved that sleep disturbance is highly correlated with the decline of quality of life. Interestingly, we also found that compared with meningioma patients without sleep disturbances, patients with sleep disturbances showed more serious anxiety, depression and fatigue, which lower the quality of life.
To the best of our knowledge, this study is the first to explore the sleep quality and its effects on the quality of life of meningioma patients newly diagnosed and ready for surgery in China. However, several limitations of this study should be considered. First, this study did not provide the details of medication used in meningioma patients, such as corticosteroids and antiepileptics. Previous studies have shown that the use of corticosteroids and antiepileptics in BT patients may disrupt patients’ sleep[38, 47]. Second, participants were recruited from a single neurosurgery clinic and sample size was rather small. Third, although the instruments used for this analysis have been validated in BT patients, self-report data are particularly subject to bias. Finally, because this study is a cross-sectional in design, we cannot exam the causal relationships between variables. Therefore, further longitudinal studies with objective or real-time sleep measures from multiple centers should be conducted to accurately quantify sleep quality, and develop the effective interventions to improve the sleep quality and the quality of life in meningioma patients.