Overview of insomnia in palliative care
- Jeremy M Hirst, MD
Jeremy M Hirst, MD
- Associate Clinical Professor of Psychiatry
- Associate Director, Palliative Care Psychiatry
- University of UC San Diego Health
- Associate Director of Psychiatry & Psychosocial Services; Patient & Family Support Services
- University of California San Diego, Moores Cancer Center
- Scott A Irwin, MD, PhD
Scott A Irwin, MD, PhD
- Associate Professor of Psychiatry
- Director, Supportive Care Services
- Samuel Oschin Comprehensive Cancer Institute
- Cedars-Sinai Medical Center
- Section Editors
- Susan D Block, MD
Susan D Block, MD
- Editor-in-Chief — Palliative Care
- Section Editor — Psychosocial Issues
- Professor of Psychiatry
- Harvard Medical School
- Ruth Benca, MD, PhD
Ruth Benca, MD, PhD
- Section Editor — Insomnia
- Professor and Chair, Department of Psychiatry and Human Behavior
- University of California, Irvine
Insomnia is a condition of impaired sleep, with difficulties in initiating or maintaining sleep, and/or experiencing sleep as nonrestorative and unrefreshing, despite having the appropriate opportunity for sleep to occur . It is a very common medical complaint in primary care patients and the same is true for patients in palliative care, which is illustrated by studies that report the prevalence of insomnia is over 60 percent [2-4]. Insomnia is associated with multiple consequences that have a negative impact on quality of life and the ability to perform normal functions. In addition, insomnia is a strong predictor of the development of psychiatric disorders. (See "Overview of insomnia", section on 'Consequences'.)
In the context of palliative care, insomnia often co-exists with other symptoms, such as pain, depression, and anxiety and the presence of one often exacerbates the other, contributing to a decrease in quality of life . Patients receiving palliative care may vary in terms of their functional status and where they are in their personal trajectory in a chronic illness. As a result, the approach and treatment to insomnia in these patients should be individualized. An overview and the general treatment approach to insomnia as well as an overview of palliative care and the assessment of patients in palliative care are discussed separately.
●(See "Overview of insomnia".)
- Costa e Silva JA, Chase M, Sartorius N, Roth T. Special report from a symposium held by the World Health Organization and the World Federation of Sleep Research Societies: an overview of insomnias and related disorders--recognition, epidemiology, and rational management. Sleep 1996; 19:412.
- Kvale EA, Shuster JL. Sleep disturbance in supportive care of cancer: a review. J Palliat Med 2006; 9:437.
- Hugel H, Ellershaw JE, Cook L, et al. The prevalence, key causes and management of insomnia in palliative care patients. J Pain Symptom Manage 2004; 27:316.
- Mercadante S, Aielli F, Adile C, et al. Sleep Disturbances in Patients With Advanced Cancer in Different Palliative Care Settings. J Pain Symptom Manage 2015; 50:786.
- Glynn J, Gale S, Tank S. Causes of sleep disturbance in a specialist palliative care unit. BMJ Support Palliat Care 2014; 4 Suppl 1:A56.
- International classification of sleep disorders, 3rd ed., American Academy of Sleep Medicine, Darien, IL 2014.
- Smith MT, Haythornthwaite JA. How do sleep disturbance and chronic pain inter-relate? Insights from the longitudinal and cognitive-behavioral clinical trials literature. Sleep Med Rev 2004; 8:119.
- Morin CM, Benca R. Chronic insomnia. Lancet 2012; 379:1129.
- Mercadante S, Girelli D, Casuccio A. Sleep disorders in advanced cancer patients: prevalence and factors associated. Support Care Cancer 2004; 12:355.
- Little A, Ethier C, Ayas N, et al. A patient survey of sleep quality in the Intensive Care Unit. Minerva Anestesiol 2012; 78:406.
- Weinhouse GL. Pharmacology I: effects on sleep of commonly used ICU medications. Crit Care Clin 2008; 24:477.
- Venkateshiah SB, Collop NA. Sleep and sleep disorders in the hospital. Chest 2012; 141:1337.
- Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med 2008; 24:51.
- Savard J, Ivers H, Villa J, et al. Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. J Clin Oncol 2011; 29:3580.
- Trudel-Fitzgerald C, Savard J, Ivers H. Evolution of cancer-related symptoms over an 18-month period. J Pain Symptom Manage 2013; 45:1007.
- Budhiraja R, Parthasarathy S, Budhiraja P, et al. Insomnia in patients with COPD. Sleep 2012; 35:369.
- Politis M, Wu K, Molloy S, et al. Parkinson's disease symptoms: the patient's perspective. Mov Disord 2010; 25:1646.
- Hayes D Jr, Anstead MI, Ho J, Phillips BA. Insomnia and chronic heart failure. Heart Fail Rev 2009; 14:171.
- Bloom HG, Ahmed I, Alessi CA, et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J Am Geriatr Soc 2009; 57:761.
- Stanchina ML, Abu-Hijleh M, Chaudhry BK, et al. The influence of white noise on sleep in subjects exposed to ICU noise. Sleep Med 2005; 6:423.
- McCurry SM, Pike KC, Vitiello MV, et al. Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: results of a randomized, controlled trial. J Am Geriatr Soc 2011; 59:1393.
- Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004; 65 Suppl 16:33.
- Khemlani, MH. Pallaitive medicine grand rounds: Insomnia in palliative care. HKSPM Newsletter 2008; Oct:20.
- Kim SW, Shin IS, Kim JM, et al. Effectiveness of mirtazapine for nausea and insomnia in cancer patients with depression. Psychiatry Clin Neurosci 2008; 62:75.
- Khoo SY, Quinlan N. Mirtazapine: A Drug with Many Palliative Uses #314. J Palliat Med 2016; 19:1116.
- Sharafkhaneh A, Jayaraman G, Kaleekal T, et al. Sleep disorders and their management in patients with COPD. Ther Adv Respir Dis 2009; 3:309.
- Randall S, Roehrs TA, Roth T. Efficacy of eight months of nightly zolpidem: a prospective placebo-controlled study. Sleep 2012; 35:1551.
- Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med 2013; 8:1.
- Lankford A, Rogowski R, Essink B, et al. Efficacy and safety of doxepin 6 mg in a four-week outpatient trial of elderly adults with chronic primary insomnia. Sleep Med 2012; 13:133.
- Tanimukai H, Murai T, Okazaki N, et al. An observational study of insomnia and nightmare treated with trazodone in patients with advanced cancer. Am J Hosp Palliat Care 2013; 30:359.
- McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer's disease. Cochrane Database Syst Rev 2014; :CD009178.
- Camargos EF, Pandolfi MB, Freitas MP, et al. Trazodone for the treatment of sleep disorders in dementia: an open-label, observational and review study. Arq Neuropsiquiatr 2011; 69:44.
- Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev 2002; :CD003346.
- Irwin MR. Depression and insomnia in cancer: prevalence, risk factors, and effects on cancer outcomes. Curr Psychiatry Rep 2013; 15:404.
- Carlsson ME. Sleep disturbance in relatives of palliative patients cared for at home. Palliat Support Care 2012; 10:165.
- Carter PA. Caregivers' descriptions of sleep changes and depressive symptoms. Oncol Nurs Forum 2002; 29:1277.
- Associated factors
- TREATMENT APPROACH
- General principles
- - Symptom management
- - Addressing the environment
- - Lifestyle modifications
- - Promote physical comfort
- - Encourage healthy sleep-wake cycles
- - Minimize disruptions
- Behavioral-based treatment
- - Atypical antidepressants
- - Benzodiazepine receptor agonists
- - Sedating antidepressants
- - Selective melatonin receptor agonists
- - Benzodiazepines
- - Over the counter agents
- - Other agents
- Special populations
- - Elderly patients
- - Dementia
- IMPACT TO CAREGIVERS
- SUMMARY AND RECOMMENDATIONS