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Overview of insomnia in palliative care

Jeremy M Hirst, MD
Scott A Irwin, MD, PhD
Section Editors
Susan D Block, MD
Ruth Benca, MD, PhD
Deputy Editor
Diane MF Savarese, MD


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 [1]. 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 that the prevalence of insomnia is over 60 percent [2-5]. 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 in adults", section on 'Consequences'.)

In the context of palliative care, insomnia often coexists 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 [5,6]. 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 in adults".)

(See "Benefits, services, and models of subspecialty palliative care".)

(See "Overview of managing common non-pain symptoms in palliative care" and "Overview of comprehensive patient assessment in palliative care".)

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Literature review current through: Nov 2017. | This topic last updated: Dec 07, 2017.
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  1. 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.
  2. Kvale EA, Shuster JL. Sleep disturbance in supportive care of cancer: a review. J Palliat Med 2006; 9:437.
  3. 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.
  4. 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.
  5. Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care 2017; 7:274.
  6. 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.
  7. International classification of sleep disorders, 3rd ed., American Academy of Sleep Medicine, Darien, IL 2014.
  8. 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.
  9. Morin CM, Benca R. Chronic insomnia. Lancet 2012; 379:1129.
  10. Mercadante S, Girelli D, Casuccio A. Sleep disorders in advanced cancer patients: prevalence and factors associated. Support Care Cancer 2004; 12:355.
  11. Little A, Ethier C, Ayas N, et al. A patient survey of sleep quality in the Intensive Care Unit. Minerva Anestesiol 2012; 78:406.
  12. Weinhouse GL. Pharmacology I: effects on sleep of commonly used ICU medications. Crit Care Clin 2008; 24:477.
  13. Venkateshiah SB, Collop NA. Sleep and sleep disorders in the hospital. Chest 2012; 141:1337.
  14. Flaherty JH. Insomnia among hospitalized older persons. Clin Geriatr Med 2008; 24:51.
  15. 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.
  16. Trudel-Fitzgerald C, Savard J, Ivers H. Evolution of cancer-related symptoms over an 18-month period. J Pain Symptom Manage 2013; 45:1007.
  17. Budhiraja R, Parthasarathy S, Budhiraja P, et al. Insomnia in patients with COPD. Sleep 2012; 35:369.
  18. Politis M, Wu K, Molloy S, et al. Parkinson's disease symptoms: the patient's perspective. Mov Disord 2010; 25:1646.
  19. Hayes D Jr, Anstead MI, Ho J, Phillips BA. Insomnia and chronic heart failure. Heart Fail Rev 2009; 14:171.
  20. 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.
  21. 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.
  22. Mercier J, Savard J, Bernard P. Exercise interventions to improve sleep in cancer patients: A systematic review and meta-analysis. Sleep Med Rev 2017; 36:43.
  23. 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.
  24. Morin CM. Cognitive-behavioral approaches to the treatment of insomnia. J Clin Psychiatry 2004; 65 Suppl 16:33.
  25. Gong H, Ni CX, Liu YZ, et al. Mindfulness meditation for insomnia: A meta-analysis of randomized controlled trials. J Psychosom Res 2016; 89:1.
  26. Johnson JA, Rash JA, Campbell TS, et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev 2016; 27:20.
  27. Khemlani MH. Pallaitive medicine grand rounds: Insomnia in palliative care. HKSPM Newsletter 2008; Oct:20.
  28. 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.
  29. Khoo SY, Quinlan N. Mirtazapine: A Drug with Many Palliative Uses #314. J Palliat Med 2016; 19:1116.
  30. Sharafkhaneh A, Jayaraman G, Kaleekal T, et al. Sleep disorders and their management in patients with COPD. Ther Adv Respir Dis 2009; 3:309.
  31. Randall S, Roehrs TA, Roth T. Efficacy of eight months of nightly zolpidem: a prospective placebo-controlled study. Sleep 2012; 35:1551.
  32. Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med 2013; 8:1.
  33. 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.
  34. 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.
  35. McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbances in Alzheimer's disease. Cochrane Database Syst Rev 2014; :CD009178.
  36. 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.
  37. Hatta K, Kishi Y, Wada K, et al. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry 2014; 71:397.
  38. Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev 2002; :CD003346.
  39. Irwin MR. Depression and insomnia in cancer: prevalence, risk factors, and effects on cancer outcomes. Curr Psychiatry Rep 2013; 15:404.
  40. Carlsson ME. Sleep disturbance in relatives of palliative patients cared for at home. Palliat Support Care 2012; 10:165.
  41. Carter PA. Caregivers' descriptions of sleep changes and depressive symptoms. Oncol Nurs Forum 2002; 29:1277.
  42. Maltby KF, Sanderson CR, Lobb EA, Phillips JL. Sleep disturbances in caregivers of patients with advanced cancer: A systematic review. Palliat Support Care 2017; 15:125.