Insomnia

Up to 50% of patients with advanced cancer report insomnia, and ~75% of patients admitted to a palliative care unit require a hypnotic medicine.

Insomnia can be distressing, can increase feelings of isolation and impact negatively on quality of life.  Further, it may exacerbate other symptoms (i.e. pain, dyspnea, nausea, depression) and may prevent achievement of symptom control. Unfortunately there is a tendency for care providers to not recognize insomnia as a significant problem.

CAUSES
The major causes for insomnia in cancer patients are:

  • uncontrolled symptoms (i.e. pain, dyspnea);
  • medications;
  • anxiety, intrusive thoughts, and worry about future;
  • increased time in bed;
  • treatment and institutional schedules;
  • immune dysfunction and metabolic abnormality.

ASSESSMENT
Insomnia is characterized by one or more of the following:

  • non-refreshing sleep;
  • difficulty falling asleep;
  • early morning awakening;
  • difficulty maintaining sleep.

Insomnia can result in tiredness, lack of energy, difficulty concentrating and irritability.

Begin by ruling out any potential contributing medical illness (i.e. depression, anxiety, seizure, substance abuse) or common sleep disturbances (periodic limb movement disorder, sleep apnea, parasomnias, sleep state misperception).

Take a detailed sleep history:

  1. Determine type of insomnia (transient/acute, persistent/chronic, intermittent).
  2. Evaluate sleep pattern (sleep onset insomnia, difficulty maintaining sleep, early wakening, non-restorative sleep).
  3. Get a current sleep hygiene history including bedtime and wake times, napping, exercise and lifestyle, caffeine, substance use.
  4. Assess for any associated events such as medications, psychosocial distress, mood changes, and immediate precipitants.
  5. Find out about previous sleep history including previous sleep quality, history of insomnia, and previous response to treatment.
  6. Ask caregiver about snoring, movement during sleep, changes in sleep quality and patterns, and changes in mood of patient.

MANAGEMENT
The management options for insomnia should begin by eliminating any inciting factors and promoting good sleep hygiene.

In addition, there are behavioural and pharmacological interventions that may be considered.

Non-Pharmacological Interventions
Promote good sleep hygiene:

  • encourage patients to keep a regular schedule - regular bedtime, avoid sleeping all day. Restorative naps are okay, unless they replace a night sleep pattern;
  • avoid mental stimulation and distress at night;
  • increase physical activity during the day;
  • avoid caffeine, alcohol, steroids, metamphetamines at night;
  • have extra covers available in case of cold;
  • keep bedding wrinkle free, clean and dry;
  • reposition and support with pillows as needed;
  • create a calm, quiet and dark environment that will encourage rest and sleep.

Relaxation therapy may be helpful and can including imagery training, meditation, abdominal breathing, progressive muscle relaxation.

Cognitive behavioural therapy to deal with stress and anxiety has also been shown to be effective in improving sleep quality, sleep efficiency and to improve quality of life in patients with advanced cancer.

Pharmacological Interventions
Pharmacologic management of insomnia generally includes anti-histamines, hypnotics, anti-depressants or neuroleptics.

Antihistamines
 Antihistamines are effective for short-term use because tolerance is rapid. They may be the agent of choice in patients with nausea. However, anticholinergic side effects are common. 

Consider:
Diphenhydramine: Side effects include constipation, daytime sleepiness, and cognitive dysfunction.

Hypnotics
Transiently effective in hastening sleep onset and decreasing awakenings.  Benzodiazepines may worsen delirium in elderly. 

Consider:
Lorazepam

Tricyclic antidepressants
Tricyclic antidepressants are sedating agents and may eliminate need for use of other hypnotics. This is the agent of choice in settling of depression or for patients with neuropathic pain or anorexia.

Consider:
Trazadone

Neuroleptics
Consider if  "sun-downing" (worstened confusion or restlessness at night) is a problem

Consider:
Haloperidol
Methotrimeprazine maleate (Nozinan)

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This page was last updated: March 8th, 2005 at 6:00pm.