What it means in practice

• Based on the available evidence, it is suggested that the clinical assessment of insomnia should focus on 
  - reversible factors which may contribute to sleeping problems
  - prognosis, which determines the length of time for which night sedation is likely to be needed, in order to minimise the use of long-term (greater than 8 weeks) sedative hypnotics.
• If the patient has a prognosis of several months, non-pharmacological options for treatment should also be considered. [2]
• Non-pharmacological interventions have not been well studied in the palliative care population [3], but in primary insomnia there is some evidence that attention to environmental issues and sleep hygiene (including avoidance of napping and sleeping in where possible), behaviour therapies, and relaxation techniques may be helpful. However behaviour therapies and relaxation techniques require some effort from the patient and may not be appropriate in patients close to the end of life. [2]
• Medications which have sedating properties may contribute to night sedation (eg, tricyclic or other sedating antidepressants, antihistamines, or antipsychotics) but should be carefully assessed with regard to their side effect profile, and are likely to be best used where there is a specific indication. [2]

• Sleep disturbance in supportive care in cancer: a review.
  Kvale, E.A., et al., Sleep disturbance in supportive care of cancer: a review. Journal of Palliative Medicine, 2006. 9(2): p. 437-50.

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased

Overview article

• Sedative hypnotics in older people with insomnia: metaanalysis of risks and benefits 
  Glass, J., et al., Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ, 2005. 331(7526): p. 1169-73.
• Cancer-related fatigue and sleep disorders 
  Roscoe, J., et al., Cancer-Related Fatigue and Sleep Disorders. Oncologist, 2007. 12(Suppl 1): p. 35-42.

Related CareSearch pages
Delirium
Depression
Fatigue

References

1. Hirst, A. and R. Sloan, Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database of Systematic Reviews, 2007. 3.
2. Kvale, E.A. and J.L. Shuster, Sleep disturbance in supportive care of cancer: a review. Journal of Palliative Medicine, 2006. 9(2): p. 437-50. 
3. Berger, A.M., et al., Sleep/wake disturbances in people with cancer and their caregivers: state of the science. Oncology Nursing Forum, 2005. 32(6): p. Online Exclusive: E98-126.