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Sleeping Problems

Background 

Sleeping problems (insomnia and poor quality sleep) are common in palliative care patients, and often have a significant impact on quality of life. The problems may be a combination of difficulty going to sleep, fragmented sleep, or early morning waking. Patients may complain that their sleep is not refreshing. Insomnia can also be a problem for the patient’s caregivers and contributes to the burden of caregiving. The sleeping problems of caregivers may continue into bereavement – either as a transient part of normal grief and bereavement, or a significant problem if the bereavement is complex or associated with depression.

Many palliative conditions cause sleep problems, but especially the cancer associated insomnia syndrome, hepatic encephalopathy in which day night reversal may occur, and cardiac failure causing orthopnoea. Other potentially reversible problems which may contribute are:

  • Depression, anxiety
  • Pain
  • Delirium
  • Dementia
  • Obstructive sleep apnoea, or other primary sleep disorder
  • Dyspnoea, cough, pleural effusion
  • Nausea, vomiting
  • Movement disorders eg, restless legs, akathisia
  • Night sweats
  • Pruritis (itch)
  • Environmental disruption, especially for in-patients
  • Changed activity patterns
  • Altered circadian rhythm
  • Reduced bed mobility, and physical problems that limit comfortable sleeping position
  • Medications eg, steroids
  • Incontinence or nocturia.

Key messages

  • Sedative hypnotics, especially benzodiazepines, are very frequently prescribed to palliative care patients. They are likely to be effective in the short term. [1]
  • There is little high level evidence to guide the choice of sedative hypnotic medications in palliative care patients. [2] Cost-effectiveness should also be considered. [3]
  • Side effects of sedative hypnotics may include worsening cognition and daytime sleepiness. [4]

Active research areas / controversies 

  • There is evidence that chronic use of sedative hypnotics in palliative care patients results in increased side effects without long term efficacy. [1,4] Patterns of benzodiazepine use in palliative care patients, their effectiveness, and their adverse effects are being studied in phase 4 clinical trials.
  • Melatonin has been identified as a medication with the potential to reduce sleep latency, but has not been studied in palliative care patients. [5] Bright light therapy is another possible approach, and needs further investigation in a palliative care setting. [6]
  • A meta-analysis of the use of acupuncture for insomnia could not find sufficient research to support this practice at this stage. [7]
  • There are few validated instruments for assessing and researching sleep problems in palliative care patients.
PubMed Searches
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Review Collection
  1. Kvale EA, Shuster JL. Sleep disturbance in supportive care of cancer: a review. J Palliat Med. 2006 Apr;9(2):437-50.
  2. Hirst A, Sloan R. Benzodiazepines and related drugs for insomnia in palliative care. Cochrane Database Syst Rev. 2002;(4):CD003346.
  3. Bain KT, Weschules DJ, Knowlton CH, Gallagher R. Toward evidence-based prescribing at end of life: a comparative review of temazepam and zolpidem for the treatment of insomnia. Am J Hosp Palliat Care. 2003 Sep-Oct;20(5):382-8.
  4. Bruera E, Fainsinger RL, Schoeller t, Ripamonti C. Rapid discontinuation of hypnotics in terminal cancer patients: a prospective study. Ann Oncol. 1996 Oct;7(8):855-6.
  5. Mahmoud F, Sarhill N, Mazurczak MA. The therapeutic application of melatonin in supportive care and palliative medicine.Am J Hosp Palliat Care. 2005 Jul-Aug;22(4):295-309.
  6. Liu L, Marler MR, Parker BA, Jones V, Johnson S, Cohen-Zion M, et al. The relationship between fatigue and light exposure during chemotherapy. Support Care Cancer. 2005 Dec;13(12):1010-7. Epub 2005 Apr 29. 
  7. Cheuk DK, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005472.
Last updated 18 January 2017