Sleeping problems (insomnia and poor quality sleep) are common in people requiring palliative care, and often have a significant impact on quality of life. [3-6] They are particularly common in patients with COPD,  patients with heart disease,  end-stage renal disease,  end-stage liver disease,  and cancers associated with the lung  and the central nervous system.  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 and sleep disturbances can exacerbate other symptoms such as pain. 
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 life-limiting conditions or the treatments associated with these conditions cause sleep problems. There are a number of potentially modifiable problems which may contribute to sleeplessness: 
There are a number of screening and assessment tools for sleep disturbances. One of the most common, validated tools used in the general population is the Pittsburgh Sleep Quality Index (PSQI).  The Edmonton Symptom Assessment System (ESAS) was recently studied for its suitability to screen for sleeping problems in patients with advanced cancer.  The authors found the ESAS was appropriate to use and recommended routine screening for patients in a palliative care setting.
A number of systematic reviews have examined both pharmacological and non-pharmacological interventions for sleep disturbances. A meta-analysis  was unable to identify sufficient evidence to draw conclusions about the use of benzodiazepines in palliative care. Agents that were included in the meta-analysis were all benzodiazepines, as well as zolpidem, zopiclone and zalpelon. Midazolam is the most commonly used benzodiazepam in palliative care, although it is rarely used specifically for sleeping problems and there is no evidence to support its use for sleep.  Melatonin has been used in a number of populations to assist with sleep. [15,16] It has been studied in advanced cancer with limited efficacy. 
Non-pharmacological interventions, such as exercise, sleep hygiene, mind-body practices and changes to the environment have been examined for efficacy at improving sleep. [3,17,18] There is low quality evidence to support these interventions. A systematic review of complimentary therapies in palliative care found no supporting evidence for these interventions to manage sleeping problems. 
Last updated 27 August 2021