Insomnia
An approach to symptom management to guide decision-making in the management of patients with life-threatening illness
Appropriate assessment to identify cause and severity of symptoms
Explanation to patient and family
Consider disease-specific palliative therapy
Institute non-pharmacological interventions
Prescribe appropriate first-line treatment
Review assessment and management
Definition
The inability to fall asleep or to remain asleep for an adequate length of time
Appropriate assessment to identify cause and severity of symptoms
- It is important to get a thorough history of the patient’s sleep pattern now and before he/she started to have problems
- Establish the patient’s understanding about insomnia and their expectations
- Identify possible medications that the patient is taking that could be causing the insomnia
- Identify possible emotional stresses that could be causing the insomnia
- Identify possible symptoms such as pain that may be causing the insomnia
Explanation to patient and family
- Explain the possible causes of insomnia
- Reassure patient and family that condition is being taken seriously
- Discuss management options with patient and family
Correct reversible factors
- Identify and treat the primary condition; e.g. pain
- Eliminate disturbance and noise
Consider disease-specific palliative therapy
- Treat insomnia with a holistic approach
- Consider physical, psychosocial and spiritual causes and management options
Institute non-pharmacological interventions
- Avoid alcohol and stimulants in the evening
- Relaxation techniques
- Massage
- Warm milk/herbal tea at night
- Cognitive-behavioural therapy
- Progressive muscle relaxation therapy
- Biofeedback
- Hypnotherapy
- Sleep hygiene.
Prescribe appropriate first-line treatment
Benzodiazepines have been successfully used for short term insomnia, although there are no systematic studies on long-term use and rare studies in palliative care.
- Nitrazepam 5-10 mg nocte
- Oxazepam 10- 15 mg nocte
Review assessment and management
- Review treatment after first night and adjust treatment accordingly
- Advise patient to inform the healthcare team if treatment stops being effective
At all stages of management consider
- Involvement of interdisciplinary team
- Management of insomnia in palliative care patients is a holistic process and the participation of the interdisciplinary team will ensure this
- Insomnia has a large psychosocial element which should be explored and addressed for optimal treatment results
Referral to appropriate service/more experienced clinician
Referral to sleep clinics is an option, but is rarely appropriate or necessary for palliative care patients.