Sleep in the Terminally Ill

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Sleep in the Terminally Ill

• Presentation for Palliative Care Elective
• John Reed
• MS IV
• Tuesday, February 19, 2008

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Evaluation

• As palliative care docs, one of the questions we
  must ask is How is the patient sleeping?
• If we get a sense they are sleeping too much or
  too little, probe further.
• Does the patient know why they are having
  difficulty?
• If not, is the problem with sleep initiation or
  maintenance?
• Is the insomnia transient or persistent?
• Does the patient have a hx of sleep problems
  before the terminal diagnosis?

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Evaluation (contd)

• The patient can usually tell you if the problem
  is secondary to some other symptom (pain).
• Difficulty initiating sleep may be a sign of
  anxiety or worry.
• Frequent awakening may be a sign of medication
  problems. This also occurs with PCAs and frequent
  urination.

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Sleep Problems

• Too much sleep
• Leads to less time with loved ones
• May mean the patient is less lucid in final hours
  before death (for good or bad)
• May be a good thing in some cases, dont be
  afraid to make the patient sleepy if that is what
  they want
• Insomnia
• May heighten pain, anxiety, depression or
  delirium
• May result from the same and be a vicious cycle
• 9 of those who die in hospitals suffer from
  insomnia
• Some 50-70 of those in hospice care suffer from
  insomnia
• Can be very debilitating and frustrating for
  patients and lead to a significant decrease in
  quality of life

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Too Much Sleep

• Many terminally ill patients receive hypnotics
  (77) for unclear reasons.
• Elderly patients (the majority of the terminally
  ill) are more likely to suffer sedating and
  cognitive side effects.
• Many terminally ill patients also already suffer
  cognitive deficiencies, hypnotics can exacerbate
  this.

Bruera et al., 1996.
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Treatment

• Rapid discontinuation of hypnotics was shown in
  one study to improve cognition and not affect
  insomnia.
• Only 2 (Bruera, 1996) had withdrawal.

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Insomnia

• Common causes
• Uncontrolled pain (60 of insomnia)
• Urinary frequency (29)
• Dyspnea (13)
• Medications
• Anxiety/stress (36 of hospice patients with
  insomnia cite worry)

Percentages from Hugel et al, 2004.
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Treatment Options

• 3 types of treatment
• Treat other symptoms causing insomnia (pain,
  dyspnea, frequent urination)
• Non-pharmacologic treatment
• Medication

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Treatment (Other Symptoms)

• Pain - treat pain adequately, especially making
  sure basal rates of PCAs are sufficient so pt
  does not wake up repeatedly in pain.
• Frequent urination
• catheterize if appropriate or cut back on fluids
  at night and immediately before sleep
• Treat hyperglycemia, hypercalcemia, check kidney
  function
• Dyspnea
• Treat pre-existing conditions, i.e. OSA
• Oxygenate (NC or mask O2)
• Opioids
• Dont treat Cheyne-Stokes breathing

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Treatment (Non-Pharm)

• Check patients medications
• CNS stimulants, BBs, bronchodilators and
  corticosteroids can lead to insomnia
• Think about withdrawal (from DOAs or medications)
• Ask about alcohol, tobacco and caffeine
• The usual non-pharm methods include
• Sleep hygiene, relaxation therapy, CBT, etc.

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Treatment (Pharmacologic)

• Hypnotics
• Avoid in pregnant women, alcoholics, those with
  OSA, renal, hepatic or pulmonary disease (or be
  careful with dosing)
• Benzos (6 commonly used are temazepam,
  flurazepam, triazolam, estazolam, lorazepam and
  clonazepam)
• Other hypnotics acting on benzo receptors (3
  commonly used are zolpidem, zaleplon and
  eszopiclone)
• Antidepressants (trazadone, amitriptyline) are
  best when patient has coexistent depression.
• Antihistamines (diphenhydramine, doxylamine) have
  a long ½ life and anticholinergic side effects,
  so use with caution.

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Conclusions

• Evaluate all hospice patients for problems with
  sleep.
• Make sure you are controlling your patients pain
  adequately.
• Treat other symptoms.
• Dont overdo the hypnotics.
• If pain control does not relieve insomnia, think
  outside the box.

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References

• Chokroverty, Sudhansu, MD, 2008. Evaluation and
  Treatment of Insomnia, UpToDate.
• El Osta, Badi, MD and Bruera, Eduardo, MD, 2007.
  Overview of Symptom Control in the Terminally Ill
  Cancer Patient, UpToDate.
• Hugel, Heino, MD et al., 2004. The Prevalence,
  Key Causes and Management of Insomnia in
  Palliative Care Patients, Journal of Pain and
  Symptoms Management, 27 316-321.
• Bruera, E., MD, et al., 1996. Rapid
  Discontinuation of Hypnotics in Terminal Cancer
  Patients A Prospective Study, Annals of
  Oncology, 7 855-856.
• Von Guten, Charles F., MD, PhD, 2005.
  Interventions to Manage Symptoms at the End of
  Life, Journal of Palliative Medicine, 8 S88-S94.