INSOMNIA IN HOSPICE
Background
A lack of restful sleep contributes to poor health, and the advent of other chronic conditions including cardiovascular diseases, mood disorders, depression, and a weakened immune system. There are several sleep disorders in existence but insomnia is the most prevalent among our hospice patients. Insomnia is characterized by difficulty falling asleep (sleep initiation or sleep latency), reduced sleep duration, and poor sleep quality. Insomnia in hospice patients may lead to daytime impairment, fatigue, and sometimes agitation that may easily be misinterpreted if the underlying cause of the agitation is not known.
Causes:
Underlying diseases such as depression, anxiety, bipolar disorder, alcoholism, restless leg syndrome, gastric ulcers, chronic and acute pain, shortness of breath, and many others.
Diagnosis:
Diagnosis of insomnia occurs when a patient has symptoms of insomnia at least three days a week for at least three months, despite adequate opportunity to sleep.
Non-Drug Treatment:
Cognitive-behavioral therapy is the preferred non-drug therapy, and this includes changes to sleep hygiene that can reduce the need for drugs.
It is also important to address the underlying medical condition that may be causing the patient to develop difficulty falling asleep.
Deprescribing medications such as Alcohol, Bupropion, Caffeine, Theophylline, Decongestants (e.g pseudoephedrine), Diuretics (causes nocturia), Fluoxetine (if taken late in the day), Steroids, Stimulants (e.g methylphenidate, phentermine), and varenicline, that can worsen insomnia, is also a good non-drug treatment approach to managing insomnia in patients in hospice.
Proper sleep hygiene:
Keep bedroom dark, comfortable and quiet.
Keep regular sleep schedule.
Avoid daytime naps, even after a poor night of sleep or limit to 30 minutes.
Reserve the bedroom for sleep and other appropriate activities (No TV and other stimulants)
Turn the face of the clock away to minimize anxiety about awake times.
If unable to sleep, get up and do something else to take your mind away from sleeping, then try again.
Establish a pre-bedtime ritual to condition your body and mind to sleep at a given time, such as relaxing with soft music, mild stretching, yoga, pleasurable reading.
Avoid exercising right before bedtime.
Do not eat heavy meals 2 hours before bedtime.
Do not take any caffeine after 4pm.
Natural products used to manage insomnia:
Melatonin and valerian have been used by some patients. Melatonin is metabolized by the enzyme CYP1A2. Prolonged effects of melatonin are seen when CYP1A2 inhibitors such as ciprofloxacin, fluvoxamine, are used. Valerian is considered to have fewer adverse effects, but there have been isolated reports of liver toxicity with an unclear significance. Some patients have also felt calmer and eventually fallen asleep after drinking Chamomile.
Drug treatment.
If non-drug treatments do not help, Sedative hypnotics are the mainstay for addressing insomnia but they produce adverse effects even when occasionally used. Non-benzodiazepines are preferred over benzodiazepines because they are associated with less physical dependence and less daytime cognitive effects. Select Non-benzodiazepines based on the actual sleeping problem.
1. Non-benzodiazepines:
Tip: Eszopiclone and Zolpidem (Ambien) appear in all three groups.
Side effects:
CNS depression
Potential for abuse and dependence (probable withdrawal symptoms if used longer than 14 days).
Somnolence
Dizziness
Ataxia
2. Benzodiazepines:
They enhance GABA, inhibitory neurotransmitter. They are used second line if Non-benzodiapines do not achieved their desired effects. Most effective and safe in hospice patients are:
L-O-T. Lorazepam, Oxazepam, and Temazepam.
For insomnia, Lorazepam and Temazepam can be used for sleep, while Oxazepam is used for anxiety in hospice patients.
Caution: Lorazepam can cause paradoxical effects when used more frequent than 4 times a day, especially in patients with concomitant anxiety. The recommended frequency of lorazepam Is every 4 hours, with a maximum daily dose of 16mg.
Caution: Risk of CNS depression and death when used together with opioids, and risk increases drastically when in combination with opioids and other muscle relaxers.
3. Antihistamines: Diphenhidramine and Doxylamine.
Periferal anticholinergic side effects.
Urinary retention
Best to avoid in hospice patients with BPH and glaucoma
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Fidelis Ariguzo, Pharm, D.
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Reference:
Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of sleep medicine clinical practice guideline. J Clin sleep Med. 2017; 13(2): 307-349