Sleep Difficulties in Palliative Care Patients

Sleep disturbance is a prevalent and debilitating problem for patients with advanced, life-limiting disease that contributes to morbidity and poor quality of life, and can exacerbate patient and caregiver suffering. Screening for this symptom in routine care followed by a focused assessment and evaluation is essential given its consequences on functioning in daily life, and emotional and mental health. The causes of disrupted sleep in palliative care populations are multifactorial and include disease physiology, uncontrolled physical symptoms, adverse effects of medications, emotional distress, and psychiatric disorders. Early detection of sleep disorders for timely referral to sleep specialists is crucial to ensure appropriate treatment. Attention to management of modifiable and perpetuating factors is essential where possible for development of an individualized treatment plan that takes into consideration the nature of the sleep disturbance, patient goals, and timing in the illness trajectory and prognosis. Nonpharmacological interventions including cognitive behavioral therapy for insomnia (CBT-I), exercise, mindfulness, and relaxation therapies may improve sleep quality and severity of insomnia but may require adaptation to palliative care populations. Simple approaches such as coaching of patients in sleep hygiene behaviors may also be helpful. In advanced disease, a combination of nonpharmacological and pharmacological interventions may be necessary. Pharmacological interventions such as hypnotics should be used with caution, restricted to patients with related distress, prescribed only for short periods and in combination with behavioral approaches, and tailored to the clinical features of the sleep disturbance and disease. Close monitoring of patients treated with pharmacological agents is essential to avoid and minimize adverse effects. This chapter provides an overview of sleep disturbance, causative factors, and management of common sleep disorders of insomnia, sleep-wake cycle reversal, hypersomnia, and nightmares in palliative care.