___________________________________________ Palliative Care and Pain Management at the End of Life
In addition, many psychological conditions associated with a life-limiting disease can cause insomnia; depression, anxiety, delirium, spiritual distress, and grief can make it difficult to fall or remain asleep [366]. Insomnia is a side effect of many drugs, most notably corticosteroids, antidepressants, deconges- tants, opioids, and some antiemetics [310; 365; 370]. Patients also may have difficulty sleeping because of disruptions in the normal sleep-wake cycle that result from inactivity and napping during the day. Lastly, stimulants, such as caffeine, and alcohol may keep patients from falling asleep easily. Prevention Adequate relief of pain and other symptoms is the mainstay of preventing insomnia. The most effective preventive measure is limiting the amount of time in bed during the day and restrict- ing the amount of daytime sleep [366]. Encouraging patients to increase activity during the day, as tolerated; to adhere to a regular schedule with limited naps; and to avoid caffeine and alcohol in the afternoon and evening can help lead to more healthy sleep patterns. Assessment Few patients with life-limiting diseases report insomnia, and few clinicians pursue sleep symptoms in their patients [366]. Clinicians should obtain a sleep history from all patients, following guidelines developed by the American Academy of Sleep ( Table 18 ) [365]. The Epworth Sleepiness Scale has been recommended as an assessment tool [310; 371].
Clinicians should evaluate patients physically as well as psy- chologically for signs and symptoms that have been identified as contributors to sleep disturbances. Management The American Academy of Sleep has developed an evidence- based guideline for the evaluation and management of chronic insomnia in adults and a practice parameter for the psycho- logical and behavioral treatment of insomnia, but neither offers specific guidelines for managing insomnia at the end of life [365; 372]. Nonpharmacologic interventions should be implemented first, with pharmacologic therapy added to the treatment plan if these interventions are not effective [366]. Optimizing sleep habits can be useful, especially if they are begun early in the course of the disease. The nonpharmacologic approaches used to prevent insomnia are also the primary management strategies. Among the rec- ommended behavioral strategies are the following [365; 372]: • Stimulus control therapy: Training the patient to reassociate the bed and bedroom with sleep and to re- establish a consistent sleep-wake cycle • Relaxation training: Progressive muscle relaxation and reducing thoughts that interfere with sleep • Sleep restriction: Limiting the time spent in bed to time spent sleeping
QUESTIONS TO OBTAIN A SLEEP HISTORY What is your primary problem with sleep: difficulty falling asleep, waking up frequently during the night, and/or poor quality of sleep? When did your sleep problems begin? How often do you have trouble sleeping (every night, most nights)? Have you ever taken any medication for sleep problems in the past? If so, what did and did not help?
What do you do before you go to bed? What is your bedroom environment like? How do you feel (physically and emotionally) in the evening? What is your average sleep-wake schedule?
How long does it typically take you to fall asleep? What factors make it longer for you to fall asleep? What factors shorten your sleep? How often do you awaken during the night?
When you awaken during the night, how long are you awake? Do you have symptoms that cause you to awaken during the night? What do you do to try to fall back asleep after awakening during the night? How many hours do you sleep each night (on average)? Do you nap during the day? If so, how often and for how long? Do you feel sleepy during the day? How do your sleep problems affect you during the day? Do you have mood disturbances? Feel confused? Feel like your symptoms are worse? Source: [365] Table 18
47
MDCA1525
Powered by FlippingBook