Insomnia in Hospice and Palliative Care
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Transcript of Insomnia in Hospice and Palliative Care
Disturbed Sleep & Counting Sheep in Hospice and
Palliative MedicineAndi Chatburn, DO, MA
Fellow, University of Kansas SOM and Kansas City Hospice & Palliative Care
February 27. 2014
Emma Jane Hogbin/CC
wittecarlosanto/CC
Goals & ObjectivesReview normal sleep physiology and architectureRecognize types, causes and effects of insomniaApply diagnosis and treatment of insomnia to patients with serious illnessDiscuss general and disease specific treatment options for insomnia
Team-severus/CC
Normal Sleep PhysiologyBased on a 24.2h circadian rhythmLight-dark cycleDuration: avg. 7-8 hours per nightStructure: Onset NREM + REM Wakefulness
Peplow, M.
Stages of Sleep
Peplow, M.
Peplow, M.
Neurotransmitters Sleep onset: Serotonin and MelatoninWakefulness: Histamine, acetylcholine, dopamine, noradrenalineMelatonin, prostaglandin D2, IL-1: sleep and immune function
Neurotransmitters and Sleep
Peplow, M.
Peplow, M.
Functions of SleepRestorative/RecoveryMediating factor in pain regulationMediator of immune function
Factors needed for normal restorative sleep
TimingSleep DriveEnvironmentPhysical comfort/absence of symptomsIntact CNS functionAbsence of psychological distress
So What is Insomnia?Defined by patientUnsatisfactory sleep affecting daytime functioningInadequate/not enough/too muchMost frequent health complaint Leads to impaired daytime functioning, poor moodMay exacerbate medical or psychiatric conditions
InsomniaDisturbances:
Sleep ONSET (latency)Sleep MAINTENANCE (efficiency)Duration of sleep (OFFSET) NON-RESTORATIVE
InsomniaTransient: lasting one to several nights
Ex: Jet lagAcute/Short-term:
lasts few days to 3 weeksChronic/Long-term:
lasts for months to years, often waxes and wanes
Categories of Sleep Disorders
Diagnostic Category Common Diagnoses
Insomnia Primary insomnia, secondary insomnia due to mental disorder
Sleep related breathing disorders
Obstructive and central sleep apnea; hypoventilation/hypoxia syndromes
Hypersomnolence Narcolepsy; idiopathic hypersomnolenceCircadian rhythm disorders Delayed or advanced sleep phase; shift
work; irregular sleep-wake rhythm
Movement Disorders Restless Leg Syndrome; periodic limb movement
Parasomnias Night terrors, sleep walking, REM sleep behavior disorder
Other Environmental sleep disorder
Quantifying: Epworth Sleepiness Score
How often are you likely to fall asleep in the following situations, in contrast to feeling “just tired”?0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Epworth Sleepiness Activities
Sitting and readingWatching TVSitting, inactive in a public place (theatre, meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoonSitting and talking to someoneSitting quietly after lunch without alcoholIn a car, while stopped for a few minutes in traffic
Environmental Sleep Disturbances
NoiseLightCo-sleeper/neighbor moaning, crying, snoring, movingFrequent interruptions: ex: vital signs, labs, glucose monitoringHeat/coldShift work and time zone changesMedications
Medications & Sleep Disturbances
Steroids (decreased REM)CNS stimulantsMethylxanthine bronchodilatorsMAO-I, fluoxetine, BuproprionAntihypertensives: methyldopa, propranololEtOHSelegiline, pramipexole, amantadine- can cause nightmares
Symptoms and Conditions Causing Distressed SleepPain: joint, wound, edema, nocturnal headachesNausea, Vomiting, Diarrhea, GERDDyspnea, Respiratory distressFever or hot flushesMovement disorders & neuropathyNocturiaItchingHyperarousal due to sleep deprivation itself
Psychosocial Symptoms Causing Disturbed SleepAnxietyDepressionCognitive impairment
Medication, metabolic, CNS disease, delirium
BehaviorExcessive time in bed, napping, irregular sleep/wake times. Daytime sleeping as a coping mechanism
Affects of Disturbed Sleep
Decreased quality of lifeFamily disruptions“compliance” with treatmentMoodImmune systemPain intensity
Categories of Disturbed Sleep
Unwanted Excessive Sleepiness: HypersomnolenceCan prevent patient and family from visiting with loved onesCentral sleep apnea: methadone
Disorders of Circadian Rhythm
Delayed Sleep Phase DisorderAdvanced Sleep Phase DisorderNon-24 hour sleep-wake disorder
Delayed Sleep Phase Disorder
Sleep onset and wake times much later than desiredTreatment:
Bright-Light (10K lumens) phototherapy in the morning hoursMelatonin administration in evening hours
Advanced Sleep Phase Disorder
Common in elderly patientsReport they can’t sleep past 5AMExcessive early evening sleepiness, even in social settingsOne family: Autosomal Dominant ASPD due to missence mutation in a circadian clock component PER2Bright-light photo therapy during the evening hours
Non-24h Sleep-Wake Disorder
Endogenous circadian rhythm out of sync with local environments- much longer than 24h“Days and nights reversed”Commonly blind individuals unable to perceive lightNightly low-dose melatonin (0.5mg) can synchronize circadian pacemaker
Sleep log: finding the cause
What’s keeping you awake when you want to be sleeping?What’s waking you up in the middle of sleep?What’s keeping you from falling back asleep?What’s getting you up so early in the morning?Review medication list!
Disease Specific Categories of
Disturbed Sleep
Disease specific Categories of Disturbed Sleep
ParasomniasRestless Leg SyndromeParkinsons ALSFibromyalgiaObstructive Sleep Apnea & Obesity Hypoventilation Syndrome
Parasomnias (NREM)Sleepwalking (Somnambulism, NREM 3-4)Sleep Terrors (NREM 3-4): autonomic arousalSleep Bruxism: dental guardSleep Enuresis (after age 6)Sleep-related eating disorderNocturnal leg cramps
Restless Leg SyndromeAlso: Periodic Limb Movements in Sleep (PLMS)Low ferritin (<40ng/mL): treat with iron supplementationMedical Tx:
Dopamine agonistGabapentinClonazepamOpioids
Sleep in ParkinsonsREM Sleep Behavior Disorder (RBD)Male > FemaleAgitated or violent behavior during sleepInjury to bed partner commonVivid unpleasant dream imagery“Seizure activity” absent on EEGTreatment: Clonazepam (0.5-1mg QHS)
Sleep in ParkinsonsNocturnal AkinesiaFrequent nighttime awakenings due to tremorRestless Leg SyndromesTreatment: supplemental nighttime doses of carbidopa/levodopaNighttime Urinary Urgency
Sleep in ALSChronic Nocturnal HypoventilationTreatment:
Non-Invasive Ventilation (CPAP/BiPAP) 4 hours a day, typically when sleeping
Sleep in FibromyalgiaDisruption of NREM stage 4 and repeated alpha wave intrusions
Also seen in healthy individuals with emotional distress or joint pain due to arthritis
Low levels of serotonin in CSFTheory: sleep disturbance a factor in causing fibromyalgia and pain of fibromyalgia keeps making it worse
Obstructive Sleep Apnea/Hypopnea Syndrome
Symptoms of excessive daytime sleepinessAND:
sleep breathing pauses lasting >10 sec Hypopneas >10 sec (breathing continues but ventilation reduced by >50%)Constant repetitive awakenings to open airway
Obstructive Sleep Apnea/Hypopnea Syndrome
Increased in: Obesity (>50% have BMI >30)Short Mandible/MaxillaMales, most middle age 40-65
Associated with:Tonsillar hypertrophy of AIDSPierre Robin SequenceHypothyroidismAcromegalyMyotonic dystrophyEhlers Danlos Syndrome
Sleep in Cancer/AIDSSleep deprivation altered immune function sleep deprivationImmune activation stimulates NREM stage 3 sleepNREM Stage 3 Sleep enhances immune function
Sleep in ESRDRLS and PLMS commonSleep apnea commonInsomnia caused by pain pain caused by insomnia
Sleep in ESRDCohort Study:
53% of pre-dialysis patients reported poor sleep 77% of dialysis patients had subclinical or clinical sleep disordersLab derangements not correlated with sleep quality
Sleep disturbance in Family Care Givers
Sleep disturbance common in caregiversDisruptions due to caring for loved one leads to fatigue and contributes to hopelessnessGrief, anxiety and depression are common95% of cancer caregivers report severe sleep problems
Interventions for Disturbed Sleep
Treatment for Disturbed Sleep
Treat underlying conditionTreat pain
Kinsman et al: “Pain relief is the most effective intervention for improving sleep maintenance”
Non-Pharmacologic InterventionsPharmacologic Interventions
Non-Pharmacologic Interventions
Sleep hygieneSleep log reviewMindfulness meditationCognitive Behavioral TherapyBiofeedbackProgressive muscle relaxationSleep restrictionHypnosis
Sleep HygieneTiming: same bed and wake timeAvoid nappingExercise dailyEnvironment: temperature 60-67 *F, quiet, darkComfortable mattress and pillows Avoid EtOH, cigarettes, caffeine, and heavy meals in the eveningWind down for 1 hour prior to sleepIf you can’t sleep, get up and do somethingKeep bedroom for sleep and intimacy only
Sleep Hygiene adapted for Palliative patients
Bedridden patients: provide cognitive and physical stimulation during daytime hours Nap only when absolutely necessary and avoid late afternoon/evening napsStay socially activeIdentify problems and concerns of the day before trying to sleep (problem solve while the sun shines)Avoid stimulating medication doses in the eveningMaintain adequate pain relief through the night with long acting analgesics
Pharmacologic interventions
“Z drugs”- non-benzodiazepine sedativesMelatonin AgonistsTricyclic & Tetracyclic AntidepressantsAntipsychoticsAnticholinergicsDopamine AgonistsStimulants (for hypersomnolence)Misc. Medications related to sleep
Non-Benzo GABA Agonists
“Z drugs”“Non-Benzo”- wolf in sheep’s clothing?Zolpidem (Ambien, Edular, Intermezzo, Zolpimist)Esxopiclone (Lunesta)Zaleplon (Sonata)
Benzodiazepines: Short, Mid and Long Acting
Short Acting:Alprazolam, Triazolam, Midazolam
Mid-Acting:Lorazepam, Temazepam (Restoril)
Long Acting: Chlordiazepoxide (Librium), Clonazepam, Diazepam
Melatonin AgonistsOTC MelatoninRamelteon (Rozerem): binds to melatonin MT1 and MT2 receptorsVery short acting, best for sleep latency/onset disorders
Tricyclic AntidepressantsInhibits norepi and serotonin reuptakeUsed for anticholinergic effectDespite widespread use for insomnia, evidence for efficacy in insomnia is limitedEx: Amitriptyline, Imipramine, Nortriptyline, Desipramine, Doxepin
“Tetracyclic” Antidepressants
Trazodone (Desyrel)- Serotonin reuptake inhibitor, blocks alpha-1 adrenergic & serotonin 5-HT2A receptorsMirtazapine (Remeron)- blocks alpha-2 adrenergic and serotonin 5-HT2 receptorsStudies re: sleep when used as an adjunct with another antidepressant medication
Antipsychotics (Dopamine Antagonists)
Prochlorperazine (Compazine)Haloperidol (Haldol)Chorpromazine (Thorazine)Olanzapine (Zyprexa)Risperidone (Risperdal)Quetiapine (Seroquel)
Dopamine Agonists: RLS and Sleep in Parkinson
Carbidopa/LevodopaBromocriptine (Parlodel)Pramipexole (Mirapex)Ropinirole (Requip)Rotigotine (Neupro)- transdermalGabapentin for PLMS in RLS
StimulantsMethylphenidate (Ritalin, Concerta, Daytrana, Metadate)Dextroamphetamine (Adderall, Dexedrine)Modafinil (Provigil) and Armodafinil (Nuvigil): narcolepsy, OSAHS, Shift Work Sleep Disorder, MS related fatigue
OthersPrazosin (Minipress)- nightmares related to PTSDSildenafil – jet lag
SummaryInsomnia is defined by the patientBehavioral interventions: sleep hygiene Pain makes Insomnia WorseInsomnia Makes Pain Worse
SourcesPeplow, M. Structure: The anatomy of sleep. Nature . 497, S2-S3, May 2013. Czeisler, Einkelman, Richardson. Sleep Disorders. Harrison’s Principles of Internal Medicine, 17th ed. 171-180Sateia and Byock. Sleep in Palliatinve Care. Oxford Textbook of Palliative Medicine, 4th ed. 1059-1083.National Sleep Foundation. Sleepfoundation.org. Accessed 2/2/14.