{Want of Sleep

Kyle P. Edmonds, MDFellow, Institute for Palliative MedicineSan Diego Hospice

Sleep and his half-brother

Circadian Rhythm

Getting to sleep

Absence of distress Circadian timing (time of the day)

Sleep drive (time since last slept)

Physical comfort Environment Intact CNS function

Hanks et al. (2010).

Hypnogram

Age Sleep Needs (Hours)

0-2 Mos 12-18 hours3-11 Mos 14-15 hours1-3 Yrs 12-14 hours3-5 Yrs 11-13 hours5-10 Yrs 10-11 hours10-17 Yrs 8-9 hours

Adults (inc seniors) 7-9 hours

Average Sleep NeedsAdapted from Carol (2011).

Why? Who knows?

Biological recovery Enhanced immune function Regulation of circadian hormones

Memory consolidation

Hanks et al. (2010).

Diagnostic Category Representative DiagnosesInsomnia Primary, Secondary

Sleep-related breathing d/o

OSA, CSA

Hypersomnolence Narcolepsy

Circadian rhythm disorder

Shift work

Movement disorder RLS

Parasomnia Night terror; REM sleep behavior

Isolated symptoms Primary snoring; Sleep talking

Disordered SleepAdapted from Table 10.12.1. Hanks et al. (2010).

By the Numbers

General population1 9-12%

Healthy seniors1 12-25%Hospital

population2 23%Chronic lung

disease3 50%

Cancer2 70%

HIV/AIDS3 75%

Hemodialysis3 77%

Depression3 90%

(1) Bastien et al. (2003). (2) Miller & Arnold (2011).(3) Hanks et al. (2010)

Etiology

Psycho-physiologi

c Hyperarou

sal

Increased metabolic

rate

Activated HPA axis

Increased autonomic

nervous system Increased

sleep EEG frequency

Increased cerebral

blood flow

Hanks et al. (2010).

Sleep History: Epworth

SituationSitting and reading

Watching TV

Sitting inactive in a public place (e.g. theater or a meeting)

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a care, while stopped for a few minutes in traffic

Miller & Arnold (2011).

Hygiene Chronology Environment Physical Symptoms

Medical Conditions

Spiritual ConcernsSleep History

Miller & Arnold (2011).

Sleep History: Chronology

PersistentMedical,

neurologic or psychiatric

Difficulty staying asleep

Nightmares, OSA

Frequent awakening Medications

Early morning

awakeningDepression

Day-night reversal Delirium

Miller & Arnold (2011).

Sleep History: Symptoms

Hugel et al. (2004).

Sleep History: AnxietyHugel et al. (2004).

• Symptom control38%

• Address worry21%

• Combination of measures19%

• Don’t know13%

• Sleep medications4%

Sleep History: Survey

What do you

think would

help you

sleep?

Hugel et al. (2004).

Patient/Family Characteristic

s

Disease Mgmt

Physical issues

Psych & cognitive issues

Social issues

Spiritual issues

Practical issues

End-of-life/

death mgmt

Loss, grief

Adapted from EPEC-O. (2007)

Non-Pharm Therapies

Relaxation therapies Sleep restriction therapy Stimulus control therapy Cognitive behavioral therapy

BiPAP Palatoplasty

Miller & Arnold (2011).

Hanks et al. (2010).

“Patients may be able to avoid [spiritual] concerns during the day

through the distraction of daily activities but have difficulty

ignoring them at night. Thus, it is important to directly address a

patient’s spiritual concerns, worries, and fears about dying

during the day.”

Non-Pharm TherapiesMiller & Arnold (2011).

Pharmaceuticals

Consider stopping: Steroids Stimulant antidepressants

Bronchodilators Diuretics

PharmaceuticalsSanna & Brurera (2002).

Pharmaceuticals: Bzds

Increase stage 2 (N2) Decrease stages 3 and 4 (N3)

Interfere with slow-wave sleep

Bastien et al. (2003).

Pharmaceuticals

Pharmaceuticals

Medication

Dosage

Half-life

Tmax

Metabolites Comments

Other benzodiazepine receptor agonists

Zolpidem 5 1.5-4 1-1.5 NoAmbien®;

imidazopyridine 

Zaleplon 5 1 0.5-1 No  Sonata®; pyrazolopyrimidine

Eszopiclone 2 5-7 0.5-2 Minimal  Lunesta®;

cyclopyrrolone

Melatonin agonists

Ramelteon 8 1-2 0.5-1 NoRozerem®; Not a

controlled substance

Adapted from Table 10.12.7, Hanks et al. (2010).

Studied only in depressed insomniacs

25-100mg may improve sleep*

Biphasic half-life (3-6h, 5-9h)

Pharmaceuticals: Trazodone

Proven phase-shifting capability

Mixed evidence for benefit in elderly

Poorly-regulated formulations

Pharmaceuticals: Melatonin

Pharmaceuticals: Seniors

Sedative-hypnotics Falls Hip fracture Cognitive

impairment

Preferred Zolpidem (Ambien) Eszopiclone

(Lunesta) Ramelteon

(Rozerem)

Hanks et al. (2010).

Great source of oracles to human kind,

when stealing soft, and whispering to the mind,

through sleep’s sweet silence, and the gloom of night,

thy power awakes the intellectual sight;

to silent souls the will of heaven relates, and silently reveals their

future fates.Orphic Hymn 86 to the Oneiroi

Sleep and it’s disturbance are physiologically complex

Begin with a thorough history and sleep hygiene counseling

Pharmaceuticals are only one treatment, even in palliative care

In summary

Bastien CH et al. (2003). Sleep EEG power spectra, insomnia and chronic use of benzodiazepines. Sleep. 26(3): 313-317.

Carol E (2011). "How Much Sleep Do We Really Need?". National Sleep Foundation. Undated. http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need. Retrieved 2012-09-18.

Davidson JR, MacLean AW, Brundage MD & K Schulze (2002). Sleep disturbance in cancer patients. Soc Sci Med. 54: 1309-1321.

EPEC-O (2007). Module 1: Comprehensive Assessment. Hanks G et al., Ed. (2010). Oxford Textbook of Palliative Medicine:

Sleep in palliative care. New York, NY. 1059-1083. Hugel H, et al. (2004). The prevalance, key causes and management of

insomnia in palliative care patients. J Pall Symp Mgmt. 27(4): 316-321. Maslow A (1954). Motivation and Personality. New York: Harper. Pp

236. Miller M & R Arnold (2011). Fast Facts and Conceps #101, 104, 105.

Insomnia: Patient assessment, Non-parmacologic treatments & Phamacological Therapies. EPERC.

Sanna P & E Brurera (2002). Insomnia and sleep disturbances. Eur J Pall Care. 9(1): 8-12.

References