Sleep Disturbance

Sleep habits can be varied and personal. People used to sleeping communally (lots of people in the room) are likely to find it difficult to sleep or rest if they are on their own. Some people are used to a long siesta after lunch. Others will have the habit of staying up until late at night. It can help if you talk with the person and their family (if appropriate) to understand what is normal for them.

Insomnia is likely to be underreported by patients and is often not routinely screened for.

Poorly controlled symptoms of pain, dyspnoea, fatigue, anxiety, or depression significantly impact sleep quality in people with advanced disease. Similarly, insomnia can increase the intensity of these symptoms and further complicate their management.

Family and/or carers may also experience sleep disturbance, and this can affect their ability to care.
Sleep disturbance is a common complaint during bereavement and you can include questions about this as part of following up the bereaved.

Assessment for sleep disturbances includes the exploration of predisposing factors including:

• unmanaged symptoms
  • pain
  • nocturia from frequent sipping of liquids to relieve a dry mouth
  • incontinence
  • nausea and vomiting
  • anxiety
  • depression

• changes in usual sleep patterns and sleep preferences
  • changed activity patterns
  • daytime naps and/or altered circadian rhythm

• emotional stressors
  • fears emerging in the quiet night hours especially related to the life-limiting illness
  • fear of not waking up in the morning or dying alone
  • bereavement
    co-existing conditions
  • night sweats
    pruritis (itch)
  • obstructive sleep apnoea

• medication.

Medications which may contribute to insomnia include beta or calcium channel blockers, antidepressants, steroids, herbal or over-the-counter medication, and stimulants (tobacco, caffeine, alcohol, or illicit drugs).
It may help to ask the doctor, nurse practitioner, or pharmacist to review the person’s medicines.

Assessment tools

The Symptom Assessment Scale (SAS) or Edmonton Symptom Assessment System (ESAS) (714kb pdf) can be used to screen for sleep disturbances and the Pittsburgh Sleep Quality Index (PSQI) to assess sleep disturbance.

Care of sleep disturbances initially includes treatment of:

• co-existing medical and psychological conditions i.e. good symptom management
• modifying sleep-hindering medications and substances
• optimising environmental factors to enhance relaxation and encourage sleep.

Nurses can assist the person with ways to promote healthy sleep patterns including:

• maintaining a routine sleep–wake cycle
• activity as tolerated with no exercise 4 hours before bedtime
• prioritising activities that are important or pleasurable and with frequent short rest breaks rather than a long rest period if appropriate
• avoiding large meals and limiting fluid intake in the evenings
• limiting caffeine, tobacco, alcohol
• bedroom for sleep and sex only
• limiting daytime napping to 20-30 minutes
• decreasing distracting stimuli close to time of sleep, such as noise, lights, computers, phone, television, extreme temperatures
• recommending relaxation practices such as mindfulness, medication, yoga, breathing techniques.

As a nurse you can advocate for appropriate referrals such as to a psychologist or counsellor to help manage emotional stressors, a psychologist for behaviour therapies, or a doctor or pharmacist for a medication review.

Pharmacological management usually includes benzodiazepines as well as Zolpidem, and Zopiclone. Pharmacological management should not be first-line treatment for sleep disturbance, and, if used, should complement non-pharmacological treatment.

This information was drawn from the following resources:

• Capezuti E, Sagha Zadeh R, Woody N, Basara A, Krieger AC. An integrative review of nonpharmacological interventions to improve sleep among adults with advanced serious illness. J Palliat Med. 2018;21(5):700-17. doi: 10.1089/jpm.2017.0152. Epub 2018 Jan 16.
• Klingman KJ, Sullivan S. Associations between sleep disorders and comfort at end-of-ife: Opportunities for improvement. Sleep Med Res. 2018;9(2):110-4. doi: 10.17241/smr.2018.00276.
• Kvale EA, Shuster JL. Sleep disturbance in supportive care of cancer: a review. J Palliat Med. 2006;9(2):437-50. doi: 10.1089/jpm.2006.9.437.
• Lancel M, Stroebe M, Eisma MC. Sleep disturbances in bereavement: A systematic review. Sleep Med Rev. 2020 Oct;53:101331. doi: 10.1016/j.smrv.2020.101331. Epub 2020 May 21.
• Nzwalo I, Aboim MA, Joaquim N, Marreiros A, Nzwalo H. Systematic review of the prevalence, predictors, and treatment of insomnia in palliative care. Am J Hosp Palliat Care. 2020 Nov;37(11):957-969. doi: 10.1177/1049909120907021. Epub 2020 Feb 26.
• Schroeder K. Insomnia. In: Ferrell BR, Paice JA, editors. Oxford textbook of palliative nursing [Internet]. 5th ed. Oxford: Oxford University Press; 2019. [cited 2022 Aug 8].
• Valero-Cantero I, Wärnberg J, Carrión-Velasco Y, Martínez-Valero FJ, Casals C, Vázquez-Sánchez MÁ. Predictors of sleep disturbances in caregivers of patients with advanced cancer receiving home palliative care: A descriptive cross-sectional study. Eur J Oncol Nurs. 2021 Apr;51:101907. doi: 10.1016/j.ejon.2021.101907. Epub 2021 Feb 5.
• Yennurajalingam S, Balachandran D, Pedraza Cardozo SL, Berg EA, Chisholm GB, Reddy A, et al. Patient-reported sleep disturbance in advanced cancer: frequency, predictors and screening performance of the Edmonton Symptom Assessment System sleep item. BMJ Support Palliat Care. 2017 Sep;7(3):274-280. doi: 10.1136/bmjspcare-2015-000847. Epub 2015 Oct 16.