This advice is sourced from Dr Ros Taylor a senior palliative physician
Q. What are your thoughts about insomnia in the final months or weeks of life?
Disturbed sleep is often a factor that tips family resilience over the edge and can lead to hospital or hospice admission.
There are so many reasons why sleep is disturbed in advanced illness. It could be medication e.g. steroids and opioids. It could be fear and anxiety that always gets worse in the dark. Some patients are worried that they may die in their sleep. Or it could simply be that the patient is moving about less and taking naps in the day. Just exploring the cause can be helpful and open up a conversation about the nightime concerns and environment.
Q. What is your first line treatment for insomnia in the final months or weeks of life?
I always ask my patients if there has been a sleep problem before and if so what has helped them in the past.
I would first try non medication strategies that improve sleep hygiene. However the threshold for prescribing hypnotics is lower than in non-palliative illness.
If medication is needed then I would normally start with a z drug such as zolpidem or zopiclone in the lowest dose, and advise not to take every night to avoid tolerance. If these don't help then my next steps would be a sedative antidepressant such as amitriptyline or mirtazapine, again in a low dose.
Melatonin is another option if it is prescribable locally. It is particularly helpful if there are diurnal rythmn disturbances or a high risk of falls.
Q. How do you assess the risks of using hypnotics for insomnia in patients who are on multiple other sedating medications e.g. opiates?
This can be a real problem if people are on several psychotropic drugs to help with pain, nausea and mood.
Adding in a hypnotic may tip the balance and there could be a risk of falls, especially at night if someone is frail. I open up a discussion about benefits vs risks with patients and their family.