Sleep Disturbance

Short Answer

A. Incorrect. Haloperidol would be most appropriate in a patient who has symptoms of delirium at night, or has clear day-night reversal; neither of these are present in this patient. Trazodone would be a better choice in this elderly patient.

B. Incorrect. Diphenhydramine is often effective in the short-term, but patients quickly develop tolerance. Anticholinergic side effects can also be troubling in the elderly and it can cause delirium, so this is a second-line agent. Trazodone would be a better choice.

C. Incorrect. Benzodiazepines can often worsen dementia and cause delirium in the elderly, and would not be the best choice in this patient. Trazodone has fewer side effects.

D. Incorrect. If the cause of the sleep disturbance were awakening with pain, this would be appropriate, but that is not an issue for this patient. Trazodone is the best choice for her problem

E. Correct! Trazodone is often effective and well-tolerated for difficulty falling asleep at night in elderly patients.


Long Answer

The correct answer is E. Trazodone, 25 mg po qhs

Insomnia.
When assessing the palliative care patient complaining of disordered sleep, there may be clues in the sleep pattern that will assist in diagnosing and managing the cause of sleeplessness. Insomnia is difficulty falling asleep or awakening during the night (distinguish from awakening with confusion, which is delirium [^] see below). This may be due to excessive sleeping during the day, uncontrolled symptoms such as pain or dyspnea, psychosocial or spiritual distress, anxiety, or medications such as caffeine.

Where possible, it is best to establish and maintain a regular sleep schedule, as well as a schedule of activities during the day. The patient should be out of bed while awake if possible, with some stimulation during the day. Caffeine should be reduced, and alcohol use may also interfere with sleep. Treatment of pain or other symptoms with longer-acting medications can allow a patient to not have to wake up to take medications for relief. Social work or chaplaincy intervention may be helpful; psychosocial and spiritual issues are often most bothersome in the evening.

The most common appropriate medications are benzodiazepines, trazodone, and neuroleptics. Trazodone (25 mg po qhs, can increase up to 100 as needed) is often the best tolerated in the frail and elderly. Benzodiazepines may worsen dementia and delirium in the elderly, but are often very useful in the terminally ill, especially when anxiety is a strong component. Temazepam, 15-30 mg po qhs, might be a good initial choice; lorazepam may be helpful if there is a strong anxiety component. Zolpidem, 5-10 mg po qhs, may have fewer adverse effects in the elderly. Patients often develop tolerance to diphenhydramine, and the anticholinergic side effects, such as orthostatic hypotension, can be troublesome in the ill or elderly patient, but it may be useful in some cases (25-50 mg po qhs).

Depression.
Early morning awakening may be a sign of depression, which is common in the chronically or terminally ill. Choose an antidepressant that will help with sleep as well.

Delirium.
Delirium is extremely common in the chronically and terminally ill. Day-night sleep pattern reversal is common in patients with dementia, delirium, and cirrhosis, as is sundowning and increased agitation at night. Get rid of nonessential medications, since almost anything can contribute to delirium. If the delirium is bothersome, neuroleptics may be needed, especially if there is day-night reversal or delirium or agitation at night. Haloperidol is usually the best tolerated (start at 1-2 mg po qhs).

Last update: 7/13/02; 4:36:22 PM.