Abstract
Introduction
Nonspecific Treatments
I. Improving Sleep Hygiene
Sleep hygiene education should be provided to anyone with insomnia. First, there is no arbitrary rule for how much someone should sleep. Generally, older patients need less sleep. Second, patients should be advised to keep a regular sleep schedule; this means going to bed and getting up at the same time. Third, patients should avoid long daytime naps, alcohol, and caffeine. These principles may be difficult for seriously ill patients, particularly maintaining a regular routine for hospitalized patients and avoiding naps for fatigued, seriously ill patients.
II. Behavioral Treatments
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The last two therapies are the only evidence-based psychological treatments for insomnia in older adults.
III. Physical Exercises
Although the data is limited, studies in elderly patients suggest significantly improved sleep duration and onset latency and minimal enhancement in sleep efficiency with community-based endurance training programs such as low-impact aerobics, brisk walking, and Tai Chi Chih.
Choosing which therapy to use first depends mainly on provider experience and patient motivation. It is difficult to know how long nonpharmacologic therapy should be tried before attempting other measures. This depends on the patient
Specific Treatments
Obstructive sleep apnea is treated with bi-level positive airway pressure (BiPAP) ventilation at night. Although some patients report difficulty becoming accustomed to sleeping with the BiPAP mask on, this therapy can dramatically improve symptoms. Surgery is sometimes indicated for obstructive sleep apnea. Symptoms from an underlying medical disorder can also contribute to insomnia. Adequately treating a patient's pain, nausea, and vomiting (see Fast Fact #5), or dyspnea (see Fast Fact #27) should improve sleep.
Spiritual and existential concerns can be an important cause of insomnia in palliative care patients. Patients may be able to avoid these 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. Brief psychotherapy may be helpful.