The Patient With Pain
Since enhanced pain control improves sleep, appropriate analgesics or nonpharmacologic pain management should be administered before introducing sleep medications. Tricyclic antidepressants can be particularly useful for the treatment of insomnia in patients with neuropathic pain and depression. Patients on high-dose opioids for pain may be at increased risk for the development of delirium and organic mental disorders. Such patients may benefit from the use of low-dose neuroleptics as sleep agents (e.g., haloperidol 0.5–1.0 mg).The Older Patient
Older patients frequently have insomnia due to age-related changes in sleep. The sleep cycle in this population is characterized by lighter sleep, more frequent awakenings, and less total sleep time. Anxiety, depression, loss of social support, and a diagnosis of cancer are contributory factors in sleep disturbances in older patients.
Sleep problems in older adults are so common that nearly half of all hypnotic prescriptions written are for persons older than 65 years. Although normal aging affects sleep, the clinician should evaluate the many factors that cause insomnia, such as medical illness, psychiatric illness, dementia, alcohol and/or polypharmacy, restless legs syndrome, periodic leg movements, and sleep apnea syndrome. Nonpharmacologic treatment of sleep disorders is the preferred initial management, with the use of medication when indicated and referral to a sleep disorder center when specialized care is necessary.
Providing a regular schedule of meals, discouraging daytime naps, and encouraging physical activity may improve sleep. Hypnotic prescriptions for older patients must be adjusted for variations in metabolism, increased fat stores, and increased sensitivity. Dosages should be reduced by 30% to 50%. Problems associated with drug accumulation (especially flurazepam) must be weighed against the risks of more severe withdrawal or rebound effects associated with short-acting benzodiazepines. An alternate drug for older patients is chloral hydrate.Somnolence Syndrome in Children
Cranial irradiation and intrathecal methotrexate are used to prevent the development of central nervous system leukemia in children with acute lymphocytic leukemia. Somnolence syndrome (SS) is a complication of cranial irradiation occurring in 30% to 50% of patients who receive more than 18 Gy at daily dose fractions of 1.5 Gy to 2 Gy. The syndrome may appear 4 to 6 weeks posttherapy. SS is characterized by mild drowsiness to moderate lethargy and, occasionally, low-grade fever. The pathophysiology is unknown, but electroencephalogram and cerebral spinal fluid abnormalities are detectable in affected children. Although supportive care measures cannot prevent the occurrence of SS, acknowledgment of the existence of this problem may prevent or minimize anxieties for children and parents when symptoms of SS appear.Sleep Apnea Following Mandibulectomy
Anterior mandibulectomy can result in the development of sleep apnea. All patients with head and neck tumors who have had extensive anterior oral cavity resection should be evaluated before decannulation of the tracheostomy tube. Subsequent flap and/or reconstruction of the lower jaw seems to prevent the development of sleep apnea. In contrast, facial sling suspension of the lower lip does not prevent the development of sleep apnea. Assessment for symptoms and preparation for the appearance of symptoms in this population provide indications for interventions related to sleep apnea.References
- Berlin RM: Management of insomnia in hospitalized patients. Ann Intern Med 100 (3): 398-404, 1984. [PUBMED Abstract]
- Johnston JE: Sleep problems in the elderly. J Am Acad Nurse Pract 6 (4): 161-6, 1994. [PUBMED Abstract]
- Panje WR, Holmes DK: Mandibulectomy without reconstruction can cause sleep apnea. Laryngoscope 94 (12 Pt 1): 1591-4, 1984. [PUBMED Abstract]