Sleep – Beyond Benzodiazepines

About the Author: Dr. Rajashree is an Assistant Professor at the Department of Pain and Palliative Medicine, Amrita Institute of Medical Sciences, Kochi. She is also a Faculty at the Institute of Palliative Care, Thrissur, and at the Trivandrum Institute of Palliative Sciences, Thiruvananthapuram.




What do we compromise on if we are too close to a deadline?

Food? …definitely Not!

Fun? …Not at all!!

Sleep? …Yeah, I can sleep later!!!

This is what most of us say and do. However, have you ever thought that sleep is one of the dearest things to all of us? Having a sound sleep without queries and worries is ‘dream’ for many and several are dependent on medications to get that!

Why do we need sleep?

Sleep is an active physiological process necessary for life. It normally occupies one-third of our lives, and plays a fundamental role in ones’ physical, mental, and emotional health. The sleep patterns and needs are influenced by a complex interplay between one’s chronological age, and one’s genetic, behavioural, environmental, and social factors.

Sleep deprivation is associated with an increased risk of adverse health outcomes. It causes excessive daytime sleepiness and also impaired cognitive and safety-related performance. Sleep deprivation may also result in the deregulation of immune responses with increased pro-inflammatory signalling and also act as a risk factor for the onset and worsening of an infection, as well as inflammation-related chronic diseases. Sleep profoundly affects the endocrine and metabolic pathways too.Needless to say, sleep deprivation adds to the burden of disease in patient with serious and long term illnesses. It is also a strong predictor of the development of psychiatric disorders.

The most common form of sleep disruption is insomnia. Insomnia is defined as ‘a persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep, and results in some form of daytime impairment’.

Sleep and quality of life in palliative care patients

The importance of having a good and sleep cannot be emphasised more, in palliative care. Patients suffering with cancer and other life limiting illnesses often suffer from Insomnia and poor sleep quality, which interferes with their coping ability, symptoms, and treatment outcomes.

Sleep disorders are often under-diagnosed in cancer patients. The significant psychological impact of the disease, the chemotherapy, and medications such as corticosteroids have all been reported as potential contributors. A study reports that Indian cancer patients suffer from short sleep duration and poor quality of sleep, with a higher prevalence of sleep disturbances seen among female cancer patients. Other significant factors contributing to the extent of sleep difficulties may relate to the clinical features of the cancers (type, stage, and location of the cancer and metastasis), and the Eastern Cooperative Oncology Group (ECOG) functional capacity score. For example, lung cancer patients had higher prevalence of sleep related problems when compared to breast cancer patients.

Can we assess sleep?

There is inadequate research on quality of sleep in cancer patients. However, there are numerous approaches to measure sleep. The Pittsburgh Sleep Quality Index (PSQI) is a self-reported questionnaire, which is commonly used to assess the quality of sleep.

How can we help patients having sleep deprivation?

A) Sleep hygiene measures:

  • Educate the family that the normal sleep duration is 6 to 10 hours per night and that it may include 1–2 awakenings per night
  • Ensure good symptom control – physical, psycho social and spiritual
  • Ensure that the mattress is comfortable for the person
  • Establish a ‘buffer zone’ before going to bed – lights should be dimmed, stimulants should be avoided
  • Minimise ambient light and noise; consider using eye masks and earplugs
  • Restrict napping, avoid multiple naps, and naps in the evening. A short nap in the afternoon ‘may’ be helpful, for about 30 minutes, before 3 or 4 p.m.
  • Bed-bound patients require as much cognitive or physical stimulation as possible during the day to have a good’s night sleep
  • Wake up at the same time each day (irrespective of sleep duration), except in poorly controlled symptoms where night sleep can be compromised
  • Ensure exposure to natural or artificial light after awakening by pulling out the curtains or switching on the lights

B) Recommendations on use of pharmacological interventions for sleep disturbance:

  • Medications should be restricted to patients with distressing sleep disturbance and must be tried along with other sleep hygiene measures
  • The choice of medication depends on a variety of factors, including patient-related factors (age, co-morbidities), clinical features (sleep pattern, associated symptoms) and drug related factors (duration of action, side effect profile)
  • Medications should be prescribed for only short periods (generally 1 week with a maximum of 3 weeks)
  • Patients with difficulty to initiate sleep and in whom daytime sedation is undesirable, should be prescribed drugs with a short duration of action – zopiclone
  • Patients with difficulty in maintaining sleep and in whom daytime sedation is acceptable should be prescribed drugs with a long duration of action – nitrazepam
  • Melatonin is an alternative for patients with trouble in initiating sleep
  • Benzodiazepines and the Z-drugs (zopiclone, zolpidem) should be avoided in the elderly due to potential side effects-confusion, falls. They should also be used with caution in patients receiving opioid analgesics due to potential side effects of sedation and respiratory depression
  • Benzodiazepines and the Z-drugs cause physical and psychological dependence, and are associated with clinically significant withdrawal reactions which can occur up to 3 weeks later.

Patients receiving palliative care may vary in terms of their functional status and also depending upon the stage of their disease trajectory in a chronic illness. The approach and treatment to insomnia in such patients should therefore be individualized with careful attention being paid to the patient’s goals.

So, let’s make others sleep well in the night for a vibrant day!

Tail piece: I finished this article at 2 am, which is 3 hours later than my usual sleeping time! Oh, I feel sleepy!!


This article is a republication from the April edition of the Indian Association of Palliative Care‘s newsletter.

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