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Insomnia treatment options, treatments of cancer - Review

Author: admin
Patient information: See related handout on insomnia, written by the authors of this article. In this paper, I will outline my guidelines for the recognition, treatment, and monitoring of these ill and suffering patients. In addition to insomnia, excess cerebral autonomic activity caused by intractable pain may cause mental confusion, memory loss, depression, anxiety, and fatigue. When first addressing insomnia in patients with chronic pain, it is always important to review the basics of good sleep hygiene with the patient (Table 2). Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated. An approach to the evaluation and treatment of the patient with insomnia is shown in Figure 1.
I will not discuss the usual behavioral, electromagnetic, nutritional, and over-the-counter approaches to insomnia, which are appropriate for mild to moderate forms of primary insomnia, and which are well described elsewhere.9,10 Discussed here are treatment options for patients with severe insomnia secondary to centralized, intractable pain—and who have not benefited from the usual therapies for primary insomnia.

However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. If the initial evaluation identifies an acute stressor such as grief or noise, no further evaluation is indicated and treatment can be initiated. Consequently, addressing both the patient’s chronic pain and secondary insomnia may require a complex regimen of treatments.
If the patient is on a medication that might be contributing to their insomnia, such as albuterol or theophylline, consideration should be given to adjusting the timing of administration (morning versus evening). I try to initiate treatment with an antidepressant or antihistamine accompanied by melatonin, tryptophan, or valerian.
Treatment should begin with nonpharmacologic therapy, addressing sleep hygiene issues and exercise. A more comprehensive evaluation should be pursued with nonresponders or if a comorbid condition is present or suspected.The evaluation of chronic insomnia should involve a detailed history and examination to detect any coexisting medical or psychiatric illness and may include an interview with a partner or caregiver.

Table 4 summarizes the FDA-approved medications, as well as other prescription products, which have evidence for use in managing insomnia. Despite the use of a potent treatment agent(s), the length of sleep is woefully short in some patients.
Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena.

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