Hospice symptom management
Hospice insomnia management
Insomnia in hospice is rarely a primary problem — it is a symptom of something else: uncontrolled pain, dyspnea, anxiety, depression, delirium, or medication side effects. Effective hospice insomnia management starts with identifying what is keeping the patient awake and treating that first.
Educational content only. Individual clinicians must confirm current dosing and drug availability against their hospice medical director and current formulary. This is not a substitute for your hospice’s policies or your medical director’s clinical judgment.
Quick framework
- Assess for reversible triggers: pain, dyspnea, anxiety, depression, delirium, restless legs, urinary frequency, environmental noise.
- Correct the primary trigger before starting a hypnotic.
- Preserve day/night rhythm: bright light and activity by day, dim quiet room at night.
- First-line hypnotic when needed: mirtazapine 7.5–15 mg PO QHS (also improves appetite, mood, nausea).
- Alternative: trazodone 25–100 mg PO QHS for anxiety-predominant insomnia.
Pharmacology
- 01Mirtazapine 7.5–15 mg PO QHS — sedating antidepressant that also improves appetite, mood, and nausea. Best broad-benefit choice in most hospice contexts.
- 02Trazodone 25–100 mg PO QHS — sedating, low addiction potential, but can drop blood pressure.
- 03Zolpidem 5–10 mg PO QHS — effective short-term; watch for delirium in elderly and hospice patients on other CNS depressants.
- 04Lorazepam 0.5–1 mg PO/SL QHS — reserve for anxiety-predominant insomnia; watch for paradoxical excitation in the elderly.
- 05Melatonin 3–5 mg PO QHS — low side-effect profile; modest benefit for circadian-rhythm-related insomnia.
- 06Olanzapine 2.5–5 mg PO ODT QHS — excellent when insomnia coexists with nausea, anxiety, or delirium.
Non-pharmacological approaches
- Reduce environmental noise and light at night; use a night light instead of an overhead light for bathroom trips.
- Discourage daytime naps > 30 minutes when possible.
- Bright natural light and activity by day.
- Warm bath, warm milk, chamomile tea, or a family member reading aloud at bedtime.
- Address urinary frequency: schedule voiding before bed, minimize evening fluids, evaluate for retention with overflow.
- Address restless legs: check ferritin if reversible; use dopamine agonist only if aligned with goals.
When to escalate
- Insomnia persists despite treating the underlying cause (pain, dyspnea, anxiety).
- New nighttime confusion — evaluate for delirium (do not treat as insomnia with a benzodiazepine).
- Patient reports distressing dreams or nightmares — consider prazosin 1–2 mg PO QHS if PTSD component.
- Family exhausted by nighttime awakenings — consider respite or IDG conversation about additional support.
Documentation example
A composite narrative illustrating a defensible chart entry (identifying details fictionalized):
Patient with metastatic breast cancer reports waking every 1–2 hours with pain 6/10. Reviewed pain regimen: on morphine ER 30 mg q12h with IR 10 mg q4h PRN — using ~5 doses/day. Escalated morphine ER to 45 mg q12h + added ibuprofen 400 mg PO TID (renal function permitting). Additionally started mirtazapine 7.5 mg PO QHS for its sleep + appetite + mood benefits. Family instructed on sleep-hygiene principles. Reassess in 3 days.
FAQ
Should we start with a benzodiazepine?
Does mirtazapine really work at 7.5 mg?
What about melatonin?
Grow every hospice competency, one symptom at a time.
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Educational content only. Not a substitute for your organization’s policies, your medical director’s clinical judgment, or current hospice formulary.