Clinical bottom line
Sleep disturbances are common and distressing in patients with advanced illness, including those receiving palliative care. Optimizing management requires a tailored, multimodal approach that addresses underlying causes, symptom burden, and psychosocial factors. Evidence supports prioritizing non-pharmacological interventions alongside cautious pharmacotherapy, with ongoing reassessment to balance symptom relief and potential adverse effects. Despite limited high-quality trials, emerging data from palliative care settings highlight the importance of individualized strategies to improve sleep quality and overall quality of life in this vulnerable population (Schacter et al., 2025; Montoya et al., 2021).
What the evidence shows
Sleep disturbances in advanced illness are multifactorial, often involving pain, psychological distress, medication side effects, and disease-related physiological changes (Montoya et al., 2021). Prevalence estimates in advanced cancer and other serious illnesses range widely but are consistently high, with insomnia, fragmented sleep, and early awakening frequently reported (Mercadante et al., 2015; Schacter et al., 2025).
Non-pharmacological interventions such as sleep hygiene education, cognitive-behavioral therapy for insomnia (CBT-I), relaxation techniques, and environmental modifications have demonstrated benefit in improving sleep parameters and patient-reported outcomes in palliative care populations, though data remain limited and often extrapolated from non-palliative cohorts (Montoya et al., 2021). Multidisciplinary approaches integrating psychosocial support are emphasized to address anxiety and depression contributing to sleep disruption (Breitbart et al., 2014).
Pharmacological management is commonly employed but requires careful consideration due to altered pharmacokinetics in advanced illness and risk of adverse effects such as sedation, delirium, or respiratory depression. Agents including low-dose benzodiazepines, non-benzodiazepine hypnotics, melatonin, and certain antidepressants are used, but evidence for efficacy and safety in palliative care is sparse and largely based on expert consensus and retrospective reviews (Schacter et al., 2025; McPherson et al., 2016). Regular medication review is critical to minimize polypharmacy and optimize symptom control.
Sleep disturbances often coexist with other symptoms such as fatigue and pain, necessitating integrated symptom management plans. Addressing pain effectively can improve sleep quality, and vice versa, highlighting the need for comprehensive assessment (Breitbart et al., 2014; Mercadante et al., 2015).
Caveats and uncertainty
The evidence base for sleep management in palliative care is limited by small sample sizes, heterogeneity of populations, and lack of randomized controlled trials specifically targeting sleep outcomes. Most pharmacological recommendations derive from studies in general or cancer populations rather than exclusively palliative cohorts, limiting generalizability (Schacter et al., 2025).
Non-pharmacological interventions, while promising, require resources and trained personnel that may not be universally available. Patient cognitive status and disease trajectory can also affect feasibility and adherence.
The complex interplay of symptoms and comorbidities in advanced illness complicates attribution of sleep disturbances to a single cause, challenging targeted interventions. Furthermore, the balance between improving sleep and avoiding sedation or delirium remains delicate, underscoring the need for individualized care and frequent reassessment (McPherson et al., 2016).
How this may change practice
Clinicians in palliative care should proactively screen for sleep disturbances as part of routine symptom assessment, recognizing their high prevalence and impact on quality of life. A multimodal approach combining non-pharmacological strategies with judicious pharmacotherapy tailored to patient goals and clinical context is advisable.
Education on sleep hygiene and relaxation techniques can be integrated into care plans, with referral to psychosocial support services when available. Medication regimens should be regularly reviewed to identify and minimize contributors to poor sleep, including polypharmacy and inappropriate sedative use.
Collaboration among palliative care teams, including nursing, psychology, and pharmacy, can facilitate comprehensive management. Further research is needed to establish evidence-based guidelines specific to palliative populations, but current data support individualized, symptom-focused approaches to optimize sleep and overall comfort in advanced illness (Schacter et al., 2025; Montoya et al., 2021).