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Fatigue and Sleep Disturbances

 

Guiding Priniciple:

Fatigue is a very common symptom in end-stage kidney disease and it is often multifactorial. Treat the patient's tiredness and/or daytime drowsiness if it is affecting their quality of life.

  • Exercise (if appropriate)
  • Nutrition and hydration management
  • Cognitive and psychological approaches (eg. relaxation therapy, hypnosis, stress management, delegating and setting limits)
  • Complementary treatments such as acupressure/acupuncture (no high quality evidence to support this; no lasting adverse effects)
  • Energy Conservation Strategies (See: Tiredness Patient Handout)
  • Promoting good sleep hygiene (See: Sleep Patient Handout)
  • Incorporate relaxation techniques
  • Consider suggesting to your patient:
    • Wake up at the same time every morning
    • Do not go to bed until you feel sleepy
    • Do not “try” to fall asleep
    • Avoid napping during the day
    • Avoid caffeine in the evening
    • Save your bedroom for sleep (and sex) only
    • Leave your day’s dilemmas at the door
  • Reassess medications prescribed for the treatment of insomnia after 2-4 weeks. Avoid OTC sleep aids and benzodiazepines if possible.
  • Consider low-dose gabapentin ( particularly if the patient has concomitant symptoms of neuropathic pain, RLS, or uremic pruritus ):
    • Gabapentin 50-100 mg PO nightly. If not effective, it can be further titrated by 100 mg every 7 nights to a maximum of 300mg PO qhs. It should be taken 1-2 hours before bed.
  • If ineffective, cautiously consider:
    • Mirtazapine (Remeron) 7.5 mg PO at bedtime (not if taking Tramadol or antidepressants)
    • Doxepin 10 mg PO at bedtime (monitor carefully for anticholinergic side effects and cardiac arrhythmias)
    • Zopiclone 3.75-5 mg PO at bedtime for short term use
    • Melatonin 2-5 mg PO at bedtime (although the evidence is somewhat limited and inconclusive)

Special considerations at End of Life:

  • As a patient’s condition deteriorates, certain non-pharmacological interventions will become less realistic (eg. exercise). Energy conservation and restoration will become of utmost importance.
  • Ensure that appropriate supports are in place to assist with activities of daily living and that nursing care is available as needed.
  • Drowsiness may increase as the end of life approaches due to disease progression (and/or medications.) Some patients and families may even prefer increased sleepiness if the patient remains comfortable.

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