Fatigue and Sleep Disturbances
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.