title: Insomnia among patients with advanced disease during admission in a Palliative Care Unit: a prospective observational study on its frequency and association with psychological, physical and environmental factors.
abstract: BACKGROUND
  
  1) to assess the frequency of insomnia among patients during admission in a Palliative Care Unit (PCU); 2) to study the association between emotional distress and insomnia, taking physical, environmental and other psychological factors into account.
  
  
  METHODS
  Prospective observational study including patients consecutively admitted to a PCU during eight months, excluding those with severe cognitive problems or too low performance status. Insomnia was assessed by asking a single question and by using the Sleep Disturbance Scale (SDS), and emotional distress using the Hospital Anxiety and Depression Scale (HADS). Physical, environmental and other psychological factors potentially interfering with sleep quality were evaluated. Association between insomnia and the factors evaluated was studied using univariate and multivariate regression analyses.
  
  
  RESULTS
  61 patients were included (mean age 71.5 years; 95% with oncological disease); 38 (62%) answered "yes" to the insomnia single question and 29 (47%) showed moderate to severe insomnia according to the SDS. 65% showed clinically significant emotional distress and 79% had nocturnal rumination. The physical symptoms most often mentioned as interfering with sleep quality were pain (69%) and dyspnoea (36%). 77% reported at least one environmental disturbance. In the univariate analysis, answering "yes" to the insomnia single question was significantly associated with higher HADS score, anxiety, nocturnal rumination, clear knowledge of the diagnosis, higher performance status and dyspnoea; moderate to severe insomnia was significantly associated with nocturnal rumination, higher performance status, environmental disturbances and daytime sleepiness. In the multivariate regression analysis, answering "yes" to the single question was associated with dyspnoea (OR 7.2 [1.65-31.27]; p = 0.009), nocturnal rumination (OR 5.5 [1.05-28.49]; p = 0.04) and higher performance status (OR 14.3 [1.62-125.43]; p = 0.017), and moderate to severe insomnia with nocturnal rumination (OR 5.6 [1.1-29.1]; p = 0.041), and inversely associated with daytime sleepiness (OR 0.25 [0.07-0.9]; p = 0.043).
  
  
  CONCLUSIONS
  Insomnia was highly frequent. Several physical, psychological and environmental factors seemed to influence insomnia. Within the multimodal management of insomnia, the assessment of nocturnal rumination may be of particular interest, irrespective of emotional distress. Further studies with larger sample sizes could confirm this result.
authors.affiliation: School of Nursing Science and Institute of General Practice and Family Medicine, Faculty of Health, University of Witten/Herdecke, 50 Alfred-Herrhausen-Str, 58448 Witten, Germany ; Geriatric Service, Hospital de l'Esperança, Centre Fòrum, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.
authors.forename: Anna
authors.initials: A
authors.lastname: Renom-Guiteras
authors.affiliation: Palliative Care Unit, Department of Medical Oncology, Hospital de l'Esperança, Parc de Salut Mar, Barcelona, Spain ; Universitat Autònoma de Barcelona, Barcelona, Spain ; IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
authors.forename: José
authors.initials: J
authors.lastname: Planas
authors.affiliation: Palliative Care Unit, Department of Medical Oncology, Hospital de l'Esperança, Parc de Salut Mar, Barcelona, Spain ; Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Cristina
authors.initials: C
authors.lastname: Farriols
authors.affiliation: Scientific and Technical Services, IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain.
authors.forename: Sergi
authors.initials: S
authors.lastname: Mojal
authors.affiliation: Geriatric Service, Hospital de l'Esperança, Centre Fòrum, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain ; Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Ramón
authors.initials: R
authors.lastname: Miralles
authors.affiliation: Palliative Care Unit, Department of Medical Oncology, Hospital de l'Esperança, Parc de Salut Mar, Barcelona, Spain.
authors.forename: Maria A
authors.initials: MA
authors.lastname: Silvent
authors.affiliation: IMIM (Hospital del Mar Medical Research Institute), Barcelona, Spain ; Department of Psychiatry, Institute of Neuropsychiatry and Addiction, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain.
authors.forename: Ada I
authors.initials: AI
authors.lastname: Ruiz-Ripoll
keywords: Insomnia; Oncology; Palliative care [MeSH]; Rumination; Sleep Disturbance Scale; Sleep disorders [MeSH]; Symptom assessment [MeSH]