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Causes of insomnia include:

  • discomfort arising from immobility
  • pain due to stiffness of joints or muscles
  • muscle spasticity
  • shortness of breath
  • excessive saliva or dry mouth
  • taking stimulants at bedtime.

Additionally, because breathing cannot be controlled voluntarily when sleeping, weakened muscles may lead to ineffective breathing (nocturnal hypoventilation). Sleep apnoea is the temporary cessation of breathing while sleeping. This may cause wakefulness, as the disruption of the oxygen supply wakes the person to resume normal breathing (MND Australia 2014).

Miller and others 2009b

What pharmacologic interventions reduce insomnia?

  • Insomnia is common in ALS and may be a symptom of early respiratory weakness, underlying anxiety, depression, or pain. There is a concern that sedative/hypnotic agents may suppress the respiratory drive in patients with ALS.
  • Conclusion
    • There have been no studies of treatment for insomnia in ALS.
  • Recommendation
    • There are insufficient data to support or refute specific treatment for insomnia in ALS (Level U).

MND Victoria 2010

Strategies for insomnia include:

  • try not to remain in the same position in bed for too long
  • satin or silk sheets may help moving about in bed
  • an electric bed can be adjusted to a variety of positions at the push of a button (side rails, bedside furniture and extra pillows can give added support)
  • a segmented overlay mattress and specialised pillows distribute body pressure more evenly
  • muscle spasticity may be relieved with quinine sulphate. Where pain from muscle tightness and joint stiffness is more disturbing, Lioresol (Baclofen) is a commonly used muscle relaxant. Analgesics such as aspirin or paracetamol relieve mild discomfort.
  • joint pain may be relieved by stretching or range-of-motion exercises before retiring. A physiotherapist may be able to find the origin of the problem and recommend a remedy.
  • breathing may be helped by elevating the head and chest with an extra pillow or two. This relieves pressure on the diaphragm and improves lung expansion.
  • before going to bed, avoid conflict, violent TV shows, over-exertion, caffeinated beverages, smoking, and heavy meals. Too much food puts pressure on the diaphragm and aggravates breathing problems. Warm milk, ovaltine or custard may induce drowsiness.
  • retire at the same time each night, and reduce daytime napping. Make sure the bedroom is quiet, cool, dark, and comfortable. Light bedclothes allow easier movement and are more suitable for those who perspire freely.
  • impaired swallowing reflexes may cause choking on saliva or mucus. This is annoying, especially for those with an ineffective cough. Sleep with the head elevated to prevent secretions from moving toward the cough reflex centre. Some people require a suction device for adequate removal of secretions.
  • a slow rhythmic back rub or a light massage of aching muscles promotes relaxation. One exercise for reducing stress is deep abdominal breathing.
  • soft music or reassuring conversation can promote sleep.

If these methods do not help insomnia, and attention is required by a carer during the night, it may be helpful to employ a night assistant to prevent carer burnout.

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