Inpatient Insomnia
Ben Johnson
Background
- Sleep disturbances in the hospital are multifactorial
- Consequences of sleep disturbances include changes in cognition, behavior, anxiety, pain perception, respiratory function, inflammation, and metabolism
Management
- Non-pharmacologic interventions (when medically appropriate):
- Minimize:
- Potential for overnight alarms (telemetry etc.)
- Overnight vital signs
- Overnight and early morning lab draws
- Overnight IV fluids and late-night diuretics
- Discourage daytime naps
- Administer nighttime medications earlier in the evening
- Turn off or mute the television
- Close room doors
- Encourage care team to be as quiet as possible overnight
- Keep lights on during the day and off at night
- Ensure patient has CPAP available if used at home
- Pharmacotherapy:
- Background
- The best first step is to minimize medications such as sedative-hypnotics, opioids, glucocorticoids, beta blockers, and certain antibiotics that disturb sleep architecture
- Medications
- Melatonin: 1-5 mg PO qhs
- First-line choice based on mild side-effect profile, low potential for drug-drug interactions, and improves circadian rhythms; Dose 2-3hrs before bedtime
- Trazodone: 25-50 mg PO qhs (max 200 mg/day)
- Side effects: headache, dry mouth, and nausea o Monitor for orthostasis and infrequent atrial arrhythmias; use lowest effective dose
- Mirtazapine: 7.5-15 mg PO qHS
- A primary alpha-2 antagonist with 5-HT2 and H1 antagonism
- Consider when insomnia appears to be related to primary depression
- Can increase appetite and cause weight gain
Additional Information
- Avoid the following in the inpatient setting:
- Benzodiazepines
- Reduces sleep latency and increases total sleep time but avoided due to significant adverse effects: respiratory depression, cognitive decline, delirium, daytime sleepiness, and falls, particularly in hospitalized older adults
- Non-benzodiazepines benzodiazepine receptor agonists (e.g., zolpidem, eszopiclone/zopiclone, zaleplon) Commonly used in the outpatient setting but associated with cognitive dysfunction, delirium, and falls in hospitalized patients
- Diphenhydramine
- Trials evaluating its effectivenessas a sleep aid are limited and show mixed results
- Many potential side effects that are enhanced in the inpatient setting: impaired cognition, anticholinergic effects (constipation, urinary retention)
