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Inpatient Insomnia

Julian Raffoul, Jose Alberto Arriola Vigo

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

  • Goals while inpatient: optimize sleep environment, minimize stimulating or sleep-related side effects of concomitant medications, utilize non-pharmacologic strategies

Management

  • Non-pharmacologic interventions:

    • Noise reduction: (ear protection, white noise, etc.)

    • Keeps lights on during the day and off at night

    • Reducing nighttime interruptions: Retime VS checks and lab draws

    • Minimize devices (ex: telemetry) and lines as able

  • Pharmacotherapy:

    • Minimize medications such as sedatives/hypnotics, opioids, glucocorticoids, beta blockers, and certain antibiotics that disturb sleep architecture

    • 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

      • 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 their effectiveness as sleep aids are limited and show mixed results

      • Many potential side effects that are enhanced in the inpatient setting: impaired cognition, anticholinergic effects (constipation, urinary retention)