Skip to content

Inpatient Insomnia

Ben Johnson, reviewed by Jonathan Smith and Daniel Daunis

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 quite as possible overnight

    • Keeps 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

        • 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)