Etiology and Risk Factors

• Psychological (anxiety, grief)
• Physical (pain, decreased mobility, dyspnea)
• Delirium
• Medical condition e.g., infection, metabolic, polyuria (diuretics given at night), incontinence, sleep apnea
• Medications e.g., anticholinergics, beta-agonists, clonidine, steroids, caffeine, nicotine, phenylephrine, Dilantin, SSRIs, theophylline, thyroxine or medication withdrawal

Evaluation

• Obtain a brief history to evaluate for any underlying, potentially treatable problem that is causing the insomnia (e.g., pain).
• Prior to initiating any pharmacological intervention consider potential medication interactions, underlying medical conditions which may affect medication clearance, and risks of adverse effects (e.g. respiratory depression).

Management

• Prioritize non-pharmacologic measures. Although these can be difficult to achieve, simple measures such as minimizing nighttime disruptions and keeping the room dark and quiet can help to improve sleep-wake cycle in hospitalized patients. Ask the nurse if earplugs or eye-masks are available. For certain patient groups (e.g., ESLD, severe COPD), sedation can be dangerous; focus on non-pharmacologic measures for these sub-groups.
• Medication options: start with melatonin 3 mg before bedtime (can be increased to 6 mg). Second line agents include low-dose trazodone (25-50 mg at bedtime PRN). Avoid hypnotics (e.g. zolpidem) or benzodiazepines unless this is a continuation of a chronic home regimen.
• If a patient has a medication that has worked for them in the past (and there are no contraindications to this medication currently), it may be appropriate to use this medication again. You may want to start with a lower dose than the patient’s home dose, particularly if you are concerned about oversedation (e.g., if the patient is on new pain medications).

Medication dosing

Normal vs. elderly or cirrhotic patients

• Trazodone: start at 25-50 mg PO, maximum 300 mg.  If age > 65 or cirrhosis present, start at 25 mg, maximum 100 mg.
• Benadryl: start at 25-50 mg PO, maximum 100 mg. Caution if age >65 given anti-cholinergic effects.
• Zolpidem: start at 5-10 mg PO, maximum 10 mg. Avoid if age >65. If cirrhosis present, start at 5 mg.
• Lorazepam: start at 0.5-1 mg PO, maximum 4 mg.  Avoid if age > 65. If cirrhosis present, start at 0.25 mg, maximum 1 mg.
• Temazepam: start at 15 mg PO, maximum 30 mg.  Avoid if age > 65. If cirrhosis present, start at 7.5 mg, maximum 15 mg.

Key points

• It is best to write a one-time order only overnight; the primary team can evaluate and determine a long-term plan the next day.

Lenhart SE, Buysse DJ. Treatment of insomnia in hospitalized patients. Ann Pharmacother 2001;35:1449-1457.

Rosenberg RP. Sleep maintenance insomnia: strengths and weaknesses of current pharmacologic therapies. Ann Clin Psychiatry 2006;18:49-56.