Inpatient Insomnia

Inpatient Insomnia – Julian Raffoul, Jose Alberto Arriola Vigo

Background

  • Sleep disturbances in the hospital are multifactorial
  • Consequences of sleep disturbances in the hospital 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, utilizing non-pharmacologic strategies 

 

Management

  • Non-pharmacologic interventions:
    • Noise reduction: use of ear protection, sound masking (white noise), sound proofing acoustic materials, and behavioral modifications (or "quiet time" protocols)
    • Light therapy: Use of eye masks in conjunction with ear plugs will improve sleep, however, nocturnal light appears to be less of an issue compared with inadequate daytime light exposure, which improves circadian rhythms, nocturnal sleep, and minimizes delirium
      • Light exposure typically consists of two to five hours of daytime to early evening light in the range of 2000 to 5000 lux
    • Reducing nighttime interruptions: Alter workflow/lab draws, if possible, to permit 8-hr nocturnal "quiet time"
    • Relaxation techniques: Music or white noise may subjective sleep quality and duration
    • Equipment: for severely ill pts, minimize hardware and tubes that can alter sleep due to physical presence and alarms
  • Pharmacotherapy:
    • Melatonin: 1-5 mg PO qhs; (dosing is not standardized); the best first-line choice based on mild side-effect profile, low potential for drug-drug interactions, and improves circadian rhythms; Most effective 2-3hrs before bedtime
    • Ramelteon: 8 mg PO qhs; a melatonin-receptor agonist; May also play a role in preventing delirium in older adult inpatients
    • Trazodone: 25-50 mg PO qhs (max 200 mg/day); a serotonin modulator w/ significant sedation as a side effect, also headache, dry mouth, and nausea are common
      • 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
      • Advise that appetite and weight gain may also occur
    • Minimize medications such as vasopressors, sedatives/hypnotics, opioids, glucocorticoids, beta blockers, and certain antibiotics that disturb sleep architecture

 

Additional Information

  • Avoid the following in the inpatient setting:
    • Benzodiazepines:  While effective at reducing sleep latency and increasing total sleep time, benzodiazepines are associated with significant adverse effects, particularly in older adults, e.g., respiratory depression, cognitive decline, delirium, daytime sleepiness, and falls, particularly in hospitalized adults
    • Non-benzodiazepines: Benzodiazepine receptor agonists (e.g., zolpidem, eszopiclone/zopiclone, zaleplon) are effective in the outpatient setting and commonly used in the inpatient setting; however, they may be associated with cognitive dysfunction, delirium, and falls in hospitalized patients
    • Diphenhydramine: Trials evaluating their effectiveness as sleep aids are limited and show mixed results w/ many potential side effects that are enhanced in the inpatient setting: impaired cognition, anticholinergic effects (constipation, urinary retention)
    • Others: (anticonvulsants, antidepressants, antipsychotics, barbiturates) are usually used in outpatient setting, but have not been well studied in the inpatient setting