What is a safe sleep medication to prescribe in a hospital setting?

Safe Sleep Medications in Hospital Settings

For hospitalized patients requiring sleep medication, short-acting non-benzodiazepine hypnotics such as eszopiclone (2-3 mg) or zolpidem (5 mg in elderly, 10 mg in non-elderly) are the safest pharmacological options, with ramelteon (8 mg) being preferred for patients with substance abuse history or when avoiding controlled substances is desired.

First-Line Pharmacological Options

Non-Benzodiazepine Receptor Agonists (BzRAs)

• Eszopiclone (Lunesta)

  • Dosage: 2-3 mg at bedtime (1 mg in elderly or debilitated patients) 1
  • Indicated for both sleep onset and maintenance insomnia 1
  • Intermediate-acting with no short-term usage restriction
  • Take on empty stomach for maximum effectiveness

• Zolpidem (Ambien)

  • Dosage: 5 mg for elderly/debilitated patients, 10 mg for non-elderly 1
  • Primarily effective for sleep onset insomnia 1
  • Short-to-intermediate acting
  • Important safety consideration: Lower doses recommended for women due to slower metabolism 1

Melatonin Receptor Agonist

• Ramelteon (Rozerem)
  • Dosage: 8 mg at bedtime 1, 2
  • Non-controlled substance (not scheduled by DEA)
  • Primarily for sleep onset insomnia 1
  • Advantage: No abuse potential - preferred option for patients with history of substance abuse 2
  • No evidence of withdrawal or rebound insomnia 2

Special Considerations for Hospital Settings

Risk Factors to Assess

1. Age: Elderly patients (≥65 years) require lower doses of all sleep medications
2. Hepatic function: Dose reduction needed with impairment
3. Respiratory status: Caution in patients with compromised respiratory function
4. Medication interactions: Avoid with other CNS depressants

Hospital-Specific Concerns

• Delirium risk: In a study of hospitalized patients ≥50 years, 19.3% experienced adverse drug reactions with zolpidem, with 80.8% being CNS-related (confusion, dizziness, daytime somnolence) 3
• Falls risk: Zolpidem has been associated with increased risk of falls in hospitalized patients 4
• Timing of administration: 36.7% of sleep medications in hospitals are given at suboptimal times (before 9 PM or after midnight) 5

Decision Algorithm for Hospital Sleep Medication Selection

1. For patients WITHOUT history of substance abuse or respiratory compromise:

   • First choice: Eszopiclone 2-3 mg (1 mg in elderly)
   • Alternative: Zolpidem 5-10 mg (lower dose for elderly, women, hepatic impairment)

2. For patients WITH history of substance abuse:

   • Ramelteon 8 mg (non-controlled substance) 1, 2

3. For patients with sleep maintenance issues:

   • Eszopiclone (better for maintenance than zolpidem) 1
   • Low-dose doxepin (3-6 mg) may be considered 1

4. Avoid in hospital settings:

   • Diphenhydramine and other antihistamines 1
   • Benzodiazepines (higher risk of delirium)
   • Trazodone (insufficient evidence for efficacy) 1
   • Propofol (not recommended for sleep promotion alone) 1

Common Pitfalls to Avoid

1. Inappropriate dosing: Using standard adult doses in elderly patients
2. Poor timing: Administering sleep medication too early or too late
3. Medication continuation: 34.3% of previously sleep medication-naïve patients are discharged with a sleep aid prescription 5
4. Overlooking non-pharmacological approaches: Consider implementing a sleep-promoting protocol including noise/light reduction and minimizing nighttime interruptions 1
5. Complex sleep behaviors: All BzRAs carry risk of sleepwalking, sleep-eating, sleep-driving 1, 6

Non-Pharmacological Interventions

Before or alongside medication use, implement a multicomponent sleep protocol 1:

• Noise and light reduction
• Clustering care to minimize nighttime interruptions
• Offering earplugs and eye masks
• Maintaining regular sleep-wake schedules
• Avoiding caffeine and other stimulants before bedtime

By carefully selecting appropriate sleep medications and implementing non-pharmacological strategies, clinicians can help improve sleep in hospitalized patients while minimizing risks of adverse effects.