What is the recommended treatment for acute insomnia in a hospital setting?

Management of Acute Insomnia in the Hospital Setting

For acute insomnia in hospitalized patients, first implement environmental modifications and if needed, use zolpidem 10mg (5mg in elderly) for sleep onset insomnia or low-dose doxepin (3-6mg) for sleep maintenance insomnia as first-line pharmacological options. 1

Non-Pharmacological Interventions (First-Line)

Environmental modifications should be attempted first before resorting to medications:

• Noise and light reduction: Offer earplugs, eye masks, and minimize unnecessary disruptions 1, 2
• Temperature control: Maintain a comfortable room temperature 1
• Timing of care activities: Coordinate nursing care to minimize nighttime disruptions 1
• For ventilated patients: Consider assist-control ventilation at night rather than pressure support ventilation 1

Pharmacological Interventions (Second-Line)

If non-pharmacological interventions are insufficient, consider medication based on insomnia type:

For Sleep Onset Insomnia:

1. Zolpidem: 10mg for adults, 5mg for elderly 1
2. Zaleplon: 10mg 1
3. Ramelteon: 8mg - FDA approved specifically for sleep onset insomnia 1, 3

For Sleep Maintenance Insomnia:

1. Low-dose Doxepin: 3-6mg (non-habit forming with minimal next-day sedation) 1
2. Eszopiclone: 2-3mg (1mg for elderly) 1
3. Temazepam: 15mg 1

Special Clinical Considerations

• For patients with depression/anxiety: Consider trazodone (50-100mg) or mirtazapine (7.5-15mg) 1
• For patients with PTSD/nightmares: Prazosin is first-line 1
• For patients with neuropathic pain: IV gabapentin can improve both pain and sleep 1
• For patients with substance use history: Prefer non-scheduled options like low-dose doxepin 1
• For elderly patients: Use lower doses (zolpidem 5mg, eszopiclone 1mg) due to increased fall risk 1

Safety Considerations and Contraindications

• Avoid benzodiazepines in patients with respiratory conditions due to risk of respiratory depression 1
• Avoid antihistamines like hydroxyzine, especially in older patients, due to risk of daytime sedation and delirium 1
• Never use propofol solely for sleep due to REM suppression and respiratory depression 1
• Use caution with opioids in patients with sleep-disordered breathing 1
• Monitor for paradoxical reactions to benzodiazepines, especially in elderly patients 1

Monitoring

• Assess pain regularly using appropriate scales for non-verbal patients 1
• Monitor for signs of oversedation, respiratory depression, and hemodynamic changes 1
• Evaluate effectiveness within 2-4 weeks of starting treatment 1

Common Pitfalls to Avoid

1. Overreliance on medications: Many clinicians jump to pharmacological interventions without adequately implementing environmental modifications 1, 2
2. Prolonged use of hypnotics: The FDA recommends short-term use only 1
3. Ignoring underlying causes: Acute insomnia in hospitalized patients is often due to illness effects, environmental disruptions, medication side effects, anxiety, or depression 4
4. Using medications with poor safety profiles: Newer-generation non-benzodiazepines have better safety profiles than traditional benzodiazepines for long-term use 5

While recent evidence suggests eszopiclone and lemborexant may have favorable profiles for long-term treatment 6, the hospital setting typically requires focus on short-term management of acute insomnia with emphasis on safety and minimal side effects.