Are intravenous (IV) sleep medications safe for elderly patients in a hospital setting?

From the Guidelines

Intravenous (IV) sleep medications should be avoided in elderly patients in a hospital setting due to the high risk of adverse effects, and non-pharmacological approaches should be prioritized. The use of IV sleep medications, such as benzodiazepines, can lead to significant harms, including falls, cognitive impairment, and respiratory depression, particularly in older patients 1. The 2019 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guidelines advise against the use of benzodiazepines and trazodone for the treatment of chronic insomnia disorder due to their adverse effect profile, which substantially outweighs their benefits 1.

Some key points to consider when managing sleep in elderly hospitalized patients include:

• Non-pharmacological approaches, such as maintaining day-night cycles, reducing nighttime interruptions, and addressing pain or discomfort, should be tried first
• If pharmacological interventions are necessary, the lowest effective dose should be used for the shortest duration possible
• Medications with shorter half-lives are generally preferred to avoid daytime sedation and cognitive impairment
• Close monitoring of vital signs and mental status is essential when using IV sleep medications

The elderly metabolize and eliminate these drugs more slowly due to age-related changes in liver and kidney function, which contributes to their increased sensitivity 1. Therefore, it is crucial to prioritize non-pharmacological approaches and exercise caution when considering the use of IV sleep medications in elderly patients in a hospital setting.

From the FDA Drug Label

In the elderly, debilitated, or ASA-PS III or IV patients, rapid (single or repeated) bolus dose administration should not be used for MAC sedation (see WARNINGS). A rapid bolus injection can result in undesirable cardiorespiratory depression including hypotension, apnea, airway obstruction, and oxygen desaturation The rate of administration should be over 3 minutes to 5 minutes and the dosage of propofol injectable emulsion should be reduced to approximately 80% of the usual adult dosage in these patients according to their condition, responses, and changes in vital signs (see DOSAGE AND ADMINISTRATION)

The use of intravenous (IV) sleep medications, such as propofol, in elderly patients in a hospital setting requires caution.

• Key considerations for elderly patients include:
  • Avoiding rapid bolus dose administration
  • Reducing the dosage to approximately 80% of the usual adult dosage
  • Administering the medication over 3 minutes to 5 minutes
• Potential risks associated with IV sleep medications in elderly patients include:
  • Cardiorespiratory depression
  • Hypotension
  • Apnea
  • Airway obstruction
  • Oxygen desaturation According to 2 and 2, it is essential to individualize the dosage and administration rate based on the patient's condition, responses, and changes in vital signs.

From the Research

Safety of IV Sleep Medications for Elderly Patients

• The safety of intravenous (IV) sleep medications for elderly patients in a hospital setting is a concern due to the potential for adverse effects, such as delirium and falls 3.
• Studies suggest that non-benzodiazepines, such as barbiturates and pseudobarbiturates, have a higher toxic potential and are less useful for treating sleep disturbances in the elderly 4.
• Benzodiazepines, on the other hand, can be safe and effective for older patients when used at appropriate dosages and indications 4.
• However, the use of pharmacological sleep aids, including IV medications, is common in hospitalized patients, despite the risks, and many patients are discharged with a prescription for a sleep aid 3.

Alternatives to IV Sleep Medications

• Non-pharmacologic interventions, such as establishing a bedtime routine, relaxation training, biofeedback, and self-hypnosis, can be effective in managing sleep disturbances in elderly patients 4, 5.
• Melatonergic drugs, such as ramelteon, have been shown to be effective in improving sleep quality and reducing sleep onset time in elderly patients 6, 7.
• Other alternatives, such as low-dose doxepin and suvorexant, can also be used to improve sleep maintenance and sleep onset in elderly patients 6.

Considerations for Elderly Patients

• Elderly patients are at a higher risk of polypharmacy and medication side effects, making non-pharmacologic interventions a preferred first-line approach for managing sleep disturbances 5.
• The choice of a hypnotic agent in elderly patients should be symptom-based, taking into account the patient's specific sleep disturbance and medical history 6.
• IV sleep medications should be used with caution in elderly patients, and alternative treatments should be considered whenever possible 3.