What are the best sleeping aids for inpatients?

Best Sleeping Aids for Inpatients

Nonpharmacological interventions should be the first-line approach for managing sleep in hospitalized patients, with earplugs and eye masks being the most effective and safest options. 1

Nonpharmacological Interventions

Environmental Modifications

• Implement noise and light reduction strategies to improve sleep quality and reduce delirium in hospitalized patients 1
• Use earplugs and eyeshades to maintain sleep quality and reduce interruptions, which has been shown to improve patient-reported sleep quality 1, 2
• Cluster patient care activities to minimize nighttime interruptions and protect patients' sleep cycles 1, 2
• Designate quiet time periods on both day and night shifts to promote sleep, with 12-5 AM being identified as a period most likely to be uninterrupted 1, 3
• Postpone morning medication rounds and vital sign measurements from night shift to day shift when possible, which can increase total sleep time by approximately 40 minutes 2

Sleep Hygiene Protocol

• Implement a multidisciplinary "TUCK-in" type protocol that includes timed lights-off periods, minimizing nighttime noise, distribution of earplugs, and cued toileting before bedtime 4, 5
• Reduce modifiable interruptions during designated sleep periods 4, 2
• Consider relaxing music if requested by patients, though evidence for this intervention alone is limited 1

Pharmacological Interventions

When nonpharmacological approaches are insufficient, pharmacological options may be considered, though evidence for their use specifically in the inpatient setting is limited:

First-Line Pharmacological Options

• Melatonin is the most commonly prescribed inpatient sleep aid (50% of prescriptions) despite limited evidence for efficacy 5, 1
• The panel makes no recommendation regarding melatonin use due to the balance between minimal adverse effects and lack of high-quality evidence 1
• Short-acting benzodiazepine receptor agonists (zolpidem, eszopiclone) may be considered for short-term use when necessary 6, 7
  • Zolpidem has been shown to improve sleep latency and sleep duration in controlled studies 7, 8
  • These medications should be used at the lowest effective dose and for the shortest duration possible 6, 9

Second-Line Pharmacological Options

• Low-dose doxepin (3-6 mg) may be considered for sleep maintenance insomnia 6, 10
• Sedating antidepressants like trazodone may be appropriate, particularly for patients with comorbid depression or anxiety 6, 10

Special Considerations for Inpatients

Medication Administration

• For patients with PEG tubes, consider medications available in liquid formulations (like doxepin) or those that can be crushed and dissolved (like immediate-release zolpidem) 10
• Never crush extended-release or enteric-coated formulations 10

Monitoring and Safety

• Monitor for adverse effects including excessive sedation, confusion, and falls, especially in elderly patients 9, 10
• Avoid first-generation antihistamines like hydroxyzine due to anticholinergic effects and risk of delirium, particularly in older adults 9
• Consider the impact of sleep medications on delirium risk, which is already elevated in the hospital setting 1, 9

Implementation Challenges

• Despite evidence supporting nonpharmacological approaches, they are underutilized in hospital settings, with one study showing only 3% of patients receiving ordered nonpharmacological sleep interventions 5
• Implementing and sustaining multifaceted clinical practice protocols requires institutional commitment and resources 1, 5

Algorithm for Sleep Management in Inpatients

1. First implement nonpharmacological interventions:

   • Provide earplugs and eye masks 1
   • Reduce noise and light 1
   • Cluster care activities to minimize interruptions 1, 2
   • Designate quiet time periods 1, 3

2. If nonpharmacological interventions are insufficient:

   • Consider melatonin as a relatively safe option despite limited evidence 1, 5
   • For persistent sleep issues, consider short-acting benzodiazepine receptor agonists for short-term use 6, 7
   • For patients with comorbid depression/anxiety, consider low-dose sedating antidepressants 6, 10

3. Avoid:

   • First-generation antihistamines (hydroxyzine) due to delirium risk 9
   • Long-term use of any sleep medication in the inpatient setting 6, 9
   • Medications that may worsen delirium or increase fall risk 9, 10