What is a suitable alternative for sleep management in an elderly person with episodes of delirium at night who has been receiving alprazolam (benzodiazepine) for sleep?

Immediate Management: Discontinue Alprazolam and Implement Non-Pharmacological Interventions

Alprazolam must be discontinued immediately as benzodiazepines are strongly associated with causing and worsening delirium in elderly patients, and you should NOT substitute it with another sleep medication but rather focus on non-pharmacological sleep hygiene measures and delirium management. 1

Critical First Steps

1. Discontinue the Offending Agent

• Stop alprazolam immediately as benzodiazepines are a well-established cause of delirium in older adults and should not be used as initial treatment for delirium in patients not already taking them 1, 2
• The American Geriatrics Society Beers Criteria explicitly identifies benzodiazepines as potentially inappropriate medications in older adults due to increased risk of cognitive impairment, delirium, falls, fractures, and motor vehicle accidents 1
• Benzodiazepines can themselves cause increased patient agitation and delirium, creating a vicious cycle 1

2. Manage Benzodiazepine Withdrawal Risk

• If the patient has been on alprazolam for more than a few weeks, you cannot abruptly stop it without risking severe benzodiazepine withdrawal delirium, which can be life-threatening 3, 4
• For patients requiring withdrawal management, substitute with a longer-acting benzodiazepine like chlordiazepoxide (50 mg for each 1 mg of alprazolam in younger patients, 25 mg in elderly) or diazepam, then taper over 7-14 days 3, 4
• Monitor closely during the taper period as withdrawal itself can precipitate or worsen delirium 3

Primary Treatment: Multicomponent Non-Pharmacological Interventions

For Delirium Management

The NICE guidelines emphasize that non-pharmacological interventions should be maximized before any pharmacologic interventions are used for both delirium and sleep disturbances 1

Implement these specific interventions immediately: 1

• Reorientation protocols: Provide visible clocks, calendars, and familiar objects; staff should regularly reorient the patient to time, place, and person
• Cognitive stimulation: Engage patient in conversation and activities appropriate to their cognitive level during daytime hours
• Sleep hygiene measures: Avoid nursing procedures during sleeping hours, schedule medication rounds to avoid sleep disruption, reduce noise to minimum during sleep periods 1
• Sensory optimization: Ensure hearing aids and glasses are available, functioning, and being used; check for and remove impacted ear wax 1
• Mobilization: Encourage daytime activity and avoid prolonged bed rest
• Nutrition and hydration: Ensure adequate intake and properly fitting dentures 1

For Sleep Specifically

• Maintain stable bedtimes and rising times 5
• Avoid daytime napping or limit to 30 minutes before 2 PM 5
• Eliminate sleep-fragmenting substances: caffeine after 4 PM, nicotine, alcohol 5
• Use bedroom only for sleep, not for activities 5

Pharmacological Management: Only If Absolutely Necessary

When to Consider Medication

Pharmacological therapy should be implemented only if the patient poses a safety risk to themselves or others due to severe agitation, or if perceptual disturbances (hallucinations, illusions) are causing significant distress 1, 2

First-Line Pharmacological Option: Low-Dose Antipsychotic

If medication is required for severe agitation or distressing perceptual disturbances associated with delirium: 1

• Quetiapine 25 mg PO at bedtime is the preferred choice as it is sedating, less likely to cause extrapyramidal side effects, and addresses both delirium symptoms and sleep disturbance 1
• Alternative: Olanzapine 2.5 mg PO or SC at bedtime (reduce dose in elderly patients; has sedating properties) 1
• Alternative: Risperidone 0.5 mg PO (reduce dose in elderly patients) 1

Critical caveats: 1, 2

• Start on PRN (as needed) basis initially, not scheduled dosing
• Use lowest effective dose for shortest possible duration
• Antipsychotics treat the symptoms of agitation and distress but do NOT treat the underlying delirium itself
• Monitor for orthostatic hypotension, falls, and extrapyramidal side effects
• These medications carry black box warnings for increased mortality in elderly patients with dementia

What NOT to Use for Sleep

Avoid these medications entirely: 1, 5

• Any benzodiazepine (including switching to another benzodiazepine for sleep) - associated with delirium, falls, cognitive impairment 1
• Z-drugs (zolpidem, zaleplon) - similar risks to benzodiazepines in elderly 1
• Diphenhydramine or other antihistamines - strong anticholinergic effects increase confusion and delirium risk 1, 5
• Trazodone - not recommended by guidelines despite common off-label use 1, 5

Melatonin: Weak Evidence But Safer Profile

If you feel compelled to prescribe something specifically for sleep after delirium resolves and non-pharmacological measures have been optimized: 6, 5

• Melatonin 2 mg prolonged-release, 1-2 hours before bedtime has a favorable safety profile with minimal adverse effects
• However, the American Academy of Sleep Medicine provides only a weak recommendation against melatonin due to very low quality evidence and modest effects (approximately 19 minutes reduction in sleep latency) 6
• Melatonin is NOT listed on the Beers Criteria and does not worsen delirium 6

Algorithmic Approach

Step 1: Assess duration of alprazolam use

• If <2 weeks: Stop immediately
• If ≥2 weeks: Initiate supervised taper with longer-acting benzodiazepine 3, 4

Step 2: Implement all non-pharmacological interventions simultaneously 1

Step 3: Identify and treat reversible causes of delirium (infection, metabolic disturbances, other medications) 1

Step 4: Assess severity of agitation/distress

• If mild-moderate and no safety risk: Continue non-pharmacological measures only
• If severe with safety risk: Add low-dose antipsychotic PRN 1, 2

Step 5: After delirium resolves, reassess sleep

• If sleep improves with non-pharmacological measures alone: Continue these
• If persistent insomnia after delirium resolution: Consider melatonin 2 mg or low-dose doxepin 3-6 mg (though doxepin evidence is for primary insomnia, not post-delirium) 6, 7

Common Pitfalls to Avoid

• Do not simply substitute alprazolam with another "safer" sleep medication - the primary issue is the delirium, which requires non-pharmacological management 1
• Do not abruptly stop benzodiazepines in chronic users - this can cause life-threatening withdrawal delirium 3
• Do not use antipsychotics as routine treatment for delirium - they are only for managing dangerous agitation or severe distress, not for treating delirium itself 8, 2
• Do not prescribe medications for sleep while delirium is active - focus on treating the delirium first 1