What is the best approach to manage inpatient insomnia?

Management of Inpatient Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for all hospitalized patients with insomnia, with short-term pharmacotherapy (zolpidem 5-10 mg or ramelteon 8 mg) reserved as an adjunct when behavioral interventions alone are insufficient or impractical in the acute inpatient setting. 1, 2

First-Line Treatment Approach

Start with behavioral interventions immediately upon admission, even in the acute hospital setting where full CBT-I may not be feasible. 1

Practical Behavioral Strategies for Inpatients

• Implement stimulus control: Patients should use the bed only for sleep, leave the bed if unable to sleep within approximately 20 minutes (without clock-watching), and return only when drowsy. 1

• Maintain consistent sleep-wake schedules: Set regular bedtime and wake times despite the hospital environment disruptions. 1

• Optimize the hospital sleep environment: Minimize nighttime vital sign checks when medically safe, reduce noise and light exposure, avoid stimulating activities before bedtime, and limit caffeine intake after early afternoon. 1

• Avoid daytime napping: If napping occurs, limit to 30 minutes before 2 PM to preserve nighttime sleep drive. 3

Pharmacotherapy Algorithm

When medication is necessary due to severe daytime impairment or behavioral interventions prove insufficient, use the following stepwise approach:

First-Line Medications

For sleep onset insomnia (difficulty falling asleep):

• Zolpidem 10 mg (5 mg in elderly) is the preferred first-line agent, with proven efficacy for reducing sleep latency. 2, 4
• Ramelteon 8 mg is an alternative first-line option, particularly for patients with substance abuse history or concerns about benzodiazepine receptor agonist risks. 2, 5
• Zaleplon 10 mg may be used specifically for sleep onset problems when shorter duration of action is desired. 2

For sleep maintenance insomnia (frequent awakenings or early morning awakening):

• Zolpidem 10 mg (5 mg in elderly) addresses both sleep onset and maintenance. 2, 4
• Eszopiclone 2-3 mg is effective for sleep maintenance issues. 2
• Temazepam 15 mg can be considered for both onset and maintenance problems. 2

Second-Line Medications

If first-line agents fail or are contraindicated:

• Doxepin 3-6 mg specifically for sleep maintenance insomnia, particularly in elderly patients. 2, 1
• Suvorexant (orexin receptor antagonist) for sleep maintenance problems. 1, 2
• Low-dose sedating antidepressants (trazodone, mirtazapine) when comorbid depression or anxiety is present, though trazodone is not recommended by the American Academy of Sleep Medicine for primary insomnia. 1, 2

Medications to Avoid

Do not use the following agents for inpatient insomnia:

• Over-the-counter antihistamines (diphenhydramine) due to lack of efficacy data, anticholinergic side effects, daytime sedation, and delirium risk especially in elderly and medically ill patients. 2, 1
• Antipsychotics as first-line treatment due to problematic metabolic side effects and lack of evidence. 2
• Long-acting benzodiazepines (flurazepam) due to extended half-life and increased fall risk. 1, 2
• Herbal supplements and melatonin due to insufficient evidence of efficacy. 2

Critical Safety Considerations for Hospitalized Patients

Dose Adjustments and Monitoring

Elderly patients require lower doses: Use zolpidem 5 mg maximum (not 10 mg) due to increased sensitivity, fall risk, and cognitive impairment. 2, 4

Ensure adequate sleep opportunity: Patients must have 7-8 hours remaining before needing to be alert, as next-day psychomotor impairment (including impaired ambulation) is significantly increased with shorter sleep duration. 4

Avoid combining multiple sedatives: Combining sedative medications significantly increases risks of complex sleep behaviors, cognitive impairment, falls, and fractures. 2

Medication Duration

Limit pharmacotherapy to short-term use only (typically less than 4 weeks for acute insomnia), using the lowest effective dose for the shortest period possible. 1, 2

Reassess every 2-4 weeks during active treatment to evaluate effectiveness, side effects, and continued need for medication. 3

Special Populations

Patients with Dementia or Cognitive Impairment

Avoid benzodiazepines entirely due to unacceptable risk-benefit ratio with increased falls, cognitive impairment, dependence, and daytime sedation. 3

Consider trazodone 50 mg or orexin receptor antagonists (suvorexant, lemborexant) if behavioral interventions are insufficient. 3

Patients with Depression

Exercise extreme caution with hypnotics as worsening depression and suicidal ideation have been reported. 4, 5

Prescribe the minimum number of tablets feasible to reduce intentional overdose risk. 4

Patients with Cancer or Advanced Illness

Identify and treat underlying causes first: Address pain, medication side effects, or other cancer-related symptoms contributing to insomnia when possible. 1

Combine pharmacological and non-pharmacological approaches rather than relying on medication alone. 1

Common Pitfalls to Avoid

Do not prescribe hypnotics without implementing behavioral strategies, as combined approaches are more effective and allow for lower medication doses. 1, 3

Do not continue pharmacotherapy long-term without periodic reassessment, as dependence and tolerance can develop. 2

Do not ignore complex sleep behaviors: Discontinue zolpidem immediately if sleep-walking, sleep-driving, or other complex behaviors occur. 4

Do not use sedating agents without considering their specific effects: Match medication half-life to the patient's specific sleep complaint (onset vs. maintenance). 1, 2

Do not overlook drug interactions and contraindications, particularly with other CNS depressants, alcohol, or medications that increase zolpidem blood levels. 4

Do not assume insomnia is benign: Failure of insomnia to remit after 7-10 days of treatment indicates the need to evaluate for primary psychiatric or medical illness. 4, 5