What treatment should be given for a patient with severe sleep disturbance, having only slept 1-2 hours in 2 days?

Immediate Management of Severe Acute Sleep Deprivation

For a patient who has slept only 1-2 hours over 2 days, immediately administer a short-acting benzodiazepine receptor agonist (zolpidem 10 mg, zaleplon 10 mg, or eszopiclone 2-3 mg) tonight to restore sleep urgently, as this represents acute severe sleep deprivation requiring immediate pharmacologic intervention. 1, 2

Immediate Action (Tonight)

First-line pharmacologic options for immediate use:

• Zolpidem 10 mg at bedtime - rapid onset (15-30 minutes), effective for sleep initiation, minimal next-day sedation 1, 2
• Zaleplon 10 mg at bedtime - ultra-short half-life (1 hour), can even be given middle-of-night if needed, no residual morning effects 1, 3
• Eszopiclone 2-3 mg at bedtime - effective for both sleep onset and maintenance, longer duration than zolpidem 1, 2

Alternative if BzRAs unavailable:

• Ramelteon 8 mg - particularly appropriate if patient has substance use history, zero addiction potential, though slower onset than BzRAs 1, 4

What NOT to Give

Avoid these medications for acute severe insomnia:

• Antihistamines (diphenhydramine, doxylamine) - lack efficacy data, cause anticholinergic effects (confusion, urinary retention, falls), significant daytime sedation 1, 2
• Trazodone 50 mg - insufficient evidence for primary insomnia, not recommended by guidelines 1, 2, 5
• Atypical antipsychotics (quetiapine, olanzapine) - explicitly warned against due to weak evidence and significant adverse effects including weight gain, metabolic syndrome, neurological side effects 1, 2
• Long-acting benzodiazepines (lorazepam, clonazepam) - excessive morning sedation, cognitive impairment, fall risk, not appropriate for acute management 1, 6

Critical Assessment Before Prescribing

Evaluate for underlying causes requiring different management:

• Sleep apnea symptoms - loud snoring, witnessed apneas, gasping - requires polysomnography, not hypnotics 7
• Substance use - stimulants, caffeine, alcohol - address causative agent first 1
• Psychiatric emergency - acute mania, severe anxiety, psychosis - requires psychiatric evaluation and different pharmacotherapy 1
• Medical causes - pain, dyspnea, nocturia - treat underlying condition concurrently 1

Follow-Up Plan (Next 1-2 Weeks)

After immediate crisis resolution:

1. Reassess after 1-2 nights - evaluate sleep latency, total sleep time, daytime functioning 2
2. If insomnia persists beyond 3-5 days, initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as definitive treatment - includes stimulus control, sleep restriction, relaxation training 1, 2
3. Continue short-term hypnotic use (maximum 2-4 weeks) while implementing CBT-I, using lowest effective dose 1, 2
4. Taper medication gradually once sleep normalizes - reduce dose by smallest increment over several days to weeks to minimize rebound insomnia 1

Special Population Considerations

For elderly patients (≥65 years):

• Reduce zolpidem to 5 mg (not 10 mg) due to increased fall risk 2
• Prefer ramelteon 8 mg or zaleplon 5-10 mg - minimal cognitive impairment and fall risk 1, 2
• Avoid temazepam and long-acting benzodiazepines completely - excessive cognitive impairment 1, 2

For patients with substance use history:

• Ramelteon 8 mg is the only appropriate choice - non-DEA scheduled, zero abuse potential 1, 2, 4

For patients with hepatic impairment:

• Reduce eszopiclone to 1 mg maximum 2
• Ramelteon remains safe option 2

Critical Safety Warnings

Inform patient about:

• Complex sleep behaviors - sleepwalking, sleep-driving with all BzRAs, FDA black box warning 2
• Next-day driving impairment - particularly with zolpidem, avoid driving for 8 hours after dose 2
• Avoid alcohol - potentiates sedation and respiratory depression 1
• Single dose tonight, then reassess - do not continue nightly without re-evaluation 1