Sleep Management for Hospitalized Inpatients
Implement noise and light reduction strategies with earplugs and eyeshades as the cornerstone of inpatient sleep management, while avoiding routine pharmacologic sleep aids unless absolutely necessary. 1, 2
Nonpharmacologic Interventions (First-Line Approach)
Environmental Modifications
- Provide earplugs and eyeshades to all patients – this low-cost intervention improves patient-reported sleep quality and reduces delirium risk 1, 2
- Reduce nighttime noise and light exposure through dimming lights, closing doors, and minimizing alarms 1, 2
- Cluster patient care activities to minimize nighttime interruptions, particularly protecting the 12:00 AM to 5:00 AM window 2
- Designate quiet time periods on both day and night shifts 2
The Society of Critical Care Medicine guidelines specifically recommend noise and light reduction strategies based on RCT evidence showing maintained preoperative sleep quality in cardiac surgery patients and reduced delirium in nonsedated critically ill adults 1. While the evidence quality is low due to lack of blinding and inclusion of less severely ill patients, the intervention carries minimal risk and low cost 1.
Additional Nonpharmacologic Options
- Consider relaxing music only if specifically requested by patients, though evidence for efficacy is limited 1, 2
- The Society of Critical Care Medicine suggests against routinely using aromatherapy or acupressure due to resource requirements and limited evidence 1
Pharmacologic Interventions (Use Sparingly)
General Principles
- Avoid routine use of sleep medications in hospitalized patients – the evidence for efficacy is limited and risks often outweigh benefits 2
- When pharmacotherapy is necessary, use the lowest effective dose for the shortest duration possible 2, 3, 4
- Always attempt nonpharmacologic interventions first 2
Medication Options (When Necessary)
Melatonin:
- Most commonly prescribed inpatient sleep aid despite limited efficacy evidence 2
- The Society of Critical Care Medicine makes no recommendation for or against melatonin use due to minimal adverse effects balanced against lack of high-quality evidence 2
- Consider for patients with circadian rhythm disruption 2
Short-Acting Benzodiazepine Receptor Agonists:
- Zolpidem (immediate-release) or eszopiclone may be considered for short-term use 2, 3, 4
- Critical FDA warnings: Both carry risks of complex sleep behaviors (sleep-driving, sleep-walking), next-day impairment, falls (especially in elderly), and CNS depression 3, 4
- Zolpidem requires a full 7-8 hours of sleep time remaining and patients must be warned against driving the next day 4
- Eszopiclone at 2-3 mg doses can impair daytime function even when used as prescribed 3
- Discontinue immediately if complex sleep behaviors occur 4
Low-Dose Doxepin:
- Consider 3-6 mg for sleep maintenance insomnia 2
- Available in liquid formulation, making it suitable for patients with PEG tubes 2
Trazodone:
- May be appropriate for patients with comorbid depression or anxiety 2
Medications to Avoid
- Never use first-generation antihistamines (diphenhydramine, hydroxyzine) due to anticholinergic effects and increased delirium risk, particularly in older adults 2, 5
- Avoid benzodiazepines due to increased fall risk, cognitive impairment, and adverse events 5
Special Considerations
Patients with Feeding Tubes
- Use medications available in liquid formulations (doxepin) or immediate-release tablets that can be crushed and dissolved (zolpidem immediate-release) 2
- Never crush extended-release or enteric-coated formulations 2
Elderly Patients
- Heightened risk of falls, cognitive impairment, and next-day psychomotor impairment with all sedative-hypnotics 3, 4
- Monitor closely for excessive sedation, confusion, and falls 2
- Zolpidem and eszopiclone carry specific warnings about increased fall risk in elderly patients 4
Monitoring Requirements
- Assess for delirium development, as poor sleep is associated with 30% increased risk of mental status changes 1
- Monitor for next-day impairment, which can occur even in the absence of subjective symptoms 3
- Evaluate for underlying causes of sleep disturbance (pain, nocturia, medications, anxiety) rather than reflexively prescribing sleep aids 1, 2
Critical Pitfalls to Avoid
- Do not routinely use physiologic sleep monitoring (polysomnography, actigraphy, BIS) in hospitalized patients – the Society of Critical Care Medicine recommends against this due to lack of evidence for improved outcomes 1
- Do not ignore the association between poor sleep and delirium – while causation is unproven, the correlation is strong enough to warrant sleep-protective interventions 1
- Do not prescribe sleep medications without first attempting environmental modifications 2
- Do not continue sleep medications long-term without reassessing need and attempting nonpharmacologic alternatives 2
- Recognize that alcohol and other CNS depressants dramatically increase risks with sedative-hypnotics – specifically counsel patients not to use zolpidem or eszopiclone if they consumed alcohol that evening 3, 4
Implementation Algorithm
Assess for modifiable factors: Review medications that disrupt sleep (β-blockers, bronchodilators, corticosteroids, diuretics, SSRIs), evaluate pain control, identify environmental disruptors 1, 2
Implement environmental modifications: Provide earplugs and eyeshades, reduce noise and light, cluster care activities 1, 2
If sleep remains poor after 24-48 hours of environmental interventions: Consider short-term pharmacotherapy with melatonin (first choice due to safety profile) or low-dose doxepin 3-6 mg for sleep maintenance 2
Reserve zolpidem/eszopiclone for refractory cases only: Use lowest dose, ensure 7-8 hours sleep time available, counsel about next-day driving impairment, discontinue if complex sleep behaviors occur 3, 4
Reassess daily: Attempt to discontinue medications as soon as possible, continue environmental modifications throughout hospitalization 2