Insomnia

1.     Ask nurse to check patient's allergies and/or other meds (for potential interactions). Think also about the patient's underlying medical conditions (i.e. does the patient have renal or hepatic dysfunction that is going to affect the clearance of what's being given?).

2.     Obtain a brief history by asking the nurse or evaluating the patient yourself to see if there is any underlying, potentially treatable problem that is causing the insomnia (e.g. pain).

  • Differential diagnosis: psychological (anxiety, grief), physical (pain, decreased mobility, dyspnea), delirium, infection, metabolic, polyuria (diuretics given at night), incontinence, underlying medical condition, sleep apnea.
  • Medications that can cause insomnia (only a partial list): anticholinergics, beta-agonists, clonidine, steroids, caffeine, nicotine, phenylephrine, dilantin, SSRI?s, theophylline, synthroid.

3.     Generally start with antihistamine, e.g. diphenhydramine (Benadryl) 25-50 mg or hydroxyzine (Atarax or Vistaril) 50-100 mg po qhs prn insomnia. Watch out for anticholinergic side-effects, especially in older patients (e.g. dry mouth, blurry vision, urinary retention, wackiness).

4.     Low dose trazodone is often effective. Sedative doses usually 25-50 mg po qhs prn although some patients may need up to 100-200 mg.  Especially useful in elderly patients.

5.     If above ineffective, benzodiazepines are often used next. Most commonly, medium half-life benzos are used such as temazepam (Restoril) 15-30 mg or lorazepam (Ativan) 0.5-1 mg po qhs prn insomnia.

6.     Medication dosing: normal vs. elderly or cirrhotic patients

  • Trazodone: start at 50 mg, max 300 mg.  If age > 65 or (+) cirrhosis, start at 25 mg, max 100 mg.
  • Ativan: start at 0.5-1.0 mg, max 4 mg.  If age > 65 or (+) cirrhosis, start at 0.25 mg, max 1 mg.
  • Restoril: start at 15 mg, max 30 mg.  If age > 65 or (+) cirrhosis, start at 7.5 mg, max 15 mg.

7.     If above measures do not work, you may want to evaluate patient first before giving more powerful sedatives.  In addition, in any patient in whom you think sedation is potentially dangerous (e.g. end- stage liver disease, severe COPD) evaluate the patient and consider not treating the insomnia.

 

Lenhart SE, Buysse DJ. Treatment of insomnia in hospitalized patients. Ann Pharmacother 2001; 35:1449-57.