Psychosocial, Behavioral & Cognitive · Topic 7 of 7

Sleep Disturbance & Insomnia in the Hospital

Psychosocial · sleep in the hospital

Sleep Disturbance & Insomnia in the Hospital

Fix the cause and the environment first; in older adults, benzodiazepines, Z-drugs and diphenhydramine are Beers drugs to avoid.

Key numbers

Safer: low-dose doxepin, ramelteon, orexin antagonistdoxepin ≤ 6 mg

01 · AvoidAvoid benzodiazepines, Z-drugs and diphenhydramine

In adults 65 and older, avoid benzodiazepines, Z-drugs (zolpidem, eszopiclone, zaleplon) and first-generation antihistamines (diphenhydramine, hydroxyzine, doxylamine) for sleep: they cause delirium, falls and fractures (AGS Beers 2023, strong).

02 · DoReduce noise and light at night

Use noise and light reduction at night (earplugs, eye masks, dimmed lights) within a multicomponent sleep-promoting protocol; SCCM suggests both for critically ill adults.

03 · GiveSafer: low-dose doxepin, ramelteon, orexin antagonist

If a hypnotic is truly needed in an older adult, safer short-term choices are low-dose doxepin (≤ 6 mg), ramelteon, or an orexin antagonist (suvorexant, lemborexant, daridorexant).

Causes & risk factors

Why it happens

ICU sleep disruptors: pain, environment, interruptionsIn the ICU, sleep quality is disrupted by pain, environmental noise and light, care-related interruptions, psychological distress, respiratory factors and medications.

Hospitalization causes short-lived adjustment insomniaHospitalization is an acute stressor that causes adjustment insomnia, which usually resolves once the stressor abates; poor sleep hygiene, caffeine and daytime naps worsen it.

Do right now

In this order

First moves

Treat the cause; sleep hygiene before hypnotics

→

Reduce noise and light at night

→

Safer: low-dose doxepin, ramelteon, orexin antagonistdoxepin ≤ 6 mg

Why each step

Treat the cause; sleep hygiene before hypnoticsFind and treat what is keeping the patient awake — pain, dyspnea, nocturia, anxiety, medications, noise, light and nighttime care — and try sleep hygiene before any hypnotic, because hypnotics raise fall and delirium risk.

Reduce noise and light at nightUse noise and light reduction at night (earplugs, eye masks, dimmed lights) within a multicomponent sleep-promoting protocol; SCCM suggests both for critically ill adults.

Safer: low-dose doxepin, ramelteon, orexin antagonistIf a hypnotic is truly needed in an older adult, safer short-term choices are low-dose doxepin (≤ 6 mg), ramelteon, or an orexin antagonist (suvorexant, lemborexant, daridorexant).

Management

Orders

Diphenhydramine is not a sleep aidDiphenhydramine is highly anticholinergic (confusion, urinary retention, constipation) and tolerance to its sedation develops quickly; it should not be used for sleep or sedation — acute treatment of severe allergic reactions remains acceptable.

Z-drugs are not safer than benzodiazepinesZ-drugs carry benzodiazepine-like harms in older adults — delirium, falls, fractures, ED visits, motor vehicle crashes — with minimal improvement in sleep latency and duration.

Do not use antipsychotics as hypnoticsAntipsychotics such as quetiapine are not sleep drugs: Beers advises avoiding them except for FDA-approved indications or short-term antiemetic use, given stroke, cognitive-decline and mortality risk in dementia.

Melatonin is suggested for ICU patientsSCCM's 2025 focused update conditionally suggests melatonin for adults in the ICU (low-certainty evidence).

Stop hospital-started hypnotics before dischargeHypnotics started for hospital sleep are often continued unnecessarily at discharge; reconcile and stop them so a short-term inpatient drug does not become a chronic one.

Taper home benzodiazepines; never stop abruptlyPatients physically dependent on a home benzodiazepine should not have it stopped abruptly — withdrawal can cause seizures; continue it or taper gradually with a patient-specific plan.

Red flags & don'ts

Avoid harm

Do not give propofol to promote sleep avoidSCCM suggests not using propofol to improve sleep: it shows no sleep benefit and suppresses REM sleep, with hypotension and respiratory depression.

Poor sleep is linked to delirium complicationSleep disruption is thought to contribute to ICU delirium and prolonged ventilation; in one RCT, earplugs reduced delirium and improved perceived sleep (delirium management: see the Delirium sheet).

Hypnotics in older adults: avoid or safer?

Commonly confused

Examples	Benzodiazepines, zolpidem, eszopiclone, zaleplon, diphenhydramine, hydroxyzine
Main harms	Delirium, falls, fractures, motor vehicle crashes; anticholinergic effects (antihistamines)
Effect on sleep	Z-drugs: minimal gain in sleep latency and duration; tolerance to antihistamine sedation
Place in therapy	Avoid for insomnia

More detail

Reference

Show 5 reference facts

For ventilated patients, SCCM suggests assist-control rather than pressure-support ventilation at night to improve sleep (conditional, low-quality evidence).

SCCM made no recommendation on nighttime dexmedetomidine solely for sleep; if a stable patient already needs an overnight sedative infusion, dexmedetomidine is reasonable.

Long-acting benzodiazepines (diazepam, chlordiazepoxide, flurazepam) or their metabolites can have half-lives up to 96 hours in older adults, so toxicity may appear days to weeks after starting.

Beers advises against combining 3 or more CNS-active drugs (benzodiazepines, Z-drugs, opioids, antipsychotics, antidepressants, antiepileptics, muscle relaxants) because falls and fractures rise.

SCCM suggests against aromatherapy, acupressure or music at night solely to improve ICU sleep.

Pearl

For an older inpatient, the best sleeping pill is a quiet, dark, uninterrupted night.

Sources · Merck Manual Professional — Hospital Care and Older Adults · 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2023;71:2052–2081 · Merck Manual Professional — Drug Categories of Concern in Older Adults (anxiolytics and hypnotics) · Devlin JW et al. SCCM Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS). Crit Care Med 2018;46:e825–e873 · Lewis K et al. A focused update to the SCCM PADIS guidelines (anxiety, agitation/sedation, delirium, immobility, sleep). Crit Care Med 2025 (and executive summary) · Merck Manual Professional — Insomnia and Excessive Daytime Sleepiness (EDS) · Merck Manual Professional — Medication-Related Problems in Older Adults · FDA Drug Safety Communication (Sept 2020) — Boxed Warning updated for the benzodiazepine class: dependence and withdrawal; use a gradual taper · Merck Manual Professional — Pharmacokinetics in Older Adults · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).