(& Insomnia)

Insomnia is very common in hospitalized patients. It can result from anxiety, physical discomfort, or just hospitalization in general. After ruling out more severe causes, such as delirium or mania, there is much to be done to help with insomnia.

Behavioral interventions include ensuring fewer nighttime awakenings and increased sunlight during the day. Caffeine at anytime can increase insomnia.

To treat insomnia, benzodiazepines are very effective, but as with anxiety disorders should only be used for a brief period. Longer acting benzodiazepines are better, such as temazepam (15 mg to start, and can increase to 30 mg). Lorazepam and oxazepam are not very sedating and are less than ideal.

In addition to benzodiazepines, diphenhydramine is a great choice at 25-50 mg. If those doses are not effective, then higher doses can be used. Trazodone (starting at 50-100 mg) is reasonable, though sometimes patients experience a 'hangover' afterwards.

More contemporary hypnotics, such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata) are fairly expensive but reasonably effective. Zolpidem has been associated with sleep-walking and sleep-driving. All should be given only over limited periods.

Ramelteon (Rozerem) is a novel hypnotic that has a high affinity for melatonin receptors. It has no affinity for GABA receptors. Ramelteon does have an active metabolite that is has a lower receptor affinity. Ramelteon also has rapid absorption and efficacy. Since there is no GABA activity, it is not a controlled substance and can be used indefinitely. Of course, it is expensive.