Evaluation of Medications Used for Hospitalized Patients With Sleep Disturbances: A Frequency Analysis and Literature Review

Abstract

Purpose: Poor sleep during hospitalization is common and implicated in worse patient outcomes. Despite implementation of non-pharmacologic techniques, medications are still frequently required. The study objective is to assess the frequency of new medications administered for sleep in hospitalized patients and to review literature evaluating these drug therapies in the inpatient setting. Methods: This retrospective study included adult inpatients if they received a new medication for sleep during a 5-day period. Patients were excluded if the medication was continued from home or if sleep was not the documented indication. For the literature review, a MEDLINE search was conducted to identify studies pertaining to pharmacotherapy for sleep in hospitalized patients. Results: Of 1,968 patient-days reviewed, a medication for sleep was given for 166 patient-days (8.4%) in 78 patients. Melatonin was most commonly received (70.5%), followed by benzodiazepines (9.6%). A review of antihistamines, benzodiazepines, melatonin, quetiapine, trazodone, and Z-drugs (non-benzodiazepine hypnotics) was conducted and 23 studies were included. Conclusions: Despite widespread use of pharmacotherapy for sleep, there is a paucity of data evaluating use in the inpatient setting. Although there is significant heterogeneity among studies, melatonin has the strongest evidence for use and is an attractive option given its lack of adverse reactions and drug interactions. Benzodiazepines and Z-drugs were also frequently utilized; however, their reduced clearance in the elderly and potential for compounded sedative effects should be weighed heavily against potential sleep benefits. Antipsychotic agents cannot be recommended for routine use due to limited data and the potential for significant adverse effects.

Night-Time Noise and Sleep Quality in an Internal Medicine Ward in Portugal: An Observational Study

“…Our results regarding sedatives/hypnotic medicines showed that most patients frequently start these medications during hospitalization, which is undesirable, and values reached are higher than the 8% reported by White et al in the USA. 10 In their study, the most commonly prescribed drug was melatonin (70.5%), followed by benzodiazepines (9.6%) and zolpidem (8.4%). 10 Although melatonin is an interesting drug to be used, it is not available in our hospital.…”

“…10 In their study, the most commonly prescribed drug was melatonin (70.5%), followed by benzodiazepines (9.6%) and zolpidem (8.4%). 10 Although melatonin is an interesting drug to be used, it is not available in our hospital. 16 A positive point to notice is that hydroxyzine is no longer used prior and during hospitalization in elderly patients, since previous data from our department showed that hydroxyzine was a frequent inappropriately prescribed drug.…”

“…The PSQI is a questionnaire of 19 items, with a total range score from 0 (no sleep difficulty) to 21 (severe sleep difficulty), refers to the previous month of sleep and a score above 5 corresponds to bad sleep quality. 10 Both previous and current prescriptions of hypnotic/sedative drugs were reviewed from electronic medical records. They were classified as regular/daily, if they were prescribed for everyday and pro re nata (PRN), if prescribed 'as needed'.…”

Prescribing decision making by medical residents on night shifts: A qualitative study

“…12,14 Despite clinical guidelines recommending nonpharmacologic or less risky pharmacologic alternatives, they are often prescribed on night shifts to efficiently handle agitation, delirium or sleep concerns. [15][16][17][18] Unfortunately, suboptimal prescribing can lead to an increased risk of poor clinical outcomes, such as falls, particularly in older adults. 13,19,20 We believed that some of suboptimal prescribing could be related to how physicians, particularly medical residents, make decisions during times of stress.…”

“…System 1 thinking may be particularly problematic for potentially inappropriate medications with well‐known adverse effects, such as anti‐psychotics, benzodiazepines and sedative hypnotics (e.g., zolpidem or eszopiclone), which continue to be widely used despite recommendations from numerous professional societies against their use 12,14 . Despite clinical guidelines recommending nonpharmacologic or less risky pharmacologic alternatives, they are often prescribed on night shifts to efficiently handle agitation, delirium or sleep concerns 15–18 . Unfortunately, suboptimal prescribing can lead to an increased risk of poor clinical outcomes, such as falls, particularly in older adults 13,19,20 .…”