GIM Question 16 Instructor

You are called to the ward because a patient is requesting a sleeping aid.

  1. What are important questions to ask this patient?
    Insomnia in the hospital setting can have many causes. The best treatment for insomnia is managing the underlying cause.
    Questions to ask the patient include:

    • Why are they unable to sleep?
    • Pain/ breathlessness/ nausea/ anxiety/ discomfort
    • Have they had difficulty sleeping in the past?
    • Do they take sleeping aides regularly?
  2. What non-pharmacological strategies can you use for insomnia?
    Non-pharmacological treatments are preferred when possible. These include reorientation (providing a familiar environment and family members) and use of earplugs if the patient is bothered by noises.
  3. What medications can you offer this patient?
    Pharmacologic options include:

    • Non-benzodiazepine medication – Zopiclone
    • Benzodiazepines – diazepam, lorazepam, temazepam
    • Melatonin receptor agonists (contraindicated in liver failure)- ramelteon
    • Antihistamine (not as effective at inducing sleep, and has anticholinergic properties, so be careful in elderly) – diphenhydramine, doxylamine, hydroxyzine
    • Antidepressant (have anticholinergic properties) – amitriptyline, trazodone, mirtazapine
  4. What is your first choice medication?
    If a patient was on a sleeping medication prior to admission, start that patient on the same medication. If not, benzodiazepines or non-benzodiazepine medications are often first choice since they have a rapid onset and less anticholinergic properties.

Ramakrishnan K and Scheid DC. Treatment Options for Insomnia. Am Fam Physician. 2007, 76:517-526.

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