Geriatric Quick Consult Patient Can't Sleep Do #5
|
| Knowledge | Action |
|---|---|
| In general, short acting hypnotics, like Zolpidem (Ambien) and Zaleplon (Sonata), are more helpful for sleep onset than sleep maintenance insomnia and cause less daytime sedation.
Zolpidem and Zaleplon, are not benzodiazepines, are not anxiolitic and offer the advantage of avoiding rebound insomnia or anxiety at discontinuation. They should be used with caution in patients with severe COPD and obstructive sleep apnea (OSA), although preliminary data show that they are safe in patients with mild or moderate COPD. At the recommended dose of 5 mg, zolpidem was as effective as triazolam; but CNS side effects (nightmares, agitation and drowsiness) were noted in 10% of elderly hospitalized insomniacs treated with this medication. One study of zolpidem use by older people found a two-fold increase in risk of hip fractures. Zaleplon has an onset of action of 15-30 minutes and a half life of about 1 hour. Thus it appears to cause little daytime sedation and may be useful for patients who have delayed sleep onset. It will not help with nighttime awakenings. The most common adverse effects of Zaleplon are headache and dizziness. Like benzodiazepine hypnotics, zolpidem and zaleplon are approved by the FDA only for short-term use. |
|
|
Intermediate acting benzodiazepines, like temazepam, estazolam and lorazepam, are more helpful for sleep maintenance.
Temazepam is preferable to estazolam as it undergoes hepatic conjugation, while estazolam undergoes oxidative metabolism. Drugs undergoing oxidative metabolism are more susceptible to drug interaction and their clearance may be decreased in older patients and patients with liver dysfunction. Lorazepam is not approved by the FDA for insomnia, but it has pharmacological properties similar to temazepam and is available for intravenous use. A small dose (0.25 mg) may be helpful for patient with significant anxiety due to the hospitalization that does not respond to discussion and reassurance. Intermediate acting agents cause less withdrawal and rebound then short acting benzodiazepines, but may cause more daytime sedation. |
Note: Interim benzodiazepines may cause daytime sedation. |
| Low dose sedating antidepressants like trazodone, (25-50 mg) or nefazodone (50 mg) may be used at night for insomnia, particularly in patients with depression.
They are not FDA approved as hypnotics in patients without depression. They have a low abuse potential and no effect on respiratory drive, making them particularly useful in patients with a history of drug abuse, severe COPD or OSA. Orthostatic hypotension and GI upset are less likely with nefazodone compared to trazodone. Orthostatic hypotension can be minimized by administration with food. Avoid using Triazolam (Halcion) or long acting benzodiazepines (see DON'Ts). |
|
