Medications for Anxiety and Sleep in the Hospital Setting

Sleep Disturbances in Hospitalized Patients

The American Academy of Sleep Medicine recommends short-to-intermediate acting benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon, temazepam) or ramelteon as first-line pharmacologic treatment for hospitalized patients with sleep disturbances, with trazodone (25-100 mg at bedtime) as an effective alternative, particularly when comorbid depression or anxiety is present 1, 2
Zolpidem 5 mg at bedtime is recommended for sleep onset difficulty, with a very short half-life, reducing sleep latency with minimal residual sedation 1, 3
Temazepam is suitable for patients needing help with sleep maintenance, not just initiation, with a medium duration of action, improving both sleep onset and maintenance 1
Zaleplon is recommended for sleep initiation with minimal morning effects, with an ultra-short half-life 1, 4
Eszopiclone is effective for sleep maintenance but has a higher risk of residual sedation, with a longer half-life 1, 4
Ramelteon is a non-DEA scheduled alternative, particularly appropriate for patients with substance use history 1, 4
Trazodone 25-100 mg at bedtime is specifically recommended for hospital settings, particularly useful when treating comorbid depression or anxiety 1, 3

For acute anxiety or agitation, benzodiazepines remain first-line, with lorazepam 0.5-1 mg (oral, sublingual, subcutaneous, or IV) recommended, using lower doses (0.25-0.5 mg) in elderly, frail patients, or when co-administered with antipsychotics 6, 3
Midazolam 2.5 mg subcutaneous or IV is recommended for severe agitation and distress, using lower doses (0.5-1 mg) in elderly or when combined with antipsychotics 6

Patient education must include treatment goals, realistic expectations, safety concerns, and potential side effects, with the American Academy of Sleep Medicine recommending patient education on treatment goals and realistic expectations 1, 2
Monitoring requirements include following patients every few weeks initially to assess effectiveness and side effects, using the lowest effective maintenance dose, and attempting medication tapering when conditions allow 1, 2
The American Academy of Sleep Medicine recommends starting with lowest doses of all sedative-hypnotics in elderly patients, with higher risk of falls, confusion, oversedation, and memory impairment 6
Extreme caution is required with benzodiazepines in patients with respiratory compromise, due to respiratory depression risk, with the American Academy of Sleep Medicine recommending considering non-benzodiazepine alternatives first 6, 5

The National Comprehensive Cancer Network recommends assessing sleep disturbance type using validated tools (Epworth Sleepiness Scale), ruling out and treating contributing factors, and initiating pharmacotherapy based on sleep disturbance type 3
The American Academy of Sleep Medicine recommends initiating pharmacotherapy with zolpidem 5 mg or zaleplon for sleep onset difficulty, temazepam or eszopiclone for sleep maintenance difficulty, trazodone 25-100 mg for comorbid anxiety/depression, and ramelteon for substance use history 1, 3, 4