I generally don't unless it's a home medication. All of my adult pts are on narcotic pain meds, sometimes a lot in the early post-op period, so I tend to shy away from adding benzos or z-drugs unless they've already been taking and tolerating them at home.
My go to sleep meds:
1) melatonin prn for every adult pt - the night person will thank you
then other options depending on the person's other meds and pmhx -
2) benadryl
3) hydroxyzine
4) seroquel
5) Trazadone
6) Tizanidine
7) Gabapentin
I would change the order of you list and have other thoughts.
1 mg melatonin PRN, and if not effective after an hour another 1 mg, I don't like to go to 3 mg because there's risk of a paradoxical effect although some patients can tolerate 5 mg, but those are ones that are usually coming in and have been on it a while. Sometimes it's the actual effect of melatonin that sees them off to sleep, sometimes it's the placebo of being given a pill x 2 that is working for you. Point being, you can hardly hurt someone with it.
I would give trazodone next, I strongly disagree with having benadryl or hydroxyzine next because of the anticholinergic effects, I think that's bad for the elderly and would not use those for sleep unless I had to, they're reasonable if the patient is on narcotics and has nausea/itching as opiates can cause histamine reaction
I would give ambien for sleep next instead of working further down your list
I would not give seroquel for sleep unless the patient was agitated or delirious. I take antipsychotic use pretty seriously. It has anticholinergic side effects like urinary retention even at low doses. It can *cause* delirium in the patient that isn't delirious. (its role in treating delirium has more to do with calming agitation and helping to stabilize wake/sleep cycle, and restoring *that* is what is most effective in clearing delirium, these are the ends to which it is useful for delirium). Also it can cause akathisia even at low doses and *that* can definitely interfere with sleep. Also be sensitive to the risk of akathisia in delirious patients, if they're not settling down as you increase dose that could be a factor to consider.
I've not familiar with tizanidine
I can't say I know much about using gabapentin off label for insomnia.
The fact is that sleeping in the hospital sucks balls and sometimes they have to just deal. Not every bit of discomfort in the hospital can be addressed or should be treated with a pill.
Always ask *why* the patient can't fall asleep. That can help steer your intervention as I state below.
Try warm milk or herbal tea first, or warm broth. Heck, maybe some ice cream. Maybe someone isn't super hungry but a treat in the belly can help sleep.
Can also try a warming pad - even in the absence of back pain it can help, on the belly or back can make you feel sleepy.
If pain is a factor, you can try icing (sounds weird for sleep no one likes cold, but if you get a painful spot numb, sometimes that can help you fall asleep) or lidocaine patch. Otherwise offer APAP/ibuprofen as appropriate.
If noise is a factor, some hospitals have stocked ear plugs, they can also be trimmed down with scissors if too large for the canal to sleep with.
I've never known a hospital to carry a facemask if light is an issue (pull the blinds, it doesn't take much light from equipment/moon to interfere with sleep) but if sleep is an ongoing problem for this reason and the patient might tolerate a facemask, suggest family/patient try to get one from giftshop where you can usually find one. Or try placing a wash cloth over the eyes to sleep.
Melatonin as stated.
Trazodone
Ambien
Benadryl or hydroxizine as stated
Seroquel - not for sleep but if otherwise appropriate as stated
Ativan - IF appropriate. I would avoid for risk of delirium but it's fine in some patients. Appropriate if anxiety is a factor. Otherwise I avoid like the plague.
To be honest, I've almost never had to go higher than trazodone unless delirious or it's a home med.
Otherwise, they may just have to tough it out.
That would be my strategies, after that the patient will just have to deal.
