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An Implementation Guide to Promote Sleep and Reduce Sedative-Hypnotic Initiation for Noncritically Ill Inpatients

Educational Objective
To summarize effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation among inpatients and to propose an implementation strategy to guide quality-improvement teams.
1 Credit CME

Sedative-hypnotic medications are frequently prescribed for hospitalized patients with insomnia, but they can result in preventable harm such as delirium, falls, hip fractures, and increased morbidity. Furthermore, sedative-hypnotic initiation while in the hospital carries a risk of chronic use after discharge. Disrupted sleep is a major contributor to sedative-hypnotic use among patients in the hospital and other institutional settings. Numerous multicomponent studies on improving sleep quality in these settings have been described, some demonstrating an associated reduction of sedative-hypnotic prescriptions. This selected review summarizes effective interventions aimed at promoting sleep and reducing inappropriate sedative-hypnotic initiation and proposes an implementation strategy to guide quality improvement teams.

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Article Information

Accepted for Publication: March 14, 2019.

Corresponding Author: Christine Soong, MD, MSc, Division of General Internal Medicine, Mount Sinai Hospital, 433-600 University Ave, Toronto, Ontario M5G 1X5, Canada (

Published Online: June 3, 2019. doi:10.1001/jamainternmed.2019.1196

Author Contributions: Dr Soong had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Soong, Burry, Cho, Gathecha, Kisuule, Tannenbaum, Morgenthaler.

Acquisition, analysis, or interpretation of data: Soong, Burry, Cho, Gathecha, Tannenbaum, Vijenthira, Morgenthaler.

Drafting of the manuscript: Soong, Burry, Morgenthaler.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Soong.

Administrative, technical, or material support: Soong.

Supervision: Soong, Tannenbaum.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Pamela Johnson, MD, Department of Radiology, Johns Hopkins University, and Justin Turner, PhD, Faculty of Pharmacy, Université de Montréal, provided review and helpful suggestions in the development of this guide. They were not compensated for their contributions.

Additional Information: Drs Soong, Burry, Cho, Gathecha, Kisuule, Vijenthira, and Morgenthaler are members of the High Value Practice Academic Alliance. The High Value Practice Academic Alliance is a consortium of academic medical centers in the United States and Canada working to advance high-value health care through collaborative quality improvement, research and education. For additional information, visit

Bachhuber  MA, Hennessy  S, Cunningham  CO, Starrels  JL.  Increasing benzodiazepine prescriptions and overdose mortality in the United States, 1996-2013.  Am J Public Health. 2016;106(4):686-688. doi:10.2105/AJPH.2016.303061PubMedGoogle ScholarCrossref
Kang  D-Y, Park  S, Rhee  C-W,  et al.  Zolpidem use and risk of fracture in elderly insomnia patients.  J Prev Med Public Health. 2012;45(4):219-226. doi:10.3961/jpmph.2012.45.4.219PubMedGoogle ScholarCrossref
Lyons  PG, Snyder  A, Sokol  S, Edelson  DP, Mokhlesi  B, Churpek  MM.  Association between opioid and benzodiazepine use and clinical deterioration in ward patients.  J Hosp Med. 2017;12(6):428-434. doi:10.12788/jhm.2749PubMedGoogle ScholarCrossref
Cumbler  E, Guerrasio  J, Kim  J, Glasheen  J.  Use of medications for insomnia in the hospitalized geriatric population.  J Am Geriatr Soc. 2008;56(3):579-581. doi:10.1111/j.1532-5415.2008.01598.xPubMedGoogle ScholarCrossref
Agarwal  SD, Landon  BE.  Patterns in outpatient benzodiazepine prescribing in the United States.  JAMA Netw Open. 2019;2(1):e187399. doi:10.1001/jamanetworkopen.2018.7399PubMedGoogle ScholarCrossref
Black  CD, McCarthy  L, Gomes  T, Mamdani  M, Juurlink  D, Tadrous  M.  Interprovincial variation of psychotropic prescriptions dispensed to older Canadian adults.  Can Geriatr J. 2018;21(3):269-273. doi:10.5770/cgj.21.307PubMedGoogle ScholarCrossref
Finkle  WD, Der  JS, Greenland  S,  et al.  Risk of fractures requiring hospitalization after an initial prescription for zolpidem, alprazolam, lorazepam, or diazepam in older adults.  J Am Geriatr Soc. 2011;59(10):1883-1890. doi:10.1111/j.1532-5415.2011.03591.xPubMedGoogle ScholarCrossref
Allain  H, Bentué-Ferrer  D, Polard  E, Akwa  Y, Patat  A.  Postural instability and consequent falls and hip fractures associated with use of hypnotics in the elderly: a comparative review.  Drugs Aging. 2005;22(9):749-765. doi:10.2165/00002512-200522090-00004PubMedGoogle ScholarCrossref
American Geriatrics Society 2015 Beers Criteria Update Expert Panel.  American Geriatrics Society 2015 Updated Beers criteria for potentially inappropriate medication use in older adults.  J Am Geriatr Soc. 2015;63(11):2227-2246. doi:10.1111/jgs.13702PubMedGoogle ScholarCrossref
Pek  EA, Remfry  A, Pendrith  C, Fan-Lun  C, Bhatia  RS, Soong  C.  High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults.  J Hosp Med. 2017;12(5):310-316. doi:10.12788/jhm.2739PubMedGoogle ScholarCrossref
Garrido  MM, Prigerson  HG, Penrod  JD, Jones  SC, Boockvar  KS.  Benzodiazepine and sedative-hypnotic use among older seriously ill veterans: choosing wisely?  Clin Ther. 2014;36(11):1547-1554. doi:10.1016/j.clinthera.2014.10.007PubMedGoogle ScholarCrossref
Choosing Wisely Canada. Hospital medicine: five things physicians and patients should question. Updated June 2017. Accessed February 5, 2019.
Choosing Wisely Canada. Geriatrics: five things physicians and patients should question. Updated June 2017. Accessed March 6, 2016.
Choosing Wisely. American Academy of Nursing. Published June 12, 2016. Accessed February 5, 2019.
Gillis  CM, Poyant  JO, Degrado  JR, Ye  L, Anger  KE, Owens  RL.  Inpatient pharmacological sleep aid utilization is common at a tertiary medical center.  J Hosp Med. 2014;9(10):652-657. doi:10.1002/jhm.2246PubMedGoogle ScholarCrossref
Frels  C, Williams  P, Narayanan  S, Gariballa  SE.  Iatrogenic causes of falls in hospitalised elderly patients: a case-control study.  Postgrad Med J. 2002;78(922):487-489. doi:10.1136/pmj.78.922.487PubMedGoogle ScholarCrossref
Kolla  BP, Lovely  JK, Mansukhani  MP, Morgenthaler  TI.  Zolpidem is independently associated with increased risk of inpatient falls.  J Hosp Med. 2013;8(1):1-6. doi:10.1002/jhm.1985PubMedGoogle ScholarCrossref
O’Reilly  R, Rusnak  C.  The use of sedative-hypnotic drugs in a university teaching hospital.  CMAJ. 1990;142(6):585-589.PubMedGoogle Scholar
Nakao  M, Sato  M, Nomura  K, Yano  E.  Benzodiazepine prescription and length of hospital stay at a Japanese university hospital.  Biopsychosoc Med. 2009;3:10. doi:10.1186/1751-0759-3-10PubMedGoogle ScholarCrossref
Bell  CM, Fischer  HD, Gill  SS,  et al.  Initiation of benzodiazepines in the elderly after hospitalization.  J Gen Intern Med. 2007;22(7):1024-1029. doi:10.1007/s11606-007-0194-4PubMedGoogle ScholarCrossref
Zisberg  A, Shadmi  E, Sinoff  G, Gur-Yaish  N, Srulovici  E, Shochat  T.  Hospitalization as a turning point for sleep medication use in older adults: prospective cohort study.  Drugs Aging. 2012;29(7):565-576. doi:10.1007/BF03262274PubMedGoogle ScholarCrossref
Perry  SW, Wu  A.  Rationale for the use of hypnotic agents in a general hospital.  Ann Intern Med. 1984;100(3):441-446. doi:10.7326/0003-4819-100-3-441PubMedGoogle ScholarCrossref
Grad  RM.  Benzodiazepines for insomnia in community-dwelling elderly: a review of benefit and risk.  J Fam Pract. 1995;41(5):473-481.PubMedGoogle Scholar
Flaherty  JH.  Insomnia among hospitalized older persons.  Clin Geriatr Med. 2008;24(1):51-67, vi. doi:10.1016/j.cger.2007.08.012PubMedGoogle ScholarCrossref
Glass  J, Lanctôt  KL, Herrmann  N, Sproule  BA, Busto  UE.  Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits.  BMJ. 2005;331(7526):1169. doi:10.1136/bmj.38623.768588.47PubMedGoogle ScholarCrossref
Wilt  TJ, MacDonald  R, Brasure  M,  et al.  Pharmacologic treatment of insomnia disorder: an evidence report for a clinical practice guideline by the American College of Physicians.  Ann Intern Med. 2016;165(2):103-112. doi:10.7326/M15-1781PubMedGoogle ScholarCrossref
Bartick  MC, Thai  X, Schmidt  T, Altaye  A, Solet  JM.  Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff.  J Hosp Med. 2010;5(3):E20-E24. doi:10.1002/jhm.549PubMedGoogle Scholar
Chung  S, Youn  S, Park  B, Lee  S, Kim  C.  A sleep education and hypnotics reduction program for hospitalized patients at a general hospital.  Psychiatry Investig. 2018;15(1):78-83. doi:10.4306/pi.2018.15.1.78PubMedGoogle ScholarCrossref
McDowell  JA, Mion  LC, Lydon  TJ, Inouye  SK.  A nonpharmacologic sleep protocol for hospitalized older patients.  J Am Geriatr Soc. 1998;46(6):700-705. doi:10.1111/j.1532-5415.1998.tb03803.xPubMedGoogle ScholarCrossref
Lareau  R, Benson  L, Watcharotone  K, Manguba  G.  Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients.  Geriatr Nurs. 2008;29(3):197-206. doi:10.1016/j.gerinurse.2007.10.020PubMedGoogle ScholarCrossref
Browne  C, Kingston  C, Keane  C.  Falls prevention focused medication review by a pharmacist in an acute hospital: implications for future practice.  Int J Clin Pharm. 2014;36(5):969-975. doi:10.1007/s11096-014-9980-3PubMedGoogle ScholarCrossref
Nishtala  PS, Hilmer  SN, McLachlan  AJ, Hannan  PJ, Chen  TF.  Impact of residential medication management reviews on drug burden index in aged-care homes: a retrospective analysis.  Drugs Aging. 2009;26(8):677-686. doi:10.2165/11316440-000000000-00000PubMedGoogle ScholarCrossref
Crotty  M, Halbert  J, Rowett  D,  et al.  An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing.  Age Ageing. 2004;33(6):612-617. doi:10.1093/ageing/afh213PubMedGoogle ScholarCrossref
Avorn  J, Soumerai  SB, Everitt  DE,  et al.  A randomized trial of a program to reduce the use of psychoactive drugs in nursing homes.  N Engl J Med. 1992;327(3):168-173. doi:10.1056/NEJM199207163270306PubMedGoogle ScholarCrossref
Elliott  RA, Woodward  MC, Oborne  CA.  Improving benzodiazepine prescribing for elderly hospital inpatients using audit and multidisciplinary feedback.  Intern Med J. 2001;31(9):529-535. doi:10.1046/j.1445-5994.2001.00139.xPubMedGoogle ScholarCrossref
Kashyap  M, D’Cruz  S, Sachdev  A, Tiwari  P.  Evidence-based information leads to reduction in inappropriate drug prescribing: results from Indian older inpatients.  Int J Risk Saf Med. 2015;27(4):209-217. doi:10.3233/JRS-150665PubMedGoogle ScholarCrossref
Agostini  JV, Zhang  Y, Inouye  SK.  Use of a computer-based reminder to improve sedative-hypnotic prescribing in older hospitalized patients.  J Am Geriatr Soc. 2007;55(1):43-48. doi:10.1111/j.1532-5415.2006.01006.xPubMedGoogle ScholarCrossref
Carey  DL, Day  RO, Cairns  DR, Pearce  GA, Wodak  AD, Lauchlan  RL.  An attempt to influence hypnotic and sedative drug use.  Med J Aust. 1992;156(6):389-392, 396. doi:10.5694/j.1326-5377.1992.tb139841.xPubMedGoogle Scholar
Westbury  J, Jackson  S, Gee  P, Peterson  G.  An effective approach to decrease antipsychotic and benzodiazepine use in nursing homes: the RedUSe project.  Int Psychogeriatr. 2010;22(1):26-36. doi:10.1017/S1041610209991128PubMedGoogle ScholarCrossref
Hanlon  JT, Schmader  KE.  The medication appropriateness index at 20: where it started, where it has been, and where it may be going.  Drugs Aging. 2013;30(11):893-900. doi:10.1007/s40266-013-0118-4PubMedGoogle ScholarCrossref
Hagen  BF, Armstrong-Esther  C, Quail  P,  et al.  Neuroleptic and benzodiazepine use in long-term care in urban and rural Alberta: characteristics and results of an education intervention to ensure appropriate use.  Int Psychogeriatr. 2005;17(4):631-652. doi:10.1017/S1041610205002188PubMedGoogle ScholarCrossref
Westbury  J, Tichelaar  L, Peterson  G, Gee  P, Jackson  S.  A 12-month follow-up study of “RedUSe”: a trial aimed at reducing antipsychotic and benzodiazepine use in nursing homes.  Int Psychogeriatr. 2011;23(8):1260-1269. doi:10.1017/S1041610211000421PubMedGoogle ScholarCrossref
Larkin  I, Ang  D, Steinhart  J,  et al.  Association between academic medical center pharmaceutical detailing policies and physician prescribing.  JAMA. 2017;317(17):1785-1795. doi:10.1001/jama.2017.4039PubMedGoogle ScholarCrossref
Ivers  N, Jamtvedt  G, Flottorp  S,  et al.  Audit and feedback: effects on professional practice and healthcare outcomes.  Cochrane Database Syst Rev. 2012;(6):CD000259. doi:10.1002/14651858.CD000259PubMedGoogle Scholar
Colla  CH, Mainor  AJ, Hargreaves  C, Sequist  T, Morden  N.  Interventions aimed at reducing use of low-value health services: a systematic review.  Med Care Res Rev. 2017;74(5):507-550. doi:10.1177/1077558716656970PubMedGoogle ScholarCrossref
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