Ambien sleep amnesia9/12/2023 Other comorbid conditions, such as dementia, may also cloud a patient's clinical picture and make it difficult to determine if medications used as sleep aids are contributing to adverse effects. Clinical judgment is needed to weigh the potential risks and benefits of utilizing such agents and to tailor therapy based on patient-specific characteristics such as age, organ dysfunction, and drug interactions. In this case, hydroxyzine, a medication where both the parent drug and active metabolite are renally excreted, was used in an older patient on hemodialysis ( 7), further escalating the risk for prolonged accumulation and adverse effects. Since many medications are excreted by the kidneys, patients with renal dysfunction are at even higher risk for this. As patients age, the pharmacokinetics of many medications change due to slower metabolism and decreased clearance, which can lead to drug accumulation and a prolonged and increased effect. Patients with certain comorbid conditions may be at an increased risk for adverse effects from medications used to promote sleep. Patients may also experience anticholinergic adverse effects, such as urinary retention and xerostomia, from some sleep aid medications including diphenhydramine. Common adverse effects of sleep aids include residual daytime sedation leading to increased risk for falls, altered mental status (delirium), and respiratory depression.( 5) In one study ( 6), zolpidem tartrate was found to be an independent risk factor for falls in hospitalized patients. In fact, approximately 34% of patients who do not have a documented sleep disorder prior to hospitalization and were not previously prescribed a pharmacologic sleep aid are discharged from the hospital on a sleeping medication.( 4)ĭespite emerging evidence that sleep aid utilization is associated with adverse effects and detrimental outcomes, such medications are still commonly prescribed during hospital stays and on discharge.( 4) A wide variety of medication classes are used as sleep aids, including first generation antihistamines (e.g., diphenhydramine), benzodiazepines (e.g., lorazepam), antidepressants (e.g., amitriptyline), typical antipsychotics (e.g., haloperidol), atypical antipsychotics (e.g., quetiapine), melatonin, and melatonin agonists (e.g., ramelteon). Poor sleep among inpatients has multiple causes, including underlying illness(es), diagnostic and therapeutic procedures, medication effects, and environmental factors.( 1,2) Surveys reveal that as many as half of hospitalized general medicine patients complain of sleep disruptions.( 3) As a result, patients are frequently prescribed pharmacological sleep aids during hospitalizations. This case highlights the risks associated with sleep aid utilization in hospitalized adults. Although duplicate therapy alerts for zolpidem and hydroxyzine appeared on the order entry screen, it was a "soft stop" without management recommendations, and the ordering physician bypassed the alerts. Then, at the time of admission, she received additional doses of both medications. The zolpidem dose had also been increased from 5 mg to 10 mg at bedtime as needed. Two days later, the patient was alert, awake, fully oriented, and hemodynamically stable.Ĭase review revealed that prior to admission, the patient's nephrologist had added a prescription for hydroxyzine 25 mg by mouth at bedtime as needed, because the patient had been complaining of itchiness and continuously picked at her skin. A CT scan showed no evidence of a new stroke. The patient was transferred to the medical intensive care unit for close observation and hemodialysis. Laboratory results were suggestive of respiratory and metabolic acidosis. At 03:00, the nurse noted that the patient was agitated, crying out, "I will not cooperate until I get some rest." At 11:20, the nurse noted acute changes in mental and neurological status, including severe drowsiness, unresponsiveness to painful deep stimuli, and unequal pupil size. That night, the patient was given her home medications at the prescribed doses: zolpidem 10 mg at 22:03 and hydroxyzine 25 mg by mouth at 00:48. She was transferred to the hemodialysis unit where she underwent hemodialysis and was then admitted to the medical floor. She had a past medical history of end-stage renal disease (on hemodialysis 3 times/week), hypertension, type 2 diabetes, and a left below-knee amputation. A 64-year-old woman came to the emergency department complaining of cough and shortness of breath, along with an itchy throat and a runny nose.
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