Sleep Protocol

A sleep protocol is a written, nurse-delivered, non-drug bundle of measures given at bedtime to any older patient who has difficulty initiating sleep or who requests a sedative, with the aim of avoiding hypnotic drugs.

It is needed because hospitalised older people sleep badly — noise, light, nocturnal observations and blood sampling, pain, nocturia, unfamiliar environment and daytime inactivity all fragment sleep — and because sedative-hypnotics in older people cause delirium, falls, fractures, daytime sedation, cognitive impairment and increased mortality.

Normal ageing changes in sleep must be distinguished from disease: increased sleep latency, reduced deep (slow-wave) sleep, reduced REM sleep, more frequent awakenings, reduced sleep efficiency, phase advance (early to bed and early to rise), and more daytime napping. Total sleep need does not change much. The Classical Non-pharmacological Sleep Protocol

The original protocol (McDowell and Inouye, JAGS 1998) has three components — a warm drink (milk or herbal tea), relaxation music or tapes, and a back rub or massage.

It is given to any patient complaining of difficulty initiating sleep or requesting a sedative; the sedative is given only if the patient still requests it after one hour. Adherence in the original study was 74%, and it substantially reduced the use of sedative-hypnotic drugs with no toxicity.

The sleep protocol is one of six standardised protocols in the Hospital Elder Life Program (HELP), alongside those for cognitive impairment, immobility, visual impairment, hearing impairment and dehydration. HELP prevents delirium in 30–40% of cases and reduces falls, length of stay and cost.

Reduce noise: silent pagers and mobile phones, lowered alarm and television volume, soft-close bins and doors, staff conversation moved away from the bedside, and designated 'quiet hours' (typically 10 pm to 6 am).

Control light: dim corridor and bay lights at night, use torches rather than overhead lights, and provide eye masks and earplugs to willing patients.

Cluster nursing activities so that patients are not woken repeatedly. Avoid non-essential night-time observations, blood sampling, weighing and medication rounds; give diuretics early in the day and avoid overnight intravenous fluids where possible.

Treat what wakes the patient: pain (multimodal analgesia), dyspnoea, cough, nocturia, gastro-oesophageal reflux, pruritus, cramps and anxiety.

Increase daytime activity, especially outdoors and in sunlight; get the patient out of bed, dressed in day clothes, and mobilised. Avoid prolonged daytime sleep and going to bed too early.

Scheduled bright-light therapy resynchronises the circadian rhythm by entraining the suprachiasmatic nucleus to the light/dark cycle, and is particularly useful in institutionalised elders and in dementia. Timing must be individualised.

Exercise timing matters: afternoon exercise advances the biological clock, while exercise at night delays the circadian phase. Light exercise should be finished at least three hours before bedtime.

Keep a regular schedule — go to bed and wake at the same time daily; constant changes increase the probability of severe, chronic sleep difficulty.

Optimise the environment — temperature about 18–21°C, no noise or light, a proper mattress. Avoid heavy meals, but do not go to bed hungry or thirsty; dairy products contain tryptophan, which helps induce sleep.

Limit stimulants — coffee, tea, cola, alcohol and nicotine, especially after 5 pm. Alcohol is often self-prescribed for insomnia but shortens latency and then fragments the second half of the night.

Remain in bed no more than eight hours — spending too long in bed produces fragmented, light sleep. Allow a nap after the midday meal of no more than 30 minutes. Follow a fixed bedtime ritual.

Take a full sleep history from the patient and, where possible, the bed partner or caregiver. Ask specifically about mood, since insomnia and depression have a two-way relationship.

Rule out treatable specific sleep disorders — obstructive sleep apnoea (loud snoring, witnessed apnoea, daytime sleepiness; treat with CPAP), restless legs syndrome (check iron; dopaminergics), periodic limb movement disorder, REM sleep behaviour disorder (clonazepam; and it predicts Parkinson's disease and dementia), and advanced sleep phase.

Review the drug chart — beta-blockers, corticosteroids, NSAIDs, bronchodilators, diuretics, SSRIs, cholinesterase inhibitors, decongestants and caffeine-containing preparations all disturb sleep.

Keep a sleep diary for a minimum of two consecutive weeks, because of day-to-day variability. Actigraphy or wrist accelerometers may help. Polysomnography, multiple sleep latency testing and maintenance of wakefulness testing are not routinely required for insomnia unless another disorder is suspected.

Cognitive behavioural therapy for insomnia (CBT-I) is the first-line treatment — sleep restriction, stimulus control, relaxation, cognitive restructuring and sleep hygiene. It is effective even in patients with cognitive decline, and its benefit outlasts drug therapy.

Melatonin is the hypnotic of first choice when a drug is indicated in a patient over 55. It improves sleep latency and quality without altering sleep architecture, shows efficacy for up to six months with no tolerance, rebound or withdrawal, does not impair next-morning psychomotor performance or driving, and does not increase postural instability (unlike zolpidem). In mild-to-moderate Alzheimer's disease it was associated with significantly less cognitive impairment.

Avoid benzodiazepines and Z-drugs. They shorten sleep latency and increase total sleep time but do not improve, and may worsen, daytime function. Z-drugs such as zolpidem cause awakenings, complex behaviours (sleepwalking, hallucinations) and rebound; the class causes memory and cognitive impairment, disinhibition, delirium, falls, accidents and increased mortality.

Avoid antihistamines — their anticholinergic effect causes urinary retention, constipation and delirium. Avoid quetiapine even at low doses, and use other antipsychotics only with great caution because of the risk of sudden death in the elderly.

If a hypnotic is unavoidable, use the lowest effective dose for the shortest possible time, with a documented review date and exit plan, and never continue a hospital-initiated hypnotic on the discharge prescription.

Institutionalised elders are at particular risk because of comorbidity, polypharmacy and the institutional environment (loud noise, low light exposure, few circadian cues). They need an integrated pharmacological and environmental approach; circadian disorders respond well to chronotherapy, melatonin and properly scheduled light therapy, thereby avoiding the need for sedative-hypnotics.

Outcomes of a sleep protocol: reduced hypnotic use, less delirium, fewer falls, shorter length of stay, better patient satisfaction, and no adverse events — at negligible cost. Monitor with a sleep diary, the Pittsburgh Sleep Quality Index, Insomnia Severity Index and Epworth Sleepiness Scale, and hand over the sleep plan at every nursing shift change.

2023 AGS Beers Criteria — benzodiazepines, non-benzodiazepine 'Z-drug' hypnotics (zolpidem, zopiclone, eszopiclone) and first-generation antihistamines remain potentially inappropriate medications in all older adults and should be avoided for insomnia. This reinforces the non-pharmacological protocol as the default.

Digital CBT-I (dCBT-I) delivered by app or web is now shown to be effective in older adults and addresses the chronic shortage of trained therapists; it is increasingly recommended as a first step where face-to-face CBT-I is unavailable.

Dual orexin receptor antagonists (DORAs) — suvorexant, lemborexant and daridorexant — are the most important new drug class. A systematic review and meta-analysis in older adults showed that compared with placebo they reduce wake after sleep onset and latency to persistent sleep and increase total sleep time at both 1 and 3 months, including subjective total sleep time.

Safety profile of DORAs in the elderly: daridorexant showed a favourable safety profile, whereas lemborexant and suvorexant had higher rates of treatment-emergent adverse events than placebo, without an increase in serious adverse events. Class effects to counsel about are nightmares, abnormal dreams, sleep paralysis, hallucinations and next-day somnolence.

Agent selection by sleep parameter: network meta-analyses suggest lemborexant is best for sleep onset and daridorexant for sleep maintenance; daridorexant also has the lowest rebound risk, and is therefore the preferred agent when switching during deprescribing.

Deprescribing guidance: expert consensus opposes a blanket prohibition on long-term use of DORAs and some non-benzodiazepine agents, but requires periodic re-evaluation of the risk-benefit balance, particularly in older adults; when stopping, taper gradually rather than stopping abruptly.

DORAs and delirium: small studies of suvorexant and lemborexant in critically ill and post-operative patients suggest a possible reduction in delirium incidence, in contrast with benzodiazepines; the evidence is not yet strong enough for routine recommendation.

Melatonin and ramelteon for delirium prevention have shown inconsistent results across trials and meta-analyses, and melatonin is not universally endorsed for this indication — but it remains the preferred hypnotic in older adults with insomnia.

Multicomponent non-pharmacological bundles — earplugs and eye masks, relaxation and guided imagery, massage, music therapy, aromatherapy and warm milk-based drinks — were confirmed in 2024–2025 systematic reviews to improve sleep quality and duration in hospitalised adults, with no adverse events reported. Back massage in one study increased total sleep time by more than an hour.

Sleep and dementia risk: longitudinal data continue to link insomnia and short sleep with subsequent cognitive impairment, and short sleep (under six hours) with higher cardiovascular mortality — strengthening the case for treating sleep as a modifiable risk factor rather than a nuisance symptom.

Indian context: hypnotic and benzodiazepine prescribing to older adults remains high and is often over-the-counter; alprazolam and diazepam are widely used despite their long half-lives. Practical priorities are deprescribing benzodiazepines, screening for OSA (which is underdiagnosed in India), and building simple ward sleep protocols into NPHCE geriatric wards and district hospital care.