“Can I give him something to sleep?”

THE PHONE — BEFORE YOU STAND UP

This call sounds like the smallest one in the book. It is the one most likely to cause a fall, a hip fracture and a death.

Ask: Is he awake because he cannot sleep, or is he awake because something is wrong? Then: Any confusion? Pain? Breathless? Needing the toilet? What time did he nap today? Does he take anything at home?

WHAT IS ACTUALLY HAPPENING

Night-time wakefulness can be the first face of delirium, and nobody has counted how often — which is exactly why you screen rather than assume in either direction. Sedating it hides it and worsens it. See entry 06 and screen properly before you prescribe
It is a symptom of something untreated: pain, dyspnoea, nausea, urinary frequency, itch, restless legs, or alcohol/nicotine/benzodiazepine withdrawal
It is the ward: lights, noise, four-hourly observations, a daytime nap, a 6 a.m. blood round
It is anxiety about what happens tomorrow, and nobody has asked

The prescribing risk is concrete. Benzodiazepines and Z-drugs in the older inpatient raise the risk of falls, fractures, delirium and respiratory depression — and a drug started “just for tonight” in hospital is a drug a striking proportion of patients are still taking months after discharge. You are not writing a one-off; you are frequently starting something.

FIRST MOVES Treat the cause. Offer the non-drug measures and actually implement them: reduce noise and light, cluster the observations where it is clinically safe — you do not thin out a sick patient’s monitoring to improve his sleep — warm drink, ear plugs and an eye mask, daylight and activity and mobilising during the day rather than a long afternoon asleep, though a genuinely ill patient is allowed to rest. If the patient takes a hypnotic or a benzodiazepine at home, continuing it is usually safer than abrupt withdrawal — check the home list, verify the dose and timing, and individualise it with pharmacy or a senior if there is oversedation, respiratory compromise or delirium. If, after all that, a drug is genuinely justified, choose the lowest sensible dose of the safest agent for that patient’s age and comorbidity, prescribe it as a single as-required dose with an explicit stop date, write in the notes why, and make sure somebody reviews it tomorrow so that it does not quietly walk out of the hospital with him. Never prescribe a hypnotic to a patient with untreated hypoxia or acute confusion.

ESCALATE NOW IF the sleeplessness is agitation with confusion · suspected withdrawal · new breathlessness or hypoxia at night · nocturnal chest pain.

THE PROMPTPASTE READY

Ward call: [AGE]-year-old [SEX], day [X] for [REASON].
Nurse requesting night sedation. Patient is [SETTLED BUT AWAKE /
RESTLESS / CONFUSED / DISTRESSED]. Orientation [X].
Pain [X/10]. Breathless [Y/N]. Sats [X]%. Nocturia/retention [X].
Daytime napping [X]. Home hypnotics or benzodiazepines: [WHICH — and
were they continued on admission?]. Alcohol/nicotine: [X].
Falls risk / previous fall: [X]. Renal and liver function [X].
Other sedating drugs already prescribed: [LIST].

Do not just recommend a hypnotic. First tell me what to exclude,
starting with delirium and untreated symptoms, and give me the specific
non-pharmacological measures for this ward setting. Tell me the risk
this drug carries for THIS patient's age and falls risk in one blunt
sentence. If a drug is still justified, give agent, dose, and a stop
date, and name the agents I should avoid in this patient.

NOTE STUB Request for night sedation. Delirium screened: [4AT/CAM or equivalent] — result. Untreated symptoms sought: pain, dyspnoea, retention, withdrawal — findings. Non-pharmacological measures instituted: … Home hypnotic [continued/not]. Drug given/withheld because … If given: agent, dose, single dose only, stop date [x], falls risk documented and discussed.

This is one of twenty.