Use of Zolpidem to Treat Severe Insomnia in a Critically Ill Patient with Delirium

This report details a 71-year-old man, Mr. A, admitted to the intensive care unit with community-acquired pneumonia complicated by sepsis, hypotension, metabolic issues, and severe hypoactive delirium that resulted in sleep-wake disturbances. Psychiatry was consulted due to refractory insomnia believed to exacerbate delirium and hinder rehabilitation.

Despite minimal agitation, Mr. A's sleep was fragmented, significantly affecting his cognitive function and participation in therapy. Various pharmacologic interventions, including ramelteon and doxepin, were unsuccessful in improving his sleep or cognitive performance. Following resolution of his sepsis-related hypotension and metabolic issues, severe insomnia was identified as a potentially modifiable factor affecting his delirium.

After careful consideration, zolpidem 5 mg was initiated. Improvement in sleep continuity was documented after just one night, alongside enhanced daytime alertness and reduced cognitive fluctuations. His Delirium Rating Scale-R-98 score decreased from 27 to 19, and cognitive tests showed significant improvement in his recall ability. The dose of zolpidem was adjusted to 10 mg to maintain sleep continuity before tapering it off prior to discharge without a return of insomnia or delirium.

The case highlights that sleep disruption is a central aspect of delirium pathophysiology, not just a consequence. In critically ill patients, delirium can cause fragmented sleep and reduced cognitive function, complicating rehabilitation. While pharmacologic options for managing sleep disturbances in delirium are limited, nonpharmacologic strategies are typically preferred as first-line treatment.

Concerns surrounding the use of Z-drugs stem from literature linking them to delirium and other adverse effects, particularly in older patients. However, most studies focus on outpatient settings, not the closely monitored acute situations encountered in the hospital. This creates uncertainty about the safety of zolpidem in these contexts.

In this instance, zolpidem was used only after multiple treatment failures and showed promise as a short-term solution for severe insomnia exacerbating delirium. Its short half-life and selective receptor binding allowed for vigilant monitoring and swift discontinuation once normal sleep patterns resumed. While this result should not be generalized, it suggests that zolpidem may be beneficial in rare cases of persistent insomnia in critically ill patients when other treatments have proven ineffective.

This case was published in the Primary Care Companion for CNS Disorders on June 11, 2026. Authors include Matthew Gunther, JR Maldonado, and Sheng Jiang, associated with Stanford University and the University of Florida.