That Drowsiness Might Be Due to Sleeping Pills—Over-sedation and FIM as Seen by a Convalescent Care Pharmacist

Series: Pharmacists Improving FIM #2

It's time for morning rehabilitation, but...

Their responses are unclear.
They can't move well.
They have no strength in their body.

Have you ever been consulted by a PT like this?

“They often seem sleepy lately.
They seem kind of dazed.”

That drowsiness might be a side effect of sleeping pills.

From the perspective of a "rehab pharmacist," over-sedation is one of the biggest hidden causes of "FIM not improving."
over-sedation is one of the biggest hidden causes of "FIM not improving."is one of the biggest hidden causes of "FIM not improving."

This time, I would like to focus on "over-sedation due to sleeping pills," which is encountered particularly frequently in convalescent rehabilitation wards, and organize the pharmacist's perspective and key points for intervention.
I would like to focus on "over-sedation due to sleeping pills," which is encountered particularly frequently in convalescent rehabilitation wards, and organize the pharmacist's perspective and key points for intervention.
I would like to focus on "over-sedation due to sleeping pills," which is encountered particularly frequently in convalescent rehabilitation wards, and organize the pharmacist's perspective and key points for intervention.
I would like to focus on "over-sedation due to sleeping pills," which is encountered particularly frequently in convalescent rehabilitation wards, and organize the pharmacist's perspective and key points for intervention.

■ Why are sleeping pills a problem?

Many patients admitted to convalescent rehabilitation wards are transferring from acute care hospitals or from home.

It is not uncommon for sleeping pills started in the acute phase to address "insomnia" caused by changes in environment or medical condition to be continued as is.

The Japanese Society of Hospital Pharmacists' "Guide for Pharmacists in Convalescent Wards (2024)" also states that
patients admitted to convalescent wards are taking an average of 7 or more types of medication, and hypnotics/anxiolytics are listed as one of the most frequently used medications that are PIMs (Potentially Inappropriate Medications).one of the most frequently used medications that are PIMs (Potentially Inappropriate Medications).

https://www.jshp.or.jp/activity/guideline/20240201-1.pdf

Getting a good night's sleep and
regulating your circadian rhythm is, of course, important.
Using sleeping pills for that purpose is also necessary.

The problem is that
medication prescribed with the goal of "just getting them to sleep at night" remains in their system until the next morning's rehabilitation time.

■ Types of medication and "impact on rehabilitation"

There are several types of sleeping pills.
In the context of convalescent care, the following two classes have a particularly large impact on rehabilitation.

① BZD and BZD receptor agonists (so-called benzodiazepines and similar drugs)

Representative drugs include the following.

• Halcion (triazolam), Lendormin (brotizolam) = BZD class

• Myslee (zolpidem) = non-BZD class

• Depas (etizolam) = similar action to BZD class, etc.

These are the groups most likely to cause problems.
Strictly speaking, Depas (etizolam) has a different structure (thienodiazepine class) than the BZD class, but its action on GABA receptors is equivalent.

In practice, I think it is safe to assume it carries the same risks as the BZD class.

Myslee (zolpidem) is a non-BZD class drug, but
because it acts on the same GABA receptors,
there is no difference in the risk of carry-over effects or muscle relaxation in the elderly.

By acting on GABA receptors,
it exerts sedative and hypnotic effects, but
muscle relaxation, memory impairment, and carry-over to the next morning
(hangover effect) become issues.

Especially in the elderly, because drug metabolism is slow,
the drug's effects often remain
during rehabilitation time the next morning.

The Japanese Society of Sleep Research alsoexplicitly states that "BZD class drugs are excluded from first-line choices for the elderly due to side effects such as cognitive decline, amnesia, and falls/fractures."as well.

(2) Antihistamine class (OTC/some prescription drugs)

Representative drugs: Restamin (diphenhydramine), etc.

These are ingredients contained in cold medicines and over-the-counter sleep aids,
which cause strong drowsiness.

It is rare to use over-the-counter drugs during hospitalization, but
it is something to be aware of.

■ Impact of over-sedation on FIM

In the guide for the involvement of pharmacists in convalescent rehabilitation wards,
"cases where appropriate sleep medication is not selected for the type of insomnia, leading to complaints of somnolence during rehabilitation" are clearly identified asa pattern that hinders the progress of rehabilitation.

There are mainly three mechanisms by which over-sedation leads to a decline in FIM.

• Lower quality of training participation: Concentration drops due to somnolence, making it harder to follow PT instructions

• Increased risk of falls: Unsteadiness and muscle relaxation make it impossible to perform walking training safely

• Decreased activity level: Cutting morning rehabilitation short, inability to perform independent practice

When these overlap,
a situation arises where both
FIM locomotion and cognition items fail to improve.

■ So, how should a pharmacist evaluate this?

When I enter the ward, I am particularly conscious of checking
the following four points.

1. Drug type and half-life

The longer the half-life,
the more likely a carry-over effect to the next morning will occur.
Even with ultra-short-acting types (Halcion),
caution is required for elderly patients.

2. Relationship between medication timing and wakefulness

Check chronologically whether the medication taken before sleep
is still present at the start of morning rehabilitation (around 9:00 AM).

3. Duration of use and changes in dosage

There are many cases where medication is continued as is from the acute phase,
so it is necessary to check if the dosage has been increased.

4. Information from PTs and nurses

'They seem sleepy during rehab'
'They sleep at night but can't wake up in the morning'
—such information is a crucial sign to suspect over-sedation.

■ Proposals to the doctor—Communicating in the 'language of rehab'

When over-sedation is suspected,
I would like to introduce the way I keep in mind to communicate it.

'Side effects are occurring'
—instead of this,

'This patient continues to show somnolence during morning rehab. It is possible that the carry-over effect of this sleeping pill is influencing them. I believe that moving the administration time earlier or changing to a drug with a shorter half-life could lead to an improvement in FIM.'

The key is to propose
concrete alternatives as well.

For example,

• Proposing a switch from BZD-based drugs to orexin receptor antagonists (Belsomra, Dayvigo)

• Proposal to move administration from 9 PM at bedtime to 7–8 PM (to reduce carryover effects the next morning)

• Propose making it "as needed" (PRN) in principle and consider whether the patient can be weaned off daily administration

These are just suggestions.
Depending on the facility and the patient,
I believe it is necessary to explore the optimal approach.

Now that the importance of FIM gain for hospital management has increased with the 2026 revision,
the message that
“this one move could potentially improve FIM”
is more likely to be received
than ever before.

I have compiled phrases for proposing changes to doctors,
categorized by common situations.

They are arranged in a way that you can use them starting tomorrow,
so please feel free to pick them up when needed.

The key to these phrases isto communicate them not as "side effects" but as "opportunities for FIM improvement"
.

Doctors will be more receptive to a pharmacist's proposal
when it is framed as an "ally in advancing rehabilitation."

■ Summary

• Drowsiness in a convalescent rehabilitation ward should always be suspected as being partly caused by oversedation from sleeping pills

• BZD and non-BZD drugs have carryover effects, muscle relaxant properties, and impacts on cognitive function in the elderly, making them top-tier PIMs

• Oversedation suppresses both the mobility and cognitive items of the FIM

• The keys to intervention are "checking the half-life," "reviewing the timing," and "proposing a switch to orexin receptor antagonists"

• It is the pharmacist's role to connect the casual comment of "they look sleepy" from physical therapists or nurses to the medication

“They look sleepy.”
I value this phrase very much.

When physical therapists or nurses casually say,
“They’ve looked sleepy lately”
or “They seem dazed,”
—for a pharmacist, this is the most important sign
to suspect oversedation.

Rehabilitation staff and nurses are professionals
who observe the patient's level of consciousness all day long,
from the closest proximity.

I believe it is the pharmacist's job
to "connect" those observations to the medication.

A convalescent rehabilitation ward is not a place to "add" medication, but rather a place to "review" medication
in order to maximize the effects of rehabilitation.

Sleeping pills, in particular,
are often continued aimlessly from the acute phase,
and are medications that are easily carried over
into life at home after discharge.

Taking a moment to pause right now and
asking yourself, "Is this medication truly necessary for the patient at this time?"
will lead not only to improvements in FIM, but also to
preventing falls and maintaining cognitive function after discharge.

Although this article is written for pharmacists,
I would be very happy if PTs, OTs, STs, and nurses
could also share signs of "drowsiness"
with the pharmacist.

To "move the FIM" as a team,
please add the perspective of medication as another tool in your arsenal.

In the next installment (#3), I plan to focus specifically on "anticholinergic drugs and cognitive FIM."

▶ My practical notes on convalescent rehabilitation pharmacy are compiled in a magazine.
Please feel free to read them if you are interested.