Module 202 – Insomnia
We all need a good night’s sleep. Kathy Oxtoby advises on how you can help those who don’t get the rest they require
The role you can play in tackling insomnia
In this article you will learn about: • what insomnia is, who it affects and how to spot this condition • the treatments available to support people with insomnia • the self-help treatments you could recommend to help patients with insomnia • when to refer patients with insomnia to a pharmacist
Most people have problems sleeping at some point in their life. According to health website NHS Choices, a third of people in the UK have bouts of insomnia where they are unable to fall asleep or stay asleep as long as desired. In 2011, the Sleep Council's Toxic Sleep survey found that nearly half of us are getting just six hours' sleep or less a night, and four out of five people complain of disturbed or inadequate sleep. Anyone can be affected by insomnia, but this condition tends to be more common in women and more likely to occur with age.
It is difficult to define what ‘normal' sleep is, as everyone is different. Age, lifestyle, environment and diet all play a part in influencing the amount of sleep people need. For example, newborn babies can sleep for 16 hours a day, while school-age children need to have an average of 10 hours' sleep each night.
Most healthy adults sleep for an average of seven to nine hours a night. As people get older, it is normal to find sleep harder to maintain, although they still need the same amount of sleep.
People with insomnia find it difficult to get to sleep, or to stay asleep for long enough to feel refreshed the next morning, even though they have had enough opportunity to rest.
The symptoms of insomnia depend on the type of sleeping problem an individual has. Some people will lie awake for a long time at night before falling asleep; others will wake up several times in the middle of the night; some individuals wake up early in the morning and are not able to get back to sleep; some experience a combination of these sleep difficulties.
Other typical symptoms of insomnia include tiredness, not being able to function properly during the day, difficulty carrying out normal tasks, finding it hard to concentrate and feeling anxious and/or irritable. Forgetfulness, clumsiness and a lack of patience are also common problems experienced by people with insomnia.
People with sleep problems may clock watch, checking the time each time they wake up, which may make them feel irritated or anxious and more likely to remember the times of wakefulness. Even if the total amount of time spent asleep is ‘normal', they may still feel tired and that they've had a bad night's rest.
Symptoms of insomnia may be temporary, such as when people are experiencing jet lag or a specific stress-related issue. But for those who experience insomnia over longer periods, this condition can have a detrimental impact on their quality of life.
According to Patient.co.uk, absenteeism, accidents at work and road accidents are increased in people with insomnia. This condition can also result in anxiety and depression, and put people more at risk of having high blood pressure than those with normal sleep patterns.
As noted above, there are many different causes of insomnia. Some people experience insomnia in response to a stressful event and it can continue even when the stress has been resolved. This is because they have learned to associate the sleeping environment (ie their bed at night) with being alert.
Worrying about work, money or health, or having to deal with bereavement, are all causes of stress and likely to keep people awake at night. Underlying mental health problems, such as depression and anxiety, can also affect people's sleeping patterns.
Insomnia can also be caused by underlying physical conditions – such as heart disease, respiratory disease and hormone problems, such as an overactive thyroid, arthritis, urinary incontinence and long-term pain.
Women going through the menopause may also experience sleep disruption, as night sweats and anxiety are commonly associated with this condition.
Obstructive sleep apnoea is another reason why people experience insomnia and is common among those who are overweight. The disorder is characterised by alarming pauses in night-time breathing and is caused by obstruction of the airway due to obesity, anatomical obstructions and poor sleep hygiene. Restless legs syndrome (RLS), where people have the uncontrollable urge to keep moving their legs due to sensations such as tingling, jumping and, in its most serious form, pain, can also result in insomnia.
Alcohol and drug misuse and nicotine can affect people's ability to sleep soundly. "Too many stimulants in the diet, such as tea, coffee, nicotine and alcohol, can disrupt sleeping patterns," says Sonia Memmi, dispensing assistant at Bilston Hub, Midcounties Co-operative Pharmacy, Wolverhampton.
Some prescribed treatments or medicines that are available over the counter can cause insomnia. These include: antidepressants, epilepsy medicine, treatments for asthma, medication for high blood pressure and hormone replacement therapy (HRT).
WWHAM questions are vital when counter staff come across patients who are complaining of sleep difficulties. "Sleep issues can be symptomatic of other health problems, so asking relevant questions about sleep patterns is vital before recommending a treatment," says Emma Charlesworth, Numark's communications manager. There are a number of OTC conventional and herbal sleep aids that counter staff can recommend for short-term use. Several popular short-term treatments for insomnia contain diphenhydramine – an antihistamine that causes drowsiness by binding to histamine receptors in the brain.
It decreases the time it takes to fall asleep and also helps improve the quality and depth of sleep. Usually these are only suitable for patients aged over 16 years.
Promethazine is also used; this has a similar effect to diphenhydramine but typically lasts longer, so should not be used by patients waking during the night. Both drugs can cause side effects such as dizziness, nausea, dry mouth and headaches.
Herbal remedies contain natural ingredients, which offer an alternative treatment for people presenting with sleep difficulties.
According to NHS Choices, these remedies, which contain such ingredients as chamomile and passionflower, have been reported to have positive effects. However, they have not had a thorough clinical testing, so their effectiveness and long-term safety is unknown.
When recommending and selling any sleep product, you must advise that the product is for short-term use only and that, if symptoms persist, customers should see a doctor.
"This information may seem basic, but they may not be coming back to you to purchase it, so advising them at the time of purchase is appropriate," says Ms Charlesworth.
While medication can offer a short-term solution to sleep difficulties, there are many measures counter staff can recommend to help patients to help them sleep well.
"It is important to give patients advice about sleep hygiene – which is about the different ways you can help them to build a routine that will encourage a good night's sleep," says Jane Devenish, clinical service development lead for the Co-operative Pharmacy.
Winding down is a critical stage in preparing for bed. There are many ways of relaxing, including taking a warm bath, avoiding alcohol and stimulants such as caffeine, and maintaining a comfortable sleeping environment, which is not too hot, cold, noisy or bright.
Relaxation exercises, such as light yoga stretches, can help relax the muscles. Exercise during the day may also be helpful, but vigorous exercise should be avoided a few hours before going to bed, as it will have the opposite effect. Reading a book or listening to the radio can help some people to wind down by distracting them from current stresses. Writing to-do lists for the next day can help with organising thoughts and clearing the mind of any distractions.
Those with sleep problems should be advised to avoid napping during the day and to establish fixed times to go to bed and wake up. They should also avoid sleeping in after a poor night's sleep. Pharmacy staff can also advise people with sleep difficulties to keep a sleep
Refer to the pharmacist if…
● you suspect the patient is over-using a product for insomnia, which should be taken for no longer than a week ● if they are taking any other medication, such as antidepressants, or if they have a pre-existing condition such as heart disease or a respiratory disease ● if the patient is pregnant or breastfeeding ● if the patient is aged under 16 years ● the patient has been experiencing long-term problems with sleeping
Your next steps
● Find out more about the different ingredients used in sleep aids stocked by your pharmacy ● Ask the pharmacist about prescription-only sleep aids, such as z-drugs ● Look at healthcare websites featuring articles about insomnia such as NHS Choices, Patient UK and organisations such as The Sleep Council