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Helping patients manage their sleep

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Stress is the most common reason people aren’t able to sleep

From sleep hygiene to OTC medicines, do you know how you can help patients to achieve a better night’s sleep?

From this pharmacy CPD module on helping patients manage poor sleep you will learn about:

  • Why sleep is important
  • The different factors that affect sleep
  • The dos and don’ts of sleep hygiene
  • When you should refer patients with sleep problems

Download this module - this includes the 5 minute test - here.

Perrigo has paid for this piece and has been involved in its creation and editing.

How important is sleep?

Everyone has different sleeping patterns and behaviours – with most adults requiring between six and nine hours of sleep every night.1 However, it is not the number of hours a person sleeps that is important, but how they feel the next day. If they wake in the morning not feeling refreshed, then it could be an indicator that they have not had enough, or enough good quality, sleep.

Sleep is not simply ‘switching off’. Instead, it is a complex and dynamic process that ensures the maintenance of normal cognitive function, such as forming long- and short-term memories and the ability to make decisions.2

Sleep therefore plays a vital role in maintaining good health and wellbeing. Getting enough quality sleep at the right times can help protect an individual’s mental health, physical health and quality of life.3 Lack of sleep can also increase the risk of injury and accidents in the home, in the workplace and on the roads.4

Lack of sleep – referred to as insomnia – is a common problem, estimated to regularly affect around one in three people in the UK and is particularly common in the elderly.5 Older adults tend to have a harder time falling asleep and staying asleep, although sleep disturbance among the elderly can be attributed to other conditions and the medications used to treat them. It is a common misconception that as we get older, our sleep needs decline.6

While we are asleep our brains process and reorganise memories – helping us with insights and creative ideas. In addition, research has shown that sleeping after learning new information helps with retention.7

Consistently poor sleep can increase the risk of serious medical conditions including:8

  • mental health issues (eg anxiety)
  • obesity
  • diabetes
  • heart disease
  • shortened life expectancy.

Sleep deprivation can cause serious medical conditions

Stages of sleep

Sleep consists of rapid eye movement (REM) sleep and non-REM sleep. REM is the involuntary quick movement of the eyes in various directions during sleep. During a typical night, an individual will cycle through three stages of non-REM sleep, and then transition into REM sleep. This process is repeated several times throughout the night.

The stages of non-REM sleep are:

Sleep cycle - REM and non-REM

As the sleep progresses towards morning, the duration of REM sleep increases.9

Although a lack of REM sleep leads to surprisingly few negative effects on behaviour, it has been shown to impair the ability to learn complex tasks. This suggests that REM sleep is a vital component of our sleep patterns, particularly during early childhood development, when REM sleep makes up a much larger percentage of total sleep.10

What factors can affect sleep?

Your patients will have their individual reasons for why they cannot sleep, but there are a range of factors that are well known for leading to lost sleep:

Psychological issues

These can be caused by a range of factors. Stress is the top reason people aren’t able to sleep11 – issues such as anxiety or depression, bereavement, work pressures, money concerns and family problems can be common causes.12,13,14

Lifestyle

Many behaviours can upset the normal sleep pattern, for example: unusual work shift patterns, jet lag, poor sleep routine, eating late at night, caffeine, nicotine and alcohol. In addition, the patient’s partner could be unwittingly causing the sleep disturbances; for example, if they are restless in bed or if their snoring prevents their partner from sleeping.

Poor physical health

Pain has been found to be the second most likely cause of lost sleep.11 Those suffering from chronic pain may lose sleep, resulting in more pain the following day, and this can continue into a cycle. The symptoms of a wide range of conditions are also linked to sleep disorders and contribute to sleep loss, for example: cardiovascular conditions, obesity, diabetes, stroke and attention deficit hyperactivity disorder.

In addition, conditions such as restless leg syndrome can disturb sleep by causing an impulse to move the legs at night, while other patients may snore so vigorously that they wake themselves up. A relatively common condition is obstructive sleep apnoea (OSA), where the walls of the throat relax and narrow during sleep, interrupting normal breathing. This may be characterised by periods where breathing is interrupted by gasping or snorting.

Medication

Certain medicines can act as stimulants and affect sleep, such as alpha and beta blockers, antidepressants, epilepsy medicine, corticosteroids and recreational drugs.

Poor sleeping environment

Most people will have their own sleep preferences, but changes can disturb an individual’s sleep, for example: an uncomfortable or unfamiliar bed, or a bedroom that’s too light, noisy, hot or cold.

When sleep is affected, you should check whether it is:

  • temporary – lasting one or two nights
  • short-term – repeated issues sleeping over a period of between one and four weeks
  • long-term – lasting over four weeks.

There are a range of other conditions that could be implicated in insomnia, including menopause and gastrointestinal conditions such as heartburn.15

Discussing sleep with patients

In order to effectively counsel patients on how to manage their sleep problems, you need to get a better understanding of the patient’s sleep history. To do this you can use the ‘DREAMS’ mnemonic:

  • Daytime sleepiness – it is important to assess whether the patient feels sleepy throughout normal waking hours. Ask them: “Have you ever fallen asleep during the day when you had not planned to?”
  • Regularity of sleep – assess whether the patient goes to sleep and wakes up at regular times. This should encompass whether they get regular sleep during this period. You can ask them: “Do you feel you normally get enough sleep?” or “Do you work irregular shifts or hours?”
  • Evening routine – try to assess any factors that could lead to difficulty sleeping throughout the night, by asking: “What do you do in the lead-up to going to bed?”; “How long does it take you to fall asleep” or “What do you think stops you from falling asleep?”
  • Awareness – you can ask: “What wakes you up at night?” (provide examples such as: pain, toilet visit or shortness of breath); “How often and for how long are you awake?” or “What keeps you from falling back asleep?”
  • Morning waking – assess whether the patient is having difficulty sleeping in the morning. You can ask questions such as: “At what time do you usually wake up?”; “What is your mood like in the morning?” or “Do you feel refreshed in the morning?”
  • Snoring – this helps you establish if breathing problems are leading to sleep disturbances. You can ask: “Have you or anyone else noticed that you snore or stop breathing in your sleep?”

Snoring can disturb sleep

What is sleep hygiene?

Although sleep disturbances are often transient and pass with time, some individuals are blighted by ongoing sleep loss. Sleep hygiene is a method of improving the quality of sleep by changing practices and habits that are detrimental to sleep.

According to the National Institute for health and Care Excellence (Nice), sleep hygiene should generally be recommended to those with short-16 (less than four weeks) and long-term17 (greater than four weeks) sleep problems. Sleep hygiene can broadly be split into a list of dos and don’ts.18

Do:

  • exercise regularly (but avoid exercise within four hours of bedtime)
  • keep the bedroom dark, quiet and comfortably warm (not too hot or cold)
  • maintain a routine, with fixed times for waking and going to bed
  • use the bed for sleep only (ie avoid watching TV or using a mobile phone in bed)
  • maintain natural exposure to daylight
  • try to relax and unwind before going to bed.

Don’t:

  • sleep or take naps during normal waking hours
  • take caffeine, nicotine or alcohol within six hours of going to bed
  • exercise late in the evening
  • check/watch the clock throughout the night
  • eat a heavy meal late in the evening
  • undertake strenuous mental activities just before bed (eg work or study).

You can advise patients to keep a sleep diary, as this may uncover daily activities or lifestyle habits that are contributing to sleep loss. This diary may also uncover underlying conditions, such as stress and anxiety.19

It’s important that patients don’t force sleep, as the harder they try, the more worked up they will get by not falling asleep. If they have been in bed for more than 15 minutes without drifting off, they should get up and do something relaxing, such as reading a book until they feel sleepy, before returning to bed.

If patients are finding a particular stress or worry is keeping them up at night, then you could recommend they set aside time earlier in the evening or during the day to consider, write down and find solutions to their problems. Some people may also benefit from using mindfulness or meditation to help them wind down and relax before bed.

As everyone is different, each person will need to develop their own individual methods to help them achieve a good night’s sleep. However, you and your staff can recommend that patients maintain three general principles to help get better sleep:

  • quiet mind
  • relaxed body
  • sleep-friendly environment.
Over-the-counter treatments for insomnia

Sleep

Sleep hygiene may not be effective alone in treating mild insomnia and some people may require additional care. Over-the-counter sleep aids can therefore be effective at helping patients achieve a good night’s sleep.

Herbal remedies

Remedies such as valerian, passiflora and hops are readily available in many pharmacies and health food stores. They are all believed to cause drowsiness or sedation and some patients may believe it helps aid their sleep, but there is mixed evidence of the effectiveness of these products and as such they may be suitable for patients who prefer herbal remedies.

Sedating antihistamines

Sedating antihistamines, such as diphenhydramine and promethazine, are suitable for those over 16 years of age. They are generally absorbed quickly and should therefore be taken between 20 and 30 minutes before going to bed.

Due to the risk of developing tolerance, sedating antihistamines should only be recommended for short-term use. For example, diphenhydramine products are indicated for a maximum of two weeks’ 20 use, whereas promethazine-based products are indicated for a maximum of seven days.21 These time periods are intended to be used as an intervention to help patients return to a normal, healthy sleep pattern.

If the patient’s sleeping issues continue beyond two weeks of sedating antihistamine use and sleep hygiene issues are taken into account, then there could be an underlying issue, which should be referred to their doctor. The side effects of the sedating antihistamines are generally non-specific and may include the intended anticholinergic action – drowsiness – and other side effects such as dizziness, dry mouth or blurred vision.

This patient has trouble sleeping. Can you help?

George Thomas, 52, comes into your pharmacy and asks to speak to you.

“I’ve been having trouble sleeping for the past few days, what would you recommend?” he says.

Mr Thomas is often in your pharmacy picking up his wife’s prescription, but you are unsure if he takes any medication prescribed elsewhere or bought over the counter. On further questioning, he explains that he hasn’t taken any medicine – prescribed or otherwise – for several years.

You ask a few questions to assess his sleep status and then ask about his bed routine to assess his general sleep hygiene. You find out that Mr Thomas is normally a very good sleeper, with a regular night-time routine and that he only ever has difficulties when he has had a few alcoholic drinks late in the evening.

“Have you any other symptoms?” you ask.

“My wife asked me to landscape the garden three days ago and while I was doing it I managed to aggravate my back. It doesn’t stop me doing the job, but I have noticed it bothering me ever since. I have a week or so left of the landscaping project, but I am sure it will get better soon,” he replies.

What do you need to consider?

Although Mr Thomas originally sought your advice for sleep, you should also consider helping him with his back pain. This could be contributing towards his sleep loss in a negative cycle, as the pain in the daytime can result in reduced night-time sleep, leading to increased pain the next day.22

Back pain and sleep loss case study

In this case, to ensure optimum relief it is appropriate to use a combination of therapy for both Mr Thomas’s insomnia and his pain. It is important to determine which treatment will provide restorative sleep, as this may even help improve the effectiveness of pain management.23

What can you recommend?

There is a need to take a holistic approach to the patient’s care and, as such, you should recommend a suitable sleep aid and painkiller. In this case, you can recommend a sedating antihistamine, such as diphenhydramine or promethazine, to help Mr Thomas get back into a normal sleep routine.

As Mr Thomas has indicated that the garden work is ongoing, it may be useful to use a sedating antihistamine that is licensed for a longer duration; for example, diphenhydramine, which can be used for up to two weeks. This will allow him to continue the work he is carrying out, while helping him maintain a regular sleep pattern.

For the pain, you can recommend either paracetamol or a non-steroidal anti-inflammatory drug (NSAID), or a combination of both if one alone is ineffective.

Mr Thomas explained that he sometimes has a bad night’s sleep due to alcohol intake and so you should also recommend that he avoid drinking during his treatment. If the pain and sleep issues do not get better after a couple of weeks, then you can advise Mr Thomas to speak to his GP as he may need further investigation and a prescribed medicine.

Mr Thomas says he will take on board your advice and he purchases some paracetamol and Nytol One-A-Night containing diphenhydramine, promising to let you know how he – and his garden – get on.

Learning points

This case study demonstrates that when a patient complains of a sleep problem, there is a need to assess the individual holistically. It is important to determine any other symptoms or conditions that may be present and contributing to the patient’s sleep loss. Sometimes these may be obvious – such as back pain from unexpected physical toil – but in other cases they may be less so; for example, if the patient is suffering from stress, anxiety or depression.

Addressing patient concerns about sedating antihistamines

Patients seeking to treat their sleep problems may be concerned about the side effects of treatment. For example, a patient may ask: “Are they safe?”; “Will it leave me feeling groggy the next day?” or “Will I get addicted to my sleeping med?”

These are perfectly reasonable questions and it is the role of you and your pharmacy staff to provide accurate advice to help alleviate these concerns.

You should explain that all medicines have side effects and that this does not necessarily mean they are unsafe. Sedating antihistamines have all been approved for use based on their quality, safety and efficacy and have been sold as OTC medicines for over 25 years.

The ‘hangover’ effect is the groggy feeling associated with sedating antihistamines.24 Although it does not affect all users, some patients may notice it the next morning. However, those who are suffering from sleep loss need to weigh up whether a full night’s sleep is worth the potential groggy feeling of the medication. In addition, if the medicine is taken before bed and the individual has a full night’s sleep, then this may help reduce the effect. Diphenhydramine has a half-life of roughly 8-9 hours, whereas promethazine has a half-life of 12 hours.25,26

Patients aware of the body’s ability to develop a tolerance to sedating antihistamines may express concern about becoming ‘addicted’ to their medication. You can reassure them that in the short periods of time that OTC sleeping aids are recommended for, tolerance is unlikely to develop. You should also stress that patients who have trialled the OTC sleeping aid for the maximum recommended time and have not found that natural sleep has returned to them should speak to their GP.

When to refer

You should refer patients to their GP for further investigation to determine if they require specialised treatment if they have any of the following:27

  • long-term insomnia
  • no clear cause of their insomnia
  • insomnia that has not responded to OTC treatment or sleep hygiene advice
  • symptoms suggestive of psychological issues, such as anxiety or depression
  • making regular, repeat requests for OTC sleep aids or sedating medication (eg cough syrup)
  • under 12 years of age.

Tips for your planned learning CPD entry on helping patients manage their sleep

What are you planning to learn?

I want to learn more about sleep, including why it’s important, the different factors that affect sleep and the dos and don’ts of sleep hygiene. I also want to improve my knowledge of when patients with sleep problems should be referred.

This learning will help me to improve my knowledge of sleep problems, to confidently provide advice to patients and carers about sleep hygiene and OTC sleep remedies and to know when to refer.

How are you planning to learn it?

Give an example of how this learning has benefited the people using your services.

I provided OTC advice at the counter to a patient about the amount of sleep they need and how to ensure good sleep hygiene.

Nytol sleep aid

Nytol One-A-Night 50mg tablets

List of active ingredients: Nytol One-A-Night contains diphenhydramine hydrochloride. Supply classification (P/GSL): P. Indication: an aid to the relief of temporary sleep disturbance. Dosage and directions: adults and children 16 years and over: one tablet taken 20 minutes before bed. Children under 16 years: not recommended. Do not use for more than two weeks without medical advice. Avoid concomitant use of alcohol or other antihistamine-containing preparations. Do not drive or operate machines. Contraindications: Stenosing peptic ulcer, pyloroduodenal obstruction, known hypersensitivity to ingredients. Caution: The elderly, pregnancy/lactation, myasthenia gravis, epilepsy or seizure disorders, narrow-angle glaucoma, prostatic hypertrophy, urinary retention, asthma, bronchitis and COPD, moderate to severe renal or hepatic impairment, intolerance to some sugars. Interactions: CNS depressants (including alcohol), monoamine-oxidase inhibitors, anticholinergic drugs (eg atropine, tricyclic depressants), metoprolol, venlafaxine. Side effects: fatigue, hypersensitivity reactions, confusion, paradoxical excitation, sedation, drowsiness, dizziness, dry mouth, GI disturbances, muscle twitching, headache, blurred vision, tachycardia, palpitations, convulsions. PL number: PL 02855/0070. MAH: Omega Pharma Limited, 32 Vauxhall Bridge Road, London, SW1V 2SA. RRP (ex. VAT): 20s £5.03 SPC: www.medicines.org.uk/emc/medicine/19778

References
  1. NHS Choices. How to get to sleep. Accessed August 8, 2018.
  2. National Institute of Neurological Disorders and Stroke. Brain basics: understanding sleep. Accessed August 8, 2018.
  3. The National Heart, Lung, and Blood Institute. Sleep deprivation and deficiency. Accessed August 8, 2018.
  4. NHS Choices. Sleep and tiredness. Accessed August 8, 2018.
  5. NHS Choices. Insomnia. Accessed August 8, 2018.
  6. Sleep foundation. Insomnia and older adults. Accessed August 8, 2018.
  7. Sleep foundation. Improve your memory with a good night’s sleep. Accessed August 8, 2018.
  8. NHS. Why lack of sleep is bad for your health. Accessed August 8, 2018.
  9. National Institute of Neurological Disorders and Stroke. Brain basics: understanding sleep. Accessed August 8, 2018.
  10. How sleep works. Rem sleep – types and stages of sleep. Accessed August 8, 2018.
  11. Causes of sleep disruption – Hall & Partners, 2013 – Consumer survey of 1,500 people suffering with sleep issues.
  12. Bhatti P, Mirick DK, Randolph TW. et al. Oxidative DNA damage during night shift work. Occup Environ Med. 2017, 74: 680–368. Accessed August 8, 2018.
  13. Wolkow A, Aisbett B, Reynolds J. et al. The impact of sleep restriction while performing simulated physical firefighting work on cortisol and heart rate responses. Int Arch Occup Environ Health.2016, 89: 461–475. Accessed August 8, 2018.
  14. Luik AI, Bostock S, Chisnall L. et al. Treating depression and anxiety with digital cognitive behavioural therapy for insomnia: a real world NHS evaluation using standardised outcome measures. Behav Cogn Psychother. 2017, 45: 91–96. Accessed August 8, 2018.
  15. AllsleepSleep Disorders Misdiagnosis. Accessed August 8, 2018.
  16. Nice – Clinical knowledge summaries – Insomnia, less than four weeks. Accessed. August 8, 2018.
  17. Nice – Clinical knowledge summaries – Insomnia, more than four weeks. Accessed August 8, 2018.
  18. Nice – Clinical knowledge summaries – Insomnia, good sleep hygiene. Accessed August 8, 2018.
  19. NHS Choices. How to get to sleep – keep a sleep diary. Accessed August 8, 2018.
  20. Electronic medicines compendium. Nytol original 25mg tablets. Accessed August 8, 2018.
  21. Electronic medicines compendium. Phenergan 10mg tablets. Accessed August 8, 2018.
  22. Tang NKY. Insomnia co-occurring with chronic pain: Clinical features, interaction, assessments and possible interventions. Reviews in pain 2008; 2(1).
  23. Webster L. Exploring the relationship between sleep and pain. Medscape Neurology.
  24. Zhang D et al. hangover effect of orally administered antihistamines measured by brain histamine h1 receptor occupancy using PET and 11C-doxepin: A comparison between diphenhydramine and bepotastine in healthy subjects. Accessed August 8, 2018.
  25. Electronic medicines compendium. Nytol one a night. Accessed August 8, 2018.
  26. Electronic medicines compendium. Phenergan night time 25mg film-coated tablets. Accessed August 8, 2018.
  27. NHS. Insomnia – Treatment from a GP. Accessed August 8, 2018.

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