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)
- heart disease
- shortened life expectancy.
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:
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:
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
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.
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?”
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
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 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.
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, 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.
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.
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
- NHS Choices. How to get to sleep. Accessed August 8, 2018.
- National Institute of Neurological Disorders and Stroke. Brain basics: understanding sleep. Accessed August 8, 2018.
- The National Heart, Lung, and Blood Institute. Sleep deprivation and deficiency. Accessed August 8, 2018.
- NHS Choices. Sleep and tiredness. Accessed August 8, 2018.
- NHS Choices. Insomnia. Accessed August 8, 2018.
- Sleep foundation. Insomnia and older adults. Accessed August 8, 2018.
- Sleep foundation. Improve your memory with a good night’s sleep. Accessed August 8, 2018.
- NHS. Why lack of sleep is bad for your health. Accessed August 8, 2018.
- National Institute of Neurological Disorders and Stroke. Brain basics: understanding sleep. Accessed August 8, 2018.
- How sleep works. Rem sleep – types and stages of sleep. Accessed August 8, 2018.
- Causes of sleep disruption – Hall & Partners, 2013 – Consumer survey of 1,500 people suffering with sleep issues.
- 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.
- 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.
- 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.
- Allsleep – Sleep Disorders Misdiagnosis. Accessed August 8, 2018.
- Nice – Clinical knowledge summaries – Insomnia, less than four weeks. Accessed. August 8, 2018.
- Nice – Clinical knowledge summaries – Insomnia, more than four weeks. Accessed August 8, 2018.
- Nice – Clinical knowledge summaries – Insomnia, good sleep hygiene. Accessed August 8, 2018.
- NHS Choices. How to get to sleep – keep a sleep diary. Accessed August 8, 2018.
- Electronic medicines compendium. Nytol original 25mg tablets. Accessed August 8, 2018.
- Electronic medicines compendium. Phenergan 10mg tablets. Accessed August 8, 2018.
- Tang NKY. Insomnia co-occurring with chronic pain: Clinical features, interaction, assessments and possible interventions. Reviews in pain 2008; 2(1).
- Webster L. Exploring the relationship between sleep and pain. Medscape Neurology.
- 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.
- Electronic medicines compendium. Nytol one a night. Accessed August 8, 2018.
- Electronic medicines compendium. Phenergan night time 25mg film-coated tablets. Accessed August 8, 2018.
- NHS. Insomnia – Treatment from a GP. Accessed August 8, 2018.