Clinical tips: insomnia

From ajp.com.au

Issues caused by poor sleep can be wide-ranging, writes Karalyn Huxhagen

Insomnia is defined by the American College of Physicians as “dissatisfaction with sleep quantity or quality and is associated with difficulty initiating or maintaining sleep and early-morning waking with inability to return to sleep”.
Insomnia has a ripple effect on the health of the individual as lack of quality sleep can then lead to other medical issues:

• Fatigue
• Cognitive function disorder e.g. impaired concentration and/or memory
• Mood disturbance
• Irritability
• Pervasive malaise
• Inability to perform tasks such as driving a motor vehicle, operating machinery which may in turn impact on employment
• Inability to perform tasks of personal hygiene, parenting children, household maintenance.

The Diagnostic criterion for chronic insomnia is:

Symptoms must cause clinically significant functional distress or impairment

Be present for at least three nights per week for at least three months

Not be linked to any other sleep, medical or mental disorder

In adults, the recommended treatment for chronic insomnia disorder is cognitive behaviour therapy (CBT). Other behaviour therapies that can be trialled are multicomponent behaviour therapy or brief behavioural therapy (BBT). Therapies such as stimulus control, relaxation strategies and sleep restriction can also be trialled.
If CBT alone is not successful then short-term use of pharmacological agents can be trialled. Patients need to be made aware of the benefit and harm and scope of the medication. Some of these medications are expensive.
Patients presenting to pharmacy requesting assistance with sleep are an ideal Medscheck patient as the questions that need to be asked and the counselling that is needed can be extensive and takes time.

Sadly most patients are looking for the ‘quick fix’ option and may not be ready for the discussion that is needed to identify:

• Underlying cause
  • Stress, anxiety, worry, pain
  • Medical condition e.g. irritable bladder, restless leg syndrome
  • Medication e.g. antipsychotics, appetite suppressants, beta-blockers, beta-agonists, fluid tablets, levodopa, methyldopa, SSRIs, thyroid preparations
  • Over the counter medication e.g. pseudoephedrine
  • Illicit drug use e.g. ICE, amphetamines
  • Withdrawing from medication or illicit drug use
  • Diet issues e.g. heavy reliance on caffeine, chocolate and sugar overload before bed
  • Poor sleep hygiene e.g. sleeping with the ipad
  • Poor circadian rhythm due to shift work or rotating rosters
  • Family issues e.g. teething baby, sick children
  • Pets or children in the bed
  • Snoring and/or sleep apnoea of patient or sleep partner
  • Nicotine before bed
  • Stimulating strenuous exercise before bed
• Circadian rhythm disturbance
• Sleep hygiene issues
• Lifestyle issues e.g. heavy exercise before bed.

 Discussion points when counselling:

• Most people require six to 10 hours of sleep.
• Less than four hours and more than nine hours of sleep is associated with higher mortality rates than the average eight hours.
• When sleep requirements are not met, sleep deficit accumulates.
• If sleep deficits accumulate, sleep episodes will occur through the day – micro sleeps.
• A decrease in sleep of 1.5 hours is enough to reduce daytime alertness by 33%.
• Chronic insomnia may contribute to depression.

Medications that may be used for treating insomnia

Over the counter

• Antihistamines—only sedating types, as they are lipid soluble and cross the blood brain barrier.

The issue with using the sedating antihistamines for sedation is that tolerance does develop. The realistic question in every pharmacist’s mind when the habitual patient purchases a weekly box of Restavit/Sleep Aid/ Dozile is whether this medication is effectively helping with sleep or is there now a placebo effect?
Is it truly sedation occurring or is the antihistamine having another action e.g. reducing anxiety/reducing muscle tension? These are centrally acting antihistamines.
After three to seven days of continuous dosing tolerance to the sedative effect of antihistamines will occur. There needs to be a washout period (three to five half-lives) to regain the sedative effect of the centrally acting antihistamine.

• Supplements –many manufacturers have sleep products that contain herbs for relaxation, essential oils, milk derivatives

Pharmacological

• Short acting benzodiazepines (BZDs)
• Long acting benzodiazepines can be used if treating drug withdrawal as well as establishing normal sleep patterns. Not recommended for insomnia due to risk of daytime drowsiness. May be used in chronic insomnia as the short acting BZDs are more likely to cause withdrawal effects.
• Low dose tricyclic antidepressants
• Mirtazapine
• Atypical antipsychotics may be beneficial in olderschizophrenic patients with sleep disturbance; Alzheimer’s
• Antipsychotics e.g. Serenace, Largactil
• Agomelatine e.g. Valdoxan
• The Z drugs e.g. Zolpidem, Zopiclone-only a sedative action. Very rapid onset and short acting. Major issues when combined with any form of alcohol. Tolerance to sedation may occur after several weeks. They have minimal anxiolytic, muscle relaxant and antiepileptic properties.
• Melatonin
• Suvorexant e.g.Belsomra an orexin receptor antagonist-works to suppress the wake drive. It is indicated for the treatment of insomnia for those patients who experience issues with sleep onset and/or sleep maintenance.

Alternative therapies

• Behavioural therapies e.g. CBT, Mindfulness
• Bright light therapy
• Passive body heating
• Management of sleep disorders such as snoring, sleep apnoea
• Sleep hygiene counselling
• Relaxation therapies e.g. hypnosis , meditation, deep breathing and progressive muscle relaxation
• Stimulus control
• Sleep restriction

Sleep hygiene counselling tips:

• Sleep only when sleepy.
• If they cannot fall asleep within 20 minutes get up and do something boring until they fall asleep.
• Do not take naps.
• Make a sleep diary including daytime naps and add up hours that they are asleep. See nps.org.au for a sleep diary.
• Ask someone else to record the sleep hours as the patient may have a different perception of whether they are asleep or not.
• Develop a consistent time of going to bed and rising from bed.
• If disturbed during sleeping hours fix the issue e.g. toileting, snoring, animals or children in/on the bed..
• Do not use blue light emitting devices before sleep e.g. Ipads, Smart phones.
• Bedrooms are for sleep and intimacy not watching television or doing computer work
• Refrain from exercise at least four hours before bedtime.
• Stay away from alcohol, nicotine and caffeine at least four to six hours before bed.
• Avoid alerting, stressful ruminations before bedtime. Discussion on controversies, financial and family problems need to occur earlier in the day.
• Have a light snack before bed.
• Place water beside the bed so they do not rise for a drink.
• Take a hot bath 90 minutes before bedtime.
• Make sure the bed and bedroom are quiet and comfortable.
• Use sunlight/bright light to reset circadian rhythms.

Discussion on how to manage insomnia and sleep hygiene is a large topic but a topic that community pharmacists face constantly. We live in an age of fast paced activity and good quality sleep may be lost in our quest to achieve all of our daily goals.

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.

https://ajp.com.au/columns/clinical-tips/clinical-tips-insomnia-2/