Originally found on https://ajp.com.au/columns/clinical-tips/clinical-tips-insomnia-2/
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 the 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:
- Cognitive function disorder e.g. impaired concentration and/or memory
- Mood disturbance
- 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 behavior therapy (CBT). Other behavior therapies that can be trialed are multicomponent behavior therapy or brief behavioral therapy (BBT). Therapies such as stimulus control, relaxation strategies and sleep restriction can also be trialed.
If CBT alone is not successful then the short-term use of pharmacological agents can be trialed. 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 counseling 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:
- 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 counseling:
- 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.
- Behavioral therapies e.g. CBT, Mindfulness
- Bright light therapy
- Passive body heating
- Management of sleep disorders such as snoring, sleep apnoea
- Sleep hygiene counseling
- Relaxation therapies e.g. hypnosis, meditation, deep breathing and progressive muscle relaxation
- Stimulus control
- Sleep restriction
Sleep hygiene counseling 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, Smartphones.
- 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.