Insomnia

• Sleep is an important factor in many processes including neural development, learning, memory, regulation of emotion, and cardiovascular and metabolic functioning
• It's essential to allow the body to repair and restore brain and body tissues
• The mechanisms controlling sleep are complex and not yet fully understood but reflect disturbances of arousal and/or sleep-promoting systems in the brain
• The older you get, the amount of times you wake up during the night increases and the total amount of sleep time that's required decreases
• Short sleep duration (6 hours or less per 24 hours) is associated with adverse outcomes including mortality rates
• Long sleep duration (more than 9-10 hours per 24 hours) may be normal but has also been associated with adverse outcomes
• Long sleep duration may be a marker of ill-health and physical inactivity rather than a cause of ill-health
• The normal time taken to fall asleep (sleep-onset latency) is usually considered to be less than 30 minutes
• Insomnia


  Difficulty in getting to or maintaining sleep (waking up a few times during the night), or early awakening (waking up early in the morning, e.g. 3 o'clock, and can't get back to sleep) that leads to dissatisfaction with sleep quantity or quality
• Non-restorative sleep


  Occurs despite adequate opportunity for sleep
• Daytime symptoms of insomnia

  • Poor concentration
  • Mood disturbance
  • Fatigue
• Sleep disturbance in the absence of daytime impairment is not considered to be insomnia disorder
• Short-term insomnia


  Symptoms occurring for less than 3 months duration (typically a few days or weeks)
• Chronic insomnia


  Symptoms occurring on at least 3 nights per week for three months or more
• The pharmacist can manage most patients with short-term insomnia; however, cases of chronic insomnia are best referred to the doctor, as there is usually an underlying cause
• Insomnia is more common in females than males
• Insomnia is more common in older adults — increases with age
• Approximately 20% to 40% of adults report occasional sleep difficulty
• Insomnia is more common in people with co-morbidities, e.g. those with certain lung conditions such as COPD, those with heart conditions such as heart failure, those with psychological conditions like anxiety and depression etc.
• Causes of insomnia


  • Stressful events (bereavement, illness, changes in employment, exams, pending deadlines, financial difficulties)
  • Changes in sleeping patterns (birth of a child, environmental disturbance e.g. excess noise or light or extremes of temperature)
  • Psychiatric disorders (anxiety, depression)
  • Medical disorders (COPD, heart failure, neurodegenerative diseases, malignancy, musculoskeletal conditions, chronic pain)
  • Substance misuse (alcohol and illicit drugs)
  • Medication (stimulants, antiepileptics, beta blockers, SSRIs, diuretics and donepezil)
• Insomnia is a subjective complaint of poor sleep in terms of its quality and duration
• Insomnia symptoms


  • Difficulty in falling asleep
  • Difficulty in staying asleep
  • Lack of refreshment by sleep
  • Daytime fatigue but not generally sleepiness
• Insomnia can lead to poor performance at work
• Questions to ask about insomnia


  • Pattern of sleep
  • Daily routine
  • Underlying medical conditions
  • Recent travel
  • Daytime sleeping
• Many medical conditions may precipitate insomnia
• A key role for the pharmacist in these situations is to ensure that the underlying condition is being treated optimally and to check that the medication regimen is appropriate
• Sleep hygiene advice


  • Normal sleep and changes in sleep patterns with age
  • Comfortable sleeping environment (temp, noise, light)
  • Use bedroom only for sleep and intimacy
  • Avoid clock watching
  • Avoid using devices for two hours before bed
  • Avoid sleeping in very warm rooms
  • No strenuous mental activity at bedtime
  • Regular sleep schedules (going to bed when sleepy, waking up and getting out of bed at the same time every morning, increase exposure to bright light in the morning, avoiding napping during the day, no sleeping in to catch up on sleep)
  • Relaxation before going to bed (bath, reading book, relaxation exercises, visual imagery)
  • Limiting/avoidance of caffeine, nicotine and alcohol
  • Exercise (avoid within 4 hours of bedtime but beneficial earlier in the day)
  • If unable to get to sleep, get up and do something and return to bed when sleepy
• Insomnia medications


  • OTC antihistamines (e.g. diphenhydramine)
  • Herbal (e.g. valerian)
  • Alternative (e.g. melatonin supplements)
  • POM benzodiazepines
  • POM Z-drugs (e.g. zopiclone)
• Sleeping tablets are not recommended due to potential side effects and issues with sleeping tablets
• If it's taken regularly, patient can develop a tolerance, meaning the usual dose of them doesn't have an effect, so a higher dose is needed to be more effective, which will soon have no effect and the cycle continues
• People can also become addicted to or dependent on sleeping tablets and if they stop taking it, they can have withdrawal symptoms
• Trying to address the underlying cause is the best option rather than treating the insomnia
• A short course of the medications can be prescribed to be used for 3 days up to potentially 7 days max
• Patient should be monitored while they're using them
• If patients have certain other conditions, or are pregnant or breastfeeding, they will not be suitable to use
• Insomnia for which no cause can be ascertained is likely to be associated with underlying causes and requires investigation
• Symptoms suggestive of anxiety or depression - insomnia is one of the cardinal symptoms of depression and anxiety and needs investigation
• Duration 4 weeks; children — outside the remit of community pharmacists