Good sleep hygiene habits are key in combating insomnia, writes Louis Roller
Insomnia is a very common disorder that has significant long-term health consequences. Australian population surveys have shown that 13% to 33% of the adult population have regular difficulty either getting to sleep or staying asleep.
Insomnia can occur as a primary disorder or, more commonly, it can be comorbid with other physical or mental disorders. Around 50% of patients with depression have comorbid insomnia, and depression and sleep disturbance are, respectively, the first and third most common psychological reasons for patient encounters in general practice.
Insomnia doubles the risk of future development of depression, and insomnia symptoms together with shortened sleep are associated with hypertension.
Insomnia is defined in the fifth edition of the Diagnostic and statistical manual of mental disorders (DSM-5) as difficulty getting to sleep, staying asleep or having non-restorative sleep despite having adequate opportunity for sleep, together with associated impairment of daytime functioning, with symptoms being present for at least four weeks.
Having a sleep experience that does not meet our expectation, such as with some transient awakenings but with good daytime functioning, does not constitute insomnia.
Acute and chronic insomnia require different management approaches.
Chronic insomnia is unlikely to spontaneously remit, and over time will be characterised by cycles of relapse and remission or persistent symptoms.
Chronic insomnia is best managed using non-drug strategies such as cognitive behaviour therapy.
For patients with ongoing symptoms, there may be a role for adjunctive use of medications such as hypnotics.
Many people who complain of insomnia are found to have perfectly normal sleep when studied in a sleep laboratory, whereas others who do not complain of insomnia have detectable sleep disturbances.
About 90% of adults sleep six to nine hours per night, with the largest number sleeping seven and a half to eight hours. While some people sleep only six to seven hours, most of these people have measurable signs of sleepiness during the day, even if they do not realise it. It appears that most adults require eight to nine hours of sleep to be free from daytime sleepiness.
Some patients, particularly older persons, frequently have daytime naps and that needs to be considered when calculating sleep duration as sleep physiology changes with increasing age. Interestingly, a recent study found a significant correlation between day-napping, short night sleeping and risk of diabetes.
In older persons, less time is spent in Stage 4 (deep sleep) and REM (rapid eye movement) sleep (where most dreaming occurs), the total duration of sleep becomes shorter, sleep becomes more shallow and disrupted, the number of nocturnal awakenings increase, and sleep latency usually remains normal.
Many individuals function well on the amount of sleep they obtain and may only need to be reassured. Symptoms of insomnia are often secondary to some underlying medical, psychological or environmental problems. Frequently, the sleep problem begins at a time of loss or stress, and then persists long after the crisis has resolved.
Medicines that may induce or exacerbate insomnia include alcohol, appetite suppressants, bupropion, calcium channel blocking agents, corticosteroids, dopamine agonists, methyldopa, SSRIs, sympathomimetics, theophylline/caffeine/theobromine, tricyclic antidepressants and venlafaxine.
For individuals who have insomnia caused by anxiety, many non-pharmacological, anxiety reducing programs are available (eg relaxation therapy, progressive muscle relaxation techniques, hypnosis, biofeedback and meditation).
A first prescription for a hypnotic is an ideal opportunity for the pharmacist to introduce the concept of sleep hygiene. Pharmacists undertaking medication reviews have great difficulty in encouraging older persons to decrease and hopefully cease taking these agents after many years of usage.
Insomnia can be improved by better management of any underlying problem such as angina, nocturnal asthma, dyspnoea, oesophageal reflux, nocturia, or pain.
Perhaps an important first step in treatment of insomnia is to educate the patient in sleep hygiene, encouraging adopting of habits that promotes good sleep, and to eliminate those habits that erodes sleep. Below are some suggestions that may lead to better sleep patterns.
- Keep the bedroom dark, comfortable and quiet.
- Keep a regular sleep schedule. Awaken at the same time daily.
- Avoid daytime naps even after a poor night of sleep.
- Do not live in bed: the bedroom should be reserved for sleep and sex.
- No eating, watching TV or working in bed: it increases stress.
- Turn the face of the clock aside to minimise anxiety about falling asleep.
- If unable to sleep, get out of bed and do something to take your mind off sleeping.
- Establish a pre-bedtime ritual to condition your body to sleep.
- Relax before bedtime with soft music, mild stretching, yoga or pleasurable reading.
- Exercise early in the day before dinner to alleviate stress.
- Do not exercise before bedtime as it could keep you awake.
- Do not eat heavy meals before bedtime.
- Do not take any caffeine in the afternoon (eg coffee, tea, chocolate, cola drinks).
- Consult with a pharmacist, doctor or other primary care provider about your sleep problem because: a physical or mental condition can cause poor sleep; and prescribed medication can interfere with sleep.
PSA Self Care cards: Sleeping Badly and Relaxation Techniques
Associate Professor Louis Roller, from the Faculty of Pharmacy and Pharmaceutical Sciences Monash University, was the 2014 recipient of the PSA Lifetime Achievement Award.