It’s good night from me

Advocates for sleep health argue it’s high time we move sleep issues off the backburner, making sleep a national health priority, says Leanne Philpott.

Experts say that Australia is in the midst of a sleep deprivation epidemic, which is having a negative impact on productivity, work safety and our health. Indeed, research by the Sleep Health Foundation reveals that 33-45% of adults sleep either inadequately or not long enough most nights, leaving them feeling fatigued and irritable the following day.

The 2016 Sleep Health Survey of Australian Adults, conducted by researchers from The Adelaide Institute for Sleep Health at the University of Adelaide, on behalf of the Sleep Health Foundation, shows sleep problems are increasingly common in the community.

Key findings of the report reveal:

  • Sleep issues occur across all age groups.
  • Medical sleep conditions are common with diagnosed sleep apnoea affecting 8%, significant insomnia 20% and restless legs 18% of adults.
  • Average reported sleep time is 7 hours, although 12% sleep less than 5 1⁄2 hours and 8% over 9 hours. Three-quarters (76%) who sleep less than 5 1⁄2 hours report frequent daytime impairment or sleep-related symptoms.
  • 24% of men and 17% of women reports frequent, loud snoring. Frequent, loud snoring and breathing pauses in sleep are more often seen in middle age. Among those with frequent, loud snoring, 70% report daytime impairment or other sleep-related symptoms.
  • Among the 19% of people with frequent loud snoring and/or witnessed breathing pauses but no prior diagnosis of sleep apnoea, 63% report awakening unrefreshed, and 65% report one or more daytime sleep-related symptoms, suggesting undiagnosed sleep apnoea is relatively common in the community.

Sleep hygiene

“There are an enormous number of people living with insufficient sleep on an ongoing basis. The problem is that people don’t prioritise sleep. They don’t stop and take stock and consider what the problem is,” says Professor Dorothy Bruck, Chair of the Sleep Health Foundation.

“Sleep health is fundamental to having good quality of life and being able to perform optimally in work and at home. Poor or insufficient sleep has a major impact on many areas of the body. For example, your ability to think, concentrate and remember things can deteriorate. Emotionally you become more volatile and can become grumpy, irritable, withdrawn or sad; depression is much higher in people who sleep poorly.

“From a physical health point of view, poor sleep can leave you more prone to sports injuries, plus there’s some evidence that your immune system might suffer.

“We also know that people who repeatedly experience fragmented sleep are more likely to develop the pre-clinical signs of diabetes, leaving them at increased risk of diabetes down the track.

People need to take a problem-solving approach to find out what is it that’s affecting their sleep. They also need to educate themselves about what might be going wrong and how they can help rectify it.

“Herbal sleep treatments can be useful for people where anxiety might be a problem. If you have someone who seems to be running at full throttle, can’t unwind – then a herbal approach can help reduce anxiety by assisting with relaxation and inducing sleep.”

She says pharmacists can play a role by advising on some of the basic sleep hygiene tips. “Pharmacists can ask how long the person is spending in bed at night, as it might be more than the requirement (on average 7.5-8.5 hours for adults).

“If someone is spending 9-10 hours in bed we often see a lack of consolidation of sleep where they’re continually waking up, particularly in the second half of the night. Sometimes the single best advice you can give a person is to tell them not to have naps in front of the TV and to perhaps go to bed a little later, as this gives them more sleep pressure.”

Professor Bruck adds, “In terms of insomnia, what we’re seeing is that people are not winding down when they come home from work; they’re checking their emails and catching up on chores.

“Despite the 24/7 society in which we live, it’s important for people to give themselves a cut off, for example setting the rule that after eight o’ clock they’re not doing anymore work emails and not responding to texts; this allows a buffer zone before bed.

“We talk in terms of a 1-2 hour buffer zone with no computer work because of the blue light and the stimulation.”

Despite the many actions people can undertake to improve and maintain a good night’s sleep, simple measures are all too often overlooked.

According to clinical guidelines from The Royal Australian College of General Practitioners, key practices include:

  • Only sleeping as long as necessary to feel rested
  • Maintaining a regular sleep schedule
  • Avoiding caffeine in the afternoon and evenings
  • Not forcing sleep. If you are not asleep within 15-20 minutes, get out of bed and return only when feeling drowsy
  • Avoiding alcohol and/or smoking
  • Refraining from daytime or evening naps

Pharmacy role in sleep apnoea

Specific sleep disorders, such as obstructive sleep apnoea (OSA), have been linked to several health issues including coronary heart disease, stroke, diabetes, hypertension, depression, cognitive impairment and mortality risk.

While specific diagnosis for sleep apnoea is common, under-diagnosis is also widespread. As such, researchers of the 2016 Sleep Health Survey say that having healthcare practitioners within the community recognise that ‘snoring may not be a benign symptom and that daytime impairment may have a pathological cause is an important first step’ in improving the diagnosis and treatment of sleep apnoea.

According to Sydney Sleep Centre, symptoms of sleep apnoea include:

  • Loud or frequent snoring
  • Choking or gasping while you sleep
  • Pauses in breathing
  • Morning headaches
  • Excessive daytime sleepiness
  • Insomnia due to difficulty staying asleep
  • Waking up with dry mouth or a sore throat
  • Frequent need to urinate during the night
  • Trouble concentrating
  • Memory or learning problems
  • Moodiness, irritability or depression

Snore Australia lists the following know risk factors for sleep apnoea:

  • Obesity (especially obesity around the abdomen and neck) – but remembering, OSA can also occur in people who are not overweight or obese
  • Large neck circumference (>43cm for men and >40cm for women)
  • Age over 65 years (although OSA affects individuals of all ages, including children and adolescents)
  • Family history of OSA or sleep-disordered breathing
  • Certain facial abnormalities, including a high, narrow, elongated, soft palate, a small chin, an abnormal bite and a small jaw
  • Cigarette smoking and excessive alcohol consumption
  • Medications, especially sedatives at night.

Elise Apolloni, pharmacist and managing partner at Capital Chemist Wanniassa, says the highly accessible nature of pharmacy means that pharmacists see many people with chronic health conditions (high blood pressure, diabetes, obesity) that might put them at risk of sleep apnoea; this puts pharmacist in an ideal place to help screen for the condition.

“As part of our in-pharmacy sleep apnoea service we have a screening questionnaire that patients can complete any time they’re in the pharmacy. A high score may indicate further investigation could be helpful.

“We also provide at-home sleep studies whereby we advise patients how to wear a device which measures their breathing patterns during overnight sleep. The results of the study are sent to a sleep specialist for assessment and detection of any abnormalities. The patient then returns to the pharmacy and we share with them the report and the findings from the doctor.

“If sleep apnoea is detected, we can then help them further by starting them off on a one-month trial of CPAP therapy. We can also order parts, update machines and masks and help with the consumables associated with CPAP therapy.” 

Dr Peter Eastwood, President of the Australasian Sleep Association (ASA), says, “In many cases pharmacists are the frontline between the general public and the healthcare system; if patients present with a series of symptoms that are suggestive of a sleep disorder the pharmacist needs to know what the appropriate next steps are.

“In most cases it will be a visit to the GP, but people should do this on an informed basis. Informed conversation by trained health individuals is key to having an appropriately aware population.

“Our knowledge of sleep is relatively new and yet there’s a huge burden of disease out there and pharmacists, along with many other allied health groups, are constantly seeing people with the symptoms of poor sleep and this indicates a desperate need for education – particularly in the frontline professions, like pharmacy.”

Dr Eastwood tells The AJP, “Pharmacists need to know how to identify potential sleep problems and to provide a recommendation to go and see a GP, but they should not be diagnosing.”

While Dr Eastwood believes pharmacists should not be offering at-home sleep studies, he doesn’t deny the important role they play in sleep apnoea.

“Pharmacists have an interesting role as in Australia CPAP devices are not prescription items; they can be sold in pharmacies, as they are. This is completely appropriate, if the recommendation for the treatment has come from a sleep physician or from a GP who has recognised someone as having a very high probability of having sleep apnoea.

“In this instance CPAP fitting is a really important area for pharmacists to get involved in. They should be trained in what the appropriate masks are, the choices available and how to fit the mask. This is where pharmacists play a fundamental role.

“However, pharmacists should not be doing sleep studies. The level three and four studies they offer are much more difficult than the comprehensive studies to interpret and can lead to increased likelihood of under or over-diagnosis,” says Dr Eastwood.

Late last year the ASA together with the PSA released new guidelines for pharmacists to help them establish and deliver a high-quality CPAP service.

“We want to help pharmacists deliver the best services they can. We want pharmacists to understand how to diagnose sleep apnoea, what you can get from the different levels of sleep studies and what it means if it’s negative, as well as how to manage sleep apnoea and provide CPAP services of a high standard,” says Dr Eastwood.

While CPAP therapy is the gold standard of treatment for sleep apnoea, a major limitation is patient adherence. However, this is an area pharmacists can help address.

Apolloni explains that patient follow-up is vital in optimising patient adoption and long-term adherence to CPAP. “Some people feel amazing using a CPAP machine, compared to how they felt before treatment, but other people don’t necessarily feel as profoundly different.  Constant follow-up is important to reiterate the importance of the therapy, reinforce the positive health outcomes associated with treatment, while also optimising comfort and convenience for the patient.

“Even when you have a patient established on CPAP, as with any routine we can get out of the habit, so we need to constantly check in with people and make sure they are getting the most out of their treatment.

“Sometimes a simple factor, such as a rash from wearing the mask, an uncomfortable mask, or a noisy machine that needs replacing or servicing, is the barrier to treatment. And yet we can solve those problems for the patient.” 

She adds, “Just like any professional service, it takes time to become trained and competent to deliver the service. Being accessible, educated and convenient is key. People want human connection when it comes to their health and pharmacy-delivered CPAP services offer that connection.” 

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