Prescribing a good night’s sleep

Numerous studies have shown pharmacists are well placed to support sleep health. However, what is the true depth and feasibility of their role in this area?

We are now more aware than ever of the importance of sleep to our overall health.

Poor, or inadequate, sleep has been identified as a significant risk factor for developing chronic health concerns such as heart disease, type 2 diabetes, obesity, stroke, cancer and mental health issues. There are also links between sleep duration and mortality.

Yet, despite the serious nature of sleep disorders, they continue to be under-diagnosed. As such, there is an opportunity for pharmacists to play a greater role in this area by raising awareness of sleep health, as well as identifying and investigating the underlying reasons for sleep disturbances.

Lack of recognition

Dr Brendon Yee, a sleep and respiratory physician with the Royal Prince Alfred Hospital and the Woolcock Institute of Medical Research, says there are three main reasons why sleep disorders are poorly recognised and managed.

“Firstly, there is the lack of awareness and training in sleep medicine and the association between sleep apnoea and other health concerns, such as diabetes, cardiovascular disease, psychiatric disorders and obesity, for example.

“Secondly, many people may under-record or fail to recognise their symptoms. Sleep, by nature, involves a loss of awareness, so it’s not uncommon for people to be unaware they are experiencing disturbed or poor quality sleep.

“Thirdly, the presentation can be different. For example, the presentation of sleep apnoea in males tends to be the classic loud snoring, gasping and choking at nighttime before falling asleep.

“Whereas, in females the presentation can sometimes be a little more subtle or the symptoms can vary in severity. Maybe it is more fragmented sleep they are experiencing or insomnia-like symptoms, such as feeling tired during the day rather than actual daytime sleeping.”

Pharmacy services in action

Angela Boyatzis, from Amcal Community Pharmacy in Como, was named WA Pharmacist of the Year 2020 for her impressive work in the area of sleep management and healthcare.

She tells the AJP, “When we started out, my main goal was to raise awareness about sleep health. We know that obstructive sleep apnoea (OSA) is prevalent; around one in five people have it, but about 80% are undiagnosed. So we began by raising consumer awareness of common sleep health issues.

“This led onto doing the initial sleep apnoea screening, referral, where necessary, and providing treatment—which might involve a trial of Continuous Positive Airway Pressure Therapy (CPAP) and a discussion about the long-term solutions and other treatments.

“Our pharmacy has quite long opening hours; so not only are we easy to access, but we can be there for the customer along every step of the journey. Of course, to be able to offer this service, many of my team members have received training in this area.”

Ms Boyatzis explains, “When we encounter someone who is having problems with their sleep, we take a holistic approach. We look at what medications they’re taking or what other medical conditions they have, which we can often see from their script history. They might be selecting an OTC supplement, such as magnesium, which might help us to recognise the potential of insomnia.

“When counselling people, I tend to start with an initial discussion around sleep hygiene and from there we might discuss more complex issues—such as sleep apnoea or insomnia, for example—that need to be considered.

“Certainly, our main role lies in the awareness and initial screening stage. Our services for sleep apnoea are more comprehensive, but for insomnia it is more about looking at other underlying factors and, if necessary, referring them to the right person.

“This is a very specialised area, so if you’re going to offer a sleep service you have to be well trained and willing to continue with that training. This is something I have learned above all else. I’ve done lots of training and I’ve trained my staff well. We also have access to a good sleep support service. It’s like running a business within your business. It might not be right for every pharmacy but if you’re interested and you think you have the ability to educate your staff I think pharmacy is in a perfect position.”

sleep apnoea - woman wearing cpap

Supporting CPAP therapy

“It’s important to acknowledge, we are not diagnosing; we are identifying at-risk patients, screening and testing. A clinical sleep specialist analyses the results. Then, if therapy is prescribed, the patient will come back to the pharmacy for the CPAP trial,” explains Ms Boyatzis.

“CPAP therapy is quite a confronting concept for people. It’s not something you use for a short while; it’s an ongoing treatment and, as such, adherence can be an issue.

“My key to supporting CPAP therapy is to always try to find out the person’s motivating factor for coming into the pharmacy in the first place. Once I have identified this, I will refer back to it throughout the trial and each time I see the person. I find this to be really useful in encouraging them to adhere to the therapy.

“For example, a common motivating factor is snoring. I’ve had many patients who come into the pharmacy to tell me they’re delighted they can share a bed again with their partner. It’s all about finding the motivating factor to try and distract from the fact there’s a machine and a mask that has to be worn.

“Certainly, CPAP therapy is not a set-and-forget treatment; follow up is really important and, as pharmacists, we have the advantage because people return to us for many different reasons. Regularly touching base with the person is key, but it’s also vital to communicate with their GP so treatment goals are consistent.”

Professor Bandana Saini, academic pharmacist and research leader at Woolcock Institute of Medical Research, adds “It’s important to adhere to the practice guidelines for sleep apnoea services, which clearly indicate that while pharmacists can do the whole gamut—from screening and referral to providing CPAP, following up on CPAP usage and offering ongoing support—it’s really important to ensure the patient has a face-to-face consult with a medical practitioner, ideally a sleep physician.

“This provides the opportunity to look at the individual’s complete medical history and personal details to identify what treatment avenue would best suit the patient.

“One of the critiques of the pharmacy sleep apnoea model is the fact the service centres on the provision of the CPAP device. However, not everyone needs CPAP. It’s gold-standard because it has the most evidence, but it’s not necessarily the first-line treatment for everyone. For example, someone with mild sleep apnoea might benefit from weight loss or positional therapy. Others might need surgery or a dental device. You need a physician involved who can weigh up the options and choose the best treatment for the individual patient,” advises Prof Saini.

Dr Yee tells the AJP, “I think training specific pharmacists in sleep medicine is very appropriate and in this case being able to directly refer to sleep physicians would be useful.

“I may assess a patient and feel they need CPAP therapy and if I know of a pharmacist who has many different machines and they have good knowledge in this area then I will suggest the patient gets their machine from this particular pharmacy. It’s a two-way street, but it’s all about pharmacists having the right training.

“If you have specialist pharmacists that have an interest in sleep disorders and the appropriate training in this area then I think that would work very well. I’d be happy to work with them.”

Training for the future

Despite the fact sleep disorders such as insomnia and OSA are commonly encountered in pharmacy, recent research shows that many pharmacists don’t feel equipped to deal with these types of conditions.
Mariam Basheti, PhD student researcher at Woolcock Institute of Medical Research, explains, “We found that pharmacists most commonly offer support in the form of basic sleep health management, including sleep hygiene education, or advice on sleep aid medication.

“In more complex cases, pharmacists prefer to refer customers to their GP as they feel they lack the sufficient knowledge or expertise to appropriately manage these presentations.”

Ms Basheti explains that a key insight from her study is the fact sleep health and sleep disorders are not really covered in the pharmacy university curriculum. “This means that pharmacists have difficulty differentiating between different kinds of sleep disorders. For example a case of insomnia may in reality be a circadian rhythm disorder. Pharmacists might know what a circadian rhythm disorder is, but they may not know the different kinds, how these circadian disorders present, the various treatments and how these may affect the person.”

She says further education, covering a broad range of sleep health topics and disorders, would assist pharmacists to play a greater and more purposeful role.

“Training is needed to cover the specifics. For insomnia, for example, pharmacists would require training on how to deliver behavioural therapy. They would also need to know what information to acquire from patients in order to ascertain whether they could deliver that service.

“However, with the appropriate funding, education and time, most pharmacists believe they could deliver this type of service within the pharmacy.”

Prof Saini says, “In terms of insomnia, none of the OTC treatments are considered to be that effective. Yet pharmacists often feel that, because the person has come to them, they are professionally obliged to provide a solution.

“But while we can’t deliver cognitive behavioural treatment because that requires a psychologist, brief behavioural treatments are fairly easy to deliver. So rather than sending someone away empty handed, we could invest the time in providing this type of service. After all, we offer behavioural related services all the time in the form of counselling for adherence, smoking cessation and the like.”

Ms Basheti adds, “Currently, despite their willingness to deliver this service, time is a barrier. The pharmacists felt there is not enough time, due to the daily tasks they are currently involved in. In order to deliver a sleep health service, most felt they would need a pharmacist who is dedicated to this area.”

Prof Saini says, “Unless there is a remunerable component introduced, it’s very difficult to predict what the role of pharmacy will be in sleep health in the future. Pharmacists are all willing, but the problem is funding.

“However, keeping sleep health top of mind is essential. People think sleep is a lifestyle and they don’t consider poor sleep as a health condition; it’s taken for granted.

“So, even if the pharmacist is not delivering comprehensive structured services in this area, they can hone in on opportunities where they can counsel people on sleep health.

“I also think it’s important for pharmacists to engage with bodies like the Sleep Health Foundation and the Australasian Sleep Association. These organisation frequently offer continuing education courses, which pharmacists can incorporate into their own continuing professional development plan.”

Alternative options for sleep apnoea

Where there is the testing and also the provision of CPAP devices, there is the potential for a conflict of interest. There is certainly a role for pharmacy, but I think pharmacists need to be aware of all the treatment options available. Despite the fact CPAP is considered the gold-standard treatment for OSA, there will be occasions where CPAP is not appropriate,” says Dr Brendon Yee.

He says pharmacists are in a good position to inform patients of the different treatment options available, as well as the factors that may contribute to their sleep apnoea. Furthermore, it may be necessary to combine multiple components.

“I don’t think patients should be told there’s one treatment only and that is CPAP. There are alternatives to CPAP, such as weight loss, dental guards, upper airway and maxilla-facial surgery, that should be considered.”

Oral appliances, such as mandibular advancement devices and tongue retaining devices, work by pushing the lower jaw forward to prevent the airway from collapsing and repositioning the tongue to prevent it from sliding back and blocking air flow.

Another alternative is positional therapy, which may incorporate the use of sleep products to help position the person on their side.

Dr Yee adds, “In cases where patients are led to believe CPAP is their only option they may try the therapy, hate it (we know that compliance rates are around 60–65%) and end up with negative connotations of sleep apnoea and sleep medicine. This is why I feel anyone who is working in the field of sleep medicine needs to be properly trained.

“It’s all about selecting the right patient for CPAP therapy. Someone with mild sleep apnoea who’s not symptomatic is not going to use the machine and really shouldn’t be expected to adhere to therapy. There may be other lifestyle modifications they can try.”

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