In Clinical

Follow this topic

Bookmark

Record learning outcomes

Many people are still uncertain and even confused when it comes to understanding how they can reduce the impact of insomnia and stress on their lives

LEARNING OBJECTIVES

After reading this feature you should be able to:

• Appreciate the negative health consequences of long-term stress and sleep deprivation
• Discuss the main patient issues relating to hypnotics and tranquillisers, including sideeffects, tolerance and dependency
• Offer patients self-care tips on sleep hygiene and stress management
  

INSOMNIA is defined as a difficulty in getting to sleep or staying asleep long enough to feel refreshed the next morning despite the opportunity to sleep. It is estimated that one-third of all UK adults experience episodes of insomnia. Recognisable symptoms include difficulty falling or staying asleep, or waking up early in the morning.

Although there is no ‘magic number’ for the hours of sleep required by each individual, most adults, including the elderly, need around seven to eight hours a night – yet research by the Sleep Council indicates that around half of people in the UK currently get six hours or less. The main effect of sleep deprivation is excessive daytime sleepiness. Mood and performance can also be adversely affected.

On top of the obvious impact on day-to-day functioning and well-being, the health consequences of sleep deprivation can be significant. Insufficient sleep has been implicated in an increased risk of several serious conditions including high blood pressure, heart attack, obesity, diabetes and Alzheimer’s disease. Severe sleep deprivation has even been linked to a higher risk of agespecific mortality.

Two of the commonest causes of insomnia are stress and anxiety, so taking steps to reduce stress and manage anxiety can have a positive knock-on effect on sleep patterns. Other underlying conditions that can also trigger insomnia include depression, schizophrenia, physical conditions (e.g. asthma and arthritis), or drug or alcohol misuse. It is particularly important for pharmacists to be aware of the range of prescribed and OTC medicines that can contribute to insomnia. These include certain antidepressants, HRT, anti-epileptics, beta-blockers, NSAIDs, stimulants such as methylphenidate or modafinil, and specific asthma medications such as salbutamol, salmeterol and theophylline.

Stress

Stress is the feeling of being under excessive mental or emotional pressure. Stress reactions flood the body with adrenaline and noradrenaline, which ramp up blood pressure and heart rate, increase perspiration and shut down stomach activity. Stress also increases secretion of cortisol, the hormone that stimulates release of fat and sugar into the system.

Although some short-term stress can be positive and is an integral part of our innate flight or fight response, long-term stress carries significant health consequences including an increased risk of heart attack and stroke. Excess or prolonged stress can cause:

• Physical symptoms: dizziness, heart palpitations, headaches, stomach disorders, and aches and pains

• Emotional effects: anxiety, fear, depression, anger and frustration. These can feed into and exacerbate the physical symptoms of stress

• Behavioural changes: withdrawal, indecision, irritability, tearfulness

Anxiety

Anxiety is defined as a feeling of unease (e.g. worry or fear) that can range from mild to severe. A number of conditions have anxiety as their main symptom including:

• Panic disorder: This form of anxiety disorder is characterised by recurring panic attacks, producing physical symptoms such as palpitations, shortness of breath and chest pains

• Phobias: A phobia is an overwhelming or debilitating fear of an object, place, situation, feeling or animal. It is a type of anxiety disorder where symptoms are triggered only by contact with the specific source of the phobia

• Post-traumatic stress disorder: This usually follows a severe trauma and is characterised by intermittent anxiety coupled with other symptoms such as flashbacks and emotional numbness and detachment

• Generalised anxiety disorder: People with this disorder typically feel anxious on most days and the condition persists long-term, causing both psychological and physical symptoms. GAD is the commonest cause of chronic anxiety and affects one in every 25 adults in the UK. It is commoner in women and peaks between the ages of 35 and 55 years

• Social anxiety disorder: This is a persistent fear of social situations and contact that exceeds normal shyness.

Treatment for most types of anxiety disorders is focused on a combination of psychological support and medication, with the aim of reducing the impact of anxiety on everyday life. Options include cognitive and behavioural therapy, anxiety management courses and anxiolytic medication including SSRI antidepressants, benzodiazepines and buspirone.

Tranquillisers and hypnotics

Benzodiazepines and the ‘Z-drugs’ (zaleplon, zolpidem and zopiclone) are commonly used short-term to treat anxiety and induce sleep. Benzodiazepines work by enhancing the effect of the neurotransmitter GABA at its target receptor, producing sedative, hypnotic, anxiolytic and muscle-relaxing effects. Short-acting benzodiazepines are licensed as sleep aids, while longer-acting variants can be used in the control of anxiety.

The use of benzodiazepines for persistent anxiety has declined in recent years. They are now mainly used as short courses (around two weeks) for severe, short-term anxiety or to help those with chronic anxiety disorders manage symptoms during a bad spell.

Z-drugs are chemically distinct from benzodiazepines but share the same basic mechanism of action, binding to brain GABA-A receptors to produce hypnotic/sedative effects. Although initially developed to overcome the short-comings of benzodiazepines, such as next-day sedation, dependence and withdrawal, Z-drugs are now acknowledged to have similar long-term usage problems.

According to NICE: “There is no compelling evidence of a clinically useful difference between the Z-drugs and short-acting benzodiazepine hypnotics from the point of view of their effectiveness, adverse effects or the potential for abuse or dependence.”

The major patient issues with benzodiazepines and Z-drugs are tolerance (where therapeutic benefit wanes over time) and dependency. Around four in every 10 patients taking benzo-diazepines daily for more than six weeks will become addicted. Withdrawal symptoms then include anxiety, depression, nausea, perceptual changes and rebound insomnia. These can develop within just a few hours of stopping short-acting benzodiazepines.

To reduce the risk of withdrawal symptoms, benzodiazepines should be tapered gradually, not stopped abruptly. Any patient on benzodiazepines daily for more than three weeks is advised to reduce his/her daily dose by an eighth or a quarter every two to four weeks before stopping. For those on longer-term benzodiazepine therapy, withdrawal may take many months, even years. Patients generally find it more difficult to come off short-acting benzodiazepines (e.g. lorazepam) and may benefit switching to diazepam (from which it is easier to withdraw).

Any patient taking benzodiazepines for more than four weeks is at risk of developing dependence, so the BNF recommends reserving them for short courses to alleviate acute conditions, such as insomnia, after causal factors have been established.

By nature of their mechanism of action, daytime drowsiness is a key side-effect of hypnotics and patients should be advised to take particular care when driving. Other potential adverse effects of benzodiazepines include difficulty concentrating, headaches, vertigo, tremor and low sex drive. Benzodiazepines have also been linked to paradoxical effects, such as increased hostility and aggression, which may necessitate dose adjustments (up or down) to attenuate these impulses.

The health consequences of sleep deprivation can be significant

OTC sleep aids

Community pharmacists are well-positioned to act as the primary source of advice on sleep-related disorders in the community – particularly for those patients who don’t regularly see their GP or rarely come into contact with other sources of healthcare. Sleep aids available from the pharmacy include sedating antihistamines and herbal sleep remedies.

The antihistamines diphenhydramine and promethazine, found in a number of OTC insomnia products, cross the blood-brain barrier and act on histamine receptors in the brain to elicit feelings of drowsiness and sedation.

Herbal sleep aids have also shown positive effects on treating sleep disturbances. Examples include valerian and passiflora which work by promoting calmness and thus encouraging natural sleep. Evidence on valerian is conflicting but there are some findings to indicate it can reduce sleep latency and boost sleep quality.

Although the hormone melatonin is not currently available over the counter in the UK, its high media profile means that community pharmacy customers with sleep problems may be prompted to enquire about it. Evidence indicates that melatonin successfully decreases sleep latency, promotes feelings of sleepiness and may extend sleep duration. However more research is required to determine optimal dosing and the long-term safety profile with regular use.

For pharmacists, ensuring that customers affected by insomnia choose an appropriate sleep aid – and use it correctly – is vital. Patients relying on OTC sleep aids long-term may be masking an underlying stress or anxiety-related problem that requires addressing. “Our research found that 30 per cent of people who experience insomnia, and who had taken sleeping remedies, had taken them for more than a month without getting advice, including 14 per cent of respondents who had taken them for more than six months,” notes the Royal Pharmaceutical Society.

Sleep hygiene

People affected by insomnia can be advised on both the optimal use of pharmacotherapy and good sleep hygiene – those steps that can help to promote normal, quality night-time sleep. The most crucial sleep hygiene advice is to maintain a regular sleep and wake pattern seven days a week. It is also important to spend an appropriate amount of time each day in bed – not too much and not too little (seven to eight hours is generally recommended).

Other important sleep hygiene tips include:

• Avoid napping during the day as this can disrupt normal sleep/wake patterns

• Avoid stimulants such as caffeine and nicotine in the six hours before bed

• Alcohol should also be avoided before bed. Although alcohol speeds the onset of sleep, it can disturb sleep in the second portion of the night when the body starts to metabolise the alcohol

• Regular exercise can promote good sleep but should be avoided within four hours of bedtime

• Avoid heavy meals before bedtime

• Ensure adequate exposure to natural light. Light exposure helps regulate the body’s normal circadian rhythms by controlling the production of melatonin by the pineal gland in the brain. This is particularly important advice for older adults who may spend significant parts of the day indoors, especially during winter months

• Establish a regular, relaxing bedtime routine. This could include a warm bath or milky drink each night before bed

• Associate your bed with sleep only. Avoid watching television, reading or carrying out other activities in bed

• Ensure the bedroom environment is conducive to sleep – minimise noise, light and excessive heat.

 

REFERENCES

1. NHS Choices
2. National Sleep Foundation
3. Sleep Council
4. American Academy of Sleep Medicine
5. Mental Health Foundation
6. Patient UK
7. Royal College of Psychiatrists
8. NICE Technology Appraisal Guidance 77.
Issued April 2004
9. Advisory Council on the Misuse of
Drugs. Z-drugs: a review of the evidence of
misuse and harm. September 2013
10. Royal Pharmaceutical Society
11. Noor Z et al. A study protocol: a
community pharmacy-based intervention
for improving the management of sleep
disorders in the community settings.
BMC Health Services Research 2014; 14:74