Sleep is characterised by altered consciousness and reduced reaction to stimuli, as well as reduced sensory and muscle activity. This helps to restore body systems – which are vital in cognition, mood, memory, metabolism and immune response, amongst others.1 The average adult requires 7 to 9 hours sleep per day.2 Benefits of adequate sleep can include improved mood, reduced stress, reduced risk of sickness, maintenance of a healthy weight and a lower risk for serious health problems.3
Unfortunately, many issues can arise with sleep from a variety of different sources. Insomnia is the most commonly diagnosed sleep disorder and is defined as the inability to fall asleep or stay asleep, which results in reduced functioning the following day. Insomnia is generally multifactorial and can be related to physiological issues, medication use, drug use, concomitant disease and poor sleep hygiene.4
Other sleep disorders include narcolepsy, a condition where an individual can’t control when they sleep,5 and sleep apnoea, a condition where the muscles and soft tissue in the throat relax and collapse which can cause a total blockage of the airway.6 Pharmacists are ideally placed in the community to recognise insomnia in patients and make interventions or refer the patient if necessary. Numerous medical conditions are associated with an increased risk of insomnia including, but not limited to, menopause, pain, cancer, dementia, Parkinson’s disease, asthma and heart disease.
Mental health disorders are among the most common conditions that lead to disruption of sleep. Anxiety, depression and post-traumatic stress disorder are examples of mental health conditions that can cause insomnia.7 Pharmacists can recognise these issues when counselling these patients, provide advice on how to improve sleep quality or refer to GP, mental health services or cognitive behaviour therapy as appropriate. Medication can have both a positive and negative impact on sleep quality. Certain drugs can be used to treat insomnia directly. Drugs can also be used to improve the medical conditions mentioned above, which can alleviate insomnia associated with these conditions. However, it’s important to consider that certain medications can also have a negative effect on sleep quality. Beta blockers, alpha blockers, SSRIs, corticosteroids and loop diuretics are among the medications associated with reduced sleep quality.
Pharmacists should have a consultation with patients or conduct a medication review to ascertain if certain medications are harming a patient’s sleep quality. For example, counselling a patient to take corticosteroids as a single dose in the morning can reduce wakefulness at night or taking diuretics in the early part of the day can reduce urinary urgency at night, which in turn can improve sleep.8 Pharmacists should also counsel patients on lifestyle advice that may reduce the need for certain medication or consult with the patient and doctor about possible alternative medication that may effectively treat the condition, without the associated adverse effect on sleep.
Lifestyle factors can greatly contribute to poorer sleep quality and insomnia. A number of habits can lead to deterioration of sleep quality including drinking alcohol or caffeine, eating large meals before bed, smoking cigarettes, shift work, sleeping during the day or looking at blue light screens before bed.2 Pharmacists are ideally placed to identify these lifestyle factors and counsel patients on how to change behaviours to reduce their negative impact on sleep.
Motivational interviewing can be an effective technique to provide direction for change and to strengthen motivation. The use of melatonin as an aid to sleep can be considered controversial in Ireland. Melatonin is a natural product that is associated with treatment of insomnia. It is available over the counter and as a food supplement in certain countries, such as the USA. However, it is not available without prescription in Ireland. It is also not licensed for use in Ireland and must be supplied on foot of a valid prescription as an exempt medicinal product. It is also currently not reimbursable under HSE schemes.
Pharmacists should be aware of the medical use, adverse effects, pharmacology, interactions etc. of melatonin due to the increasing number of prescriptions observed in recent years and the anecdotal evidence of patients obtaining medication online without a prescription.9 Nytol has been licensed as an OTC product in Ireland in recent years as a symptomatic aid to the relief of temporary sleep disturbance in adults. The active ingredient is Diphenhydramine, a sedating antihistamine at the H1 receptor. The recommended dosage is 50mg, taken 20 minutes before going to bed. Nytol should be used for the shortest possible duration – more than 7 consecutive days without physician supervision is not recommended. Diphenhydramine is associated with prolongation of the QT interval and therefore pharmacists should recognise patients may have other risk factors for QT interval prolongation. Appropriate screening is recommended due to the contraindications and cautions in using this product.10
Lifestyle changes and certain medications can be useful in providing relief for sleep disturbance – however, there are certain instances where patients should be referred for medical review. Patients should be referred to a GP or a mental health professional if they feel like they are finding it hard to cope as a result of their sleep issue or if their sleep issue is having a negative impact on their dayto-day life. Pharmacists should also refer if they suspect there is a possibility of an undiagnosed medical condition causing sleep disturbance. If the sleep problem has been persisting for weeks without improvement or getting worse and if improving sleeping habits has failed, the patient should also be referred to a GP. Therapy or talking to a professional can be a source of help – referral to cognitive behavioural therapy can help change thoughts and behaviours that reduce sleep quality.4
References available upon request
