5 Sleep Tips for Insomnia Patients

Between 10% and 15% of Americans have at least 1 chronic sleep disorder, and insomnia is the most common complaint.

“It’s something we can all relate to,” said Julie A. Dopheide, PharmD, BCPP, FASHP, professor of clinical pharmacy, psychiatry, and behavioral sciences at the University of Southern California School of Pharmacy, at a session on insomnia at the American Pharmacists Association (APhA) 2016 Annual Meeting and Exposition. “Probably all of us have had insomnia at some point in time.”

Just 1 or 2 session attendees raised their hands when the speakers of the 7 AM presentation asked who in the room slept for 8 hours the night before.

Dr. Dopheide and fellow presenter Ericka L. Crouse, PharmD, BCPP, CGP, FASHP, clinical pharmacy specialist in psychiatry and clinical associate professor of pharmacy at Virginia Commonwealth University Medical Center, discussed some of the clinical presentations of insomnia and both pharmacological and nonpharmacological approaches to treating the condition.

Pharmacists should care how much sleep their patients are getting each night because of the increased risks that accompany 6 or fewer hours of sleep, which include:

· Ischemic stroke

· Heart attack

· Obesity

· Impaired glucose tolerance

· Type 2 diabetes

· Breast, prostate, endometrial, colorectal cancers

Some of the most common reasons for not getting a good night’s sleep are homework, temperature, outside noise, light, and pets, though the most common of all is evening activities such as cellphone usage.

“Those electronics can stimulate the brain to stay awake because of the light emitting from those electronics. …It’s good for the parents to set an example, too,” Dr. Dopheide said, adding that parents should try to read in bed instead of using those devices.

Patients’ sleep patterns are also cause for concern because of the number of Americans who confess to nodding off while driving. Drs. Dopheide and Crouse pointed to one study from 2009 that found that 2% to 7.2% of Americans admitted to falling asleep behind the wheel.

Insomnia also leads to costly workplace accidents. It has been suggested that insomnia is the cause of around 274,000 accidents and errors, leading to $31 billion in extra costs, the speakers stated.

With these concerns in mind, here are 5 ways pharmacists can help their patients get more sleep.

1. Conduct a patient assessment.

Pharmacists may want to look for medical or neuropsychiatric comorbidities that require more investigation. Subsequently, factors such as sleep hygiene, cognitive behavioral therapy (CBT), or medication can be considered.

In particular, patients with anxiety or depression experiencing insomnia may require special consideration with respect to medications.

“[Pharmacists] really need to counsel patients that they have to give their antidepressant time to work…to make sure the patient is getting an adequate trial,” Dr. Dopheide explained to Pharmacy Times. “They need 4-6 weeks at their maximum tolerated dose.”

Pharmacists can also find out what the patient has tried so far and ask questions about alcohol use, which may be leading to less restful sleep. Finally, pharmacists can help the patient set goals for treatment.

2. Recommend a sleep diary.

Patients can access the National Sleep Foundation Sleep Diary to keep track of their morning and end-of-day activities. In the morning, they can record how many minutes it took them to fall asleep, how many times they woke up that night, and how they felt when they woke up.

At the end of the day, patients should record what medications they took, their caffeine intake, whether they ate 2 to 3 hours before bedtime, and how much they exercised.

3. Provide information about the risks and benefits of insomnia medication.

While zolpidem is the most frequently prescribed hypnotic, it is associated with the greatest number of hospitalizations for adverse drug events.

Drs. Dopheide and Crouse highlighted a study where researchers evaluated 3572 citations, 169 randomized controlled trials, and 12 observational studies in an effort to determine which medications for insomnia were the most effective.

They found the strongest evidence for multimodal CBT, eszopiclone (Lunesta), zolpidem (Ambien), and suvorexant (Belsomra). These therapies decreased time to fall asleep (between 10 to 45 minutes), decreased wakefulness after sleep onset (10 to 45 minutes), and increased total sleep time (20 to 90 minutes).

However, chronic hypnotic use is correlated with dementia, fractures, major injuries, and possibly cancer or death.

Pharmacists can also help patients understand that certain medications target specific sleep complaints.

For example, estazolam, flurazepam, quazepam, temazepam, triazolam, eszopiclone, zaleplon, zolpidem, ramelteon, and suvorexant can help patients with falling asleep. For those who have trouble staying asleep throughout the night, eszopiclone, zolpidem CR, doxepin, and suvorexant can help with sleep maintenance. Estazolam, flurazepam, and quazepam can help target frequent early morning or nocturnal awakenings, as well.

For patients who tend to wake up in the middle of the night, low-dose zolpidem SL could be the ticket.

Some more counseling tips for sedative hypnotics include taking them immediately before bed and on an empty stomach, refraining from driving or machinery use until fully awake, and using caution if the patient has depression, asthma, chronic obstructive pulmonary disorder, or obstructive sleep apnea.

In addition, pharmacists can tell patients that they should see their physician if their symptoms do not improve within 7 to 10 days.

4. Recommend good “sleep hygiene.”

Drs. Course and Dopheide provided the following sleep hygiene recommendations:

· Maintain a regular schedule of waking up at the same time every day.

· Exercise early in the day.

· Avoid eating late at night and avoid spicy or heavy foods.

· Keep a cool, dark, and quiet room.

· Avoid eating, watching TV, or paying bills in bed.

· Try getting out of bed and engaging in a calm or boring activity if patients cannot fall asleep within 20 minutes.

· Limit or avoid caffeinated drinks and tobacco use in the afternoon.

· Don’t drink more than 1 to 2 drinks and refrain from imbibing right before bed.

· Cover the clock face to avoid focusing too much on the time.

“I think we all can remember sleep hygiene recommendations from pharmacy school…they’ve been around a long time, but [pharmacists] need to be reminded of them,” Dr. Dopheide explained to Pharmacy Times.

5. Counsel patients on CBT options.

Beyond sleep hygiene, there are several other nonpharmacological therapies patients can try. For example, one approach is stimulus control, which reduces negative associations between the bed and insomnia.

In addition, patients can try sleep restriction, meaning the only activities they do in bed are sleep-related.

Also, relaxation training can be helpful in lowering somatic and cognitive arousal states through muscle relaxation or guided imagery. Yoga and tai chi are 2 other activities associated with improved insomnia symptoms.