It seems we are a nation of poor sleepers, with one third of people in the UK thought to have episodes of insomnia at some point, according to NHS estimates, putting all aspects of our physical and mental health at risk.
Increasingly recognised as a disorder in its own right rather than merely a symptom arising from another medical or psychiatric illness, many experts also think insomnia is underdiagnosed and undertreated. So, what can pharmacy teams do to better spot – and help – customers struggling with insomnia?
Symptoms and causes
Insomnia is difficulty getting to sleep or staying asleep for long enough to feel refreshed the next morning and is particularly common in elderly people.
While there is no standard definition of what constitutes ‘normal sleep’ since the amount needed to ensure good health varies from person-to-person. With ageing, the National Institute for Health and Care Excellence (NICE) guidelines state that it usually takes less than 30 minutes for a person to fall asleep, whereas insomnia is difficulty in getting to sleep or staying asleep, early wakening, or non-restorative sleep-in which people spend adequate time in bed but feel unrefreshed and tired upon waking. As a result, daytime symptoms typically include poor concentration, mood disturbance, and fatigue.
The causes of insomnia also vary. “Poor sleep habits including irregular sleep schedules, excessive daytime napping, stimulating activities before bedtime, or an uncomfortable sleep environment can contribute to insomnia,” says Jacquie Lee, Numark medication safety officer and information pharmacist. “It’s also important to remember that the use of caffeine, nicotine, and alcohol can affect sleep quality”.
Underlying medical conditions can also have an effect. “Chronic pain, respiratory disorders (e.g., asthma), gastrointestinal problems (e.g., acid reflux), or neurological conditions (e.g., Parkinson’s disease) can interfere with sleep,” adds Jacquie. “The side effects of medication such as antidepressants, blood pressure tablets, epilepsy, corticosteroids and NSAIDs also hold the potential to disrupt a peaceful night.”
Identifying and managing stress
Almost one in five UK adults (16 per cent) say they regularly sleep poorly, according to The Sleep Charity, with data revealing 44 per cent of people say worry and stress is the most common factor in them struggling to nod off.
Stress is a natural response to feeling under pressure or threatened, and while a small amount of stress can help people complete tasks and feel more energised, stress can become a problem when it lasts for a long time or is very intense.
Mental health charity MIND says being prepared for periods of stress can make it easier to get through them, and knowing how to manage wellbeing can help people recover after a stressful event.
MIND recommends the following tips, which pharmacy teams can advise customers experiencing stress to try:
- Take breaks in the day for things you enjoy and reward yourself for your achievements, even if they seem small
- Try to find time to relax. Taking a break can help with how you feel
- Develop interests and hobbies. If stress is creating isolation, shared hobbies can also be a good way to meet new people
- Spending time in nature can help reduce stress and improve wellbeing
- Prioritising sleep, staying physically active and eating a balanced diet can make stress easier to manage.
Once again, there are a variety of wellbeing apps – many of which are free – that can help people struggling with stress, including meditation and breathing apps such as Balance, Insight Timer, and Headspace.
Acute and chronic insomnia
NICE currently categorises insomnia according to duration or likely duration. Short-term insomnia lasts less than three months and can occur in association with stressful events or changes in sleeping patterns such as illness, financial difficulties, the birth of a child or environmental disturbance.
Long-term (or chronic) insomnia lasts for three months or longer and commonly co-exists with other psychiatric and medical conditions (for example anxiety), with NICE suggesting that what it calls “maladaptive behaviours and cognition” are thought to be involved in the development of chronic insomnia.
OTC treatment options
While OTC tablet and liquid sleep aids for insomnia containing diphenhydramine can be helpful for short-term use, they should not be considered as a long-term solution for chronic insomnia because they don’t deal with the underlying cause of the problem. Adrian Zacher, pharmacist and CEO of The British Society of Pharmacy Sleep Services (BSPSS), points out that “OTC sleep aids (typically, but not exclusively first-generation sedating antihistamines) are expressly not recommended by NICE”, adding that “sedation is not sleeping and does not address the underlying causes”.
In addition, as diphenhydramine is an antihistamine that can cause drowsiness it can make activities such as driving and operating machinery dangerous if the drowsiness persists into the following morning. Nonetheless, pharmacy teams must be ready to give balanced advice to customers who ask for these kinds of OTC products, as well as those who find traditional remedies useful for coping with the stress-sleep cycle.
“Natural remedies can provide a safe and non-addictive way of promoting better sleep,” says Elizabeth Hughes-Gapper, Kalms senior product manager. “Valerian root is a popular choice that has long been used to help people fall asleep faster, sleep better, and wake up less often [and] lavender oil also has a soothing effect and reduces anxiety and restlessness.”
Fatigue is a state of extreme tiredness or exhaustion that can result from physical or mental exertion, illness, or lack of adequate rest, and is not the same as insomnia, which is an inability to get to sleep or stay asleep.
New research from Kalms herbal remedies found that four out of five people in the UK suffer from stress and fatigue, and feeling exhausted is so common that it has its own acronym, ‘TATT’ or ‘tired all the time’.
According to the National Institute for Health and Care Excellence (NICE) there is no universal definition of tiredness or fatigue, and its experience and perception are subjective, but risk factors for self-reported fatigue include being female, having a higher body mass index (BMI), lower socioeconomic status, and having an associated physical or psychosocial comorbidity.
Jacquie Lee, Numark medication safety officer and information pharmacist, says combatting fatigue requires “a multi-faceted approach” that addresses physical, mental, and emotional well-being.
“For fatigue, customers should consider adopting a healthy lifestyle that includes regular exercise, a balanced diet, and staying hydrated,” she advises. “They should look at the sleep hygiene ideas included in this feature, such as creating a relaxing bedtime routine and maintaining a comfortable sleep environment, and look at stress management, try to set realistic goals, and take breaks to try to minimise becoming overwhelmed with pressures.”
Unsurprisingly, there are numerous sleep apps and devices available that can assist with sleep tracking, relaxation, and guided meditation, which may also help people struggling with insomnia and the reasons behind it.
“NICE guidance from the NHS recommends ‘Sleepio’ as an alternative option for treating insomnia and insomnia symptoms in people who would otherwise be offered sleep hygiene or sleeping pills,” says Jacquie. “There are many sleep tracker apps that can help customers understand their sleep patterns such as ‘SleepCycle’ and ‘ShutEye’. Some of the apps offer relaxing white noise sounds to help patients drift off to sleep such as ‘Sleep’ and ‘Rain Sleep’ while others such as ‘Calm’ offer guided meditation.”
Adrian says the pharmacy team should also encourage people not to trivialise sleep. “Sleep issues are involved with every chronic disease,” he says. “Valid, evidence-based help is available that will make them feel better and extend their healthy life. For short-term insomnia Cognitive Behavioural Therapy (CBT) is the NICE recommended first-line therapy, and digital therapeutics are available via the NHS if you live in certain regions of the UK – for example sleepful.me is an evidence-based CBTi app, that is free in app stores.”
As part of its #Letstalksleep campaign The Sleep Charity has recently launched ‘Understanding Your Sleep’ – a free downloadable sleep eBook for adults – in partnership with Bed Advice UK, with hints and tips on getting a good night’s sleep. Find out more via their website.
Lifestyle choices and sleep hygiene
Talking to customers about sleep hygiene is a great way to increase their awareness of simple behavioural or environmental factors that could help – or hinder – their chances of getting off to or staying asleep. Adrian suggests the follow advice pharmacy teams can share with customers:
- Make the bedroom a sanctuary where they can switch off and sleep
- Try to keep the bedroom cool, dark, and quiet. Use ear plugs and invest in good curtains or blinds, or a comfortable eye mask
- Try to break the habit of checking the time repeatedly
- Only go to bed when sleepy and not too early
- Calculate the number of hours they need to sleep to feel good, subtract that from their wake-up time and try not to get into bed before then
- Avoiding napping during the day. An occasional short nap may be a good thing, but lots of naps may indicate something is wrong and naps also reduce the ‘drive’ to go off to sleep at sleep time
- Relaxation before going to bed (for example watching TV, reading a book, having a warm bath, or listening to an audiobook). A free audio guide on progressive relaxation techniques is available on the Mental Health Foundation website (mentalhealth.org.uk)
- Get out of bed if they struggle to fall asleep within 20 minutes. If their mind is buzzing, Adrian suggests that they get up, write down their thoughts in a bullet point list and calm down, knowing they are not going to forget anything. When sleepy they should go back to bed
- Caffeine keeps you awake. Choose decaf if insomnia is an issue, and particularly after midday
- Limit or avoid nicotine, and speak with the pharmacist if they think they want to quit smoking
- Alcohol may get them off to sleep but it’s at the expense of not being able to stay asleep so they will feel rubbish the next day
- Exercise is good for sleep and mental health but vigorous exercise within four hours of sleep time may make it harder to calm down enough for sleep.
As the front door to the NHS, pharmacy teams are ideally placed to help everyone achieve better sleep and as ever, pharmacy is often the first place where these kinds of problems are flagged up or noticed. Taking people’s concerns about their lack of sleep seriously and being there with the time to listen and advise them can be the vital first step to help them get their sleep back on track.
A seemingly modern malady, burnout is often defined as the ‘tipping’ point of total exhaustion, either physical, mental or a combination of both. The term is most commonly linked to work, with new research from Kalms herbal remedies showing 51 per cent of those who experience burnout identifying work as a trigger – although it can also be linked to non-work-related situations such as household chores or social situations.
“Being tired is nothing new, and we all know that a poor sleep routine or habits like excessive caffeine and alcohol, can inhibit the body’s natural sleep cycle,” says Elizabeth Hughes-Gapper, Kalms senior product manager. “Burnout is much more complex. It is a state of feeling emotionally, physically and mentally exhausted, as a result of excessive and prolonged stress. When we reach this point of exhaustion, we can feel like we can no longer cope with our daily responsibilities, struggle to focus, lose our compassion for others and struggle to switch off or sleep at night.
“Pharmacy staff can help people identify the cause of their symptoms, and to focus on doing things that help them to switch off from work, deeply relax and calm their nervous system,” she says. “For example, plenty of sleep, walking in nature, gentle exercise, hot baths, nourishing food, talking to a friend or professional. Patients can also explore the use of an OTC adaptogen, such as Rhodiola rosea that can help to restore the body’s natural equilibrium from the inside out.”
- NICE Clinical Knowledge Summaries (CKS) – insomnia
- The Sleep Charity – Understanding Your Sleep free downloadable sleep eBook for adults.