Slumber solutions?

When 5-minute conversations can be the gift of hours and hours of better sleep.

Few things have a bigger impact on human health than sleep – or lack of it.

It therefore holds that there are few bigger contributions health practitioners can make to someone’s health and wellbeing than interventions which improve the quality of sleep.

A 5-minute conversation can be the difference between long-term, poor quality sleep and hundreds to thousands more hours of rejuvenating slumber.

So where does one start? Unsurprisingly, it starts with listening.

Effective interventions require a deeper understanding of sleep than a person self identifying they need a treatment for insomnia. Even the simple question ‘is it getting to sleep, or staying asleep which is a problem for you?’ can open up a conversation regarding sleep challenges.

Without this understanding, the advice you provide about using medicines, sleep hygiene or referral for a sleep study is unlikely to be relevant to the patient – and indeed they may not have been listening to you in the first place.

The Australian Pharmaceutical Formulary and Handbook treatment guideline for pharmacists on insomnia¹ provides excellent guidance on causative factors for poor sleep, which can include medicines many patients don’t associate with insomnia such as beta-blockers, opioids and alpha-receptor antagonists such as prazosin and tamsulosin.

Sometimes you’ll uncover nuggets of information which help identify simple solutions; making a single, short discussion all that is needed to help people rest better. Other times, you’ll need to signpost people towards supports for difficult challenges such as trauma, grief, work pressure or parenting responsibilities.

These conversations are not always easy. When it comes to advice and shared decisions, it is often important to push through resistance.

AP spoke to two pharmacists about patients who are now sleeping a lot better due to their brief intervention.

Case 1

Sumin Cheng MPS Pharmacist, National Pharmacies, Norwood, South Australia

A mother came into the pharmacy asking for a melatonin supplement for her 12-year-old child who had been experiencing sleep issues.

With no medical or psychiatric issues, the girl was not taking medicines for any other condition. Her mother mentioned seeing a TV advertisement suggesting melatonin is now available without a prescription in pharmacies for sleep. Her friends also told her she could buy ‘stronger’ melatonin supplements online, assuring her they are very safe because they are natural.

In my response I referenced the following issues:

Regulation information: I informed her that in Australia, the Therapeutic Goods Administration (TGA) permits the sale of 2 mg melatonin modified-release tablets without a prescription for short-term treatment of primary insomnia, however this is only for patients aged 55 and over. For anyone under the age of 55, the use of melatonin for insomnia requires a prescription from a medical practitioner.²

Safety and efficacy: I explained that melatonin is a hormone produced by the brain after dark that regulates the circadian rhythm or body clock. While it is used for certain sleep disorders in children with specific conditions or developmental problems, there is currently limited research on its long-term effects in children, and it should only be used with specialist advice e.g. a paediatrician.³ Some experts have raised concerns that melatonin could potentially interfere with other hormonal development in adolescents. More research is needed to fully understand any potential long-term effects.

Risks of unregulated products: I cautioned her that although melatonin can be bought online from overseas, such products are not regulated by the TGA. This means they may not meet Australian manufacturing standards and could contain harmful undisclosed ingredients.

Good sleep practices: We discussed the importance of establishing good sleep habits to create a relaxing sleep environment. This includes ensuring the room is quiet and dark, maintaining a suitable room temperature for sleep, using other areas of the house for play and entertainment to help the child associate the bedroom with sleep, limiting screen time before bed, and encouraging outdoor activities during the day.

The mother thanked me for the advice and said she would start by implementing these good sleep practices. She said she would make an appointment with a GP, with specialist review, if needed, should the sleep issues persist.

Case 2

Sonia Burgess MPS Pharmacist, Sleep Clinic, Amcal Plus Pharmacy, Salamander Bay, New South Wales

Mr GB, aged 78, was a regular to the pharmacy. We’d had several conversations on sleep apnoea with him in the past, but he was extremely reluctant to test. Complaining of excessive fatigue and daytime naps, Mr GB had recently been told he had a slow heart rate and would need to have a pacemaker inserted.

I used this as another opportunity to talk to him about sleep apnoea. His wife reported loud snoring, apnoea chokes, gasping, breath holding and irregular breathing. Mr GB complained of broken sleep, night sweats, shortness of breath and feeling unrefreshed in the morning.

His Epworth Sleepiness Score was 18 (out of 24) indicating severe excessive daytime sleepiness.⁴ He was referred to his GP for a sleep study referral, which we conducted urgently at the clinic.

Current medicines:

• Prednisolone 7 mg daily (polymyalgia rheumatica)
• Prazosin 1 mg twice daily (benign prostatic hypertrophy)

Results of sleep study:

Severe Obstructive Sleep Apnoea. Mr GB had an apnoea hypopnoea index (AHI), which measures the average number of apnoea and hypopnoea episodes per hour of sleep ranging from normal <5 to severe >30 – of 65.2.⁵ The longest apnoea was 90 seconds and longest hypopnoea was 67 seconds with substantial snoring.

Disrupted breathing and sleeping was seen along with the bradycardia with pauses of more than 2 seconds in ECG. Oxygenation was abnormal with frequent mild-moderate desaturations worst when in REM sleep.

Treatment recommendations: Urgent trial of CPAP.

Response to trial:

We initially set a maximum pressure of 12 but Mr GB felt he was starving for air. So, we increased the pressure to 16. Initially, like many patients, Mr GB wanted to try a nasal prong although I did advise that a full-face mask would be better with higher pressures. He slept one night on nasal prongs and then moved to a full-face mask.

Mr GB settled into therapy and now admits he can’t live without it and feels so much better.

His cardiologist was very pleased he had CPAP and it was one of the first things he asked about.

Interestingly, a few months later his mask began rubbing on a lump that had developed on his neck. He was sent for immediate referral to his GP.

It emerged he had B-Cell Non-Hodgkin’s Lymphoma (which explained his night sweats prior to the lump when he was first tested).⁶

We also conducted a Home Medicines Review once Mr GB started his new medicines for lymphoma and the pacemaker. 

References

1. Sansom LN, ed. Australian pharmaceutical formulary and handbook. 26th edn. Canberra: Pharmaceutical Society of Australia; 2024. 
2. Sleep Health Foundation. Melatonin and children. 2023. At: www.sleephealthfoundation.org.au/sleep-disorders/melatonin-and-children#:~:text=A%20young%20child%20needs%20less,a%20doctor%27s%20prescription%20in%20Australia. 
3. Therapeutic Guidelines. Sleep problems in children and adolescents. [updated 2021 Mar]. At: https://tgldcdp.tg.org.au/viewTopic?etgAccess=true&guidelinePage=Psychotropic&topicfile=sleep-problems-children-adolescents&guidelinename=Psychotropic&sectionId=toc_d1e47#toc_d1e47 
4. Australasian Sleep Association. Epworth Sleepiness Scale (ESS). 2024. At: www.sleepprimarycareresources.org.au/questionnaires/ess
5. Australasian Sleep Association. Obstructive sleep apnoea. 2024. At: www.sleephealthfoundation.org.au/sleep-disorders/obstructive-sleep-apnoea 
6. National Library of Medicine (US). Non-Hodgkin Lymphoma. StatPearls. 2023. At: www.ncbi.nlm.nih.gov/books/NBK559328/