Exploring the sleep crisis

It should be remembered that sleep cycles can vary from person to person and from night to night based on a wide range of factors such as age, recent sleep patterns and alcohol consumption.

Health risks

Most adults require between six and nine hours’ sleep each night to function physically and mentally at their best and, while there is no specific number of hours required by children at different ages, experts tend to agree that seven to 14-year-olds need around nine to 10 hours’ sleep.

Poor sleep on a regular basis contributes to an increased risk of a range of serious conditions including obesity, heart disease and type 2 diabetes, as well as mental health issues. 

Professor Ellis says there are “dozens of studies” detailing the impact sleep disruption has on metabolism, hormone regulation and even gene expression, and a lack of sleep can also result in an increase in the stress hormone, cortisol, as well as hunger hormones, leaving people with cravings for high-sugar foods, which further heighten cortisol levels.

“People who average less than six hours’ sleep a night are about 2.5 times more likely to experience frequent mental distress,” says Professor Ellis, “and as most of us know from experience, even low levels of sleep disruption can undermine our cognitive performance and wellbeing.” This creates a valuable opportunity for pharmacy teams to help.

Pharmacy advice

The first place to start when helping people tackle insomnia and stress is by offering some basic sleep hygiene tips. Naresh Rallmil, Numark lead information pharmacist, says these should include advising people to:

• Establish a bedtime routine with a sleep schedule that dictates when they go to sleep and wake up. This includes avoiding naps during the day
• Relax for at least one hour before bedtime by taking a bath or reading a book
• Avoid screen time as it can cause over-stimulation of the mind. Additionally, the blue light from screens can suppress melatonin levels, which are responsible for the sleep-wake cycle
• Keep the bedroom dark with no bright lights to prevent a blue light depletion of melatonin
• Create a conducive sleep environment with a comfortable bed and a good pillow.

Clean sheets

Actual hygiene is also something that may need to be addressed. “Our skin is our body’s largest immune system organ and while we are sleeping it is exposed to a combination of sweat, saliva, dandruff, dead skin cells, food particles, pet dander, dust mites and their excrement,” says Tracy Wright, physiotherapist and co-founder of the CleanMyBed medical-grade chemical-free allergen removal system. 

“Not only does this trigger allergic reactions which disrupt sleep, but it also creates the perfect humid environment for bacteria, viruses, fungi and mould to live.” To avoid sleeping in what she calls “a petri dish” and enhance the quality of sleep, Wright’s advice for a better night’s sleep is to:

• Change and wash linen on a hot wash (40-600C) at least once a week
• Shower before bed
• Avoid sharing a bed with pets
• Vacuum mattresses regularly, preferably with a specific HEPA-13 filter on the vacuum, or get them professionally cleaned.

Non-drug interventions

Lifestyle advice is another area where pharmacy teams are key to helping poor sleepers.

“Poor sleep quality can happen at any age but is common among older adults,” says Sue Swift, Numark Drug Tariff and information technician. This can be down to factors ranging from major lifestyle changes to the onset of chronic conditions – but tackling them doesn’t have to mean resorting to medication, she says. 

“For example, customers should aim for 20-30 minutes of exercise three or four times a week that is tailored to their physical condition and undertaken during daytime hours. This can help them sleep better, as well as providing them with more energy while they are awake.” 

Seventy-two per cent of respondents to the Puressentiel survey believed their mood and stress levels improved when they went for a walk.

Heavy meals, smoking, drinking alcohol or caffeinated drinks should all be avoided before bedtime, says Swift. “A warm cup of milk can be beneficial as it simulates the effects of tryptophan, which in turn increases melatonin and helps to deliver a restful night’s sleep”. 

For customers who find they frequently toss and turn for upwards of 20 minutes, “recommend ear plugs, sleep masks and white noise machines”. Breathing exercises can also help, she says.

Lavender essential oil has long been used to reduce stress and encourage sleep. Puressentiel’s Dr Tim Bond says studies have shown the scent of lavender produces “significant improvements in anxiety and mood in ICU patients and women with postpartum depression, as well as reducing anxiety in dental patients”. 

Herbal helpers

In addition to lavender there are a number of herbs that have a history of traditional use when it comes to relieving insomnia and stress, all of which are available on pharmacy shelves. 

“Valerian has been taken for centuries as an aid to sleep and can also act as a calming agent in stressful daytime situations, with research showing that it helps people to fall asleep more quickly and improves the quality of their sleep,” says Dr Chris Etheridge, medical herbalist and chair of the British Herbal Medicines Association.

“Passionflower is also used to relieve anxiety and is often used in combination with valerian to reduce anxiety-induced insomnia. Hops in combination with valerian and passionflower can be particularly effective – with an added benefit for menopausal women because they contain compounds that are phyto-oestrogenic, helping to reduce the frequency of hot flushes and night sweats,” adds Dr Etheridge. 

As already mentioned, lavender is a popular herb for aiding relaxation and sleep. Most studies investigating the effect of lavender on sleep have focused on silexan, which is an active substance derived from the herb.

Clinical options

There are a range of OTC, prescription and clinical management options that pharmacists and their teams can recommend to tackle continuing insomnia and stress.

“The natural hormone melatonin can be prescribed in tablet form, but is only licensed as a short-term treatment for insomnia, and only for people over 55 years in the UK,” says Etheridge. 

Although not suitable for everyone, anti-histamines can be appropriate for some people to take as an alternative to prescription drugs for insomnia. These should only be used short-term and will not address the underlying causes of insomnia. Since these antihistamines cause drowsiness, individuals who will be driving or operating machinery the following day should avoid using them. 

If non-drug measures have failed and the customer’s insomnia is severe, prescription medicines can be considered but caution is required. The Z-drugs (zopiclone, zolpidem and zaleplon) or benzodiazepines, such as temazepam, diazepam and nitrazepam, can be prescribed but long-term use is not recommended and they should only be prescribed for a maximum of two weeks.

Puressentiel’s data shows a potentially worrying focus on using medication as a quick fix for sleep issues, with one in five adults admitting they have had a prescription for sleeping tablets at some point, and almost half of this group (47 per cent) saying they had been prescribed medication since the pandemic began.

Other options

If poor sleep is caused by stress or anxiety, cognitive behavioural therapy can be suggested to provide support with stimulus control, sleep restriction and relaxation training. For those customers who struggle with stress or depression, there is the option of prescribed antidepressants should non-drug strategies fail.

On talking to customers in more depth, Chris Etheridge says pharmacists may discover “other factors at play such as acute and chronic pain, which can negatively affect sleep, or snoring and sleep apnoea, which can inhibit proper sleep and should be addressed.”

Key facts

• Sleep is made up of several rounds of the sleep cycle
• Offering some basic sleep hygiene tips can help people tackle insomnia and other sleep-related problems
• NICE recommends an app rather than medication for sleep problems.

Reference

1. The Sleep Foundation