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How to help your patients overcome sleeping problems

Kathleen McGrath
RGN RSCN CTCert
Founding Nurse
Sleep Matters
Medical Advisory Service
For more information on MAS contact Debbie Smythe or June Reed on
T:020 8995 8503

It is estimated that we spend about one-third of our lives asleep. The quality of the sleep we get has a direct impact on our growth as children, our ability to recuperate from illness and our ability to function in and enjoy our daily lives.
 
Two major types of sleep restore us for the day ahead. First, non-REM (rapid eye movement) sleep occurs when the eyes are heavy and yawning starts - it is associated with restoration of bodily tissues. This is interspersed with REM sleep, which is associated with the restoration of brain tissue and function. REM sleep is when the thoughts of the day and memories are filed away and dreaming occurs.
 
A balance of REM and non-REM sleep should leave us restored and refreshed. Where periods of inadequate sleep occur we often feel irritable and physically and mentally tired and unable to cope.

Defining the problem
Insomnia is simply defined as "inadequate restful sleep". It is important to remember that both the quality and the quantity of sleep are important to aid physical and mental wellbeing.

Figures vary, but it is estimated that sleep problems affect up to 10% of the population at any given time, and that up to 20% will suffer from sleep disruption at some point in their lives.

Insomnia can be divided into two main types - short term, which goes on for less than a month, and long term, which continues for longer than a month.

There are three common forms insomnia takes. Some people find it impossible to drop off to sleep, while others complain of waking frequently in the night and "clock watching", while a third group wake very early in the morning and cannot get back to sleep.

In expressing their concern and depression at not being able to sleep, many callers to Sleep Matters are, in effect, describing a very emotional attachment to sleep. It is a deep-seated belief that a good night's sleep is the cure-all for most physical and mental problems. Perhaps it is for this reason that healthcare professionals often ask how a patient is sleeping. However, very few of us have ever received professional education in evaluating the response.

There are two major areas in which nurses in primary care can be of practical help to patients.

Identifying the problem
Short-term sleep disturbance, progressing to longer term, is likely to occur in conditions where the patient's ability to relax is impaired. If they have problems relaxing, it may be difficult for them to fall asleep. Patients affected by the following factors should be asked about their sleep and advised appropriately:

  • Physical pain or impairment (eg, those with chronic arthritis or joint pain, GI upset, urinary frequency, respiratory disorders, joint immobilisation such as fractures).
  • Proneness to physiological changes (eg, business travellers and those training for sports events, changing exercise or diet, or making lifestyle changes).
  • Bereavement, exams, divorce and moving house (common trigger factors for insomnia).
  • Psychiatric influences (which tend to be longer term), including depressive illness, anxiety disorders, and alcohol and drug abuse.
  • Some medically prescribed treatments (eg, for asthma and hypertension).

Providing appropriate advice
All patients, whatever the duration of their problem, will benefit from sleep hygiene advice. If the patient is taught how to keep a "sleep diary", areas of lifestyle that could be changed to improve sleep can then be discussed.

A sleep diary needs to be filled in every day for a week to be of use. The patient should note when they:

  • Went to bed.
  • Tried to sleep.
  • Fell asleep.
  • Woke up.
  • Got up.

Useful suggestions:

  • Avoid naps during the day.
  • Go to bed when sleepy and get up when the alarm goes off. Don't lie in bed waiting for sleep: get up and do something!
  • Avoid strenuous exercise last thing at night.
  • A warm bath and relaxation before retiring can be helpful.
  • Make sure the house is safe, the bedroom comfortable and the bed and mattress supportive and comfy.
  • Try not to take worries to bed.

You may also suggest that an over-the-counter sleep aid, used to re-establish restful sleep, might be of help. There are several options - OTC sleep preparations, herbal remedies and antihistamines - which can be used with medical or a pharmacist's advice.

If patients are unsuitable for OTC treatment, or the problem is continuing without relief, referral to the GP or pharmacist (with a sleep diary filled in and a history of the problem) may be helpful. Introduction of prescribed sleep medicines for a set period of time and changes to existing drugs causing sleep problems may be of benefit to the patient.

Conclusion
It is important to recognise the impact of poor sleep on daily quality of life whatever the age of the patient. Observing and enquiring after a bereaved elderly patient, using the opportunity of checking on a businessman or busy mother during routine procedures - any of these may be the ideal time to offer general practical advice.

Resources
British Sleep Foundation
W:www.britishsleepfoundation.org.uk
Sleep Council
W:www.sleepcouncil.org.uk
Patient UK
Sleeping problems
W:www.patient.co.uk/illness/s/sleep_problems.htm
Sleepnet.com Insomnia information
W:www.sleep.net.com