Understanding Insomnia and Sleep Hygiene

Insomnia

• Sleep Requirements: Adults between 20 and 45 typically require 7-8 hours of sleep daily. Sleep needs decrease with age, with individuals over 70 usually needing 6 hours.
• Insomnia Characteristics: Difficulty initiating sleep, difficulty maintaining sleep, waking up too early, and non-restorative or poor-quality sleep.
• Insomnia Classification:
  • Transient: Lasting less than one week.
  • Short-term: Lasting up to three weeks.
  • Chronic: Lasting longer than three weeks.
• Transient Insomnia Causes: Changes in routine, such as time zone changes, excessive noise, new sleeping environments, or extreme temperatures.
• Short-term Insomnia Causes: Acute stress, such as exams, bereavement, job loss, upcoming marriage, or moving.
• Chronic Insomnia Referral: Pharmacists can usually manage transient or short-term insomnia, but chronic insomnia should be referred as an underlying cause is often present.
• Sleep Hygiene Importance: The key to restoring appropriate sleep patterns is sleep hygiene advice.
• OTC Product Use: OTC products can be helpful during transition periods and for periodic or transient sleep problems.
• Patient Assessment:
  • Age: Elderly individuals have shorter total sleep durations, more frequent nocturnal awakenings, and shallower sleep. They may still need more sleep and seek medication to help. Elderly individuals may nap during the day, reducing their nighttime sleep needs. Patients under 16 years require referral.
  • Duration: Chronic insomnia (longer than 3 weeks) requires referral.
  • Recent Travel: Time zone changes affect sleep patterns and can take days to adjust.
  • Symptoms:
    • Difficulty falling asleep: Often associated with anxiety and an overactive mind.
    • Waking during the night: Possible causes include stress, anxiety, or underlying medical conditions.
    • Early morning waking: A classic symptom of depression, where the patient may not have trouble falling asleep but wakes up early and cannot go back to sleep.
    • Poor sleep: This can lead to daytime drowsiness and difficulty concentrating.
    • Snoring: Might indicate sleep apnea or other obstructive sleep disorders.
• Depression and Insomnia: Depression is a significant cause of insomnia, particularly early morning waking. Look for other signs of depression like fatigue, loss of interest and appetite, feelings of guilt, difficulty concentrating, and constipation. Refer suspected cases of depression.
• Anxiety and Insomnia: Anxiety often causes difficulty falling asleep due to an overactive mind. This can happen frequently before important events like exams. Refer for regular occurrences.
• Referral for Insomnia:
  • Suspected depression.
  • Chronic problems (longer than 3 weeks).
  • Children under 16 years.
  • Snoring, apnea, restless legs.
  • Associated physical conditions.
  • Suspected alcohol dependency.
  • Insomnia with no identifiable cause.

Contributing Factors to Insomnia

• Shift Work: Working changing shifts is a classic cause of sleep problems. Those who work away from home are also prone to insomnia.
• Life Changes: Events like job loss, moving house, separation or loss of a spouse, and menopause.
• Alcohol Consumption: Heavy or continuous alcohol consumption can disrupt sleep patterns.
• Stressful Events: Exams, job interviews, celebrations, and other stressful events can lead to insomnia.
• Obesity: Can be associated with sleep apnea and snoring, both of which interrupt sleep.

Medications and Medical Problems Related to Insomnia

• Drug-Induced Insomnia: Certain drugs can cause or contribute to insomnia.
  • Stimulants: Caffeine, theophylline, sympathomimetic amines (e.g., pseudoephedrine), MAOIs (especially in early treatment).
  • Antiepileptics: Carbamazepine, phenytoin.
  • Alcohol: Low to moderate amounts can promote sleep, but excessive or long-term use can disrupt sleep.
  • Beta-blockers: Can cause nightmares, especially propranolol. Tolerance to their effects can develop.

Motion Sickness

• Epidemiology:
  • Gender: More common in women than men.
  • Children: Uncommon in children under two years (generally don't need treatment) and most common between 2 and 12 years, peaking at 12 years. Incidence decreases with age.
  • Drivers/Pilots: Less likely to be motion sick compared to passengers due to being in control of the vehicle.

Patient Assessment for Motion Sickness

• Age: The minimum age for motion sickness products varies, allowing for selection of appropriate medications for families with multiple children.
• Travel Duration: The duration of action of medications varies. For long trips, repeat doses might be necessary according to individual medication instructions.
• Previous History: Determine who in the family has experienced motion sickness previously and needs treatment.
• Medication: Gather information on:
  • Previous treatment for motion sickness and its effectiveness.
  • Other medications taken by the patient that could interact with OTC medications.

Treatment for Motion Sickness

• Non-Pharmacological Therapy:
  • General Advice:
    • Children are less likely to feel sick if they can see out of the car. Elevate seating positions for small children to allow them to see outside.
    • Maintain a straight line of vision.
    • Reading can exacerbate nausea.
    • Avoid excess food before and during travel.
    • Stay in areas where motion is least felt (e.g., front of the car, over the wing on an airplane, middle of a ship near the water line).
    • Avoid strong odors, especially from food or tobacco smoke.
    • Ensure good ventilation (e.g., open a window).
  • Acupressure Wrist Bands: Apply pressure to defined points on the inside of the wrist. Although effectiveness is not conclusively proven, they are worth trying for drivers or pregnant women.
• Pharmacological Therapy:
  • Antihistamines: Meclozine, Cinnarizine, Promethazine.
  • Anticholinergics: Hyoscine Hydrobromide.
    • Minimum age: 4 years for Kwells Kids, 3 years for Joy-Rides.
    • Adverse effects: Anti-muscarinic adverse effects.
    • Contraindications: Prostatic enlargement, glaucoma, myasthenia gravis, paralytic ileus, pyloric stenosis.
    • Caution: Patients taking interacting medications.
    • Action: Short-acting (up to 4 hours).
    • Dosage: Taken 30 minutes before travel.
• Herbal Remedies:
  • Ginger: Used for centuries to treat travel sickness. Clinical trials have shown conflicting results. Ginger is worth trying for drivers and might be considered for pregnant women for whom other antiemetics may not be appropriate.
    • Action: Thought to act in the GI tract.
    • Dosage: No established dosage level.
    • Effects: Non-drowsy.
    • Safety: May be safe in pregnancy.