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2017 HCHB_digital

Sleep Problems and

Sleep Problems and Snoring Sleep is a vital part of our wellbeing. Despite spending almost one-third of our lives asleep, scientists still have more questions than answers about why we sleep. Research has associated lack of sleep (insomnia) with attention deficit hyperactivity disorder (ADHD), Alzheimer's disease, cardiovascular disease, obesity, type 2 diabetes, mood disorders and depression. Studies have also shown that production of immature T cells – a type of white blood cell that are essential for human immunity – peaks during early nocturnal sleep. Chronic poor sleep increases your risk of dying from any cause by 15%. Appropriate sleep durations vary depending on age but range from 14 –17 hours for newborns to between seven and eight hours for older adults. One night's sleep is actually made up of, on average, five sleep cycles. Within each sleep cycle, there are five stages of sleep – the first four stages are associated with non-rapid eye movement (NREM) sleep, and the final stage is when rapid eye movement (REM) sleep occurs. Each sleep cycle takes about 90 minutes and we briefly wake up between cycles, although most of us don't remember waking. Many people experience sleep problems at some point in their life. For the majority, sleeplessness is only temporary, but for others it may persist for months or even years. Sleep disturbances may be a sign of an underlying problem, such as stress, depression, pain, or genitourinary disorders; or due to environmental disturbances (such as an unsupportive bed or high temperatures); jet lag; shift work; diet; or having a partner who snores. In many cases, no reason for the sleep disturbance is found. Initial assessment Persistent lack of sleep can take a toll on somebody's health, and you may notice your customer looks tired or has difficulty stringing sentences together. Take any complaints of sleeplessness seriously, and congratulate the person on actively doing something about their lack of sleep, as many people just put up with it for years. Referring your customer to a doctor for a sleeping pill is not the right approach. Although sleeping pills do make people sleep, it is uncertain whether they reverse any of the conditions associated with lack of sleep and most prescription sleeping tablets are highly addictive. However, some people may need a doctor's referral for other reasons, particularly if you suspect there may be an underlying medical reason for their insomnia. Try to identify any environmental or other factors (such as stress or diet) that may be contributing to the lack of sleep and suggest ways to improve these (see Advice for customers). Relaxation and calming exercises or podcasts that teach deep breathing, meditation or visualisation techniques should be the next step (see Sleep and relaxation techniques opposite page). People who travel a lot and suffer from ongoing jet lag may also like to discuss melatonin with their TREATMENT OPTIONS Category Examples Comments Sedating antihistamines Melatonin Anti-snoring treatments Restless legs/muscle cramps Natural / herbal products / supplements [PHARMACIST ONLY MEDICINE] eg, doxylamine 25mg (Dozile*) [PRESCRIPTION MEDICINE] eg, melatonin 2mg (Circadin) eg, Asonor drops (nasal drops to help dry up secretions), Aveo TSD Anti-Snoring Aid (device holds the tongue forward to keep airway open during sleep), Breathe Right nasal strips (adhesive nasal strips to reduce nasal congestion), Silence (spray which lubricates nasal passages and throat), Snoreeze (lubricating throat spray, nasal spray or oral strips), SnoreMed (mouthpiece holds lower jaw forward during sleep) [GENERAL SALE] eg, magnesium + other ingredients (Crampeze Night Cramps) Valerian, lemon balm, hops, lavender oil, passionflower, skullcap, tart cherry, tyrosine eg, Good health Deep Sleep, Nutralife Sleep Well, Remifemin Sleep, Swisse Ultiboost Relax & Sleep Use only for temporary insomnia due to an identifiable cause (eg, jet lag) and restrict use to five days. Take 20 minutes before going to bed. Tolerance may develop and side effects include dry mouth, constipation or blurred vision. Avoid drinking alcohol and driving or operating machinery within eight hours of taking doxylamine. Has the potential to be abused so refer suspicious requests to a pharmacist. See OTC Reference section, Precautions. Melatonin is a hormone produced by the pineal gland which is thought to play a role in maintaining the body’s circadian rhythm (body clock) as it is stimulated by darkness and suppressed by light. May cause daytime drowsiness and impaired concentration. These products will only help snoring, not sleep apnoea. Can be effective for mild snoring. If snoring persists and/or becomes severe despite using these strategies, refer the snorer to their doctor. Magnesium products may provide relief from, and help reduce, muscle cramps and spasms, tired, aching and restless legs. Evidence supports the use of valerian and lemon balm to improve quality and quantity of sleep. Many other ingredients (eg, tart cherry – a natural source of melatonin), lavender, passionflower) are reported to help sleep; however, evidence is often limited. Products with an asterisk have a detailed listing in the Sleep Problems section of OTC Products, starting on page 260. Page 136 HEALTHCARE HANDBOOK 2017-2018 Common Disorders

CONTINUING OTC EDUCATION Sleep and relaxation techniques •• Fall asleep in 60 seconds »» Breathing technique based on pranayam, an ancient Indian practice »» Uses the ratio 4-7-8: First exhale completely through mouth making a whooshing sound. Close mouth and breathe in through nose for four seconds. Hold breath for a count of seven. Then exhale for eight seconds making another whooshing sound. Repeat at least three times. •• Progressive muscle relaxation »» Involves progressive tensing and relaxation of muscles starting from the toes and working up to the facial muscles. Hold each tension for about five seconds and relax for 10 seconds. •• Visualisation »» With closed eyes, imagine a place or activity that is both calming and peaceful. Concentrate on how relaxed this place or activity makes you feel. doctor. Occasional use of over-the-counter medicines or prescription medicines prescribed by a doctor may be necessary to aid sleep in some people in certain circumstances. Snoring and Obstructive Sleep Apnoea Snoring is a sign that a person’s breathing is being affected by sleep. People are more likely to snore if they are overweight or have a thick or wide neck, drink too much alcohol, have a blocked nose, have certain medical conditions (such as Parkinson’s disease), smoke or take medicines that make them sleepy. Obstructive sleep apnoea (OSA) is a form of snoring where breathing pauses or is markedly reduced for short periods of time during sleep. It is more likely to develop in men who are overweight, aged over 40 years, with diabetes, and/ or who have other relatives with OSA. Women and children with a large neck circumference, enlarged tonsils or tongue, are also at risk of developing the condition. People with OSA have a higher risk of heart attack or stroke, high blood pressure, heart arrhythmias and driving accidents. People with OSA usually snore very loudly, snort or grunt, or gasp for air when their breathing pauses during sleep, and complain of daytime fatigue. Refer anybody with suspected OSA to a doctor or a sleep apnoea clinic. Advice for customers • Exercise daily, but not within four hours of going to bed. • Set a bedtime that is not too early or late, and stick to that time every night. • Start preparing for bed 30–60 minutes before bedtime. Turn off electronic devices, shower and brush teeth, and do something relaxing but not stimulating. • Try to keep the temperature of the bedroom around 18°C. Make sure the bed is supportive and comfortable and the room is used only for sleeping in. The bedroom should be dark once the lights are out (use blackout curtains to prevent any street lighting from shining in). • Set your alarm clock and wake up at the same time each morning. Ensure you Refer to PHARMACIST The following questions aim to identify customers who would benefit from further input from a pharmacist. Your initial assessment may have already provided some answers. Decide if any further questions still need to be asked and refer any “yes” answers to a pharmacist. • Does the person have any other health conditions (eg, heart or lung problems, diabetes, is pregnant or breastfeeding)? • Does the person take any medicine or complementary medicine, either prescribed by a doctor or bought from a shop? • Is the person a child under 12? • Has the insomnia lasted for more than three weeks? • Does the person have other symptoms that may suggest a previously undiagnosed medical condition? • Does the person appear overly anxious, stressed or depressed? • Is the person a severe snorer with symptoms suggestive of OSA? • Have self-help remedies, over-the-counter medications for insomnia or devices for snoring been tried without success? • Is the person having to wake often to go to the toilet? • Could pain be the reason for waking? • Can some changes be made to the person’s prescription medicines which may improve sleep? • Does the person have any allergies to medicines? expose your face to some natural sunlight as soon as you can, because this helps maintain a healthy sleep-wake cycle. • Avoid napping during the day, taking stimulants such as caffeine, nicotine and alcohol too close to bedtime, eating a meal or large snack just before going to bed, or going to bed too early (unless you need to wake early). Page 137

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