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Non-Pharmacological Treatment Options
by William B. Dollman, BPharm, MAppSc, FSHP
Geriatric Times November/December 2004 Vol. V Issue 6
For some time now, non-drug strategies have been recommended as first-line treatments in the management of insomnia (Commonwealth Department of Health, Housing and Community Services, 1992; Mant et al., 1995). A number of well-defined, evidence-based, non-drug management techniques that deal with the causes of sleep disorders have been available. Chronic insomnia has been treated by restricting time in bed (Spielman et al., 1987), using bright light to alter a patient's circadian rhythm (Campbell et al., 1993) and using stimulus-control techniques (Baillargeon et al., 1998). It has been demonstrated that cognitive-behavioral techniques improve sleep in the short term and continue to provide sleep improvements in the longer term (Morin et al., 1999).
Despite their effectiveness, non-drug alternatives are not widely used, and the management of insomnia in the general practice setting almost always involves medication. One Australian study found 93.5% of insomnia problems were being managed with benzodiazepines, with the majority as ongoing treatment (Mant et al., 1996). A study in Norway revealed that 82% of prescriptions for hypnotics were repeat prescriptions and that elderly patients were at risk from over-prescribing (Straand and Rokstad, 1997). In Britain, a longitudinal study of benzodiazepine prescribing for the elderly showed a 2.5% incidence of prescribing, with 70% using them long term (Dollman et al., 2003a; Taylor et al., 1998). A U.S. study identified benzodiazepine prescribing as a problem, with 41% of patients being prescribed benzodiazepines during a hospital stay (Zisselman et al., 1994).
Data from the Australian Longitudinal Study of the Ageing showed 12.5% of a cohort of 1,664 people 70 and over were taking at least one benzodiazepine in 1992 (Dollman et al., 2003a; Roughead, 1998). In 1994, this had risen to 19.3%. The Australian National Health Survey showed that 61% of patients reporting taking medications for sleep in the previous two weeks had been doing so for more than six months (Australian Bureau of Statistics, 1999; Dollman et al., 2003a).
The extensive use of these drugs raises concerns about risks of dependence and overuse, especially in the elderly. They are particularly vulnerable to the adverse effects of over-sedation, ataxia, confusion, respiratory depression and short-term memory impairment (Mant et al., 1995). Benzodiazepines have been reported to be a major independent risk factor for falls, leading to femur fractures in the elderly (Herings et al., 1995).
The newer drugs such as zopiclone (Imovane) and zolpidem (Ambien) raise just as many concerns. The Australian Adverse Drug Reaction Advisory Committee (2002) has alerted prescribers that these newer drugs may be associated with distressing neurological or psychiatric reactions such as hallucinations, confusion, depression and amnesia.
Despite the apparent reluctance of general practitioners (GPs) and their patients to adopt non-drug techniques to manage insomnia, recent programs in South Australia demonstrate that these can be adapted and successfully incorporated into the general practice setting. This work followed consultations with elderly patients and GPs, during which factors were identified that would help them consider, enable and reinforce their commitment to behavioral change (Dollman et al., 2003a).
A resource kit was developed that facilitated the involvement of patients with their doctors in the diagnosis and management of their condition (Dollman et al., 2003b). The kit incorporates the steps to managing insomnia that are described below and has been widely distributed to Australian GPs.
Assessment
The first step in dealing with a sleep problem is an accurate assessment of its nature, severity and causes. Then, an appropriate diagnosis can be made and treatment implemented. When a patient reports excessive daytime sleepiness, it may be helpful to refer them to a sleep clinic. A thorough assessment, including a polysomnography, will help identify the presence of restless legs syndrome or sleep apnea. In the cases where an underlying medical cause is identified, the most appropriate management strategy involves treatment of the underlying medical condition.
To facilitate the assessment process, a number of assessment tools are available. The sleep diary provides an overall view of the patient's sleep pattern that is more reliable than global questions about their sleep, and it also benefits the patient by actively engaging them in the management process. The patient is required to record the timing of sleep and wakefulness across the 24-hour period for one week (Table 1). It is important to emphasize that the times written down need only be estimates, not accurate measurements. In addition, the sleep diary can be an adjunct to patient education. Elderly patients may become aware that they are napping during the day and that this reduces the amount of sleep they will require at night. Others can readily see an erratic pattern of going to sleep to the daily time of final awakening and detect changes in sleep behavior with different bedtimes.
Management
Non-pharmacological therapies require the health professional to work closely with the patient. It is important that the patient's progress is monitored and that the patient has the opportunity to discuss the technique and the impact it has had on their sleep problem. The GP needs to provide encouragement, support and reassurance that the patient's sleep problem will improve. If additional support is needed for a patient with a complex sleep problem, a referral to a sleep clinic is recommended.
Several potential therapies for sleep disorders are outlined below.
Cognitive therapy. Patients often have unrealistic expectations about sleep. This primes them for anxiety about sleep and facilitates the condition of an emotional response associated with the attempt to sleep. Cognitive therapy uses positive thoughts to counteract the negative about sleep. It focuses on identifying dysfunctional sleep cognitions and replaces these with more adaptive substitutes. A sample patient Sleep Fact Sheet, designed for the patient with unrealistic sleep expectations, is available online at <www.geriatrictimes.com/sleepfacts.html>. It is important to note that although cognitive therapy is a highly effective treatment, it often requires the health professional to work closely with the patient. It may take several visits to reinforce the message and support the patient.
Relaxation therapy. Patients presenting with sleep difficulties are often unable to relax and switch off at night due to stress, worry or anxiety. Relaxation is incompatible with increased arousal, so techniques that help patients relax facilitate both onset and the maintenance of sleep. There are numerous relaxation techniques available, including progressive muscle relaxation suitable for patients experiencing physical tension and mental imagery to stop a racing mind. It is important the patient feels comfortable with the technique chosen. Relaxation techniques are most effective if they have been well practiced during the day and early evening.
Bedtime restriction. Bedtime restriction therapy is based upon the recognition that excessive time spent in bed often perpetuates insomnia. Sleep spread out over a longer portion of the day becomes fragmented, with frequent intervals of wakefulness. During these intervals of wakefulness, negative emotional thoughts become increasingly conditioned to the bed and to the attempt to sleep. Bedtime restriction therapy reduces the amount of time spent in bed. This will ensure that sleep only occurs between the set bedtime and wakeup time. Sleep will then be of higher quality over a shorter period.
This is a very effective treatment in cases where excessive wakeful time is spent in bed. The effects are long term, provided the treatment is followed conscientiously. However patients should be informed that this is a difficult management method to adhere to. Support and encouragement from a partner or close friend to get through the first few nights and days should be recommended. Table 2 describes the bedtime restriction procedure.
Stimulus control therapy. Sleep problems are often triggered by stressful or disturbing life events, such as serious illness, hospitalization or death of a loved one. Once the situation has been resolved, sleep usually returns to normal. However, sometimes the insomnia can remain. This is because a negative association between going to bed and not sleeping has been formed. These negative emotions automatically triggered by going to bed increase alertness and make it more difficult to get to sleep. This type of insomnia is often referred to as conditioned insomnia.
Stimulus control therapy replaces these learned negative responses with positive ones. It makes the bed and bedroom positive triggers for sleep, ensuring that when the patient goes to bed or wakes up during the night, they can expect to fall asleep easily. Stimulus control therapy is explained in Table 3. Most patients need about three to four weeks of treatment to undo the maladaptive learning of conditioned insomnia.
Bright light therapy. Sleep-onset insomnia and early-awakening insomnia are amendable to treatment with bright light therapy. Light influences the timing of the circadian rhythm of core body temperature. Behavioral sleepiness has been shown to vary dramatically and predictably with the circadian temperature cycle. Normal sleep is embedded within a 10-hour phase of sleepiness, centered on a minimum core body temperature. This phase is bordered by two zones of wakefulness.
The first zone of wakefulness is known as a wake maintenance zone and, in most good sleepers, occurs from about 6 p.m. to 9 p.m. Sleep-onset insomnia can result from a delayed circadian rhythm in which the wake-maintenance zone occurs later (10 p.m. to 1 a.m.), when sleep onset is being attempted. These patients tend to have trouble falling asleep until very late at night and then find it difficult to wake up in the morning.
The patient with delayed sleep phase syndrome should be exposed to bright light shortly after sunrise and should avoid bright light in the evening. The exposure time will vary, depending on cloud cover and personal need. On a sunny day, exposure of 20 minutes may be sufficient, but 30 to 60 minutes is recommended. It is important to instruct the patient not to look directly at the sun.
The second zone of wakefulness, known as a wake-up zone, usually occurs from 8 a.m. to 11 a.m. Early-awakening insomnia can result from a circadian rhythm and wake-up zone occurring too early (4 a.m. to 7 a.m.). These patients fall asleep earlier than desired and then are awake in the very early hours of the morning.
The patient with this problem should be exposed to bright light during the early evening and avoid early morning sunlight. In the spring and summer, simply going outside in the sunlight in the early evening is often sufficient. Thirty to 60 minutes is generally recommended. During winter, the patient may need to be referred to a sleep clinic to obtain a light box. Exposure to the light box from 8 p.m. to 10 p.m. can be effective. The length of exposure will depend on how strong the light is. Even the light from a very bright desk lamp may be of some value.
The non-drug strategies discussed have been shown to be effective alternatives to hypnotic drugs for the management of insomnia. In some cases, more than one of the techniques are needed and recommended.
In a limited number of situations, pharmacological management may be required, such as in times of serious emotional crisis where it may prevent a short-term sleeping problem from developing into chronic insomnia (Morin et al., 1999). However, hypnotic medications should not be first-line treatments. If they are prescribed, the duration of therapy should be for the shortest time possible and a definite duration of usage agreed upon with the patient at onset (Therapeutic Guidelines, 2000).
Dr. Dollman has extensive experience in the field of pharmaceutics and an involvement in broad drug policy. His commitment to the Quality Use of Medicines movement in Australia has led to the development of a regional approach to achieving optimal use of medicines in the community, including residential aged care.
References
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