health

Sleep

Insomnia affects one third of the UK population.  That’s a staggering number of people who suffer with difficulties sleeping.  Insomnia is defined as a difficulty getting to or sustaining sleep or not having good quality sleep all of which cause problems with daily functioning (namely concentration), low mood or day-time sleepiness.  In a nutshell it’s poor quality sleep and it has a big impact on people’s lives. It is thought that 10-50% of patients seen by GPs suffer with insomnia.  When you run a search using “insomnia” as your criteria a multitude of papers with slightly alarming titles come up:

“insomnia increases risk of heart attacks and stroke”

“insomnia is linked to risk of gestational diabetes”

“insomnia increases risk of developing asthma”

The list goes on.  So aside from affecting peoples psychological health and ability to function it is also linked to some pretty serious health problems.  Therefore, it’s a big deal.

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I’d agree with the statistic above: at least one patient a day visits me to talk about difficulties sleeping and more tend to mention it as an also-ran when discussing their other health problems.  It’s a diagnostic feature of depression (early-morning wakening) as well as a key feature of anxiety (waking up in the night, difficulty getting to sleep) but given the fact that lack of sleep causes mood problems which one comes first?  Or is it just a vicious cycle?  If the long-term effects are so serious what can we do about it?  And why are GPs so reluctant to prescribe sleeping pills?

Causes

The causes of insomnia are seemingly never-ending.  As mentioned above, the most common cause is anxiety and depression affecting almost half of patients experiencing sleep difficulties.  One cause is the presence of another medical condition such as asthma (if it’s badly controlled people tend to cough at night), thyroid disorders, pain due to joint disorders and heart problems which leads nicely to the next cause: medications that we give to treat these conditions.  Anti-depressants can cause sleep problems as can medications used to treat asthma such as salbutamol (commonly known as the reliever inhaler) and steroids which are used for the treatment of asthma and other inflammatory conditions.  As well as drugs we give, drugs (legal or otherwise) that people choose to take recreationally can also cause insomnia.  I include caffeine, alcohol and nicotine in this list.  Then there are the sleep disorders…

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Sleep Disorders

The most common of these is obstructive sleep apnoea.  This is a condition where the air-ways become blocked for a period of time.  The person appears to stop breathing and the lack of oxygen causes them to rouse partially so the airways can open again.  Understandably this does not result in a  great nights sleep and people can feel very drowsy during the day, falling asleep more readily than is normal.  This condition can be assessed before you go and see a doctor: snoring is an almost universal feature of this condition but partners often report frightening “pauses” in breath.  If this is the case it’s worth doing the Epworth Sleepiness Scale.  If the score is over 10 a referral should be made to a sleep clinic for further assessment.  Before it gets to the stage of requiring machines to help keep the airways open overnight (CPAP) or devices to wear in the mouth, life-style changes like losing weight, stopping smoking, reducing alcohol intake and stopping sedative treatment can help.

Changes in the normal sleep pattern (Circadian rhythm disorders) such as jet-lag and shift work can cause insomnia.  This type of problem is characterised by difficulty going to bed at the same time as normal people do a sleeping longer with marked difficulty in waking.  And the final sleep disorders are parasomnias a group of disorders with include restless leg syndrome and sleep walking.  If no cause can be found then a diagnosis of “Primary Insomnia” is reached.

What can you do about your sleep

I often feel patients are disappointed the first time they come to see me about their difficulty sleeping.  Unfortunately there is no “magic bullet” many people desire.  Once I’ve assessed their sleep pattern and tried to ascertain a cause I usually talk about “Sleep Hygiene”.  This is the phrase we use to describe measures that can be adopted to promote good sleep and incorporates changes to the sleep environment and behaviour.

  1. The first thing to do is establish a routine.  Go to bed and wake up at the same time, this avoids the problem of oversleeping and the body often responds well to routine.  Developing a relaxing bed-time ritual (i.e. a cup of herbal tea followed by some reading time) can be beneficial.
  2. Avoid caffeine or alcohol 6 hours before bedtime and consider cutting it out altogether.
  3. Avoid screen use (TV, computer, mobile phone) for up to an hour before bed.  The light-rays from these screens is very stimulating and can delay sleep initiation.

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  1. Don’t take naps during the day
  2. Avoid exercise within 4 hours of bedtime but do exercise regularly during the day.
  3. Only use the bedroom for sleep (or sexual activity).  So if you can’t fall asleep and you’ve been trying for more that 30 minutes get up.  Also try to avoid doing work in the bedroom.  You are less likely to associated the room as a place of rest and this can result in trouble sleeping.

It has been reported that 30% of people improved with the above measures alone.  If none of these measures are beneficial and the problem has persisted for 4 weeks or more it is worth completing a sleep diary and seeing your GP as they may want to check for some of the conditions listed above.

What about sleeping tablets

Once upon a time doctors gave out sleeping tablets like they were going out of fashion.  Now you may have noticed we’re a lot more cautious.  I am sure I’m not alone in feeling wretched when I hear someone sit down and say “I’d like to have some sleeping pills” largely because I know they are likely to leave disappointed.  It’s not because we’re being difficult or trying to deprive people of that elusive good nights sleep, but the risks of taking hypnotics or sleeping pills far out-weigh the benefits.  Simply put: they’re dangerous.  And most of them are highly addictive.  If people have tried all the measures above, and they understand that medications are to be used as the exception, not the rule, I will advise that they can try over the counter medications.  These include the natural supplements and antihistamines you can get from the chemist.  If they fail I may prescribe a very limited prescription for a dreaded “Z” drug.  They can be useful when used for less that 4 weeks but they do not guarantee good sleep quality so the effects of insomnia may remain despite taking these pills.  The other issue is stopping them, they are addictive as I’ve said before, but they also cause a rebound-insomnia when they are stopped.  Unusual sleep behaviours have been reported on hypnotics such as “sleep driving” without remembering the event.

What will work?

If insomnia is caused by an underlying condition such as asthma or a heart problem, treatment of this should resolve the sleep difficulties.  Reduction in caffeine or alcohol at night will help with issues caused by stimulation from these drugs.  There are sleep therapies which can help.  The first is Cognitive Behavioural Therapy (CBT) which is a psychological talking therapy aimed at changing behaviour patterns.  Practitioners often employ techniques such as bedtime restriction.  This works by looking at the time spent in bed versus the time spent asleep using a sleep diary and restricting the time allowed in bed to the time spent asleep (for example if someone’s diary indicates they spend 8 hours in bed but only 6 hours asleep they should only spend 6 hours in bed).  This is usually started as a trial for 2 weeks and can be a very simple yet effective way of managing the problem.  In fact, the evidence shows that cognitive behavioural interventions work better than sleeping tablets in most cases.

As I said at the beginning, problems with sleeping are common and there are a myriad of causes for them.  Reaching for sleeping tablets is rarely recommended and often employing some of the changes above can make a real difference to peoples quality of life.

About Blog

About Me

Me

 

I am an NHS GP with a specialist interest in Headache, who works in South London.  I have three major passions in my life: exercise (or “training” as we’re supposed to call it now), promoting health and well-being and my family.  To be a good and effective GP takes time and life experience: I know that the events in my life have shaped what kind of doctor I have become.

 

I have always been lucky to be relatively healthy and have never needed to spend any significant time in hospital aside from trips to asses minor sports injuries and one (humiliating) A&E visit during medical school (where my Mum mistook a migraine for meningitis).  Aside from migraines, my immediate family had also always been similarly healthy until the Summer of 2012.  I was in my second year of being a fully-fledged doctor and I was in my first proper GP placement.  I have to admit at the time I hated GP because I was not in a sociable practice: people tended to work in silos isolated from each other and I had next to no support, despite having very little experience of being a doctor.  In retrospect the work I was expected to do was alarming given the lack of knowledge I had at that stage of my training.  The saving grace was that I was that I was living at home so after hours of isolation (which sounds odd when you spend all day seeing patient after patient) and mentally taxing work, it was wonderful to be able to relax and spend time with my parents.

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One night in July, my Mum woke in the night with a bad migraine.  This wasn’t particularly unusual: she’d always suffered with bad migraines fairly frequently and wasn’t keen on taking any kind of preventative treatment because she thought they were a sign that she needed to rest so if she got rid of them how would she know something was wrong?  She had the usual flashing lights, unbearable pain and panic attack she experienced with her migraines.  Unusually though, this one carried on… and on… for 5 days.  And she was being sick a lot.  On the 5th day I was stumped: I knew I was out of my depth and I told her to call her GP.  He visited her and she called me at 2pm saying he’d called an ambulance for her to go to hospital.  He thought she’d picked up a stomach bug and was dehydrated.  He’d said her blood pressure was low (she said it usually was) and that she had a heart murmur… had she had one before?  She had when my sister was born and the scan had shown that everything was fine.  He thought it was best she went in for some fluids and to get it checked out and he’d see her in a few days.  As soon as she told me she was going to hospital I burst into tears.  I was “on-call” that afternoon until 6.30 and one of only two doctors in the surgery.  They wouldn’t be happy with me leaving but I knew I couldn’t work while my Mum was in A&E.

When I arrived, my Mum had been taken straight to resus: the bit we always see on casualty where all the “exciting” stuff happens.  I knew this meant she was very unwell.  My dad and I waited in the relatives room until the nurse came to update us.  He told us there’d been some “changes on the ECG”.  I cut in, “what changes?”  He paused and I explained I was an F2 and he told me there was “ST elevation”: she’d had a heart attack.  A bit later the consultant came to talk to us: she’d admitted to some mild aching in her chest when the “migraine” started but put it down to the panic she often felt during an attack.  The ECG and blood test confirmed she’d has a massive heart attack 5 days previously.  Her organs had started to shut down.  Had we thought about resuscitation?  This was a massive shock.  My sister rushed up from London and we all went to speak to her once they’d finished their tests: hours after she’d arrived.  She was very calm and we caught up on the information they’d given us.  She told us to take my Dad home because it was far too late for him to be out so we agreed.  But could I remember to cancel her massage and hair appointments on Tuesday?  Those were the last words she said to me.

Me and Mum
Me and Mum

This sudden turn of events when I was in my mid-twenties, and, in my opinion, far too young to lose a parent, completely changed my life.  For the first time I experienced symptoms of anxiety and panic at very inconvenient times and, looking back, I was definitely depressed for at least a year.  This is all normal in the context of what happened.  I was determined to take control of my own health and well-being.  I didn’t want to feel low any more and I didn’t want to suffer the same heart problems my Mum had either.  So I started exercising regularly (sometimes, arguably too regularly)… and I’ve been hooked ever since.

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It’s also made me a better doctor.  I believe good health is far more than physical health (i.e. the absence of physical illness) but also ties in with emotional and psychological wellbeing; something which can easily be over-looked in an NHS under pressure.  Now more than ever, I think it’s vital that people (or “patients”) are empowered.  By that I mean have the knowledge and tools to cope with many of the health problems we all face day to day.  And that’s why I decided to write a blog…