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At the heart of general practice since 1960

Advising a poor sleeper on melatonin

At Mr Smith's BP check his

wife suggests that she buys melatonin because he is sleeping badly. She asks if it mixes with his medication. Dr Melanie Wynne-Jones advises.

What is normal sleep?

By 50, many people get less than six hours sleep a night, and it becomes harder both to fall and stay asleep; daytime napping is also more common as we age. People whose natural circadian rhythm is longer or shorter than 24 hours may have problems with 'normal' sleep times.

Sleep disturbance or deprivation makes us irritable and clumsy: up to 30 per cent of serious road accidents may be due to driver fatigue1. In long-term sleep deprivation, mortality from myocardial infarction is increased.

What stops people getting to sleep?

 · Physical discomfort ­ pain, noise, too hot/cold, eating late, restless legs.

 · Too much mental or physical activity (sex is often an exception).

 · Stimulant chemicals ­ coffee, tea, chocolate, cola, cheese, nicotine or medication.

 · Poor sleep hygiene (see website).

 · Anxiety.

What wakes people in the night?

 · Environmental problems ­ heat/ cold, uncomfortable bed, snoring partner, too much light or noise.

 · Physical discomfort ­ pain, full bladder, indigestion, breathlessness, obstructive sleep apnoea, menopausal night sweats.

 · Too much alcohol ­ wakes the drinker up, often with sweats and tachycardia due to falling alcohol levels.

 · Depression ­ early-morning wakening (3am or 4am) is followed by wakefulness or intermittent dozing.

What is Mr Smith's problem?

A careful sleep history may reveal the cause and solution. What time does he go to bed and what is his pre-sleep routine? When does he get up, and does he wake before the alarm? Does he (or his wife) snore? Does he suffer from daytime sleepiness ­ is he a risk behind the wheel? Does he catch up on his sleep at weekends, or by cat-napping in the day and falling asleep in the evenings?

It is important to ask about other symptoms of anxiety and depression, and to inquire about problems at work or at home. Impotence and alcohol problems are common in middle-aged men, although impotence and/or his sleep problem may be due to the anti-hypertensives prescribed.

It may be appropriate to examine him. If he is overweight, snores, and has a large collar size, consider obstructive sleep apnoea. Check for diabetes or prostatic enlargement if he has nocturia, and heart failure or asthma if he is breathless.

Referral to a sleep clinic for sleep studies may be worthwhile for some.

Should Mr Smith Take melatonin?

Melatonin has attracted a following for insomnia and the relief of jet-lag, but its full range of actions and interactions are uncertain, and although it is obtainable, it is not licensed as a medicine in the UK.

What about sleeping tablets?

These can be a short-term solution for acute stress, but have side-effects and are potentially addictive, so rarely appropriate long-term. Cognitive behaviour therapy is claimed to work in some insomniacs2, but some people are simply habitually poor sleepers.

Drugs that can interfere with sleep

l?-blockers

 · Thyroxine

 · Steroids

 · Painkillers containing caffeine

 · Diuretics (nocturia, night cramps)

 · Stimulants such as decongestants and bronchodilators

 · Some statins

 · Some SSRI antidepressants

 · Some tranquillisers produce

paradoxical agitation

Key points

 · Sleep complaints are common

 · A careful sleep history should identify contributory causes and possible solutions

 · Depression, alcohol or medication are often to blame

 · Good sleep hygiene is important; sleeping tablets are rarely appropriate

clinical casebook

References

1 Connor J et al. Driver sleepiness and risk of serious injury to car occupants: population-based case-control study.

BMJ 2002;324:1125

2 Espie CA. What insomniacs need is cognitive behaviour therapy. BMJ 2002;324:288-94

Website

Useful tips about sleep hygiene for patients can be found at:

www.umm.edu/sleep/sleep-hyg.html

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