Improving Sleep Health: A Pharmacists Intervention

Christina Eldridge
HLTH 634 B01
February 5, 2016

Introduction
One of the goals of Healthy People 2020 is to increase public knowledge of
how adequate sleep and treatment of sleep disorders improve health, productivity,
wellness, quality of life, and safety on roads and in the workplace. 1 Adults aged 18
years and older require 7-9 hours of sleep each night, however more than one-third
of U.S. adults report sleeping less than 7 hours. 2 Sleep deprivation has been linked
to many chronic diseases and conditions, such as diabetes, cardiovascular disease,
obesity and depression. Insufficient sleep is also related to motor vehicle accidents
and work-related accidents, causing injury, disability and decreased productivity. 2
With the three leading causes of death in Alaska Native people being heart disease,
cancer, and unintentional injuries3, evaluating sleep health is an important factor to
consider. Increasing rates of obesity and diabetes are also affecting the Alaska
Native population, which are also correlated to disordered sleep. 2,3 In Alaska
between 2008-2009, 27.4% adults reported not getting an adequate amount of
sleep on greater than 14 days in the past 30 days according to the Behavioral Risk
Factor Surveillance Survey (BRFSS).3
Insufficient sleep and sleep disorders are common and often under reported
to primary care providers. Sleep disorders, therefore, go undiagnosed and untreated
and may lead to more serious diseases and unintentional injuries. Pharmacists have
a unique opportunity to screen patients and provide education about sleep health
because they are easily accessible at relatively no cost. The intervention that will be
explained here outlines the opportunity that pharmacists have in improving public
health, including sleep health. In a community setting, trained pharmacists will
screen patients who may be at an increased risk of sleep-related illness. These
patients will then be referred to their primary care provider for further diagnosis and
treatment of a potential sleep disorder (sleep apnea, insomnia, restless leg
syndrome, etc.) or they will be provided with education regarding adequate sleep
duration and good sleep hygiene. This intervention will target the Alaska Native
population, where significant comorbidities such as depression, obesity, diabetes
and cardiovascular disease, are common. Patients will also be screened for
medications that are commonly known to cause insomnia and also overused
medications in the treatment of insomnia. The education piece will have a
significant role in the intervention as most people are unaware of the negative
health impacts associated with sleep deprivation.
This literature review will focus on studies that investigate the association
between sleep deprivation and chronic diseases, including cardiovascular,
inflammatory and metabolic consequences, as well as, neurobiological and mood
disorders. Research articles from the BRFSS regarding sleep duration and chronic
diseases among US adults will also be reviewed. Finally, studies about sleep health
awareness and a pharmacists role in screening and providing education in sleep
related illness will also be reviewed.
Articles were included that explained the magnitude of sleep deprivation on
chronic disease and overall well-being. Sleep is a lifestyle choice and often
considered non-essential, therefore the BRFSS will be utilized to provide useful data
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on the behavioral risk factors associated with sleep deprivation and how these
correlate to the onset of chronic disease. Other references included in this review
focused on the role that community pharmacists have in the treatment and
prevention of sleep-related disorders, especially insomnia and sleep apnea.
Successful pharmacist-led intervention programs were included to show the
feasibility of such a program within a community setting. Bringing sleep health to
the forefront of healthy living by an easily accessible trusted health care
professional can be beneficial, especially in aging populations where sleep disorders
are becoming more common.

Body of Evidence
Sleep deprivation is common in modern society, especially with increasing
demands of occupation and the social aspect of life. 5 Many people will sacrifice
sleep over other essential needs because the detrimental effects of sleep loss are
often unnoticed and has not been emphasized as a public health concern. The
physiological function of sleep may not be well understood, however sleep
significantly contributes to our process of memory and learning. 5 Sufficient sleep is
needed to foster connections with neuronal networks for memory consolidation in
the hippocampus.5 Detrimental effects of sleep deprivation were studied in
experimental animals and concluded that sleep loss has negative effects on brain
function, including memory impairment due to extended periods of wakefulness in
rats.5
Sleep deprivation not only has effects on brain function, but also is associate
with higher levels of morbidity and mortality in epidemiological studies. 6 A review of
studies in healthy individuals with no sleep disorders who sleep between 7-8 hours
per night were evaluated with experimental sleep loss. 6 A study of more than 5500
men and women who report sleeping less than 6 hours per night were 66% more
likely to have high blood pressure compared to those who slept 7-8 hours per night. 6
Another study, however, found this relationship only to be true in women. 6 Short
duration of sleep is associated with increased risk of coronary disease in women,
impair glucose tolerance in men and women, and the development of diabetes in
women.6 Of note, men and women between 30 and 54 years of age were more likely
to have metabolic syndrome markers if they had a shorter duration of sleep. 6 Long
sleep (greater than 9 hours per night) was also found to be associated with
increased risk of morbidity and mortality, however this relationship could have been
complicated by undiagnosed mood or sleep disorders. 6 The studies concluded that
insufficient sleep alters the established cardiovascular risk factors and increases the
risk of cardiac morbidity.6
Data from the 2009 BRFSS of more than 375,000 US adults evaluated the
association between perceived insufficient sleep, frequent mental distress, obesity
and chronic disease.7 Because there was a positive relationship between insufficient
sleep and each of the six chronic diseases, a recommendation was made to include
the assessment of sleep quantity and quality as part of routine medical
examinations.7 In 2010, data from the BRFSS observed sleep duration and chronic
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diseases among 54,269 adults 45 years of age and older. 8 This cross-sectional study
examined the effects of obesity and frequent mental distress on the relationship of
sleep duration with coronary health disease, stroke, and diabetes. 8 About one-third
of study participants reported sleeping less than 6 hours per night and 4.1%
reported sleeping greater than 10 hours per night. 8 It was found that those sleeping
shorter than 7 hours and more than 9 hours per night were significantly associated
with obesity, frequent mental disorders, cardiovascular disease, stroke and
diabetes.8
Now that it has been evidenced in many studies the negative effects
associated with sleep deprivation, it is important to consider what interventions
could be made to address this widespread problem. In this literature evaluation,
those with obesity, depression, diabetes, and cardiovascular disease represent an
important subset of the population that are at highest risk of morbidity and
mortality with sleep deprivation. Alaska Native adults are also at an increased risk
of the negative impacts of poor sleep health due to the increasing rates of obesity,
cardiovascular disease, diabetes and depression and therefore will be the targeted
population of a pharmacist-led intervention.
In Australia, there have been several studies that have examined the roles
that pharmacists can play in screening, educating, and counseling patient on sleeprelated illness and health. Pharmacists are at an optimal position to provide health
information and intervene in the diagnosis and treatment of many chronic
diseases.9 If pharmacists were specially trained in sleep health and the identification
of sleep-related disorders, patients could receive helpful information on good sleep
hygiene and share this with their patients upon dispensing and counseling on
prescriptions.9 Health care professionals have many opportunities to provide
education, including sleep health, to patient and often miss this chance. 9
Pharmacists are at an advantage because they are a trusted health care provider
with a vast knowledge on medications and, if properly trained, can assist in the
diagnosis and treatment of sleep disorders. 9 Since behavioral therapies are
recommended as first-line therapy for insomnia, rather than pharmacotherapy,
pharmacists are able to intervene when patients present with prescriptions for
sedatives and/or hypnotics.10 A cluster-randomized controlled trial tested the
feasibility and efficacy of pharmacist-provided brief behavioral treatment for
insomnia and found that reductions in insomnia severity can be gained from this
avenue.10 This is an excellent time to provide education about how much sleep is
adequate, a healthy sleep environment, sleep hygiene tips and consequences of
inadequate sleep.2 Interventions involving pharmacists and sleep health have not
been done in Alaska, and with extended periods of light and darkness, many have
difficulty maintaining adequate sleep schedules and may suffer from sleep-related
disorders. There is a need for offering sleep health education to those at risk for
developing sleep disorders and also for those who may need treatment for more
serious conditions, such as sleep apnea. A cohort study examined the efficacy of an
intervention by a community pharmacist in the recognition obstructive sleep apnea
(OSA).11 By the exposure to the pharmacist intervention, patients had a higher

chance of undergoing a diagnostic test for OSA. 11 This highlights the argument for a
clinical pharmacist screening program for sleep disorders. 11
Summary and Conclusions
As stated earlier, sleep quality and duration have a significant impact on the
development and maintenance of chronic disease. Although there is a lack of overall
understanding about the importance of sleep in daily living, we do know that
autonomic functioning, inflammatory mediators, and hormonal profiled are altered
during studies of controlled sleep deprivation. 6 What is not fully known is whether
these changes are short-lived and adaptable over time. 6 In available experimental
studies, short-term sleep loss increases blood pressure, inflammation, autonomic
tone and hormones in a direction that contributes to the development of
cardiovascular disease and atherosclerosis.6 More studies need to be done to
determine to the consequences of long-term versus short-term sleep loss, so that
individual prevention strategies can be developed to reduce further risk from
cardiovascular or metabolic diseases. 6
Community pharmacist-led interventions in sleep health have the potential to
improve sleep-related illness and associated comorbidities, thus improving quality
of life and overall health and well-being. At the Alaska Native Medical Center, Alaska
Native adults will be screened at the pharmacy by a trained pharmacist and those
who have been identified at an increased risk of sleep disorders will be referred for
further diagnosis and treatment. Those who do not require a referral to a primary
care provider will be provided sleep health education and will receive follow up from
the pharmacist. Poor sleep is affecting many individuals in modern society and the
downstream effects have serious implications with respect to chronic disease
morbidity and mortality.