Pulse February 2019 issue - Page 33

33 Who to refer to secondary care Possible sleep apnoea – most patients will be investigated with a domiciliary, respiratory sleep study. Treatment-resistant restless legs – refer if lifestyle factors have been addressed and treatment with a low-dose dopamine agonist or alpha-2-delta ligand fails. Injurious parasomnia – occasional sleep paralysis or sleepwalking that partners can manage without injury may not need referral. Possible narcolepsy – younger, very sleepy patients with additional vivid dreams and cataplexy. Drug management Benzodiazepines and Z-drugs – these are licensed but are addictive and there is little evidence for sustained benefit. Helpful for some parasomnias such as REM sleep behaviour disorder over the long term without dose escalation. Can worsen snoring and sleepwalking. Driving impairment is demonstrated with no awareness of impairment Melatonin – licensed for adults aged over 55 and if used for less than 13 weeks but only effective for improving sleep onset, not total sleep time. Short half-life so few side-effects. Gabapentin – there is trial evidence for short-term benefit when used 200mg at night but it is off licence. Also effective for restless legs, as is night-time pregabalin at low dose. Antihistamines – such as Nytol (diphenhydramine) – these have a long half-life, so there is potential for hangover with very limited evidence for benefit. Amitriptyline/trazodone – the long half-life limits dose escalation for many. Carries anticholinergic side-effects such as dry mouth and weight gain, use is off-license and there is limited evidence for sustained benefit. How can patients access CBTi? Management of insomnia disorder First-line treatment should be psychological therapies for insomnia disorder; insomnia- specific CBT (CBTi) outperforms drug therapy, with fewer side- effects. Group, computerised and one-to-one delivery have all been shown to be effective. 1 Guided self-help books (such as Overcoming insomnia and other sleep problems, Espie C, 2006). 2 Online versions of therapy, some availability within IAPT and NHS – such as Sleepstation and Sleepio. Also available commercially direct to patient. 3 Some regional sleep services offer assessment and therapy. 4 Talking therapies – expansion of the remit beyond anxiety and depression CBT means that some are trained and offer CBTi – provision is patchy but increasing. Dr Kirstie Anderson runs the neurological sleep service in Newcastle upon Tyne Hospitals NHS Foundation Trust, has developed digital therapies for insomnia and runs annual sleep training days Pulse February 2019