Guidelines for preventive activities in general practice

Miscellaneous

Sleep and sleep-related disorders

      1. Sleep and sleep-related disorders

Miscellaneous | Sleep and sleep-related disorders

Sufficient and good-quality sleep is essential for health and wellbeing. In prevalence studies, nearly half (48%) of all Australian adults report at least two sleep-related problems, such as inadequate sleep or sleep disorders.1 Sleep-related problems can be due to a number of predisposing, precipitating and perpetuating factors2 and conditions, such as obstructive sleep apnoea (OSA) or insomnia. OSA and insomnia can co-exist. Sleep-related problems are also associated with an increased risk of type 2 diabetes, cardiovascular disease, coronary heart disease, anxiety, depression and stroke.1,3,4 GPs can advise patients on the importance of practising good sleep hygiene.

Screening

Recommendation Grade How often References
Screening for OSA in the general population is not recommended because of insufficient evidence to assess the balance of benefits and harms. Generally not recommended N/A 5
Screening for insomnia in the general population is not recommended because there is no evidence. Generally not recommended N/A 2

Case finding

Recommendation Grade How often References
Case finding for OSA is recommended in people with symptoms (eg daytime sleepiness, fatigue, snoring, disrupted sleep) and in people with common risk factors (age >50 years, overweight or obesity, excessive alcohol intake). Commercial drivers and pilots are a priority group for case finding.

Questionnaires that can be used to identify patients who may have OSA include the: Questionnaires that can be used to identify symptoms of insomnia disorder include the:
Practice point  Opportunistically. 2

Preventive activities and advice

Recommendation Grade How often References
Advise behaviour modifications for patients with OSA risk factors, including:
  • limiting alcohol and certain common sedatives and antianxiety/antidepressant medications (eg benzodiazepines)
  • a 5–15% weight reduction for overweight or (morbidly) obese patients.
Practice point N/A 2, 6, 7
Advise patients to practice good sleep habits to help prevent sleep problems:
  • Maintain a regular wake up time, regardless of a poor night sleep
  • When sleep is of insufficient duration during the week (or work days), catch-up sleep on weekends (or non-work days) is important for health
  • Resolve concerns or worries before bedtime
  • Avoid going to bed until you are drowsy and ready to sleep
  • Try not to force sleep
  • Avoid daytime naps, especially if they are longer than 20–30 minutes or occur late in the day
  • Reserve the bedroom for sleep and intimacy and adjust the bedroom environment as needed to decrease stimuli (eg reduce ambient light, turn off the television or radio)
  • Avoid bright light immediately before bed or while in bed, including television and mobile phone use
  • Avoid visual access to a clock throughout the night
  • Allow sufficient time in bed to gain an adequate amount of sleep
  • Avoid caffeinated beverages after lunch
  • Avoid alcohol in the late afternoon and evening
  • Avoid large meals immediately before bed
  • Avoid smoking or other nicotine intake, particularly during the evening
  • Avoid pets sleeping in the bedroom
  • Exercise regularly for at least 20 minutes, preferably more than 1–2 hours prior to bedtime
  • Do not stay in bed if you do not fall asleep quickly (stimulus control therapy) and encourage relaxing activities before bedtime
Practice point N/A 2, 8, 9

Obstructive sleep apnoea

OSA is among the most common sleep disorders found in the general population worldwide.1 The prevalence of undiagnosed OSA is high,10 and it is associated with considerable morbidity.

The symptoms of OSA are varied, but can include2,5:

  • excessive daytime sleepiness, fatigue or falling asleep during the day, despite length of sleep
  • snoring (which may be loud or irregular)
  • choking or gasping during sleep
  • witnessed breathing cessation
  • sleep disruption and frequent awakenings
  • nocturia
  • difficulty with concentration, memory and other executive functions
  • depressed mood
  • decreased work performance.

Untreated OSA can have significant impacts, including:3,11

  • cardiovascular morbidity and mortality (including hypertension, coronary artery disease, stroke, atrial fibrillation, congestive heart failure)
  • increased risk of motor vehicle accidents
  • increased risk of occupational accidents
  • cognitive impairment
  • diabetes
  • lost work days
  • decreased quality of life
  • mortality.

Some of the common risk factors for OSA include:1,2

  • male sex
  • age >50 years
  • modifiable risk factors such as smoking, overweight and obesity and alcohol use
  • postmenopause (women).

There is currently insufficient evidence to screen the asymptomatic general population for OSA. Instead, initial assessment for symptomatic patients should encompass patient history, questionnaires and physical examination.

Insomnia

Insomnia causes problems falling or staying asleep, and can be categorised as acute (less than three months in duration) or chronic (more than three months duration). There are several predisposing, precipitating and perpetuating factors that may contribute to the development of insomnia disorder.2 Insomnia can greatly impact a person’s quality of life and overall health.

Acute insomnia generally occurs due to a psychological or physiological stressor, and typically resolves once the stressor has been removed or the patient has adapted to the stressor.2 It is important to reassure the patient that acute insomnia does not develop into chronic insomnia most of the time, and to manage the stressor that is causing the sleep difficulties.2

Women experiencing menopause and perimenopause may experience insomnia.12

Chronic insomnia is present for at least three nights per week for three or more months, occurs despite adequate opportunity for sleep and causes significant distress or impairment in daytime functioning.2

The assessment of insomnia disorder is based on patient-reported sleep history and questionnaires.

Please see the Resources tab for more information on behavioural therapies for insomnia.

The new topic of Sleep will be included in the new edition of the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, released mid-2024.

The prevalence of OSA is increased in patients:2

  • with type 2 diabetes
  • with hypertension and cardiovascular disease
  • prescribed sedative medications.

Case finding for OSA may be beneficial in commercial vehicle drivers and pilots.2

In addition to factors that may increase the risk of insomnia, a report to the Sleep Health Foundation found several factors associated with the highest prevalence rates of insomnia in the Australian population,13 including:

  • lower income
  • financial stress
  • unemployment
  • retirement
  • being unable to work due to disability.

The Sleep Primary Care Resources include a comprehensive list of risk factors that contribute to the development of:

Evidence-based resources and information to assess and manage adult patients with OSA and insomnia:
Sleep Health Primary Care Resources | Australasian Sleep Association

Non-drug behavioural interventions for patients experiencing insomnia and sleep problems:
Cognitive behavioural therapy for chronic insomnia in Handbook of non-drug interventions (HANDI) | RACGP
Brief behavioural therapy: Insomnia in adults in Handbook of non-drug interventions (HANDI) | RACGP
Behavioural intervention: Infant sleep problems and maternal mood in Handbook of non-drug interventions (HANDI) | RACGP

Guidance on sleep hygiene, stimulus control, sleep restriction therapy, relaxation and cognitive therapies:
GP guide to behavioural therapy for insomnia | RACGP

Evidence-based guidance on the use of benzodiazepines:
Prescribing drugs of dependence in general practice, Part B: Benzodiazepines | RACGP

  1. Australian Institute of Health and Welfare. Sleep problems as a risk factor for chronic conditions. Australian Government, 2021 [Accessed 30 March 2023].
  2. Zwar N, Soenen S. Sleep health primary care resources. Australasian Sleep Association, 2023 [Accessed 30 March 2023].
  3. Zhang Y, Jiang X, Liu J, Lang Y, Liu Y. The association between insomnia and the risk of metabolic syndrome: A systematic review and meta-analysis. J Clin Neurosci 2021;89:430–36. doi: 10.1016/j.jocn.2021.05.039.
  4. Dean Y, Shebl M, Rouzan S, et al. Association between insomnia and the incidence of myocardial infarction: A systematic review and meta-analysis. Clin Cardiol 2023;46(4):376–85. doi: 10.1002/clc.23984.
  5. Jin J. Screening for obstructive sleep apnea in adults. JAMA 2017;317(4):450. doi: 10.1001/jama.2016.20362.
  6. Qaseem A Holty J, Owens D, et al. Management of obstructive sleep apnea in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2013;159:471. doi: 10.7326/0003-4819-159-7-201310010-00704.
  7. Randerath WJ, Verbraecken J, Andreas S. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 2011;37:1000. doi: 10.1183/09031936.00099710.
  8. The Royal Australian College of General Practitioners (RACGP). Prescribing drugs of dependence in general practice. Part B – benzodiazepines. RACGP, 2015 [Accessed 30 March 2023].
  9. Sletten TL, Weaver MD, Foster RG, et al. The importance of sleep regularity: a consensus statement of the National Sleep Foundation sleep timing and variability panel. Sleep Health 2023;9(6):801–20. doi: 10.1016/j.sleh.2023.07.016.
  10. Australian Institute of Health and Welfare. Sleep-related breathing disorders with a focus on obstructive sleep apnoea. Australian Government, 2021 [Accessed 30 March 2023].
  11. Patil S, Ayappa I, Caples S, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: An American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2019;15(2):301–34. doi: 10.5664/jcsm.7638.
  12. McNamara S, Nichols T, Dash S, de Courten M, Calder RV. Sleep: A core pillar of health and wellbeing. Improving population sleep health to reduce preventable illness and injury. A policy evidence brief. Mitchell Institute and Victoria University, 2023 - a core pillar of health and wellbeing Policy Evidence Brief Oct 2023.pdf [Accessed 22 February 2024].
  13. Reynolds A, Appleton S, Gill T, et al. Chronic insomnia disorder in Australia: A report to the Sleep Health Foundation. Sleep Health Foundation, 2019 [Accessed 22 February 2024].
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