Poor sleep can lower immunity and is associated with weight gain, hypertension, depression, and increased mortality.1,2 Research has shown that clinicians understand the need to address comorbidities and sleep hygiene during sleep evaluations, but use of maladaptive coping mechanisms, including the use of alcohol and over-the-counter (OTC) sleep aids, can impact effective treatment of insomnia.2
This pilot study was done to determine any differences in sleep architecture/sleep quality during polysomnography (PSG) based on the use of maladaptive coping mechanisms to help guide future research on this topic.
Treatment guidelines for insomnia recommend cognitive behavioral therapy first and pharmacologic management second; however, providers in clinical practice often tend to prescribe sleep aids as first-line treatment.3
The National Sleep Foundation defines insomnia as difficulty falling or staying asleep.4 According to the CDC, a third of adults living in the US report getting insufficient sleep.5 Patients will present to primary care providers for sleep complaints more often than to specialists and clinicians need to understand how to effectively treat insomnia.6
Maladaptive coping mechanisms for insomnia
Patients with insomnia have been shown to use many maladaptive coping mechanisms including the use of tobacco, alcohol, caffeine, and sleep aids. They also frequently compensate for poor sleep by napping, which affects their ability to go to sleep at night and actually worsens the insomnia over time.7 Patients also resort to readily available stimulants, such as nicotine and caffeine, in order to combat the fatigue and daytime somnolence associated with poor sleep.8 However, these stimulants have been shown to decrease deep restorative sleep and increase light sleep.8 Some patients use alcohol to help relax at the end of the day, but alcohol actually causes fitful sleep instead of restorative sleep.8 Sleep aids, both OTC and prescribed, are frequently overprescribed and used incorrectly.8
Underlying psychiatric conditions are common in patients with insomnia and 90% of those with depression will report issues with sleep quality and 40% will have difficulty with sleep onset and duration.9 Benzodiazepines have been overprescribed for patients complaining of insomnia since the 1970s and are no longer recommended by sleep specialists due to their risk of dependency, abuse, and adverse reactions, including hypersomnia.10 Opioids affect sleep efficiency and those who take opioids on a regular basis are five times more likely to develop a sleep disorder.11 Diuretics may cause nocturia, which can affect sleep efficiency.12 Stimulants such as caffeine, nicotine, and some drugs (both prescribed and illicit) have all been shown to affect sleep quality in different ways, and all increase sleep latency.13 Finally, researchers have shown that many patients tend to avoid seeing healthcare providers for help with sleep issues and instead will self-treat in order to maintain control of their health.14
Methodology
The effect of maladaptive coping mechanisms on sleep quality is an emerging research topic with limited study. In order to evaluate for differences in sleep architecture/sleep quality during PSG based on the use of maladaptive coping mechanisms, we performed a retrospective chart review of a convenience sample of 137 patients who had presented to a private sleep clinic from January 1, 2017, to January 1, 2019, and had PSG evaluations during this time frame.
Loss of confidentiality is the ultimate concern with a retrospective chart review. A master list was used and kept in a locked file cabinet separate from the data. The primary investigator was the only one with access to the list, which was destroyed at the end of the study collection period. Patient charts were assigned a code number and no patient identifiers were entered into the data file or listed on the data. Institutional review board approval was obtained prior to any research or data collection. This ensured all ethical aspects of research were covered and approved. All patient information was maintained in a manner to protect privacy and confidentiality.
Measures
Demographic descriptors. Patient demographics of age, race, gender, employment status, marital status, body mass index (BMI), maladaptive coping mechanisms, and diagnoses were collected electronically from the patients' charts when available.
All medication data were collected due to the possibility of clinicians prescribing other medications that may impact sleep, primarily antidepressants, benzodiazepines, opioids, diuretics, and stimulants.
PSG/Sleep architecture descriptors. Our primary measurement tool was PSG, which is used to measure sleep architecture objectively by recording general sleep and bodily functions overnight, including vital signs, breathing patterns, oxygen levels, and limb movements.15 The PSG collects information on the descriptors of sleep architecture (sleep duration, sleep latency, sleep efficiency, arousal index, rapid eye movement [REM] latency, and number of REM cycles), which are evaluated and scored based on the American Academy of Sleep Medicine Manual for the Scoring of Sleep and Associated Events: Rules, Terminology, and Technical Specifications.16
Definitions and expected findings of sleep architecture descriptors are as follows:
* Sleep duration: Total time spent asleep.15 Seven to eight hours of sleep per night is recommended for adults 18 to 64 years of age.15
* Sleep latency: Time from lights out to the first occurrence of any stage of sleep other than wakefulness.15 Anything less than 30 minutes is considered normal for adults.15
* Sleep efficiency: Ratio of total sleep time to time spent in bed. This is calculated by dividing the number of minutes spent asleep by the total number of minutes spent in bed.15 A score of greater than 85% is considered normal for adults.15
* Arousal index: A change from deep sleep to light sleep or light sleep to wakefulness, that lasts at least 3 seconds, and is noted in the electroencephalogram frequency.15 Normal values are 10 to 25 per hour for the general population.15
* REM latency: The length of time to transition from non-REM sleep to REM sleep.15 Normal adult REM sleep latency is usually 50 to 150 minutes.15
* Number of REM cycles: A REM sleep cycle can encompass several REM sleep episodes if they are separated by more than 20 minutes.15 The number of REM cycles are known to decrease with age and three to five REM cycles are normal for all age groups.15
Sleep disorder descriptors. Sleep disorders (obstructive sleep apnea [OSA], periodic limb movement disorder [PLMD], and hypersomnia) may also affect sleep quality. PSG records the apnea-hypopnea index (AHI), which is used to measure OSA, and the number of periodic limb movements during sleep, which is used to evaluate for PLMD.15
The Epworth Sleepiness Scale (ESS) is used to evaluate hypersomnia. Since all these abovementioned disorders can affect sleep quality, the author's clinic collected and evaluated measurements for all of them.
OSA. The presence and severity of OSA are determined during PSG by calculation of the AHI, which is the number of apnea and hypopnea events during an hour of sleep.15 Apnea is defined as a pause in breathing that lasts at least 10 seconds and causes a decrease in oxygen saturation.15 Hypopnea is defined as an episode of shallow or very slow breathing lasting 10 seconds or more.15 OSA severity is determined by the AHI score, or the number of apneic and hypopneic episodes per hour of sleep: 5-14 is mild, 15-29 is moderate, and greater than or equal to 30 is severe.15
Periodic limb movement (PLM). Measurement of PLM during sleep is important because this limb movement can cause arousals and affect sleep efficiency.15 PSG criteria for leg movement include movement lasting at least 0.5 seconds per event with a minimum amplitude per event of 42 and 8 mcV increase in electromyography voltage above the limb at rest.16 Severity is determined by the amount of PLM (less than 5/h is normal, 5-24/h is mild, 25-49/h is moderate, and greater than 50/h is severe).16
ESS. The ESS is a screening tool that takes less than 5 minutes to complete and is a subjective assessment of somnolence, a chronic symptom of sleep disorders. This scale is easily administered, cost-effective, and used worldwide to assess somnolence.17 The ESS is composed of eight questions. Respondents rate on a four-point scale their propensity to doze off during usual daytime situations, such as sitting and reading and watching TV. The scale has a score range of 0 to 24: Scores of 0 to 7 are unlikely to represent abnormal sleepiness, scores of 8 to 9 represent an average amount of daytime sleepiness, a score of 10 to 15 indicates excessive sleepiness, and a score of 16 to 24 indicates excessive sleepiness that the patient should seek medical evaluation for.17
Results
Data for certain items were missing from patient records. Where data are missing, percentages are calculated only for known data.
Sample characteristics. The majority of patients were generally middle-aged, female, White, and overweight (see Patient demographic characteristics). The majority of the participants presented with the following sleep disorders: OSA (43.1%), insomnia (10.9%), and/or hypersomnia (6.6%). The remaining patients presented with a wide variety of other diagnoses.
Maladaptive coping mechanisms for insomnia. Overall, the patients did not use alcohol (63.8%) or tobacco (90.1%), but did use caffeine (68.6%) and sleep aids (67.1%, see Patients' sleep influencing factors [substances]).18 The patients rarely exercised and the majority did not work. Napping was common, with 26.8% napping daily. The majority of patients were not on antidepressants (62.8%), benzodiazepines (72.7%), opioids (73.7%), diuretics (72.3%), or stimulants (80.3%).
Maladaptive coping mechanisms: Comparison of sleep quality. The most commonly reported maladaptive coping mechanisms for insomnia were caffeine, sleep aids, and napping. Sleep quality was compared between patients who used these maladaptive coping mechanisms and those who did not. This was a pilot study that only examined raw data (after it was cleaned for outliers) to determine if the research topic required further study.
Sleep aids and sleep quality. The majority of patients reported the use of sleep aids (47.4% used prescription sleep aids and 19.7% used OTC sleep aids). Sleep quality among those who took sleep aids and those who did not (32.8%) was compared (see Maladaptive coping mechanisms with sleep quality descriptors), and it was revealed that those who did not take sleep aids went into REM sleep faster (mean = 130.78 minutes) than those taking prescription sleep medications (mean = 167.07 minutes). The mean number of REM cycles was also lowest for those on prescribed sleep aids (1.92) as compared with those on OTC sleep aids (2.48) and no sleep aids (2.16). Those on prescribed sleep aids had decreased sleep latency (21.78 minutes) as compared with those not on sleep medications (mean = 29.96 minutes) and mean sleep efficiency was higher on the prescription sleep aids (80.34%) than on no sleep aids (75.64%). The mean arousal index was also higher for those not on a sleep aid (33.02/h) as compared with those on prescription sleep medications (30.26/h) and lowest for those on OTC sleep aids (26.59/h). Mean sleep duration was higher for those on OTC sleep aids (349.00 minutes) than for those on prescription sleep aids (323.60 minutes) or not on sleep aids (292.51 minutes).
In the evaluation of the use of sleep aids with the sleep disorder descriptors of OSA, PLM, and hypersomnia (see Maladaptive coping mechanisms with sleep disorder descriptors) it was found that the number of PLMs per hour was lower in those who did not take sleep aids. The mean number of PLMs was highest in the population on OTC sleep aids (23.67/h) as compared with those not on sleep aids (8.78/h). The patients not on sleep aids also had the lowest range of PLMs (0-88/h) as compared with those on OTC sleep aids (0-145/h) and those on prescription sleep aids (0-125/h). Patients on prescription sleep aids had the lowest AHI (mean = 16.51), but the largest range of AHI (0-104 events per hour) as compared with those not on sleep aids (0-78 events per hour). The OTC sleep aid group had a lower mean ESS score (6.30) than those who did not take sleep aids (7.43) or who took prescription sleep aids (7.25).
Caffeine use and sleep quality. About 30% of the patients did not use caffeine, with the remainder consuming caffeine at least twice weekly. More than 20% used at least one caffeinated product daily. Of note, 19 patients did not have caffeine use notated on their electronic charts. REM latency was higher for those that used caffeine as compared with those that did not, except for those with greater than two caffeine servings daily.
Those that did not use caffeine had the highest mean AHI (25.86/h), number of PLMs (17.59/h), and ESS score (7.67) compared with those who did use caffeine.
Napping and sleep quality. The majority of the patients napped (82.9%). Over a quarter napped on a daily basis. Of note, 14 patients did not have napping history notated on their electronic charts. Those who did not nap had decreased sleep latency and lower ESS scores as compared with those who napped on a regular basis.
Discussion
This was a pilot study to determine if the topic warranted further study and the results supported that patients were utilizing maladaptive coping mechanisms for insomnia-primarily caffeine, sleep aids, and napping. We saw negative changes in sleep quality-primarily sleep latency-with napping. However, the patients on sleep aids did exhibit decreased sleep latency, higher sleep efficiency, lower AHI, and increased sleep duration than those not taking sleep aids.
The patients appeared to live sedentary lifestyles because they rarely exercised and the majority did not work. Additionally, the use of herbal products in over 40% of the patients as well as the use of OTC sleep aids in nearly 20% indicates that many patients are self-medicating. All of these factors can be addressed with education on sleep hygiene. While there were limited studies to review, our findings supported those of other researchers on this topic. Meredith and colleagues performed a critical review of literature regarding patients with sleep disturbances and self-care and found that the use of maladaptive coping mechanisms was common in this population.14
Limitations. The study had significant limitations. First, we conducted this study at only one site with a convenience sample which likely affected the generalizability of the results. Second, the sample was mostly middle-aged, White, and female, which also affects our ability to generalize the findings. Our sample included a wide range of ages (23 to 95) and although the mean age was 57.8, this variability in ages could have affected our results with more outliers than a general population. In addition, we drew our sample from patients with sleep complaints and a proclivity to sleep disorders which may have reduced the variability in some measures. We collected data from the electronic medical record, which did not allow the ability to add prospective measures or seek clarification. The data for certain measures, such as the use of OTC sleep aids, caffeine intake, and napping, are based on patient self-report and therefore may be subject to recall or response bias.
Implications for practice
Insomnia remains highly underdiagnosed and undertreated, and can affect the population at large with regard to decreased employee productivity and accidents related to the loss of sleep.19 The estimated annual costs related to insomnia in the US are high, ranging from $30 to 107.5 billion.19 Wickwire and colleagues also found that untreated insomnia increased the use and cost of healthcare for those on Medicare.20
Clinicians need to be adept at evaluating and treating insomnia and inquire about maladaptive coping mechanisms for insomnia when performing basic sleep evaluations and follow-ups. These maladaptive coping strategies lead to behavioral or learned factors that can continue to cause and even worsen insomnia. Researchers have shown that providing handouts and verbal advice is not sufficient.6 Clinicians need to be ready to provide robust education that addresses sleep hygiene and the maladaptive coping mechanisms of insomnia to improve patient outcomes. Providing education that allows for questions and input from the patient enhances the likelihood that the patient will make changes that can improve their sleep.
Directions for future research
Future studies should be conducted in the areas of napping, sleep aids, and caffeine, as these were the most common factors that affected sleep in our patient population. Consideration should also be given to using a broader sample of patients with representation of all races, ethnicities, and ages across the life span. Finally, a study of larger scale with a broader sample base across multiple study sites to enhance the ability to generalize findings would be beneficial.
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