Practice: Running a pharmacy sleep apnoea service

Most pharmacists will be familiar with the fact that the majority of sleep-related enquiries are for the treatment of insomnia. Often these requests are met with the sale of an OTC sleep aid. 

Gareth Evans, who runs a sleep apnoea service in his pharmacy, believes sleep education is central to managing those seeking advice on insomnia but admits that trying to convince patients to adopt sleep hygiene measures before reaching for pills is something of a tall order. You have to break down several ingrained and incorrect assumptions about sleep, he says. 

“Many patients don’t understand that a normal night’s sleep can mean that you can wake up multiple times,” he says, adding that there is also the mistaken belief among patients that unless they are able to fall asleep and stay asleep until the morning, then they must have insomnia.

So what exactly is sleep apnoea and why should pharmacists be concerned about it? 

Sleep apnoea 

Sleep apnoea (SA) is a syndrome in which breathing literally stops and starts during sleep and can result in daytime tiredness. The condition remains largely undiagnosed yet is associated with a number of cardiovascular co-morbidities such as hypertension and metabolic dysfunction. The most common symptom is snoring, reported by up to 94 per cent of patients with the condition.

Insomnia is present in between 40-60 per cent of people with sleep apnoea, so it is likely that a good proportion of those with insomnia who turn to OTC sleep aids actually have sleep apnoea as an underlying cause. This highlights the need for proper assessment. 

Service explained

Gareth’s sleep apnoea service uses a questionnaire available at snorer.com, within which is a separate section, snorer pharmacy, for all patients who complain of a sleep-related problem. The available questionnaires serve as a triage tool to allow for subsequent signposting. This can be either to a pharmacy weight management, blood pressure testing or stop smoking service, the GP or a sleep-trained dentist, who can fit adjustable mandibular advancement devices, which are recommended by NICE for the treatment of sleep apnoea. 

GPs are unable to diagnose sleep apnoea since a diagnosis can only be reached after referral to a secondary care sleep clinic. For those seeking advice on insomnia, Gareth uses the same site but with additional, recognised and validated questionnaires that address daytime sleepiness and mental health problems. Taken together, these provide a more accurate assessment of the patient’s sleep-related problem and can be used 
to support referral to a GP. 

The service began in January 2023. What has surprised Gareth most is the absence of a typical sleep apnoea patient. “You’d expect most people that you see to be male, overweight, middle to later age but we’re seeing far fewer of those people and a whole spectrum of the population are coming in with sleep problems,” he says. 

Access and referrals

Although Gareth provides a private sleep apnoea service, he has seen a rise in the number of GP referrals. This, he thinks, is because they too are unclear how to manage patients with insomnia and see the service as another option. 

Within the pharmacy, Gareth has gone to great lengths to raise awareness not just of his service but of sleep problems in general. “One of our TV screens we can adapt ourselves and this asks patients if they snore and also displays information about sleep devices.”

In addition, he describes how staff are primed to not just sell sleep aids “but to get the pharmacist to have a more in-depth conversation with the patient”. Similarly, patients wishing to purchase a snore aid throat spray are invited to consult with the pharmacist. 

Gareth is also in the process of creating a leaflet that will be offered to all patients who purchase a sleep aid and hopes that this might help improve their sleep or serve as a prompt to return for a further discussion. 

Next steps

Following screening, where there is the possibility of sleep apnoea, Gareth provides a home sleep apnoea test. This provides invaluable information to support a referral to a NHS sleep clinic, but Gareth sees testing as much more than simply raising the index of suspicion for sleep apnoea. 

“These sleep tests could be a means to delve further into those patients who want to investigate their insomnia better because they make it possible to track sleep latency, any waking up, sleep positional problems and ultimately allay a patient’s fears that may be underpinning that insomnia in the first place.” 

Gareth cites the example of a recent patient referred to the service by her GP because of night terrors. While the screening was able to exclude sleep apnoea, the home sleep test profile ultimately led to a referral to both neurology and the NHS sleep service.

Given the adverse metabolic impact of sleep apnoea and the current over-reliance on sleep and snorer aids, could it be time for more pharmacists to follow Gareth’s lead? 

Further reading
• British Society of Pharmacy Sleep Services