Latest MS research update - Can the use of sleeping tablets increase levels of fatigue in people with MS? - 9 December 2014
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Can the use of sleeping tablets increase levels of fatigue in people with MS?
Sleep problems and fatigue are both common in people with MS. Previous research has shown that a lack of sleep can make fatigue, as well as other MS symptoms, worse. Therefore in order to get a good night's sleep some people use sleeping tablets, however little is known about the use of sleeping tablets in MS and the effects that they can have on fatigue levels.
A group of 190 people with MS in the USA took part in the study and completed several questionnaires that explored their sleep habits, use of sleeping tablets, levels of fatigue and daytime sleepiness.
Nearly half of the participants (89 people) said they used sleeping tablets. 50 participants used prescription medication and 59 used over the counter products, some participants used both. The study found that more people who were suffering with fatigue were also using sleeping tablets. Participants taking sleeping tablets also had higher levels of fatigue. When the researchers investigated further, they found that the higher levels of fatigue were associated with using the over the counter products containing diphenhydramine, but not prescription medications.
The study found that there may be a risk of making MS fatigue worse by using over the counter sleeping tablets containing diphenhydramine. The researchers do stress that their study cannot prove that these medications are the cause of the higher levels of fatigue seen in these participants but their study highlights an area that warrants further investigation. They recommend that while the effect of these particular medications on MS fatigue are investigated, alternative approaches and treatments should perhaps be considered to help people with MS get a good night's sleep.
Sleep problems are common in people with MS, with about 50% reported to experience some form of sleep disturbance. Fatigue is also extremely common in people with MS and previous research has shown that a lack of sleep can make fatigue, as well as other MS symptoms, worse. In order to get a good night's sleep some people may use sleeping tablets, either prescribed by their doctor or purchased over the counter at the chemist. However little is known about the use of sleeping tablets in MS and the effect that they can have. This study aimed to look at how many people used sleeping tablets, how often they used them and if their use had any effect on fatigue levels.
How this study was carried out
190 people with MS were recruited to take part in the study via a clinic held at a university medical centre in the USA. The participants completed several questionnaires to gather information on sleep, their use of sleeping tablets and several other factors can be related to sleep or MS. These were:
- A MS-specific sleep survey to collect information on sleep quality, sleep quantity, daytime and night time symptoms.
- Sleeping tablet use to collect information on how often these were used (never, occasionally, frequently, or always) and which medications from a list of those commonly available they used.
- Fatigue Severity Scale (FSS) to determine their fatigue level
- Epworth Sleepiness Scale (ESS) to determine levels of daytime sleepiness
- Insomnia Severity Index (ISI) to collect more information on the severity and impact of insomnia
Information was also collected about the participants MS, including symptoms that interfered with sleep such as pain, tingling, spasticity and bladder problems.
What was found
Nearly half of the participants (89 people) said they used sleeping tablets. 50 participants said they used prescription medication and 59 used over the counter products, some participants used both. Of those that used over the counter products, 47 were using a product that contained a medicine called diphenhydramine.
The study found that more people who were suffering with fatigue were also using sleeping tablets at least on an occasional basis.
Participants taking sleeping tablets also had higher levels of fatigue. When the researchers investigated further, they found that the higher levels of fatigue were associated with using the over the counter products containing diphenhydramine, but not prescription medications.
What does it mean?
The study found that there may be a risk of making MS fatigue worse by using over the counter sleeping tablets containing diphenhydramine. The researchers do stress that their study cannot prove that these medications are the cause of the higher levels of fatigue seen in these participants but their study highlights an area that warrants further investigation. They suggest that these medications may still be having an effect the day after the person has used them, as their common side effects after use are decreased mental alertness and drowsiness, which may be contributing to fatigue levels in people with MS and make it appear worse.
They recommend that while the effect of these particular medications on MS fatigue are investigated, alternative approaches and treatments should perhaps be considered to help people with MS get a good night's sleep.
The study looked at two categories of sleeping tablets, those only available on prescription and those available over the counter. Prescription medications such as benzodiazepines are tranquillisers that can reduce anxiety and promote calmness, relaxation and sleep. In the UK temazepam is the benzodiazepine that's often prescribed as its effects are short lived. Z medicines are a newer type medicine that work in a similar way to benzodiazepines, these include zaleplon, zolpidem and zopiclone.
Over the counter medications that contain diphenhydramine include Nytol and many chemist and supermarket own brand of sleeping tablets, it can also occasionally be found in cold and flu remedies designed to be taken at bedtime. Diphenhydramine is an antihistamine that has sedative effects, so can also be found in anti-allergy products such as Benadryl.
More about sleep
Poor sleep is common in people with multiple sclerosis. Poor sleep quality and quantity can impact on daily life, causing daytime sleepiness, decreased concentration and memory, worsening depression, and the inability to work effectively. A lack of sleep can also lead to low energy levels or make fatigue and other symptoms of MS worse.
There can be many reasons why getting good quality sleep can be difficult. Some are well known: a new baby can mean you are up and down throughout the night or worries playing on your mind can make it difficult to 'switch off' resulting in trouble dropping off or a restless night.
Some MS related symptoms can also make sleeping difficult or interrupted. These include: spasms, pain (neuropathic or musculoskeletal), high levels of daytime fatigue and nocturia (the urge to urinate frequently at night). In such cases sleep quality can often be improved by treating the symptoms. Many treatments are available, including medications some of which have the dual advantage of treating the symptom as well as having a sedative effect, such as gabapentin used to treat neuropathic pain and spasms in MS.
Sleep quality can also be improved by following a routine, as your body and mind will become used to these regular habits.
- Try to stay as physically active as possible during the day, but avoid getting overtired by doing too much, as being too tired can make it difficult to get to sleep.
- Avoid unnecessary stress or stimulants (eg caffeine, chocolate, alcohol) in the late afternoon and evening.
- Establish a bedtime routine such as having a warm milky drink before you go to settle down or a period of quiet time and try to follow the same routine every day of the week
- Wind down before it is time to sleep. Avoid rushing around or vigorous exercise just before bedtime and write a to do list for the following day to clear your mind of distractions.
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