Sleep: the missing piece in chronic disease reviews

General practice nurses encounter patients across a range of long term condition reviews. Sleep quality is relevant to every condition we monitor, and the impact of sleep quality on health is often underestimated. Is it time we started to include sleep in our routine reviews?

Sleep is a crucial determinant of health, yet it is often overlooked in chronic disease reviews.¹ While general practice nurses (GPNs) routinely ask about smoking, alcohol, and exercise, questions about sleep rarely appear in templates. Evidence shows sleep quality directly affects outcomes,² and around a third of UK adults report disrupted sleep.³ Inadequate or irregular sleep amplifies stress, increases insulin resistance, worsens blood pressure, and impairs cognition, feeding progression of long-term conditions.² Practice nurses can address this gap by integrating sleep discussions into reviews, improving disease management and quality of life.⁴This article highlights sleep biology, common conditions, clinical significance, and practical guidance.

WHAT HAPPENS WHEN WE SLEEP? A QUICK BIOLOGY REFRESHER

Sleep is a highly regulated, cyclical process essential for health and daily functioning. Adults usually complete five or six cycles of roughly 90 minutes per night, which alternate between non-rapid and rapid eye movement (NREM and REM) stages. Adequate sleep supports cognition, learning, emotional regulation, and metabolic, cardiovascular, immune, and neurological systems. It recalibrates autonomic activity, balancing sympathetic and parasympathetic tone, underpinning stress regulation, cardiovascular stability, and homeostasis. Poor or irregular sleep disrupts these processes, causing fatigue, mood changes, impaired concentration, and increased vulnerability to chronic conditions.⁵ Circadian misalignment, from shift work, irregular routines, neurodevelopmental differences, or lifestyle factors, magnifies these effects.⁶ Understanding sleep biology empowers nurses to routinely assess and address sleep in primary care.

LIFESTYLE DETERMINANTS OF SLEEP

Sleep is profoundly linked with nutrition, physical activity, and overall health. Evening carbohydrate snacks can support sleep by increasing tryptophan bioavailability and serotonin-to-melatonin conversion. Carbohydrates trigger insulin, lowering competing amino acids, so tryptophan crosses the blood-brain barrier more effectively. High-protein foods contain tryptophan but compete with other amino acids, making them less effective than ‘carbs’ for sleep.⁷ Nurses can advise on meal timing, carbohydrate quality, and chrononutrition to optimise metabolic control and sleep.

Physical activity influences sleep: early-day exercise improves sleep latency, while late high-intensity sessions may delay it. Caffeine sensitivity from drinks or medications can affect sleep onset, and alcohol and nicotine fragment REM sleep, undermining restorative benefits.⁸

Shift work and irregular schedules disrupt circadian alignment, while stabilising sleep-wake patterns and morning light exposure or bright lamp therapy can reinforce rhythms.⁵ Mindfulness, breathing, or brief meditation can be highly beneficial, and establishing a regular routine earlier in the day can make it easier to evoke the relaxation response at bedtime.⁹

NEURODIVERSITY

Neurological differences such as like such as autism and attention deficit hyperactivity disorder (ADHD) involve distinct neurobiological sleep regulation patterns, including a deficit in melatonin production, dopamine dysregulation, and heightened sympathetic tone. In autism, persistent hyperarousal across sensory, cognitive, and autonomic systems, reflected in elevated sympathetic activity, significantly impede the ability to initiate sleep.¹⁰ In ADHD, sympathetic regulation is complex: individuals often have reduced baseline sympathetic tone, which can limit spontaneous task engagement, yet they may show exaggerated sympathetic responses during cognitive or emotional stress.¹¹ Difficulties with executive functioning, such as planning, initiating, and sequencing tasks, hinder the establishment of consistent bedtime routines.¹² Difficulty initiating routines reflects executive dysfunction, whereas difficulty switching activities, potentially to begin a bedtime routine, reflects monotropism,¹³ commonly referred to as situational hyperfocus in ADHD.¹⁴

Neurotypical individuals can also struggle with executive dysfunction and monotropism, and advice may be applicable to a wide range of neurotypes. Routines and task management are most effective when aligned with the brain’s natural rhythms. Using tools (lists, reminders, designated spaces) not as rules, but as scaffolds to support attention and flow help maintain structure while respecting the brain’s natural rhythms. Prioritising and dividing tasks into multiple smaller, manageable steps allows for natural transitions, and respects hyperfocus bursts. Integrating energy peaks, interest-driven engagement, and deliberate recovery can reinforce both productivity and consistent sleep patterns.^10,14. While these strategies are highlighted in the context of differing neurobiology, they are adaptable across all conditions discussed.

SLEEP AND LONG TERM CONDITIONS

Diabetes and metabolic conditions

Sleep deprivation and circadian misalignment reduce insulin sensitivity and elevate evening and nocturnal cortisol. This promotes hepatic glucose production, and higher fasting glucose, and HbA1c levels. Appetite-regulating hormones are affected: ghrelin rises and leptin falls, promoting weight gain and further glucose dysregulation.¹⁵ Social jet lag (>90-minute difference in midpoint of sleep between weeknights and weekends) is linked to higher HbA1c. Sleep efficiency <80% increases type 2 diabetes prevalence 1.8-fold. The 2022 ADA/EASD consensus report recognises sleep as central in managing type 2 diabetes, influencing glycaemic control, insulin resistance, and metabolic health.¹⁶ Chronic sleep disruption may accelerate stress and decline of pancreatic beta-cells, which are sensitive to oxidative stress; prolonged elevated cortisol and disrupted autonomic signalling impair function, reducing insulin secretion even before diabetes develops.¹⁷

GPNs can address sleep by asking about duration, quality, timing relative to meals and insulin, night-time awakenings, fatigue, or daytime sleepiness.¹⁸ Advice includes aligning bedtime with medication, ensuring restorative sleep before glucose monitoring or exercise, and highlighting how poor sleep worsens glycaemic variability.¹⁹ Screening for Obstructive Sleep Apnoea (OSA) is important in patients with obesity or resistant hypertension, as untreated OSA elevates HbA1c.²⁰

Cardiovascular conditions

Sleep regulates vascular tone, autonomic balance, and endothelial repair. Disrupted quantity or quality sustains sympathetic activation, elevates nocturnal cortisol, blunts parasympathetic recovery, and cumulatively increases hypertension, atherosclerosis, and arrhythmia risk.²¹

In hypertension, 1-2 hours less sleep can raise systolic pressure 5-10 mmHg. Short or irregular sleep activates the renin-angiotensin-aldosterone system, causing sodium retention and vascular stiffness, impairing nocturnal dipping. Consistent bedtimes, wake-up times, and morning light enhance control.²²

Post-myocardial infarction and coronary artery disease patients experience inflammation, oxidative stress, elevated CRP and IL-6, and delayed endothelial repair from sleep deprivation. Fragmented sleep reduces coronary flow. Addressing sleep hygiene alongside medication adherence, graded exercise, and chronotherapy (timing medications to align with circadian rhythms for optimal effect) supports vascular recovery and reduces fatigue.²¹ In peripheral arterial disease, nitric oxide is reduced and impairs endothelial function, worsening leg pain and delaying wound healing. Encouraging restorative sleep supports microvascular repair and functional recovery.²³

Arrhythmias are exacerbated by disrupted sleep, altering autonomic input to the atria, increasing premature atrial contractions. Potassium and calcium channel expression is affected, raising atrial fibrillation risk. Nurses can address palpitations, stimulant use, and promote consistent sleep-wake patterns.²⁴

In heart failure, disrupted sleep heightens sympathetic drive and norepinephrine, worsening afterload and fatigue. Frequent orthopnoea and nocturia fragment rest. Nurses can adjust diuretic timing, advise positional strategies, and optimise sleep hygiene to support self-management.²⁵

After a stroke, restorative sleep supports neuroplasticity and motor recovery. Sleep deprivation impairs synaptic remodelling, blood pressure control, and raises recurrent risk. Structured daytime activity and regular sleep-wake cycles aid circadian and cognitive recovery.²⁶

Respiratory conditions

In chronic obstructive pulmonary disease (COPD), cycles of nocturnal hypoxia and hypercapnia disturb sleep, contributing to daytime fatigue, cognitive impairment, and systemic inflammation. Fragmented sleep further compromises cardiovascular health and overall disease control. Nurses should assess night-time coughing, wheeze, sleep position, and oxygen saturation patterns. Interventions include elevating the head of the bed, optimising inhaler timing, and reviewing adherence to supplemental oxygen or nocturnal positive airway pressure (CPAP) therapy for coexisting sleep-disordered breathing. Even modest sleep improvements can enhance lung function, reduce exacerbations, and support overall management.²⁷

In asthma, nocturnal airway inflammation causes wheezing, coughing, and airflow limitation, peaking at night due to circadian variation. Reviewing inhaler technique, optimising bedtime dosing, and addressing comorbid sleep apnoea or environmental triggers such as allergens improves sleep quality and asthma control.²⁸

Mental health

Sleep disturbance is both a symptom and a driver of deteriorating mental health. Insomnia and fragmented sleep exacerbate cognitive and emotional dysregulation, impairing attention, memory, and mood stability. Chronic stress or trauma can trigger hyperarousal, leading to dysregulated cortisol and other circadian rhythms, further perpetuating poor sleep. Nurses conducting mental health reviews can play a pivotal role in addressing these interactions. Interventions include promoting consistent sleep-wake schedules, structured wind-down routines, and techniques derived from CBT for insomnia, such as stimulus control and sleep restriction. Advice should be tailored, avoiding generic directives like ‘no screens’ and instead focusing on differentiating stimulating versus passive evening activities. Supporting patients to improve sleep can enhance adherence to pharmacological and psychological therapies, reduce emotional reactivity, and mitigate the long-term burden of mental health conditions, reinforcing overall recovery and quality of life.²⁹

Learning disabilities

Sleep challenges are disproportionately common in people with learning disabilities, but are rarely straightforward. Intrinsic circadian misalignment, poor sleep efficiency, and disordered breathing often interact with environmental and sensory factors. Noise, lighting, textures, and even minor routine disruptions can cascade into several nights of fragmented sleep. Sleep deprivation can masquerade as behavioural or cognitive difficulties, meaning daytime challenges may reflect lost sleep rather than the individual’s capability.³⁰

Nurses can adopt a detective mindset: observing patterns, asking carers not just about bedtimes but sensory triggers, night waking, and subtle cues like restlessness or snoring. Small, tailored adjustments such as dim lighting, predictable cues, noise reduction, or timing meals and activities to align with natural circadian rhythms can bring substantial improvements in sleep and daytime behaviour. Understanding these feedback loops helps shape care: better sleep is not a ‘nice extra’ but a core requirement to support cognition, emotional balance and quality of life.³¹

Menopause and perimenopause

Perimenopause and menopause frequently disrupt sleep, driven by fluctuating oestrogen and progesterone levels, vasomotor instability, and mood changes. Declining oestrogen affects serotonin and thermoregulation, leading to night sweats that fragment sleep, while reduced progesterone diminishes its natural GABA-mediated sedative effect. Melatonin levels, particularly, also decline during perimenopause, further impairing sleep onset and circadian regulation. These hormonal changes contribute to insomnia, restless sleep, fatigue, cognitive fog, and increased cardiovascular and metabolic risk. Nurses conducting reviews can proactively screen for sleep issues during discussions on hormone replacement therapy (HRT) or lifestyle management. Key assessment points include night-time awakenings, frequency and severity of night sweats, sleep quality, and daytime fatigue. Practical advice includes cooling strategies, layered bedding, regular sleep-wake routines, and relaxation techniques such as mindfulness or breathing exercises. Where appropriate, hormone stabilisation via transdermal or oral HRT may dramatically improve sleep quality and reduce associated symptoms. Addressing sleep proactively supports overall wellbeing and mitigates the long-term health consequences of menopausal sleep disruption.³²

SPECIFIC SLEEP CONDITIONS

Obstructive sleep apnoea (OSA) is characterised by loud snoring and witnessed episodes of apnoea, commonly associated with obesity and hypertension. Epworth Sleepiness Scale scores >10 or strong suspicion warrant referral. OSA contributes to cardiometabolic and cognitive complications via intermittent hypoxia and sympathetic activation, mitigated by CPAP therapy.³³38

Restless Legs Syndrome (RLS), or Willis Ekbom disease, is strongly linked to dopaminergic dysfunction, particularly in subcortical motor sensory pathways, interacting with the central autonomic network, regulating sympathetic and parasympathetic activity. Many patients exhibit chronic sympathetic hyperarousal, contributing to insomnia-like symptoms. Iron deficiency should be assessed, as it exacerbates dopaminergic dysfunction.³⁴39 Screening with focused questions and addressing iron deficiency or medication triggers is critical. Stellate ganglion blocks show remarkable potential for treating RLS and show promise across diverse conditions.³⁵

Pain-related sleep disruption triggers hyperalgesia, amplifying nociception and inflammatory responses. Interventions include ergonomic bedding, stretching routines, and optimisation of analgesia. Early identification and targeted interventions in these conditions are critical to prevent downstream physical and psychological morbidity.³⁶

MANAGEMENT APPROACHES

Nurses should review medications that impair sleep, including steroids, beta-blockers, and selective serotonin reuptake inhibitors.³⁷ Supplements demonstrating benefits compared with prescription medications include magnesium glycinate, chamomile, valerian, lemon balm and fennel, passionflower, and hops. Prescribable sedatives aside, in addition to valerian, melatonin carries the most substantial evidence of effectiveness and safety; doses of 0.3-6mg reduce sleep onset latency and improve sleep quality.3810 Current NICE guidance on insomnia explicitly still advises against over-the-counter (OTC) sleep products, and recommends prescribing melatonin only to those over 55,³⁹even though research supports melatonin’s safety and efficacy across all ages.⁴⁰

In acute insomnia, if sleep hygiene advice fails, NICE recommends a short course of a z-drug, usually as a standalone intervention. For chronic insomnia (more than 3 occurrences per week for at least 3 months), NICE suggests referral for Cognitive Behavioural Therapy for Insomnia (CBT-I).³⁹

NICE acknowledges that CBT-I is ‘very rarely available in primary or secondary care’ and that neither sleep hygiene advice nor hypnotics are evidence-based first-line treatments.⁴¹ An alternative is the Sleepio App, but while the introduction of the app may represent a step forward, evidence based on user experience suggests it has some limitations, including low interactivity and insufficient scientific depth.⁴² NICE Sleepio Guidance acknowledges limited evidence comparing Sleepio with face-to-face CBT-I; web-based therapy with a virtual or real therapist outperforms other digital formats, but face-to-face remains superior.⁴¹ Sleepio’s availability on the NHS is currently limited to Scotland, Greater London and six southern counties, via NHS online registration.⁴³

Taken together, and given the prevalence of sleep difficulties,³ the gaps in approved management strategies are concerning. Patients rarely receive evidence-based insomnia care, access to face-to-face CBT-I is extremely limited,⁴¹ and guidance excludes OTC options that could service as legitimate adjuncts.^38,40 Including discussion of these products in consultations may conceivably promote patient autonomy, empowering patients to self-manage their symptoms and help reduce risking the emergence of associated physical and psychological consequences.

WHAT CAN GPNs DO?

• Integrating sleep assessment into routine clinical practice is essential for comprehensive patient care. A simple inquiry, beginning with a ‘2-minute sleep talk’ such as ‘How would you rate your sleep?’, can normalise sleep discussions alongside other health behaviours. Nurses should be vigilant for indicators of sleep disturbances, including daytime fatigue, mood dysregulation, reliance on stimulants, shift work (including rotating or variable day shifts, not just night shifts), and medication side effects.^2,6
• Incorporating a ‘Sleep Quality’ field in electronic health records ensures systematic documentation and facilitates targeted interventions. Engaging patients in conversations about sleep allows for the differentiation between poor sleep and fatigue stemming from illness, stress, or medication. This approach empowers patients to understand the links between sleep and long-term health, fostering a collaborative environment for care.
• Practical interventions can be implemented to improve sleep quality. Recommendations should include advising a consistent wake-up time, even after a poor night’s sleep; exposure to morning light or bright light therapy; avoidance of caffeine after midday, and aligning alarm times with sleep cycles.³
• Sleep isn’t a QOF indicator, likely due to measurement challenges and multifactorial interventions, but assessing it is low-burden and high-impact. A single question can initiate conversations that improve patient outcomes, support preventive care, and enhance satisfaction and engagement.

CONCLUSION

Sleep affects all risk factors nurses assess – weight, glycaemic control, blood pressure, mental health, and more. While clinicians may raise it informally, embedding quick sleep assessments into every chronic disease review ensures frontline preventive care, uncovers hidden contributors to disease and cognitive risk, and enables simple, actionable interventions for better patient outcomes.¹

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