Sleep difficulties are the most frequent complaints in adults with tinnitus—from onset to several years after. Sleep difficulties reported by people with tinnitus range from 28% in population-based studies 1 and up to 80% in clinical samples. 2,3 This is not surprising since even the mildest tinnitus can be heard in quiet environments, such as in the bedroom.
Indeed, falling asleep was the most frequently mentioned difficulty in a survey among members of a tinnitus self-help association. 4 Sleep complaints can include delayed sleep, disrupted sleep (awakening during mid-sleep and early morning), and fatigue. Nearly half of patients report sleep disturbances as a persistent problem five years after their first visit to the clinic 5 and worsening sleep quality in those with chronic tinnitus. 6 Moreover, more severe sleep complaints are correlated with greater tinnitus severity, 7–10 especially in the evening 11 and during the night. 12 In turn, poor sleep quality before the onset of tinnitus may increase the perceived severity of tinnitus at onset. 13 In sum, poor sleep remains an important comorbidity long after tinnitus onset and beyond the period of care by professionals.
CONSEQUENCES OF POOR SLEEP
Healthy sleep, generally defined as sleep of adequate duration, quality, timing, and regularity, plays a fundamental role in physical, cognitive and mental health. Adults aged 18-64 years should get 7-9 hours and those 65 years and older should get 7-8 hours of good quality sleep on a regular basis, with consistent bed and wake-up times. 14 Unequivocal evidence shows that insufficient sleep on a chronic basis is associated with a wide range of adverse health outcomes. Lack of sleep, poor sleep efficiency (time to fall asleep, waking after sleep onset), and low sleep satisfaction/quality can have short- and long-term consequences linked to altered mental (anxiety, depression), cognitive (memory, learning), and physical health (metabolic syndrome, diabetes/impaired glucose metabolism, hypertension, coronary heart disease).
Sleep loss and poor sleep quality have increased worldwide with the emergence of COVID-19, 15 especially among individuals with a preexisting vulnerability to stressors. 16 This is particularly worrisome for individuals with tinnitus, as tinnitus has been linked with abnormal stress reactivity and mental disorders. 17–19 Indeed, individuals with tinnitus have in 2020-2021 experienced greater stress load 20–22 along with tinnitus 23 and worsening sleep. 24 Notwithstanding the COVID-19 pandemic, individuals with tinnitus are exposed to an increased risk of deleterious health outcomes on the long term, over and beyond their tinnitus severity, when their poor sleep status remains undocumented or mismanaged by hearing care professionals. Improving sleep, therefore, should be a priority for clinicians working with this population.
EFFECTS OF INTERVENTIONS
If we “treat” tinnitus, or more precisely manage it, do we improve both tinnitus severity and sleep complaints? Surprisingly very little data are available to answer this question, and the level of evidence is not very high. Two studies investigating the therapeutic effect of counseling with and without sound therapy 25,26 reported improved tinnitus severity and sleep complaints, as did another study investigating the benefits of being fitted with hearing aids. 27 Likewise, targeting either sleep or tinnitus seems to improve tinnitus or self-reported sleep quality. In one study, participants used bedside sound generators for three to 14 weeks and reported improved sleep (tinnitus severity was not assessed). 28 In another study, tinnitus individuals were exposed to sound therapy for ~3 months and those using tinnitus-matched, in-ear customized devices or noise stimuli had improved tinnitus severity over those using bedside sound generator (sleep parameters were not assessed). 29 Using the sleep-inducing drug melatonin, both tinnitus severity and sleep complaints were improved in another study. 30 In a nutshell, there is some low-level evidence that managing tinnitus or sleep in general might improve sleep and/or tinnitus. However, exactly which aspect of sleep (falling asleep, staying asleep, or overall sleep quality) is improved remains unknown.
ASSESSMENT, FOLLOW UP OF SLEEP COMPLAINTS
Clinical guidelines for tinnitus such as the American Speech-Language Hearing Association 31 or the European 32 guidelines recommend using validated questionnaires to assess tinnitus severity. The Tinnitus Reaction Questionnaire, 33 Tinnitus Handicap Inventory, 34 and Tinnitus Handicap Questionnaire 35 have one question each on sleep while the Tinnitus Functional Index (TFI) 36 has three. Although this can serve as an initial indication of sleep problems, one or a few questions do not provide enough detailed information to be useful on the nature of sleep difficulties or for the follow-up of patients. Validated questionnaires targeting sleep more specifically that are quickly administered could, therefore, be used to this purpose.
The Insomnia Severity Index is a seven-item questionnaire assessing perceived severity of insomnia over the past month. 37 It measures difficulties falling asleep, ability to maintain sleep and early morning awakenings, sleep dissatisfaction, and impact of sleep difficulties on daytime functioning. The total score varies between 0 and 28. There are also useful severity categories: absence of insomnia (score of 0-7), subthreshold insomnia (score of 8-14), moderate insomnia (score of 15-21), and severe insomnia (score of 22-28). A score of ≧8 is an indicator of significant sleep difficulties.
Another validated instrument is the Pittsburgh Sleep Quality Index, 38 which assesses subjective sleep quality retrospectively over the past month. A single global index can be obtained from its 19 items, and three domains can be clustered to describe subjective sleep reports more accurately: 1) sleep efficiency, 2) perceived sleep quality, and 3) daily disturbances. A global score of >5 is a sensitive and specific measure of poor sleep quality.
These two questionnaires are sensitive, valid outcomes to measure improvement (or lack thereof) after intervention. In sum, using the right tools has the potential to a) improve the impact of hearing clinicians in their intervention and follow up of patients, and b) help them decide when to refer patients to sleep specialists or medical doctors for more precise diagnosis or intensive support.
COUNSELING TINNITUS PATIENTS
Tinnitus guidelines and experts recommend that sleep disturbances should be explicitly addressed during counseling. 32 Counseling on sleep hygiene should be given since aside from tinnitus, sleep disruptions can happen for many reasons. Before considering any pharmacological approach or cognitive behavioral therapy, basic advice can be recalled to patients reporting poor sleep. They can be summarized as follows:
- Create a consistent bedtime routine.
- Make your bedroom a haven for sleep (e.g., sleep on comfortable mattress, maintain a cool and dark bedroom).
- Establish a positive association between your bed and sleep.
- Avoid bright light exposure in the evening and night.
- Watch your caffeine, nicotine, and alcohol intake.
- Be mindful of what you eat before sleep.
- Try to exercise regularly.
- Stay awake during the day.
- Take some time to relax.
Clinicians should take time to discuss modifiable lifestyle factors with their patients such as caffeine consumption, drinking alcohol in the evening, drug abuse, and so on. Advice regarding sound enrichment should be approached as well, such as using a fan or a bedside sound generator, provided this does not disturb their sleeping partner. In addition, more advanced sleep hygiene instructions derived from the cognitive behavioral therapy for insomnia can be stressed since this is a recognized therapeutic option for insomnia 39 as well as for tinnitus. 40 The recommendations are aimed at reassociating the bed, bedroom, and bedtime stimuli with sleep rather than with the frustration and anxiety associated with sleeplessness (Table). The Canadian 24-Hour Movement Guidelines for Adults 41 offer useful information about physical activity, sedentary behavior, and sleep. Valuable resources for patients can be found on websites such as those of the American Academy of Sleep medicine, https://aasm.org/clinical-resources/patient-info/, the Canadian Sleep Network, https://www.cscnweb.ca/material-for-patients-and-the-public, and the Sleep on It Campaign, https://sleeponitcanada.ca/.
Management of sleep complaints in tinnitus remains an unmet therapeutic challenge. Yet, sleep problems are one important factor that will prompt tinnitus individuals to seek help for their tinnitus in comparison to those who will not, 42 and lack of sleep is among the factors clearly identified as aggravating among tinnitus patients. 43 Poor sleep can entail important consequences on both overall health and tinnitus severity.
Acknowledgement: Julie Carrier, PhD, and Victoria Duda, PhD, Université de Montréal, Montreal, Quebec, Canada, contributed to this article.
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