Sleep, Naturally

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Sleep, Naturally. Kathi J Kemper, MD, MPH, FAAP Caryl Guth Chair and Director of the Center for Integrative Medicine Wake Forest University School of Medicine Winston-Salem, NC. Faculty Disclosure Information - PowerPoint PPT Presentation

Transcript of Sleep, Naturally

Page 1: Sleep, Naturally
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Sleep, Naturally

Kathi J Kemper, MD, MPH, FAAP

Caryl Guth Chair and Director of the Center for Integrative

MedicineWake Forest University School

of MedicineWinston-Salem, NC

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Faculty Disclosure Information

In the past 12 months, I have had the following financial relationships

with the manufacturer of commercial product(s) and/or provider(s)

of commercial service(s) discussed in this CME activity:

Author of Mental Health, Naturally, published by the AAP in 2010.

The presentation will include no description of any proprietary items for screening, diagnosis,

or treatment.

I do not intent to discuss an unapproved/investigative use of a commercial

product/device in my presentation.

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Objectives By the end of this

presentation, you will be able to Identify the fundamentals

for healthy sleep Describe the evidence

regarding safety and effectiveness of dietary supplements, melatonin, massage, and acupuncture

Use evidence-based resources to counsel patients to make optimal behavior changes to improve sleep

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5 Fundamentals: Healthy Habits in a Healthy Habitat

1. Food2. Fitness3. Friendship with self

(stress and emotional self-management)

4. Friendship with others (nurturing relationships)

5. Fields: Environment

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Healthy Habits, Healthy Habitat

Food

FitnessManage Stress

Relationships

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1. Food as Medicine

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1. Food: Nutrition for Sleep Eat well earlier in day Avoid:

Big, heavy meals late Caffeine (guarana, watch the

chocolate) Alcohol

Bedtime snack: Protein (tryptophan) + carb snack (milk, peanut butter and crackers)

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1. Food: essential nutrients for optimal

brain function Omega-3 fatty acids Amino acids (SAM-

E, Trp, 5-HTP) Vitamins (B

vitamins, Vitamin D) Minerals (Iron,

Calcium, Magnesium, Zinc)

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Top Foods (scores > 90/100)Broccoli Green

cabbageOranges TomatoGreen Beans ClementinePineapple WatermelonRadish MangoSummer Squash NF MilkApple FigsGrapes BananasYale’s Griffin Prevention

Research Center, 2008

“Eat food. Mostly plants. Not too much.” M. Pollan. FOOD RULES

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2. Fitness: Activity/Exercise

30 -60 minutes of vigorous exercise earlier in day

NO vigorous exercise within 2 hours of bed

Gentle stretching, yoga, Tai Chi is OK

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3. Friendship with self (manage stress and

emotions) Stress is common Stress makes it hard to sleep Managing stress: exercise,

sleep, nutrition, mind/emotion/body/spirit Meditation Biofeedback Hypnosis, guided imagery,

inspiring stories, prayer, time in nature, CBT, artistic endeavors

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3. Stress management: Meditation Meditation training ↑ left-sided

anterior activation, a pattern associated with positive affect, in meditators compared with the non-meditators

Positive effects on sleep for meditation and meditative movement (yoga)

Few side effects; can combine mindfulness with CBT

Davidson RJ Psychosom Med, 2003Britton WB. Psychosom Med, 2010

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Stress, Emotion, and Physiological Activation

High Arousal/High EnergySYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Institute of HeartMath

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Stress, Emotion, and Physiological Activation

High Arousal/ High EnergySYMPATHETIC

PARASYMPATHETIC

Low Arousal/

Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”

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Stress, Emotion, and Physiological Activation

High Arousal/High Energy

Low Arousal/Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”Frustration, Anger, Hostility,

Fear, Worry Anxiety

Judgment, Resentment,Feeling Overwhelmed, Anguish

Hopelessness, Submission,Despair, Depression

Burnout, Withdrawal,

Boredom, Apathy

Exhilaration, Passion,

Love, Care,

Joy, Happiness

Kindness, Appreciation

Compassion, Tolerance,Acceptance, Forgiveness

Serenity, Inner Balance,

Reflection, Contentment

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Stress management: biofeedback HRV biofeedback: useful adjunct for anxiety,

depression, pain – all adversely affect sleep “biofeedback and paradoxical intention are

individually effective therapies in the treatment of chronic insomnia “Board of Directors of the American Academy of Sleep Medicine

Significant improvements in sleep, even in combat

McLay RN, Appl Psychophysiol Biofeedback. 2009Morgenthaler T. Sleep, 2006

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Stress Management: Compassion

Extend good will to self or another:

May you be safe and secure May you be healthy and

comfortable May you be peaceful and

content May you have good friends May life go easily for you

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Healthy habitat: Sleep environment

Bright light in early morning Sleeping room DARK (watch

night lights, electric clocks, computer screens), cool, comfortable

Turn off TV an hour before bed Quiet, white noise, or relaxing,

soothing (NOT dance along or sing along) music

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Sleep hygiene

Daytime routines Exercise Light Healthy diet Good relationships

Bedtime habits

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Bedtime habits Regular time; Routine Hot bath; cool, dark room; Massage before bed Lavender, chamomile, melatonin? 5-

HTP? Valerian? No caffeine within 8 hours of bedtime Music, calm, orderly, quiet NO TV IN BEDROOM NO vigorous exercise right before bed GET MORE versus intentional sleep

reduction/deprivation Aim for earlier; enough to awaken

refreshed

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Extras

Supplements Massage Acupuncture Electrotherapy

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Melatonin Hormone, not herb Helpful for sleep onset insomnia

in ADHD (Bendz, LM. Ann Pharmacother, 2010) Can use for sleep EEG or

brainstem audiometry (Ashrafi MR, Eur J Paediatr Neurol, 2010; Schmidt CM. Neuropediatrics, 2007)

Dose: 0.3 – 3mg 1-2 hours before bed

Products: ConsumerLab.com

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Sedative herbs: valerian, chamomile, hops, lemon balm,

passion flower) Valerian: yes 400 mg; smells bad, but works (Morin CM, Sleep, 2005; Koetter U. Phytother Res, 2007; Bent S. Am J Med, 2006)

Chamomile tea; little data, generally safe, allergies possible

Hops: sleep pillow and teas; sometimes combined with valerian

Lemon balm; tea Passionflower: tea

Meolie AL. J Clin Sleep Med, 2005

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Amino Acids: TRYP, SAM-E Acute tryptophan depletion leads to depression Dietary L-tryp -> 5-HTP -> serotonin -> melatonin Meta-analysis: 5-HTP and L-tryp better than placebo for

depression (Shaw K, Cochrane. 2002) DB Xover trial in infants; cereal supplemented with 225

mgtryp improved sleep Food sources – dairy, eggs, poultry, soy, nuts; WHEY

Cubero J. Nutr Neurosci, 2009

SAM-E Produced from ATP and methionine Meta-analysis: SAMe significantly improves depression,

comparable to antidepressant medications ; effects on SLEEP are indirect via mood

(http://www.ahrq.gov/clinic/epcsums/samesum.htm)

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Massage Decreases itch, pain, anxiety,

depression; and improves sleep (Field T, multiple years and pubs)

Can be done by parents Previously provided by nurses Found in many nurseries Licensing for professionals

varies by state

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Acupuncture

Tiny needles, needles not always necessary (pressure, massage, laser, magnets, cupping)

Acceptable for kids with proper demo (model on parents )

Meta-analysis of 46 trials: significant benefit (Cao H. JACM, 2009)

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2009 meta-analysis Acupuncture

46 RCTs with 3811 patients Meta-analyses showed a beneficial effect of acup

compared with no treatment (p = 0.02; 4 trials) and real compared with sham acup(p = 0.04; 2 trials) on Pittsburgh Sleep Quality Index.

Acup superior to medications for total sleep duration increased for >3 hours (p < 0.0001).

Acupuncture plus medications better than med alone on total sleep duration (p < 0.0001).

Acup + herbs better than herbs alone (p = 0.01). There were no serious adverse effects related to

acupuncture treatment in these trials.

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Electrosleep (Cranio-electrotherapy

stimulation) TENS-like device applied to earlobes or

occiput bilaterally Invented in USSR 1949 Most studies in Russia and France Can help with insomnia, even anxiety,

depression or those going thru drug withdrawal (Philip P. Biol Psych, 1991; Gomez E, Br J Psychiatry, 1979;Templer DI. Can Psychiatry Assoc J, 1975; Carwright RD. J Nerv Ment Dis, 1975)

No RCTs in children No serious adverse effects reported

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SMART Action plans

Specific, Measurable Achievable Relevant Time-specific)

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Pick a specific strategy More exercise early in day Better nutrition Judicious use of supplements Healthier environment Stress management;

biofeedback; journal; meditation

Massage, psychotherapy, acupuncture or other professional help

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Identify a small, achievable step

Rome was not built in a day; habits are not changed overnight: BABY STEPS.

For exercise, go from sedentary, to 5 minute walks with the dog 5 days a week.

Be specific (with or without an MP3 player; with or without a friend; regardless of weather?; distance vs. time)

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How important is this to you?

0 1 2 3 4 5 6 7 8 9 10Not Very

Why did you pick that number and not a lower number? (e.g. a 7 instead of a 5)

Asking this question helps the patient/family provide their own rationale for why this is important. They talk themselves into it!

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How confident are you that you can do this for

one month?0 1 2 3 4 5 6 7 8 9 10Not Very

If they pick an 8 or higher (pretty confident), proceed with next step of making a chart and

planning rewards and follow-up.

If they pick a number less than 8, “What would it take for you to go from the number

you picked to a higher number?” Begin to explore their ambivalence…. It’s OK to be ambivalent

about change!

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Identify Pros and Cons

  PRO CONChange More cheerful Change routine

 More fit and cool Brother might tease

 Clothes fit better Yucky dog clean up

  Better sleep  

  

No Change Easy Continued mood probs

 Mom does yucky job Get fat

   Feel ugly

    Sleep badly

   Unhappy with myself

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Plan celebrations/rewards Pick a tangible reward and timing

(will it be offered after week 1, 2, 3, 4?)

Samples: new walking shoes; stickers; choice of movie.

Support the patient’s choices. Emphasize the importance of the

reward/celebration. If the patient says they expect “good” behavior, suggest they consider celebrating it (instead of rewarding it).

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Sample behavior diary (OK to copy)

Goal                Sample: M T W Th Fri Sa Su TotalWalk dog 5 minutes 5 days a week √   √ √ √ √   5Week 1                Week 2                Week 3                Week 4                

Re-evaluate.Celebrate.Next steps?

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SUMMARY Focus on fundamentals: food (watch caffeine,

alcohol, xs meals; bedtime snack?);fitness; friendship with self (manage stress and emotional states); friendship with others; healthy environment

Routines at bedtime; no TV in bedroom Supplements: melatonin, valerian/hops;

lavender aromas; chamomile, lemon balm tea Massage, acupuncture, electrosleep Make a SMART plan consistent with family

values and goals; follow-up

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More resources Mental Health, Naturally www.wfubmc.edu/cim

Action Plan Trackers for Change ・ Pros and Cons of Change Worksheet ・ Action Plan Tracker for Successful Change

for One Week ・ Action Plan Tracker for Successful Change

for Four Weeks Action Plan Tracker for Several Changes