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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

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Page 1: Sleep, Naturally
Page 2: Sleep, Naturally

Sleep, NaturallySleep, 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

Kathi J Kemper, MD, MPH, FAAP

Caryl Guth Chair and Director of the Center for Integrative

MedicineWake Forest University School

of MedicineWinston-Salem, NC

Page 3: Sleep, Naturally

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.

Page 4: Sleep, Naturally

ObjectivesObjectives 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

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

Page 5: Sleep, Naturally

5 Fundamentals: Healthy Habits in a Healthy Habitat

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

1. Food2. Fitness3. Friendship with self

(stress and emotional self-management)

4. Friendship with others (nurturing relationships)

5. Fields: Environment

Page 6: Sleep, Naturally

Healthy Habits, Healthy Habitat

Healthy Habits, Healthy Habitat

Food

FitnessManage

Stress

Relationships

Page 7: Sleep, Naturally

1. Food as Medicine1. Food as Medicine

Page 8: Sleep, Naturally

1. Food: Nutrition for Sleep1. 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)

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)

Page 9: Sleep, Naturally

1. Food: essential nutrients for optimal

brain function

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)

Omega-3 fatty acids Amino acids (SAM-E,

Trp, 5-HTP) Vitamins (B vitamins,

Vitamin D) Minerals (Iron,

Calcium, Magnesium, Zinc)

Page 10: Sleep, Naturally

Top Foods (scores > 90/100)Top Foods (scores > 90/100)

Broccoli Green cabbage

Oranges TomatoGreen Beans ClementinePineapple WatermelonRadish MangoSummer Squash NF MilkApple FigsGrapes Bananas

Broccoli Green cabbage

Oranges 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

Page 11: Sleep, Naturally

2. Fitness: Activity/Exercise2. 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

30 -60 minutes of vigorous exercise earlier in day

NO vigorous exercise within 2 hours of bed

Gentle stretching, yoga, Tai Chi is OK

Page 12: Sleep, Naturally

3. Friendship with self (manage stress and

emotions)

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

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

Page 13: Sleep, Naturally

3. Stress management: Meditation

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

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

Page 14: Sleep, Naturally

Stress, Emotion, and Physiological Activation

High Arousal/High EnergySYMPATHETIC

PARASYMPATHETIC

Low Arousal/Low Energy

Institute of HeartMath

Page 15: Sleep, Naturally

Stress, Emotion, and Physiological Activation

High Arousal/ High EnergySYMPATHETIC

PARASYMPATHETIC

Low Arousal/

Low Energy

Negative

Emotion

Positive

Emotion

“Fight-or-Flight”

Page 16: Sleep, Naturally

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

Page 17: Sleep, Naturally
Page 18: Sleep, Naturally

Stress management: biofeedback

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

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

Page 19: Sleep, Naturally

Stress Management: Compassion

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

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

Page 20: Sleep, Naturally

Supportive relationshipsSupportive relationships Don’t go to bed mad (or

sad or worried) Social support protects

mental health Rx: spend time with

friends Volunteer – those who help

others feel better about themselves; mentor, tutor, coach, babysit

Join clubs, leagues, scouts, church

Don’t go to bed mad (or sad or worried)

Social support protects mental health

Rx: spend time with friends

Volunteer – those who help others feel better about themselves; mentor, tutor, coach, babysit

Join clubs, leagues, scouts, church

Page 21: Sleep, Naturally

Healthy habitat: Sleep environment

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

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

Page 22: Sleep, Naturally

Sleep hygieneSleep hygiene

Daytime routines Exercise Light Healthy diet Good relationships

Bedtime habits

Daytime routines Exercise Light Healthy diet Good relationships

Bedtime habits

Page 23: Sleep, Naturally

Bedtime habitsBedtime 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

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

Page 24: Sleep, Naturally

ExtrasExtras

Supplements Massage Acupuncture Electrotherapy

Supplements Massage Acupuncture Electrotherapy

Page 25: Sleep, Naturally

MelatoninMelatonin 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

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

Page 26: Sleep, Naturally

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

passion flower)

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

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

Page 27: Sleep, Naturally

Amino Acids: TRYP, SAM-EAmino 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)

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)

Page 28: Sleep, Naturally

MassageMassage 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

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

Page 29: Sleep, Naturally

AcupunctureAcupuncture

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)

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)

Page 30: Sleep, Naturally

2009 meta-analysis Acupuncture

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.

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.

Page 31: Sleep, Naturally

Electrosleep (Cranio-electrotherapy

stimulation)

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

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

Page 32: Sleep, Naturally

SMART Action plansSMART Action plans

Specific, Measurable Achievable Relevant Time-specific)

Specific, Measurable Achievable Relevant Time-specific)

Page 33: Sleep, Naturally

Pick a specific strategyPick 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

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

Page 34: Sleep, Naturally

Identify a small, achievable step

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)

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)

Page 35: Sleep, Naturally

How important is this to you?

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!

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!

Page 36: Sleep, Naturally

How confident are you that you can do this for

one month?

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!

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!

Page 37: Sleep, Naturally

Identify Pros and ConsIdentify Pros and Cons

  PRO CON

Change 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

Page 38: Sleep, Naturally

Plan celebrations/rewardsPlan 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).

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).

Page 39: Sleep, Naturally

Sample behavior diary (OK to copy)

Sample behavior diary (OK to copy)

Goal                

Sample: M T W Th Fri Sa Su Total

Walk dog 5 minutes 5 days a week √   √ √ √ √   5

Week 1                

Week 2                

Week 3                

Week 4                

Re-evaluate.Celebrate.Next steps?

Page 40: Sleep, Naturally

SUMMARYSUMMARY 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

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

Page 41: Sleep, Naturally

More resourcesMore 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

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