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The Holistic Approach to Insomnia

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Jessica Peeling was a 4th year medical student from UNECOM in Biddeford, Maine on rotation at the Falcon Clinic in Utica, NY. She gave a presentation on "Insomnia" during a luncheon at the office.

Published in: Health & Medicine
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The Holistic Approach to Insomnia

  1. 1. THE HOLISTIC APPROACH TO INSOMNIA JESSICA PEELING OMS IV
  2. 2. FIVE STAGES OF SLEEP Non-REM Sleep: Stage one- Light sleep, easily awakened, lasts up to seven minutes, production of alpha and theta waves Stage two- Also relatively light sleep, brain waves slow with occasional rapid firing called sleep spindles Stage three- Deep sleep, harder to rouse, body repairs muscles and tissues, boosts immune system, delta waves appear Stage four- Continuation of stage three, almost all delta waves and very deep sleep REM Sleep- First cycle happens approximately 90 minutes into sleep, lasts about 10 minutes, heart rate and respiratory rate increase, low voltage, high- frequency waves
  3. 3. DEFINING INSOMNIA • Insomnia - difficulty falling or staying asleep, or with early awakenings -generally occurring 3 or more times a week for at least one month -impairments reported in day-to-day life -occurs despite adequate opportunity and circumstances for sleep -subdivided into short-term, chronic, and “other” insomnia
  4. 4. SHORT-TERM AND CHRONIC INSOMNIA • Short-term insomnia is also referred to as adjustment, stress-related, transient or acute insomnia • Defined as occurring for less than three months • Usually related to an identifiable stressor • Resolves with relief of stressor • Chronic insomnia can be primary, secondary, or comorbid insomnia • Defined as occurring three times a week for three months or greater • Must not be related to inadequate opportunity to sleep or inappropriate sleep environment
  5. 5. INSOMNIA STATISTICS • Over five million office visits per year just in the United States • 69% of primary care patients in the US have insomnia at one point or another • 10% of individuals in the United States suffer from chronic insomnia • Higher prevalence in women • Correlation with poor socioeconomic status and marital issues • 3% of the population have insomnia with a comorbid psychiatric illness
  6. 6. INSOMNIA STATISTICS CONT • 37% of 20-39 year-olds report short sleep duration • 40% of 40-59 year-olds report short sleep duration • 35.3% adults report <7 hours of sleep during a typical 24-hour period • 3–5% of the overall proportion of obesity in adults could be attributable to short sleep • Costs the healthcare system $241 billion annually
  7. 7. SLEEP NECESSITY BY AGE Age Recommended duration of sleep Newborns (0-3 months) 14-17 hours Infants (4-11 months) 12-15 hours Toddlers (1-2 years) 11-14 hours Preschoolers (3-5 years) 10-13 hours School-aged children (6-13 years) 9-11 hours Teenagers (14-17 years) 8-10 hours Young adults (18-25 years) 7-9 hours Adults (26-64 years) 7-9 hours Older adults (>/= to 65 years) 7-8 hours
  8. 8. EFFECTS OF INSOMNIA • Decreased quality of life • Increased fatigue, sleepiness, confusion, depression, anxiety, and tension • Self-reported performance deficit • Increased risk of substance abuse • Hormonally-mediated increase in appetite, linked to increased BMI and obesity • Increased risk of diabetes (curvilinear relationship also) • Increased risk of fatal heart attacks • Increased age-specific mortality BMI vs Average nightly sleep
  9. 9. DIAGNOSIS • Studies have shown that health care providers are asking questions about sleep < 50% of the time • Psychiatric testing for comorbid disorders, Epworth sleepiness scale • Actigraphy • Polysomnography – when obstructive sleep apnea is part of your differential • Keeping a sleep log and sleep diary
  10. 10. STANDARD TREATMENT FOR INSOMNIA AND SIDE- EFFECT PROFILE • Benzodiazepines – Temazepam (Restoril), Flurazepam (Dalmane), Estazolam (ProSom), Triazolam (Halcion) • Nonbenzodiazepine hypnotics – Zolpidem (Ambien), Zaleplon (Sonata), Ezopiclone (Lunesta) • Melatonin agonists – Ramelteon • Antidepressants - Trazodone, Amitriptyline, Doxepin, Remeron • Suvorexant *** new, approved by FDA in 2014 but recently made available to prescribers • Atypical antipsychotics – Quetiapine (Seroquel), Olanzapine (Zyprexa) • OTC Sleep aids – Benadryl, Tylenol PM Most agents cause daytime sleepiness, fatigue, and dizziness Some cause complex sleep-related behaviors, anticholinergic effects, or problems with addiction and dependency
  11. 11. SLEEP HYGIENE
  12. 12. DIETARY AND HERBAL SUPPLEMENTS FOR INSOMNIA
  13. 13. MELATONIN • A hormone that our body makes in the pineal gland • It is the end product of a biosynthetic pathway, starting with tryptophan • The suprachiasmatic nucleus in the hypothalamus controls melatonin production • Controls our circadian rhythm • Production naturally increases with decreasing light • Noctural secretion decreases with age • Most widely studied supplement for insomnia with the most scientific evidence • Very low doses of melatonin have been shown to be just as efficacious as higher doses -Normal physiologic production is only 2-200 pg/ml! Mean serum melatonin profiles of 20 subjects sampled at intervals after ingesting 0.1, 0.3, 1.0, and 10 mg of melatonin or placebo at 11:45 am
  14. 14. TRYPTOPHAN • L-tryptophan is an essential alpha amino acid present in concentrations of 1-2% in plant and animal proteins • It is converted to 5-HTP and then to Serotonin • Melatonin is made from tryptophan • It can penetrate the blood brain barrier and has sedative effects • Common dose is 2-5 g/day • Preliminary clinical research shows decreased sleep latency and improvement in total sleep time • Can exacerbate eosinophilia, kidney, or liver dysfunction
  15. 15. VALERIAN • Valeriana officinalis – a perennial herb that is native to Asia and Europe • Applicable portion is the root • Valerian root contains as many as 150 compounds, including valepotriates, volatile oils, and valerenic acid • May potentiate and inhibit GABA A receptors and Adenosine A receptors • Poorly absorbed with large first-pass metabolism • Common dose is 200-600 mg/day • Has many studies with a large number of participants showing efficacy with improvement of sleep • Meta-analysis of 1,093 patients taking Valerian for sleep studied in 2006, and 1,317 studied in 2011 • Same efficacy as benzos??
  16. 16. CHAMOMILE • Matricaria recutita – an herb that is native to Germany • Applicable portion is the flowerhead, which contains apigenin • Has sedative properties • Many potential hypotheses for mechanism of action • Common dose is 200-300 mg/day • Recent study showing efficacy in 2011, based on fatigue severity schedule • Animal studies show that small doses help with anxiety, large doses with insomnia • May have estrogenic effects and reduces creatinine output
  17. 17. LEMON BALM • Melissa officinalis – a perennial herb and member of the mint family native to Europe • Applicable potions are the leaf and the leaf oil • Contains citronellal, neral, and geranial monoterpenoid aldehydes; flavonoids (including luteolin) and polyphenol compounds • Has sedative effects • Often sold in combination with Valerian, studies have done on this combination • Very few studies on the efficacy of lemon balm alone • Common dose is 500-1000 mg/day • Interactions with sedatives and thyroid medications
  18. 18. KAVA • Piper methysticum – a perennial plant, native to Pacific islands • Has sedative properties • Many hypotheses for mechanism of action • Also studied as an anxiolytic • Rhizome, root, and stem are the active portions • Pharmacological activity has largely been attributed to kavalactones (also known as kavapyrones) • Common dose is 100-300 mg/day • Avoid with liver disease, Parkinson's disease, a history of medication-induced extrapyramidal effects, and chronic lung disease
  19. 19. OSTEOPATHIC CRANIAL MANIPULATION Cutler MJ, Holland BS, Stupski BA et al Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. -University of North Texas Health Science Center, Fort Worth, TX -20 volunteers, 12 males, 8 females ages 22-35 • Compression of the fourth ventricle (“a technique in which the lateral angles of the occipital squama are manually approximated, taking the cranium into sustained extension and obtaining a still point”) • Sleep latency was assessed using standard Multiple Sleep Latency Test protocol, directly recorded efferent muscle sympathetic nerve activity was recorded • Sleep latency and sympathetic activity were decreased with the CV4 technique, as compared to sham treatment and placebo Patients may exhibit decreased CRI, cranial dysfunction, increased sympathetic tone or sacral dysfunction on osteopathic structural examination
  20. 20. COGNITIVE BEHAVIORAL THERAPY • Psychoeducation about sleep hygiene • Sleep restriction therapy • Stimulus control instructions – full evaluation of sleep habits and environment • Encouragement to avoid planning until out of bed, keeping sleep logs • Identify and modify sleep-interfering thoughts through discussion of sleep diary • Relaxation training • Finally, relapse prevention • Over 70% of patients shown to have lasting benefit in insomnia through CBTi • New online programs also available for utilization in rural or underserved areas “Sleepio” and “SHUTi” • Books for CBTi to suggest to patients – “Say Goodnight to Insomnia”, “Quiet your Mind and Get to Sleep”
  21. 21. ACUPUNCTURE AND ACUPRESSURE • Commonly used in China to treat insomnia • Regulating yin and yang to reinforce health • Acupuncture Increases y-amino butyric acid • 2009 meta-analysis of 46 randomized trials of 3,811 men and women showed a statistically significant benefit in symptoms of insomnia with acupuncture • Research shows some benefit of Acupressure point pressure- therapy
  22. 22. EFFECTS OF AROMATHERAPY ON SLEEP • The linalool component of lavender inhibits sympathetic nervous system activity and heightens parasympathetic nervous system activity • Most recently a study looked at 60 coronary ICU patients -Inhalation of 2% lavender essential oil for 15 days -Measured with Pittsburgh Sleep Quality Index and Beck Anxiety Inventory • Santalol, in sandalwood, has been showing to improve total waking time and NREM sleep in animal studies
  23. 23. FOODS THAT PROMOTE HEALTHY SLEEP
  24. 24. RESOURCES • Baddeley, J. L., PhD., & Gros, D. F., PhD. (2013). Cognitive behavioral therapy for insomnia as a preparatory treatment for exposure therapy for posttraumatic stress disorder. American Journal of Psychotherapy, 67(2), 203-14. • Effects of Inhalation Aromatherapy on Symptoms of Sleep Disturbance in the Elderly with Dementia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5376423/ • Rosick, ER. The Use of Supplements, Herbs, and Alternative Therapies in the Treatment of Insomnia. Osteopathic Family Physician (2014)2, 14-18 • Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem https://www.ncbi.nlm.nih.gov/books/NBK19961/ • https://www.sleepassociation.org • https://www.psychiatry.org • National Sleep Foundation’s Sleep Time Duration Recommendations: Methodology and Results Summary http://www.sleephealthjournal.org/article/S2352-7218(15)00015-7/pdf • https://naturalmedicines-therapeuticresearch-com • Cutler MJ et al., Cranial manipulation can alter sleep latency and sympathetic nerve activity in humans: a pilot study. J Altern Complement Med. 2005 Feb;11(1):103-8 • https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html • Up-to-Date: Treatment of insomnia in adults, Physiology and available preparations of melatonin, Clinical features and diagnosis of insomnia in adults • https://www.acupressure.com • http://koya.nyit.edu/Clinical_Applications/clinical_docs/Family_Medicine_Insomnia.pdf

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