Insomnia (Sleeplessness) Diagnosis and Treatment: Help for a Better Night’s Sleep by Mahmood Rana, MD

“Laugh and the world laughs with you; snore, and you sleep alone!”
-Anthony Burgess

Modern society as a whole is chronically sleep deprived. Since Edison gave us light, our waking hours are no longer tied to natural rhythms of daylight and darkness.

In a given 30 days period, almost half of Baby boomers say that they are not getting enough sleep for between 1 and 13 nights.

Most people know the frustration an occasional poor night of sleep can bring, when “counting sheep” does little to offer relief. However, for 35-50% of the American general adult population annually, this condition is more chronic in nature and is diagnosed as insomnia.

Insomnia is defined as a difficulty falling or maintaining sleep (the latter being more common) that lasts for at least one month and causes significant daytime impairment. Such individuals usually suffer fatigue, difficulty concentration, irritability, day time sleepiness, and headaches. There may also be frequent awakening episodes with difficulty returning to sleep after awakening, or awakening too early with inability to return to sleep, despite adequate opportunity to sleep. Overall, it is one of the most prevalent health conditions and more common in females, the older population (over 60 years of age), and among African Americans.

It is subdivided into Primary (not caused by underlying psychiatric or medical condition, or substance abuse) or Secondary (due to another medical or psychiatric condition such as depression or another sleep disorder).

35 – 44% of individuals presenting to a sleep specialist may have an underlying secondary cause for their insomnia, emphasizing the need to screen for these conditions. Causes of secondary sleeplessness include:
• Anxiety
• Arthritis
• Acid reflux
• Asthma
• Congestive heart failure
• Depression
• Fibromyalgia
• Hyperthyroidism
• Medications
• Menopause
• Migraine
• Pain
• Restless leg syndrome
• Sleep apnea
• Stroke
• Skin condition causing itching
• Urinary incontinence
• Unusual sleep behavior (sleep walking)

Additionally, there are several medications or substances that may disturb sleep, including: alcohol, caffeine, chemotherapy agents, diuretics, illicit drugs, nicotine (tobacco), pseudoephedrine (common in decongestants), steroids, and stimulant laxatives.

If you are a frequent binge drinker, insomnia may not be the worst of your problems, but a new study finds that for older people there appears to be a clear link between the two. The researchers found that adults 55 and older who binged on average more than two days a week had an 84 percent greater odds of reporting an insomnia symptom compared to non-binge drinkers.

“It was somewhat surprising that frequent binge drinking (more than 2 binge drinking days per week, on average) but not occasional binge drinking (more than zero, but less than 2 binge drinking days per week, on average) had a significant association with self-reported insomnia symptoms,” said lead author Sarah Canham, PhD, postdoctoral fellow in Drug Dependence Epidemiology, John Hopkins University, Bloomberg School of Public Health, Department of Mental Health in Baltimore, MD.

The research abstract was published recently in an online supplement of the journal SLEEP, and Canham presented the findings Monday, June 3rd, in Baltimore, MD at SLEEP 2013, the 27th annual meeting of the Associated Professional Sleep Societies, LLC.

Environmental factors that may adversely affect sleep include:

• A bedroom environment with too many stimuli. Temperature that is too cold or hot, bright light, noise, and pets can impact quality of sleep.
• Snoring of a partner can be disruptive.
• Unusual sleep time, such as night or rotating work shifts, and travelling across multiple time zones, can affect sleep.
In order to evaluate this condition, it is recommended to keep a sleep diary to record time going to bed and waking up, time taken to fall asleep (abnormal if taking more than 30 minutes to initiate sleep, the number and duration of awakening episodes, and the percentage of time spent in bed sleeping (for this component, normal sleep efficiency is defined as more than 85%).
The good news is that there are several steps those suffering from insomnia can take, including behavioral techniques and medications.
• Better Sleep hygiene: go to sleep and wake up at the same times each day despite having a sleepless night the day before, avoid stimulant ( caffeine – no more than 2 cups per day, avoid smoking, avoid narcotics ), limit alcohol intake to 1 drink per day, avoid day time naps, and schedule regular exercise preferably 4-6 hours prior to sleep. It is also recommended to keep one’s bedroom dark and quiet.
• Changing sleep behavior: use the bedroom for sleep only, no watching TV, reading books, talking on phone, etc. If unable to sleep for 10-20 minutes, leave the bedroom and return when feeling sleepy only. Setting the alarm for wakeup at a regular time every day and refraining from using the snooze button are also recommended.
• Relaxing training: set aside a time to relax before bed to use relaxation techniques. It helps to reduce muscle tension, and should be accompanied by paced breathing (slow inspiration and prolonged expiration) for maximum effectiveness.
• Cognitive therapy: challenge and replace dysfunctional beliefs (such as an apprehensive belief that sleep can not be controlled) with positive affirmations involving sleep.
• Light therapy – this technique uses artificial light to adjust and regularize the biological clock

Prescription Medications should be avoided and considered as a last resort. These should be prescribed for as minimum a time period as possible to help regulating sleep cycle, or to address an underlying medical condition after careful review by a health care provider and under his or her supervision. These medicines carry potential hazards and side effects. After careful review, the doctor may decide to choose a medicine from an appropriate group.

Common medication groups for sleeplessness are: Benzodiazepines such as Ativan (Lorazepam), Restoril (Temazepam), Halcion (Triazolam); Non Benzodiazepines such as Ambien and Lunesta; Antihistimine drugs including Benadryl, Unisom, and Vistaril; and Antidepressants for sleeplessness including Amitryptiline, Trazodone, Mirtazepine (Remeron). Anti-seizure medicine as Neurontin is also prescribed sometimes to assist with sleep. Sedating Antipsychotics such as Seroquel at times are also used as sleep aids.

There are several natural or over the counter remedies to consider. Herbs and Natural Supplements such as Melatonin and Valerian root are also utilized to improve sleep. Melatonin is a hormone naturally secreted during the night which generally benefits sleep initiation but not maintenance. Derivatives of the Valerian root are often used by some to treat anxiety and promote sleep. Anthihistimines, as mentioned previously, can be effective alone or in combination with an over the counter pain reliever, such as Tylenol.

It is important to partner with one’s Primary Care Physician to evaluate and treat insomnia, especially if an underlying medical condition is part of the cause. Through a combination of behavioral and/or medication therapies, individuals with insomnia will be on the right path towards a good night’s sleep.

Mahmood Rana, MD is a Primary Care Physician with Emerald Physicians. He received his medical training at Tufts University, the University of Vermont and Texas A&M University Health Science Center. Dr. Rana is inspired by his ability to slow or prevent the manifestation of disease and believes that a holistic philosophy is essential for building strong relationships with patients. He is currently welcoming new patients at his 46 North Street office in Hyannis.

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Food Supplement Linked to Lower PSA in Prostate Cancer

Food Supplement Linked to Lower PSA in Prostate Cancer

(an online article from the Medscape website)

Kate Johnson 

Jun 10, 2013

CHICAGO, Illinois — A commercially available food supplement that contains pomegranate, broccoli, green tea, and turmeric significantly lowers prostate-specific antigen (PSA) levels, compared with placebo, in patients with prostate cancer, a double-blind placebo-controlled randomized trial has shown.

The study results, presented here at the 2013 Annual Meeting of the American Society of Clinical Oncology (ASCO®), made headlines around the world and caused the polyphenol-rich supplement, known as Pomi-T (nature Medical Products), to sell out within hours.

This is a “promising new therapy,” said Tomasz Beer, MD, professor of medicine and director of the prostate cancer research program at the Oregon Health and Science University in Portland, during a “highlights of the day” session.

“We have been staggered by the level of interest…from medical professionals and the public,” Marcus Williams, owner and director of natureMedical Products, told Medscape Medical News. As soon as the results of this study were released, the company, based in Porthcawl, South Wales, United Kingdom, received a rush of orders from customers in Australia, Canada, the United Kingdom, and the United States.

“It’s awesome,” the study’s lead investigator, Robert Thomas, MD, a consultant oncologist at Bedford Hospital and Addenbrooke’s Hospital, in the United Kingdom, told Medscape Medical News.

“We didn’t expect such a big response. People are seeing that this can change practice…because men and their doctors do look at their PSA as a deciding factor in whether to stop active management,” he explained.

Significantly Different Than Placebo

The study involved 203 men (average age, 74 years) with a PSA relapse after radiotherapy or surgery for localized prostate cancer. The men, who were being managed with active surveillance, were randomized to receive the supplement 3 times a day for 6 months or placebo.

At 6-month follow-up, the median increase in PSA was 63.8% lower in the supplement groups than in the placebo group (14.7% vs 78.5; =.0008). In addition, PSA levels were stable or lower than baseline more often in the supplement group (46% vs 14%; P = .00001).

Fewer men in the supplement group than in the placebo group went on to receive brachytherapy, radiotherapy, surgery, or androgen-deprivation therapy (7.4% vs 26.0%; P = 0.01).

At the end of the study, more men in the supplement group than in the placebo group continued on active surveillance (92.6% vs 74.0%). “This is an end point we feel is important: more men were choosing to stay on treatments with less toxicity,” Dr. Thomas noted.

There were no differences between the supplement and placebo groups for baseline and serial measurements of cholesterol, blood pressure, serum glucose, C-reactive protein, or adverse events.

“Pomi-T was well tolerated,” he said. “More men experienced nonsignificant bloating or diarrhea, but 15% of men reported beneficial effects, including better digestion and improvement of urinary symptoms.”

Previous research has shown that the polyphenols and antioxidants in pomegranate, broccoli, green tea, and turmeric have individual anticancer properties, but “we believe there’s a synergistic effect in the supplement,” said Dr. Thomas.

In addition, the fact that each ingredient originates from a separate food category (fruit, vegetable, herb, and spice) might prevent potential adverse effects from the overconsumption of one particular type of polyphenol, he noted.

In the lab, polyphenols have been shown to have antiproliferative, antiangiogenic, proadhesion, antimetastatic, and proapoptotic properties, and notably, they have no phytoestrogenic or hormonal effects. “We specifically chose to steer away from anything that might have a hormonal effect.”

Because of the supplement’s effect is likely not hormonal, future trials will involve men with different stages of prostate cancer and those receiving androgen-deprivation therapy, he said. In addition, the researchers hope to look at the impact of the supplement on other slow-growing cancers and even on cancer prevention.

The study received no funding from the manufacturer of the supplement; however, the company worked very closely with the research team to develop the product, said Williams. “Unlike other nutritional supplement products, the manufacture of this supplement was significantly more time-consuming because Dr. Thomas and colleagues, for whom this was initially made, insisted on a great deal of quality assurance, over and above that normally required by the US Food and Drug Administration or European Commission, particularly in terms of purity and authenticity.”

He said the study signals “a new era for the nutritional supplement industry, which has previously relied on advertising and marketing rather than evidence of benefit. Clearly, it’s the latter that the public wants.”

Dr. Beer noted that the product’s significant effect on adherence to active surveillance is “potentially clinically meaningful… If this can be confirmed, this is really interesting,” he said, although he added that “these patients were more severe than the sort of patients that we would follow [with active surveillance] here in the United States.”

To read full Medscape article, see http://www.medscape.com/viewarticle/805549

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Important Flu Information from the Massachusetts Department of Public Health

The Massachusetts Department of Public Health has provided the following downloadable handouts with information about influenza prevention:

FLU:  What You Can Do

FLU:  What You Can Do…Caring for People at Home

 

 

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Influenza: It’s Not Too Late to Vaccinate!

Influenza is spreading and serious, and vaccination is recommended for nearly everyone, so please keep vaccinating your patients
Influenza vaccination is recommended for everyone age 6 months and older, so please continue to vaccinate your patients.

Following is a list of resources related to influenza disease and vaccination for healthcare professionals and the public.

It’s not too late to vaccinate.

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January Health “e” Living News

Check out our monthly newsletter here! 

 

 

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Women’s Health Program at Spaulding Rehab

Spaulding’s teams of physicians, psychologists, physical and occupational therapists, nutritionists and other specialists throughout the Spaulding Rehabilitation Network will collaborate with you to create a personalized, comprehensive treatment program for a variety of conditions, including:

Osteoporosis and Perimenopausal Symptoms – Our program provides specifically designed exercises and activity training to improve strength, balance and overall function in a safe manner. Education on nutrition and lifestyle changes to help prevent and treat osteoporosis is also provided.

Pregnancy and Postpartum-Related Pain Rehabilitation – We offer individualized treatment for the pregnant or postpartum woman. Treatments include exercise, manual therapy, body mechanics training, bracing and education designed to reduce pain and improve function.

Women’s Health Pelvic Pain – Pain in the pelvic region can limit normal function, including sexual intercourse. Assessment of the cause will be done by a physical therapist. Treatment may then consist of manual therapy, stretching, strengthening and education about lifestyle changes.

Urinary Incontinence – Incontinence is the involuntary loss of urine significant enough to cause a problem in daily activities. Our program includes noninvasive treatments such as exercise biofeedback and lifestyle management for urinary incontinence.

Breast Cancer Rehabilitation/RESTORE Program – Our interdisciplinary team of specially trained clinicians provides a supportive environment in which breast cancer patients in all stages of treatment improve their ability to function and their quality of life through rehabilitation strategies.

Women’s Health programs are offered at the following Spaulding Outpatient Centers on Cape Cod. Program offerings vary by location.

Spaulding Outpatient Center Orleans
Spaulding Rehabilitation Hospital Cape Cod
Spaulding Outpatient Center Yarmouth

Please visit their website for more information:

http://www.spauldingrehab.org/services/outpatient/womens-health.aspx

 

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The ABCs of Diabetes

The ABCs of Diabetes 
Dawn M.Sprague, RN, RD, CDE
Diabetes Nurse Educator
Emerald Physicians

November is American Diabetes Month and the perfect time to raise awareness about this increasingly prevalent disease. You may be surprised to learn that in 2010 25.8 million Americans (8.3 % of the U.S. population) had diabetes and of those 7 million people did not know they had the disease. This number is growing as our population ages and becomes larger in girth. Another alarming fact is diabetes is the seventh leading cause of death in the United States and cardiovascular disease is the leading cause of death for people with diabetes. Not only is it costly to one’s health, but also to the health care system as 174 billion dollars is spent annually on the treatment of diabetes.

For those of you thinking, I don’t need to worry about this as I don’t have diabetes. Ask yourself; am I at risk for diabetes? The answer is yes if you have any of these risk factors:

– Family history of diabetes
– Overweight
– Exercise less than 3 times a week
– Over the age of 45
– High blood pressure
– High cholesterol
– African American, Latino or of Asian descent

For those of you with risk factors for diabetes, discuss with your provider getting screened for diabetes. For those of you with diabetes you can protect your heart by knowing and controlling your ABCs.

ABCs Definition Goal
A1C Estimated average of your blood sugars during the past 3 months Below 7
Blood Pressure Measures how hard your heart is working. Below 130/80
Cholesterol LDL: AKA “lousy lipids” is the artery clogging cholesterol. Below 100

The good news is you can lower your risk for heart disease, stroke and other diabetes complications by knowing and controlling your ABCs. Also, ask your provider what steps you can take to reach your ABC target numbers.

http://www.cdc.gov/diabetes/pubs/references11.html

www.diabetes.org

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An Apple a Day to Keep Pancreatic Cancer Away

The following is an excerpt from an article written by David Kerr, a Professor of Cancer Medicine at the University of Oxford and past President of the European Society for Medical Oncology:

A study was published recently in Annals of Oncology [1] by an old friend of mine, Carlo La Vecchia, from the Mario Negri Institute in Milan. It is a very well-conducted case-control study of approximately 1000 individuals, 350 cases of pancreatic cancer and a corresponding 650 case-control patients.

They used a very well-validated food inventory so that they could understand the dietary basis of the individuals involved in the study. Because of the power of our understanding more about the composition of food, we have been able to do a very nice correlation between the risk of developing pancreatic cancer and the dietary composition of flavonoids and glycans, particularly a group of chemicals called proanthocyanidins, important because these are particularly common in apples, pears, and red grapes — hence the saying “an apple a day keeps the pancreatic cancer away.”

The flavonoids and glycans are an interesting class of compounds, and I urge you to look them up. We all use the word “apoptosis,” and this is a Greek expression meaning “leaves that fall from trees.” In autumn, leaves turn that terminal russet gold because they make chemicals — flavonoids and glycans — which are yellow in color, and these induce the leaves to apoptose, or to flutter down and to fall from trees. Flavonoids and glycans have a whole range of fascinating biochemical effects in terms of control of proliferation and control of cell cycle. There is an enormous volume of literature on their biochemistry. This is a very beautiful study from La Vecchia and colleagues suggesting that a diet rich in flavonoids and glycans can reduce the chances of developing pancreatic cancer by more than 25%.

This is a very well-designed study, very well delivered, and in keeping broadly with other evidence out there. The take-home message for us, for our families, and for the population of patients we care for is that an apple a day may indeed keep pancreatic cancer away.

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