Insomnia is a disorder of hyperarousal that affects up to 30% of adults. Insomnia is based on cognitive dysfunction that causes us to worry and neuroendocrine factors that upregulate our autonomic nervous system. Studies have shown that just 10 minutes of daily mindfulness practice can improve sleep. Mindfulness is able to work at the root of both causes of insomnia. It improves our ability to relax through increasing attentional factors that impart control over stress hormones and helps reduce ruminative thoughts.https://scholarworks.uvm.edu/fmclerk/1520/thumbnail.jp

Gandhi, Jinal

English

ScholarWorks @ UVM

University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2019Sleeping MindfullyJinal GandhiUniversity of VermontFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Alternative and Complementary Medicine Commons, Medical Education Commons,and the Primary Care CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationGandhi, Jinal, "Sleeping Mindfully" (2019). Family Medicine Clerkship Student Projects. 446.https://scholarworks.uvm.edu/fmclerk/446SLEEPING MINDFULLYJinal GandhiBrookfield Family PracticeDr. Laurie Davis March 2019Problem Identification■ 30% of adults suffer from insomnia defined as difficulty falling asleep or staying asleep at least 3 times per week for at least one month (1).– Increased prevalence in the elderly who disproportionately suffer from co-morbid diseases– 50% of people over age 55 have some sort of sleep problem– 40% of Americans sleep less than 7 hours per night (1).– Women are 1.3 times more likely than man to have insomnia (3). ■ Sleep mediates immune function, memory consolidation, and mood regulation. It’s no surprise that people who suffer from insomnia report decreased quality of life (2). ■ Sleep deprivation has been linked to increased whole body inflammation, obesity, heart attack, dementia, and even increased sensitivity to pain (1).■ Daytime consequences include hypersomnolence and decreased job performance. – Also puts others at risk with ↑ risk of car accidents. (2)Problem Identification ContinuedInsomnia is a disorder of hyperarousal. The hyperarousal lasts throughout the entire day and causes difficulty initiating and maintaining sleep. This state of arousal is currently explained by two theories (10).1. Cognitive DysfunctionI. Worry and rumination about life disrupts sleep. This morphs in to worry about sleeping and consequences of daytime sleepiness that turn into a vicious cycle2. Physiologic FactorsI. Insomnia is due to neuroendocrine and physiologic factors such that people with insomnia have been found to have higher metabolic rates, higher levels of urinary free cortisol excretion, and catecholaminesMindfulness is able to work at the root of both causes of insomnia. It improves our ability to relax through increasing attentional factors that impart control over autonomic activation and helps reduce ruminative thoughts. (6)Why addressing insomnia makes sense:The Public Health Cost of Poor Sleep ■ The high prevalence of insomnia means that we spend an extraordinary amount on sleep aids (3).   – In 2014, people around the world spent $58 billion on sleep aids. Projected to climb to 76.7 billion by the end of 2019.■ Mean total healthcare expenditure is 60% higher in people with insomnia (3). – Direct costs on dollars spent on insomnia treatment, healthcare services, and hospital care are estimated to be nearly $14 billion (3)– Indirect costs such as loss of work, damage from accidents, and transportation are close to $28 billion (3)■ 40% of insomniacs have co-morbid psychiatric disorders compared with 16.4% of those without (3).– Depression and anxiety are the most common – It was traditionally thought that insomnia was secondary to psychiatric disorders. In more recent large scale studies in Europe, it has been shown that insomnia more often preceded rather than followed by mood disorders (11).  Why it matters, especially in Connecticut? ■ Brookfield Family Practice resides in Fairfield County, CT which has some of the longest commute times in the entire state (5).■ A local CT newspaper, the CT Mirror, estimates that more and more CT drivers are spending greater than one hour per week driving to work approximated to be about 20% of the residents of Fairfield County (4).■ Although it’s unclear how many exactly suffer from insomnia we can estimate close to 30% based on national figures. ■ Which means that there are many residents with underlying insomnia who are losing an hour or more of additional sleep every day and are then getting behind the steering wheel (5).– And we know that upwards of 72,000 car crashes each year are attributed to drowsy driving and account for more than 44,000 injuries and up to 6,000 fatalities■ So even though the many benefits of adequate sleep may be hard to quantify such as mood regulation, decreased risk of dementia, etc, it is paramount to our own well being and the safety of people everywhere (2).And if you’re not already convinced that sleep is important, consider this….Community PerspectiveQ: Why do you think sleep is so problematic in this age group of women over 50?A: “It comes at a major time of change and stress in their life. Women are going through menopause which is causing many uncomfortable physiologic changes in their bodies. In addition, most women are working full time and juggling taking care of kids and aging parents. And it’s not just women, but from my practice they seem to disproportionately take on more of these responsibilities. How could you expect them to sleep?”Q: What has your experience been with providing sleep aids?A: “I’ve had horrible experiences with drugs like Ambien. I had one patient that said she had a dream that she had fallen down the stairs and woke up with her face black and blue. It wasn’t a dream.” Q: “Do you see a place for mindfulness in helping treat insomnia and improving sleep?”A: “Absolutely. I love using mindfulness apps on my phone. I listen to guided meditations on my way home from work and sometimes I use 5 minute emergency guided meditations when I’m stressed or overwhelmed. If I’m able to feel in control of day to day stressors and control normal anxiety, I find it’s much easier for me to sleep at night.”Answers from Anonymous Provider MD“Try to find a woman over 50 without a sleeping problem.” – Anonymous Provider MDCommunity Perspective“The current reality of our lives is that we are inundated with constant stimulus on our phones, computers, watches, you name it. Having these electronic items can be profoundly distracting in the bedroom and worsen already poor sleep habits. I think mindfulness should have a role in everyone’s life because it would allows us a chance to disconnect. I think it should be the first step for anyone having trouble sleeping.” –Anonymous Provider APRNIntervention & Methodology■ A handout was made available to patients at Brookfield Family Practice that explains how mindfulness training can improve sleep for mild to moderate insomnia. – Studies have shown that mindfulness is an effective treatment for those suffering from mild to moderate depression (6).– A JAMA Internal Medicine study in 2015 showed in a RCT setting, 10-30 minutes of mindfulness training could improve quality of sleep with greater effect than standard sleep hygiene protocol. In addition, the mindfulness group also showed a reduction in fatigue, and improvement of depression (6).■ The handout included information about mindfulness training, why it works for sleep improvement, as well as easy ways to incorporate mindfulness everyday.  ■ The handout also included information about basic sleep hygiene etiquette and  highlighted the value of CBT in insomnia treatment as well as a special initiative of the Danbury Hospital Foundation offering free CBT modules for patients with insomnia!Response“I’ve been struggling to sleep for years but never bad enough to need medication. I had heard about mindfulness from friends before, but I didn’t know it could help with sleep too. I’m really excited to see doctor’s offices include more information about natural remedies and treatments because I don’t want to take more medication than I have to.” – 63 y.o female patient“My daughter is a high school student and these days kids have so much on their plate. Sometimes she gets home at 11 PM after sports and other activities. She has a lot of anxiety because of school and all that she does. She doesn’t sleep well either. I think some of the ideas on this handout could really help her relax more. They actually seem like a great activity for us to do together every day, even if it’s just for a few minutes.” – Mom of 14 y.o patient To evaluate perceptions of mindfulness intervention on sleep, I spoke with several patients who had picked up the handout from the waiting room and brought it into the exam room with them. I included two of the responses I received that seemed to best highlight  the type of feedback I was receiving. Patients were mostly (A) happy to try something that has no cost and is medication free to improve their sleep and (B) saw it as a means of not just helping their sleep, but reigning in their anxiety.Limitations & Effectiveness ■ Mindfulness is a newer avenue for sleep treatment and research. Although small studies have been done, there are no large scale studies that have compared mindfulness training to common sleep hygiene techniques or CBT. ■ Additionally, most of the mindfulness based sleep studies have shown improvement with mainly mild to moderate insomnia but not severe.■ Due to the short time frame of the Family Medicine rotation there was little opportunity to follow patients over time who incorporated mindfulness practice into their daily habits – In addition, mindfulness practice takes time to work into one’s daily routine and so any improvements in sleep are not seen immediately – Moreover, the responses to the handout were qualitative, based on anecdotal remarks from patients from their initial perceptions of mindfulness rather than actual practice.Future Intervention■ Currently my handout is being displayed in the waiting area for patients. In the future it would be interesting for the providers to hand it out to patients who specifically express poor sleep as a concern and then follow up with them at their next scheduled appointment. They could fill out an existing PSQI regarding sleep disturbances before they are given the reading material and again at their follow up appointment. This would allow us to track progress.■ Patient summaries are now offered to patients that ask for them. The mention of sleep disturbances could auto trigger the front staff to print handout material along with their clinical summaries. Alternatively it could be converted into a dot phrase.■ Students in the future could create a list of mindfulness resources in the community such as suggestions of various yoga studios, nature preserves, acupuncturists, meditation centers, etc that would be available at the office. ■ Staff members that are interested could lead mindfulness sessions for patients once or twice a week at the office as they run various other support groups and nutrition programsReferences 1. Roth T. (2007). Insomnia: definition, prevalence, etiology, and consequences. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 3(5 Suppl), S7-10.2. Vitiello, M. V. (2009). "Aging and Sleep." Retrieved 2/15/19, from https://www.sleepfoundation.org/articles/aging-and-sleep.3. J. Christian Gillin, T. R., Thomas Roth. "Sleep Aids and Insomnia ". 02/15/19, from https://www.sleepfoundation.org/articles/sleep-aids-and-insomnia.4. Kara, J. (2018). "Census: Increase in CT drivers spending more than an hours to get to work." Retrieved 02/15/19, from https://ctmirror.org/2018/12/06/census-increase-drivers-spending-hour-get-work/.5. (2018, 11/07/18). "Drowsy Driving: Asleep at the Wheel." Retrieved 02/15/19, from https://www.cdc.gov/Features/dsDrowsyDriving/index.html.6. Black, D. S., O'Reilly, G. A., Olmstead, R., Breen, E. C., & Irwin, M. R. (2015). Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: a randomized clinical trial. JAMA internal medicine, 175(4), 494-501.7. Davis, D. M. and J. A. Hayes (2011). "What are the benefits of mindfulness? A practice review of psychotherapy-related research." Psychotherapy (Chic) 48(2): 198-208.8. Edinger, J. D. and M. K. Means (2005). "Cognitive-behavioral therapy for primary insomnia." Clin Psychol Rev 25(5): 539-558.9. Services, U. D. o. H. a. H. (2005, August 2011). "Your Guide to Healthy Sleep." Retrieved 02/15/19, from https://www.nhlbi.nih.gov/files/docs/public/sleep/healthy_sleep.pdf.10. Harvey, A. G. (2002). "A cognitive model of insomnia." Behav Res Ther 40(8): 869-893.11. Ohayon, M. M. and T. Roth (2003). "Place of chronic insomnia in the course of depressive and anxiety disorders." J Psychiatr Res 37(1): 9-15.

Sleeping Mindfully

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