6/2/2014 THE VALUE OF REST AND THE FUTURE OF SUPPORTING HEALTHY SLEEP PATTERNS. How Important is Sleep? Your Wellness Program :

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1 THE VALUE OF REST AND THE FUTURE OF SUPPORTING HEALTHY SLEEP PATTERNS Scott Theirl, DC, DACNB, FACFN Diplomate- American Chiropractic Neurology Board Fellow- American College of Functional Neurology How Important is Sleep? Sleep Deprivation is like intoxication: METHODS Performance effects were studied in the same subjects over a period of 28 hours of sleep deprivation and after measured doses of alcohol up to about 0.1% blood alcohol concentration (BAC). RESULTS After hours without sleep, performance on some tests was equivalent or worse than that at a BAC of 0.05%. Response speeds were up to 50% slower for some tests and accuracy measures were significantly poorer than at this level of alcohol. After longer periods without sleep, performance reached levels equivalent to the maximum alcohol dose given to subjects (BAC of 0.1%). Occup Environ Med. Oct 2000; 57(10): Your Wellness Program : Increased risk of: Cardiovascular disease: HTN, heart disease and stroke Chronic pain, inflammation Depression/mood disorders Cognitive decline: poor executive function and working memory/concentration Insulin resistance and Type 2 diabetes Metabolic syndrome/obesity Accidents 4.5% nodded off or fell asleep while driving the past month 1,550: annual car crash fatalities attributed to falling asleep 40,000: annual nonfatal car crash injuries attributed to falling asleep A leading cause of absenteeism and presenteeism at work All of these are consequences of suboptimal sleep 1

annually (Am J Manag Care. Roth, 2009) Estimated that 48% of Americans (approx 150 million) report occasional insomnia and 22% (approx 69 million) report chronic insomnia with a 1.

2 Why Perform Home Sleep Studies with Employee Wellness? Sleep disorders are very common in the US (population 315 million) Over 80 types of sleep disorders, 11 types are insomnia (American Academy of Sleep Medicine) Direct and indirect costs = $30 billion annually (Am J Manag Care. Roth, 2009) Estimated that 48% of Americans (approx 150 million) report occasional insomnia and 22% (approx 69 million) report chronic insomnia with a 1.5 greater chance if >65yo (National Sleep Foundation) Approximately 6% of Americans (18 million) have apnea Approximately 3-7% of adult men (9-22 million) and 2-5% of adult women (6-16 million) have OSA (Proceedings of the American Thoracic Society. Punjabi, 2008) Less than 20% of sleep disorders are apneas, so what are we doing to help the 80% of sleep disorder patients that aren t CPAP eligible? Fifty-six million prescriptions for sleeping pills were written in 2008, up 54 percent over the previous four years (Nat Geographic, The Secrets of Sleep, May 2010) According to IMS, a health care information and technology company, about 60 million prescriptions were dispensed in 2011, up about 20 percent since 2006 (New York Times January 10, 2013) In 2006, consumers spent $3.6 billion on prescription sleep medications, up 29% from 2005, according to health care and pharmaceutical consulting company IMS Health (USA Today 3/21/2007) January 10, 2013, FDA tells manufacturers of prescription sleep aids to half the doses as evidence points to morning after drowsiness resulting in car accidents, especially for women Sleep and Wellness Research Sleep and Wellness Research 2

Sleep and Wellness Research In 2010, Americans spent more than $16 billion on antipsychotics, $11 billion on antidepressants and $7 billion for drugs to treat attentiondeficit hyperactivity disorder

3 Sleep and Wellness Research In 2010, Americans spent more than $16 billion on antipsychotics, $11 billion on antidepressants and $7 billion for drugs to treat attentiondeficit hyperactivity disorder (ADHD). Source: American Psychological Association, Inappropriate prescribing, Brendan L. Smith, June 2012, Vol 43, No. 6 The Bottom Line Is insomnia eating away at your company s precious health care dollars? Is insomnia the primary cause of absenteeism and presenteeism at your workplace? Can optimizing sleep wellness pave the way for better accomplishing your other wellness program goals? ie: cardiovascular disease/htn, optimal weight/bmi, stroke risk, attention and cognitive performance, mood disorders, absenteeism Is insomnia the first step in your corporate wellness program currently? Should it be? How are you evaluating and supporting your employees sleep wellness? What Does a Sleep Wellness Program Look Like? What to discuss with your employees If there are red flags with the subjective questions, then move on to sleep education. If lifestyle education isn t enough, move on to data collection. Objective sleep testing. Objective biomarker testing. Natural support of neuroendocrine systems involved in sleep wellness 3

What to ask your employees Do you have difficulty: Falling asleep? Staying asleep, how frequently do you wake up? Falling back to sleep after waking? With total sleep duration?

4 What to ask your employees Do you have difficulty: Falling asleep? Staying asleep, how frequently do you wake up? Falling back to sleep after waking? With total sleep duration? With fatigue/sleepiness during the daytime? Dr. T s 12 tips for better sleeping : lifestyle education resources.html Objective and Actionable Data Collection 4

In-home Sleep Screening Device FDA approved home sleep study device Records the physiology of

breathing rate using a 2 lead ECG Reference Thomas RJ, Mietus JE, Peng CK, Goldberger AL.

2005; 28(9): 1151-1161 Add to CPC: actigraphy, body position (from an accelerometer) and snore

Study #1 46yo female with Hx of easy to fall asleep, chronic difficulty staying asleep, wakes 2-3

5 In-home Sleep Screening Device FDA approved home sleep study device Records the physiology of sleep using CPC (cardiopulmonary coupling) which couples HRV (heart rate variability) with breathing rate using a 2 lead ECG Reference Thomas RJ, Mietus JE, Peng CK, Goldberger AL. An electrocardiogram-based technique to assess cardiopulmonary coupling during sleep. Sleep. 2005; 28(9): Add to CPC: actigraphy, body position (from an accelerometer) and snore detection = comprehensive and non-invasive method for identifying sleep quality and quantity Case Study #1 46yo female with Hx of easy to fall asleep, chronic difficulty staying asleep, wakes 2-3 times per night, and feels elevated heart rate when she wakes in the night Meds: occasional xanax for sleep initiation Test Kits 5

6 ANS and Chronic Stress Responses Autonomic nervous system has 2 parts Sympathetic fight or flight Parasympathetic rest and digest Sympathetic vs Parasympathetic land Controlled by multiple brain areas, but under stress the hypothalamic-pituitary-adrenal axis (HPA) fires at an increased rate shifting you into a sypathetic fight or flight mode 3 stages of stress response NeuroAdrenal Stress Stages 5 Common Patterns with Insomnia Excitatory NT s are elevated Inhibitory NT s are depleted Immune markers are elevated Cortisol is elevated at night Melatonin is depleted Patient can have any combination and even all of these findings 6

7 Neurotransmitter Basics Can be tested in the urine, blood or CSF Urine NT testing has been around for many decades, but more markers added since 1999 Urine NT tests are primarily peripheral NTs Validity reference: Neurotransmitters excreted in the urine as biomarkers of nervous system activity: validity and clinical applicability. Marc, David, et al., NeuroSci Biobehav Review. Jan 2011 Neurotransmitter Basics Generally categorized as excitatory or inhibitory based on their physiologic outcome Inhibitory NTs include: serotonin, GABA, taurine and glycine Excitatory NTs include: glutamate, histamine, PEA, dopamine, norepinephrine and epinephrine Sleep/wake cycles are a delicate balance between excitatory and inhibitory NTs as well as melatonin and cortisol, among others Reference: Hypothalamic regulation of sleep and circadian rhythms. Saper, Clifford, et al., Nature Oct 27, Neurotransmitter Specifics Inhibitory Neurotransmitters Serotonin: inhibitory, sleep, mood, appetite, GI function and immune responses GABA: inhibitory, sleep, mood (anti-anxious), most prevalent CNS inhibitory NT Taurine: inhibitory, sleep, mood (calming- GABA receptors), cardio protective, technically an amino acid that has neurotransmitter effects Glycine: inhibitory, sleep and calming, technically an amino acid that has neurotransmitter effects, can elevate with immune responses 7

8 Neurotransmitter Specifics Excitatory Neurotransmitters Glutamate: excitatory, sleep, mood, energy, memory, most prevalent CNS excitatory NT, can elevate with immune responses Histamine: excitatory, sleep, energy (think antihistamine meds), can elevate with immune responses PEA: excitatory, sleep, focus and attention, cognition, energy Neurotransmitter Specifics Excitatory Neurotransmitters Catecholamines Dopamine: excitatory and inhibitory, sleep, energy, motivation, reward systems, movement Norepinephrine: excitatory, sleep, emotional stability, adrenal stress response with emotional symptoms Epinephrine: excitatory, sleep, energy, metabolism, adrenal stress response with physical symptoms Cortisol Basics Cortisol: hormone produced by the adrenal glands, has a diurnal rhythm (high in the morning and low at bedtime), will elevate with acute stress, can deplete with chronic stress Excitatory, sleep onset, daytime energy, adrenal stress response, immune response 8

Cortisol Basics Low morning cortisol can be associated with fatigue High nighttime cortisol can disrupt sleep (difficulty falling or staying asleep) Melatonin Basics Melatonin: neurohormone produced

9 Cortisol Basics Low morning cortisol can be associated with fatigue High nighttime cortisol can disrupt sleep (difficulty falling or staying asleep) Melatonin Basics Melatonin: neurohormone produced in the brain, released by the pineal gland upon darkness, helps initiate sleep to support our circadian rhythm Should be high in the evening and low during the day Serotonin is the precursor to melatonin Has antioxidant properties Case Study 46yo female with Hx of easy to fall asleep, chronic difficulty staying asleep, wakes 2-3 times per night, and feels elevated heart rate when she wakes in the night Meds: occasional xanax for sleep initiation 9

10 Case Study Case Study Case Study 10

11 In summary she has elevated excitatory, some low inhibitory, only one immune marker, optimal cortisol and low melatonin This is a Stage 2/midstage NeuroAdrenal stress response Case Study Case Study Follow-up Test Case Study Follow-up Test 11

Gaining Insomnia Insight Combining a FDA approved home sleep study with biomarker testing is the most comprehensive approach to objectifying insomnia and sleep wellness Determine what stage of stress

12 Gaining Insomnia Insight Combining a FDA approved home sleep study with biomarker testing is the most comprehensive approach to objectifying insomnia and sleep wellness Determine what stage of stress response patients are in Provides a custom roadmap for neurochemistry support via supplementation Retesting helps identify additional opportunities Objectify sleep quality and quantity improvement for patients Help patients avoid the comorbid disorders associated with chronic insomnia The Importance of Sleep Wellness Boost metabolism Improve blood sugar regulation Minimize cravings Lessen fatigue and gain energy Strengthen immune system Optimize employees healthy stress response Improve productivity and lessen absenteeism and presenteeism Thank You! Questions? Scott Theirl, DC, DACNB drtheirl@yourbestbrain.com

Patient Fernand Ovellette 1014 Smythe St Fredericton, NB E2B 3H2 CANADA 2:00 PM 4/19/10 6:00 AM 4/19/10 6:00 PM 4/19/10 8:00 AM 4/19/10

Patient Fernand Ovellette 1014 Smythe St Fredericton, NB E2B 3H2 CANADA 2:00 PM 4/19/10 6:00 AM 4/19/10 6:00 PM 4/19/10 8:00 AM 4/19/10 NeuroScience Inc. - Report 43546 (Fernand Ovellette) Page of 3 Report Information Health Care Professional Integrative Psychiatry 3392 Magic Oak Lane Sarasota, FL 34232 Order Details Improving Health Through