Author name: Tony Laughton

This week on Lifestyle Matters  I talked with Dr Saveena about sleep phase disorder.

Our natural sleep wake circadian rhythm does not usually last exactly 24 hours. Some people have an earlier sleep phase with a circadian rhythm that lasts less than 24 hours, whereas some people have a later sleep phase with a circadian rhythm that lasts longer than 24 hours. People with a shorter than 24-hour sleep phase are the typical morning larks that jump out of bed in the morning with boundless energy and people who can stay up all night partying are the night owls.

Re rely on zeitgebers (environmental time cues) such as the circadian day night cycle to entrain our sleep wake cycle to the length of a standard day, i.e., 24 hours. Nonetheless some people experience difficulties with such entrainment, and problems can occur, usually at the extremes of age.

Teenagers have difficulty getting up in the morning, but enjoy staying up late at night, and they can be considered to have delayed sleep phase disorder, whereas it is common for elderly patients to wake up too early in the morning and they can be considered as having advanced sleep phase disorder.

The administration of melatonin in the evening, in conjunction with early morning light exposure can help people with delayed sleep phase disorder. The administration of melatonin in the morning in conjunction with morning darkness can help people with advanced sleep phase disorder.

Jet lag is also a form of sleep phase disorder. It usually occurs when we cross five or more time zones. When we travel eastward, we chase the sunrise and experience delayed sleep phase disorder, i.e., we feel awake when everyone else is trying to get to sleep. Light exposure in the early part of the day at the destination and melatonin in the destination’s evening will help. When we travel westward, we chase the sunset and experience advanced sleep phase disorder, i.e., we want to go to bed when everyone else is still awake. Exposure to bright light in the late afternoon and evening will help us stay awake until a more reasonable bedtime

The transition care program

Today I spoke with Zoe Lance, RN, about the transition care program, otherwise known as “TCP”. TCP can be conceptualised as a half-way house between acute care and being able to manage safely at home. The gateway to TCP is the aged care assessment, without which a TCP referral cannot be accepted. Referrals are usually received from acute hospital settings or from geriatric evaluation and management (GEM) services.

There are broadly two streams of TCP, a residential stream and a community stream. The determination of which stream a patient enters depends on the initial TCP assessment of function. For instance, patients who are unable to weight bear would not be deemed as suitable for community TCP but would be directed to residential TCP.

Residential TCP can provide 24 hours per day nursing and care support for patients in a residential care setting. Factors that suggest that a Patient would be deemed as fit for community TCP would include that fact that the patient would be weight bearing.

Services that can be provided for community TCP patients include visits by district nurses, the provision of personal care and the provision of services such as meals on wheels.

All TCP programs have stated goals of care. These are the functional goals that the patient would be expected to manage at the end of a twelve-week program. These can include being able to manage all activities of daily living (such as dressing bathing showering toileting and feeding) and managing medication safely.

Whilst both these services are heavily subsidised patients are expected to contribute approximately $10.85 for community-based TCP services and $52.71 for residential TCP services. The patient’s contribution to residential TCP services is similar to that payable for residential respite services.

GPs have a role in providing mental health treatments and should bear in mind that talking therapies have as good if not better levels of success than pharmacological approaches and they have no side effects. Efficacy without side efficacy! What’s more there is no possibility of physiological dependency and therefore no withdrawal syndrome.

For talking therapy to be effective both the practitioner and the patient need to be in the moment. But what does that mean? It can mean that your mind, body and soul are in harmony, that your full attention is in a specific place and time i.e. in the therapy space.

This can be formalised explicitly – as in Acceptance and Commitment Therapy, or implicitly – as in Solution Based Brief Therapy.

Either way, you should not be sitting in the therapy space whilst thinking about having a coffee with a friend or what you will eat for dinner. Another way of describing it is getting rid of your internal dialogue. If a stray thought pops up, and they will, then let it go and then refocus your attention back to that therapy space.

Solution focussed therapy does not dwell on the past, but rather works from a premise that the future is negotiable. Solution Focus is not so much a set of therapeutic steps as a way of communicating with the patient and letting them open their own eyes to their own functional solution to their problem. Knowing the problem or engaging in analysis is quite unimportant.

So, what is the process?

Well, it begins by asking the patient.

Actually ask the patient how they want to live their lives, don’t tell them how to do it. Admonishment as therapy is so twentieth century!

Ask your patients what is better since they last saw you. Ask them what their “exceptions” were that show their suffering is not entirely constant. Ask them if they can be complimented on anything. Was there anything that the patient handled that was challenging, that they coped with when others would have crumbled. These complements are reflections on the resilience, coping and values of the patient. Ask them what their hopes are for the session you have with them that day.

Self-knowledge

Sun Tzu said “If you know the enemy and know yourself, you need not fear the result of a hundred battles. If you know yourself but not the enemy, for every victory gained you will also suffer a defeat. If you know neither the enemy nor yourself, you will succumb in every battle.” Sometimes therapy can feel like a battle of wills, but it should not be seen thus. Rather it can be a space wherein both the patient and the therapist achieve an in depth understanding of the patient’s strengths and weaknesses, their ideas concerns and expectations and their concept of purpose. With this understanding the levers of change can be engaged. The patient needs to see where their own levers are, so they can use them to effect meaningful change. The therapist is not trying to win but trying to coach the patient to develop their own self efficacy, their own hope and ultimately to win their own battle.

A useful question to ask in this context is “what are they good at”? what would a significant other/close friend/child/colleague say they were good at? Third party perspectives can be more powerful in unlocking this truth, and it can sometimes be useful to ask this question about someone whom the patient fears or does not like. With this question we get an idea of the connections the patient may have with other people and question provides an opportunity for the patient to consider themselves within the context of a family, a tribe and society.

The miracle question

The miracle question is also a useful tool to unlocking the potential for change. IT is a question designed to evoke a detailed vision of their desired future.
The question might be phrased as follows.

“So, you go to bed tonight and you don’t know it happened, but during the night a miracle happened and all the things that brought you here today just dissolved. What would be the first clue that the miracle had happened? What would someone else see hear or feel? What would they see you do?

It is important to drill down, get detail, about what their desired future would look like on day one.
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Follow up questions might include the following.

What would you do differently?
What would you still do?

And the line of questioning could then be brought back to bear on the present by asking such questions as “Could you do something different now, as if the miracle had happened? Would you be prepared to try?”

Having a dream, a hope, and noticing that the problem is not there all the time (exceptions caused by a degree of agency) works towards them determining the small steps required to get big results.

Dead men’s goals

When considering solution focussed therapy and change management it is important to recognise and avoid dead men’s goals. An example could be “to not drink”. These goals are so called because the dead don’t drink. Rather, it is more engaging and beneficial to use the instead” question. An example might be “So what would you do instead of drinking?”. And an answer might be “I’d spend more time playing with my kids.”

The power of the right question ta the right time delivered in the right context should not be underestimated.

The image below represents a starting point on the journey a therapist takes with a patient towards successful change management and recovery.

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On Lifestyle Matters Saveena and I chatted about the hormonal regulation of the fed and fasted state.

When we eat we ingest carbohydrates, proteins and fats, these are broken down by the digestive system into glucose, amino acids and triglycerides. These substances are then absorbed by the body. Therefore, In the fed state our bodies are full of sugar that needs to go somewhere. Insulin is secreted by the pancreas in response to two signals. Firstly the presence of food in the gastrointestinal tract triggers the gut to secrete incretin hormones (GIP and GLP-1) which in turn triggers the pancreas to secrete insulin. Secondly the presence of glucose in the blood stream also stimulates the pancreas to secrete insulin.

Insulin is the main storage hormone in the body and as such acts to “bring in the harvest. It has three main actions. Therefore, it limits the sugar high that occurs after eating.

It stimulates the liver to convert glucose to starch (also known as glycogen). Secondly it acts to trigger the conversion of amino acids to proteins, and thirdly it stimulates fat cells to convert free fatty acids into fat, a process known as lipogenesis.

When the liver’s glycogen stores are saturated then insulin directs excess glucose towards the production of fat, hence insulin is known as the “fat hormone”.

After a couple of hours, the glucose rush abates, and our glucose levels drop. We then enter the fasting state. At this point a different hormone comes into play. Glucagon, also secreted by the pancreas, is released in response to a low blood glucose and stimulates the liver to convert its glycogen stores back into glucose. This then maintains the body’s constant level of glucose in the fasted state. The liver however has a limited supply of glycogen that can be broken down into glucose. When glycogen stores run out another hormone, growth hormone, acts to trigger fat cells to release their stored energy in the form of glycerol (which can be converted into glucose) and free fatty acids, which can be used as an alternative energy store.

Growth hormone also acts to stimulate protein synthesis, which provides a survival benefit. When we are in a prolonged fasting state growth hormone causes our bodies to preferentially burn fat and preserve muscle, allowing our ancestors to hunt and gather, and allowing us to drive and go shopping.

Therefore, it can be seen the both the highs and lows of glucose as we progress between the fed and fasted state are tightly regulated by the opposing actions of insulin in the fed state and glucagon and growth hormone in the fasting state.

Appetite is also regulated hormonally. Our empty stomachs secrete a hunger hormone, ghrelin which stimulates us to eat. After eating ghrelin secretion reduces. Food then stimulates insulin secretion, which in turn causes our fat cells to secrete leptin which acts to trigger our brains into thinking we are full. Therefore, appetite and glucose is closely regulated by the interaction of hormone sin our body. In obesity however, leptin secretion is increased, but despite the higher levels of leptin circulating in our bodies the leptin signalling is blunted, the body does not recognise the “I am full” message. This lack of satiety messaging, despite higher-than-normal levels of leptin, is known as leptin resistance, one of the hormonal hallmarks of obesity.

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On Lifestyle Matters show this week

COLTE – how to entrain your sleep wake cycle.

This week I chatted with Dr Saveena about the factor that help regulate our sleep wake cycle.

Our natural sleep-wake cycle is more than 24 hours. So, we need to constantly entrain our sleep-wake cycle to the natural day night cycle that does last 24 hours. We do this by use of zeitgebers which are environmental time cues. The most significant zeitgeber is light.

Daylight, and particularly blue light which has a wavelength of approximately 480 nm has an activating effect. It suppresses melatonin secretion; it increases cortisol secretion and activates our sympathetic nervous system causing an increased heart rate and blood pressure. These effects are all beneficial in the morning when we need to get up and face the challenges of the day. Prior to the advent of industrial lighting, the evening, associated with dim light allowed the secretion of melatonin which then caused drowsiness and prepared us for sleep. This interaction between external light and darkness therefore kept our sleep wake cycle entrained to the 24-hour day.

However, with the advent of industrial lighting we are exposed to light, including blue light, well into the evening which can have the effect of causing inappropriate activation and interfere with melatonin secretion and the onset of sleep. Lack of exposure to daylight can also have an adverse effect on sleep by rendering the body more sensitive to even low levels of evening light further impairing the natural sleep wake cycle. Therefore, we need adequate exposure to daytime light and night-time darkness to sleep well.

Light however is not the only factor that can affect our sleep. If we look at the COLTE mnemonic C stands for carbohydrates. When we ingest carbohydrates, the insulin rise also stimulates intracellular storage of amino acids, all except tryptophan. Therefore, in the presence of a high carbohydrate load the relative concentration of tryptophan increases. Tryptophan is then metabolised to serotonin and melatonin which as we know contribute to sleep.

This effect occurs maximally four hours after ingestion of carbohydrates so we should be eating our last meal of the day four hours before out anticipated sleep time.

O stands for osmolality. Osmolality refers to the salt and water content of body fluids. During early sleep blood vessels dilate which reduces blood pressure and allows heat to escape from the core to the peripheries. High salt content or relative dehydration impairs the dilation of blood vessels and therefore impairs the reduction of blood pressure and the core body temperature that need to occur in early sleep.

T stands for temperature. AS discussed above early sleep requires a reduction of core body temperature and an increase in peripheral temperature. Therefore, we need to be mindful of the ambient bedroom temperature and we may benefit from wearing bed socks to keep our peripheries warm to facilitate early sleep.

E stands for exercise. Exercise activates our adrenaline and cortisol, hormones which activate us. Therefore, we should exercise in the early morning preferably outdoors to catch the morning light. Exercise in the late afternoon may also be beneficial in promoting unbroken sleep. Exercise prior to attempting sleep however is not advisable. All that adrenaline and cortisol surging through our bodies will just keep us awake.
So, we can see that COLTE (carbohydrates, osmolality, light, temperature and exercise) relate to the factors that can influence how well we sleep at night. An understanding of how to manipulate these factors is an essential component of the lifestyle medicine interventions that we can offer for people with sleeping difficulties.