The effect of meditative movement on sleep quality: A systematic review.

The purpose of this systematic review was to identify and assess evidence related to the efficacy of meditative movement (MM) on sleep quality. We conducted a comprehensive review of relevant studies drawn from English and Chinese databases. Only randomized controlled trials (RCTs) reporting outcomes of the effects of MM (tai chi, qi gong, and yoga) on sleep quality were taken into consideration. Twenty-seven RCTs fulfilled our inclusion criteria and formed the basis for this review. Due to clinical heterogeneity, no meta-analysis was performed. Seventeen studies received a Jadad score of ≥3 and were considered high-quality studies. Findings of the 17 studies showed that MM has beneficial effects for various populations on a range of sleep measures. Improvement in sleep quality was reported in the majority of studies and was often accompanied by improvements in quality of life, physical performance, and depression. However, studies to date generally have significant methodological limitations. Additional RCTs with rigorous research designs focusing on sleep quality or insomnia and testing specific hypotheses are needed to clearly establish the efficacy of MM in improving sleep quality and its potential use as an intervention for various populations.

Open-Loop Audio-Visual Stimulation (AVS): A Useful Tool for Management of Insomnia?

Audio Visual Stimulation (AVS), a form of neurofeedback, is a non-pharmacological intervention that has been used for both performance enhancement and symptom management. We review the history of AVS, its two sub-types (close- and open-loop), and discuss its clinical implications. We also describe a promising new application of AVS to improve sleep, and potentially decrease pain. AVS research can be traced back to the late 1800s. AVS's efficacy has been demonstrated for both performance enhancement and symptom management. Although AVS is commonly used in clinical settings, there is limited literature evaluating clinical outcomes and mechanisms of action. One of the challenges to AVS research is the lack of standardized terms, which makes systematic review and literature consolidation difficult. Future studies using AVS as an intervention should; (1) use operational definitions that are consistent with the existing literature, such as AVS, Audio-visual Entrainment, or Light and Sound Stimulation, (2) provide a clear rationale for the chosen training frequency modality, (3) use a randomized controlled design, and (4) follow the Consolidated Standards of Reporting Trials and/or related guidelines when disseminating results.

Open-Loop Neurofeedback Audiovisual Stimulation: A Pilot Study of Its Potential for Sleep Induction in Older Adults.

This pilot study tested the efficacy of a 30-min audio-visual stimulation (AVS) program for the treatment of chronic insomnia in older adults. Chronic insomnia has been conceptualized as entailing increased cortical high frequency EEG activity at sleep onset and during NREM sleep. We hypothesized that an AVS program gradually descending from 8 to 1 Hz would potentially reduce the excessive cortical activation that is thought to contribute to difficulties with initiating and maintaining sleep. Accordingly, we conducted an intervention study of AVS using a pre-post design. Eight older adults (88 ± 8.7 years) complaining of chronic insomnia self-administered a 30-min AVS program nightly at bedtime for one month. Sleep was assessed at baseline and throughout the 4-week intervention. After using AVS for 4 weeks, significant improvement was reported in insomnia symptoms (ISI, p = 0.002) and sleep quality (PSQI, p = 0.004); with moderate to large effect sizes (Partial Eta2: 0.20-0.55)(Cohen's d: 0.7-2.3). The training effect (self-reported sleep improvement) was observed at the end of week one and persisted through the 1-month intervention. The results from this pilot study suggest that further exploration of AVS as a treatment for insomnia is warranted.

Insomnia (primary) in older people: non-drug treatments.

INTRODUCTION: Up to 40% of older adults have insomnia, with difficulty getting to sleep, early waking, or feeling unrefreshed on waking. The prevalence of insomnia increases with age. Other risk factors include psychological factors, stress, daytime napping, and hyperarousal. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical question: What are the effects of non-drug treatments for primary insomnia in older people (aged 60 years and older)? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2014 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 14 studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: cognitive behavioural therapy for insomnia (CBT-I), exercise programmes, and timed exposure to bright light.

A pilot study of audio-visual stimulation as a self-care treatment for insomnia in adults with insomnia and chronic pain.

This pilot study tested the efficacy of an audio-visual stimulation (AVS) program for the promotion of sleep in individuals with chronic pain. Insomnia and chronic pain are common comorbid conditions and their relationship has been viewed as bidirectional. Recent studies suggest a relatively dominant role of sleep in this dyad. The premise of this pilot study was that AVS enhances low frequency while reducing high frequency brain activity resulting in decreased hyperarousal and improved sleep with potential consequent reduction in pain. We conducted a pilot intervention study of AVS using a pre-post design. Participants self-administered a 30-min AVS program nightly at bedtime for 1 month. Sleep and pain were assessed at baseline and at the conclusion of the 4-week intervention phase. Nine adults (mean age 33 ± 15.8 years; female, 89 %) completed the study. After using the AVS device for 4 weeks, significant improvement was seen in reported insomnia (ISI, p = 0.003), pain severity (BPI, p = 0.005), and pain interference with functioning (BPI, p = 0.001). Large effect sizes (Partial η(2) 0.20-0.94) (Cohen's d 0.44-1.45) were observed. The results of this pilot study suggest that the AVS program may be efficacious in decreasing both insomnia and pain symptoms. In order to better assess the efficacy of AVS for sleep promotion and possible pain reduction, more definitive randomized controlled trials will be needed. These should include appropriate sample sizes, objective measures of sleep and pain, and longitudinal follow-up.

Sleep in older adults: normative changes, sleep disorders, and treatment options.

Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.

Growth hormone-releasing hormone effects on brain γ-aminobutyric acid levels in mild cognitive impairment and healthy aging.

IMPORTANCE: Growth hormone-releasing hormone (GHRH) has been previously shown to have cognition-enhancing effects. The role of neurotransmitter changes, measured by proton magnetic resonance spectroscopy, may inform the mechanisms for this response. OBJECTIVE: To examine the neurochemical effects of GHRH in a subset of participants from the parent trial. DESIGN: Randomized, double-blind, placebo-controlled substudy of a larger trial. SETTING: Clinical research unit at the University of Washington School of Medicine. PARTICIPANTS: Thirty adults (17 with mild cognitive impairment [MCI]), ranging in age from 55 to 87 years, were enrolled and successfully completed the study. INTERVENTIONS: Participants self-administered daily subcutaneous injections of tesamorelin (Theratechnologies Inc), a stabilized analogue of human GHRH (1 mg/d), or placebo 30 minutes before bedtime for 20 weeks. At baseline and weeks 10 and 20, participants underwent brain magnetic resonance imaging and spectroscopy protocols and cognitive testing and provided blood samples after fasting. Participants also underwent glucose tolerance tests before and after intervention. MAIN OUTCOMES AND MEASURES: Brain levels of glutamate, inhibitory transmitters γ-aminobutyric acid (GABA) and N-acetylaspartylglutamate (NAAG), and myo-inositol (MI), an osmolyte linked to Alzheimer disease in humans, were measured in three 2 × 2 × 2-cm3 left-sided brain regions (dorsolateral frontal, posterior cingulate, and posterior parietal). Glutamate, GABA, and MI levels were expressed as ratios to creatine plus phosphocreatine, and NAAG was expressed as a ratio to N-acetylaspartate. RESULTS: After 20 weeks of GHRH administration, GABA levels were increased in all brain regions (P < .04), NAAG levels were increased (P = .03) in the dorsolateral frontal cortex, and MI levels were decreased in the posterior cingulate (P = .002). These effects were similar in adults with MCI and older adults with normal cognitive function. No changes in the brain levels of glutamate were observed. In the posterior cingulate, treatment-related changes in serum insulin-like growth factor 1 were positively correlated with changes in GABA (r = 0.47; P = .001) and tended to be negatively correlated with MI (r = -0.34; P = .06). Consistent with the results of the parent trial, a favorable treatment effect on cognition was observed in substudy participants (P = .03). No significant associations were observed between treatment-related changes in neurochemical and cognitive outcomes. Glucose homeostasis in the periphery was not reliably affected by GHRH administration and did not account for treatment neurochemical effects. CONCLUSIONS: Twenty weeks of GHRH administration increased GABA levels in all 3 brain regions, increased NAAG levels in the frontal cortex, and decreased MI levels in the posterior cingulate. To our knowledge, this is the first evidence that 20 weeks of somatotropic supplementation modulates inhibitory neurotransmitter and brain metabolite levels in a clinical trial, and it provides preliminary support for one possible mechanism to explain favorable GHRH effects on cognition in adults with MCI and in healthy older adults. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00257712.

Yoga for osteoarthritis: nursing and research considerations.

Osteoarthritis (OA) is a leading cause of pain and disability worldwide. Current treatment guidelines recommend nonpharmacological approaches such as yoga for firstline treatment of OA. Yoga is a promising mind-body practice that includes physical postures, breathing practices, and meditative mental focus. This article presents the current evidence, as well as a proposed conceptual model for future research. Current research on yoga for OA is scant but promising, showing some evidence of reduced pain, sleep disturbance, and disability. The conceptual model described here proposes musculoskeletal effects (strengthening, flexibility, relaxation), reduction of autonomic arousal, and therapeutic cognitive patterns (distraction, mindfulness) as potentially important mechanisms of yoga. This article also describes considerations for patients and health care providers when evaluating the potential usefulness and safety of yoga programs: yoga style, instructor qualifications, and amount of time spent in yoga practice.

Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: results of a randomized, controlled trial.

OBJECTIVES: To test the effects of walking, light exposure, and a combination intervention (walking, light, and sleep education) on the sleep of persons with Alzheimer's disease (AD). DESIGN: Randomized, controlled trial with blinded assessors. SETTING: Independent community living. PARTICIPANTS: One hundred thirty-two people with AD and their in-home caregivers. INTERVENTIONS: Participants were randomly assigned to one of three active treatments (walking, light, combination treatment) or contact control and received three or six in-home visits. MEASUREMENTS: Primary outcomes were participant total wake time based on wrist actigraphy and caregiver ratings of participant sleep quality on the Sleep Disorders Inventory (SDI). Secondary sleep outcomes included additional actigraphic measurements of sleep percentage, number of awakenings, and total sleep time. RESULTS: Participants in walking (P=.05), light (P=.04), and combination treatment (P=.01) had significantly greater improvements in total wake time at posttest (effect size 0.51-0.63) than controls but no significant improvement on the SDI. Moderate effect size improvements in actigraphic sleep percentage were also observed in active treatment participants. There were no significant differences between the active treatment groups and no group differences for any sleep outcomes at 6 months. Participants with better adherence (4 d/wk) to walking and light exposure recommendations had significantly less total wake time (P=.006) and better sleep efficiency (P=.005) at posttest than those with poorer adherence. CONCLUSION: Walking, light exposure, and their combination are potentially effective treatments for improving sleep in community-dwelling persons with AD, but consistent adherence to treatment recommendations is required.

A pilot study of gentle yoga for sleep disturbance in women with osteoarthritis.

OBJECTIVES: The purpose of this study was to test the feasibility and acceptability of a gentle yoga intervention for sleep disturbance in older women with osteoarthritis (OA) and to collect initial efficacy data on the intervention. METHODS: All participants completed an 8-week yoga program that included 75-min weekly classes and 20 min of nightly home practice. Participants were women with OA and symptoms consistent with insomnia. Symptom questionnaires and 1 week of wrist actigraphy and sleep diaries were completed for 1 week pre- and post-intervention. RESULTS: Fourteen women were enrolled of whom 13 completed the study (mean age 65.2 ± 6.9 years). Participants attended a mean of 7.2 ± 1.0 classes and practiced at home 5.83 ± 1.66 nights/week. The Insomnia Severity Index and diary-reported sleep onset latency, sleep efficiency, and number of nights with insomnia were significantly improved at post-intervention versus pre-intervention (p < .05). Other sleep outcomes (Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, diary-reported total sleep time and wake after sleep onset) showed improvement on mean scores at post-intervention, but these were not statistically significant. Actigraphic sleep outcomes were not significantly changed. CONCLUSIONS: This study supports the feasibility and acceptability of a standardized evening yoga practice for middle-aged to older women with OA. Preliminary efficacy findings support further research on this program as a potential treatment option for OA-related insomnia.

Pharmacokinetics of valerenic acid after single and multiple doses of valerian in older women.

Insomnia is a commonly reported clinical problem with as many as 50% of older adults reporting difficulty in falling and/or remaining asleep. Valerian (Valeriana officinalis) is a commonly used herb that has been advocated for promoting sleep. Valerenic acid is used as a marker for quantitative analysis of valerian products with evidence of pharmacological activity relevant to the hypnotic effects of valerian. The objective of this study was to determine the pharmacokinetics of valerenic acid in a group of elderly women after receiving a single nightly valerian dose and after 2 weeks of valerian dosing. There was not a statistically significant difference in the average peak concentration (C(max)), time to maximum concentration (T(max)) area under the time curve (AUC), elimination half-life (T(1/2)) and oral clearance after a single dose compared with multiple dosing. There was considerable inter- and intra-subject variability in the pharmacokinetic parameters. C(max) and AUC deceased and T(1/2) increased with increased body weight. The variability between the capsules was extremely low: 2.2%, 1.4% and 1.4%, for hydroxyvalerenic acid, acetoxyvalerenic acid and valerenic acid, respectively. In conclusion, large variability in the pharmacokinetics of valerenic acid may contribute to the inconsistencies in the effect of valerian as a sleep aid.

A randomized clinical trial of valerian fails to improve self-reported, polysomnographic, and actigraphic sleep in older women with insomnia.

OBJECTIVE: To test the effects of nightly valerian (Valeriana officinalis) extract to improve sleep of older women with insomnia. METHODS: Participants in this phase 2 randomized, double-blind, crossover controlled trial were 16 older women (mean age=69.4+/-8.1 years) with insomnia. Participants took 300 mg of concentrated valerian extract or placebo 30 min before bedtime for 2 weeks. Sleep was assessed in the laboratory by self-report and polysomnography (PSG) at baseline and again at the beginning and end of each treatment phase (total of nine nights in the laboratory) and at home by daily sleep logs and actigraphy. RESULTS: There were no statistically significant differences between valerian and placebo after a single dose or after 2 weeks of nightly dosing on any measure of sleep latency, wake after sleep onset (WASO), sleep efficiency, and self-rated sleep quality. In comparing each treatment to baseline in separate comparisons, WASO significantly increased (+17.7+/-25.6 min, p=.02) after 2 weeks of nightly valerian, but not after placebo (+6.8+/-26.4 min, NS). Side effects were minor and did not differ significantly between valerian and placebo. CONCLUSION: Valerian did not improve sleep in this sample of older women with insomnia. Findings from this study add to the scientific evidence that does not support use of valerian in the clinical management of insomnia.

Factors associated with concordance and variability of sleep quality in persons with Alzheimer's disease and their caregivers.

STUDY OBJECTIVES: To describe the day-to-day variation in sleep characteristics and the concordance between nighttime sleep of persons with Alzheimer's disease (AD) and their family caregivers. PARTICIPANTS: N = 44 community-dwelling older adults with probable or possible AD and their co-residing family caregivers. DESIGN: Participants wore an Actillume (Ambulatory Monitoring, Inc) for one week and completed an assessment battery to evaluate patient and caregiver mood, physical function, medication use, caregiver behavior management style, and patient cognitive status. MEASUREMENTS AND RESULTS: Actigraphically derived sleep measures included bedtime, rising time, total time in bed, total sleep time, number of awakenings, total wake time, and sleep percent (efficiency). For each sleep parameter, total variance was determined for between-subject variance and within-subject variance from day-to-day. Sleep concordance was examined using multinomial logistic regression to compare trichotomous patient-caregiver combinations of good and bad sleepers. For both patients and caregivers, between-subject daily variability accounted for more of the variance in sleep than within-subject variability. Patient depression and caregiver management style were significant predictors both for concordant poor sleep (both patient and caregiver with sleep efficiency < or =85%) and patient-caregiver sleep discordance. CONCLUSIONS: This study provides data that sleep disturbances for persons with AD and their family caregivers vary considerably night to night, and that poor sleep in one member of the caregiving dyad is not necessarily linked to disturbed sleep in the other. Understanding the complex interrelationship of sleep in AD patients and caregivers is an important first step towards the development of individualized and effective treatment strategies.

Circadian rhythm sleep disorders: part II, advanced sleep phase disorder, delayed sleep phase disorder, free-running disorder, and irregular sleep-wake rhythm. An American Academy of Sleep Medicine review.

OBJECTIVE: This the second of two articles reviewing the scientific literature on the evaluation and treatment of circadian rhythm sleep disorders (CRSDs), employing the methodology of evidence-based medicine. We herein report on the accumulated evidence regarding the evaluation and treatment of Advamced Sleep Phase Disorder (ASPD), Delayed Sleep Phase Disorder (DSPD), Free-Running Disorder (FRD) and Irregular Sleep-Wake Rhythm ISWR). METHODS: A set of specific questions relevant to clinical practice were formulated, a systematic literature search was performed, and relevant articles were abstracted and graded. RESULTS: A substantial body of literature has accumulated that provides a rational basis the evaluation and treatment of CRSDs. Physiological assessment has involved determination of circadian phase using core body temperature and the timing of melatonin secretion. Behavioral assessment has involved sleep logs, actigraphy and the Morningness-Eveningness Questionnaire (MEQ). Treatment interventions fall into three broad categories: 1) prescribed sleep scheduling, 2) circadian phase shifting ("resetting the clock"), and 3) symptomatic treatment using hypnotic and stimulant medications. CONCLUSION: Circadian rhythm science has also pointed the way to rational interventions for CRSDs and these treatments have been introduced into the practice of sleep medicine with varying degrees of success. More translational research is needed using subjects who meet current diagnostic criteria.

Circadian rhythm sleep disorders: part I, basic principles, shift work and jet lag disorders. An American Academy of Sleep Medicine review.

OBJECTIVE: This the first of two articles reviewing the scientific literature on the evaluation and treatment of circadian rhythm sleep disorders (CRSDs), employing the methodology of evidence-based medicine. In this first part of this paper, the general principles of circadian biology that underlie clinical evaluation and treatment are reviewed. We then report on the accumulated evidence regarding the evaluation and treatment of shift work disorder (SWD) and jet lag disorder (JLD). METHODS: A set of specific questions relevant to clinical practice were formulated, a systematic literature search was performed, and relevant articles were abstracted and graded. RESULTS: A substantial body of literature has accumulated that provides a rational basis the evaluation and treatment of SWD and JLD. Physiological assessment has involved determination of circadian phase using core body temperature and the timing of melatonin secretion. Behavioral assessment has involved sleep logs, actigraphy and the Morningness-Eveningness Questionnaire (MEQ). Treatment interventions fall into three broad categories: 1) prescribed sleep scheduling, 2) circadian phase shifting ("resetting the clock"), and 3) symptomatic treatment using hypnotic and stimulant medications. CONCLUSION: Circadian rhythm science has also pointed the way to rational interventions for the SWD and JLD, and these treatments have been introduced into the practice of sleep medicine with varying degrees of success. More translational research is needed using subjects who meet current diagnostic criteria.

A systematic review of valerian as a sleep aid: safe but not effective.

Valerian is an herb that is widely available in a variety of commercial preparations and is commonly used as a sleep aid. A recent systematic review and meta-analysis of valerian concluded that evidence in support of the effectiveness of the herb was inconclusive. Therefore, in an effort to more closely examine this issue, a systematic review was conducted to examine the evidence on the efficacy of valerian as a sleep aid with specific attention to the type of preparations tested and the characteristics of the subjects studied. A comprehensive search of studies investigating valerian was conducted through computerized databases and hand searches of reference lists. Standardized forms were used to summarize findings and standardized criteria were used to assess study quality. Out of 592 articles initially identified, a total of 36 articles describing 37 separate studies met criteria for review: 29 controlled trials evaluated for both efficacy and safety, and eight open-label trials evaluated for safety only. Most studies found no significant differences between valerian and placebo either in healthy individuals or in persons with general sleep disturbance or insomnia. None of the most recent studies, which were also the most methodologically rigorous, found significant effects of valerian on sleep. Overall, the evidence, while supporting that valerian is a safe herb associated with only rare adverse events, does not support the clinical efficacy of valerian as a sleep aid for insomnia.

Evidence-based psychological treatments for insomnia in older adults.

The review describes evidence-based psychological treatments (EBTs) for insomnia in older adults. Following coding procedures developed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology, two treatments were found to meet EBT criteria: sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy. One additional treatment (stimulus control therapy) partially met criteria, but further corroborating studies are needed. At the present time, there is insufficient evidence to consider other psychological treatments, including cognitive therapy, relaxation, and sleep hygiene education, as stand-alone interventions beneficial for treating insomnia in older adults. Additional research is also needed to examine the efficacy of alternative-complementary therapies, such as bright light therapy, exercise, and massage. This review highlights potential problems with using coding procedures proposed in the EBT coding manual when reviewing the existing insomnia literature. In particular, the classification of older adults as persons age 60 and older and the lack of rigorous consideration of medical comorbidities warrant discussion in the future.

Pharmacokinetics of valerenic acid after administration of valerian in healthy subjects.

OBJECTIVES: To describe the pharmacokinetics of valerenic acid in a group of healthy adults after a single oral dose of valerian using a newly developed sensitive assay for serum concentrations of valerenic acid, a commonly used marker for qualitative and quantitative analysis of valerian root and valerian products. STUDY DESIGN: Six healthy adults (22-61 years, five men, one female) received a single 600 mg dose of valerian at 08:00. Blood samples were collected for 8 h after administration. Valerenic acid was extracted from serum and measured using a LC/MS/MS method developed in our laboratory. RESULTS: The maximum serum concentration of valerenic acid for five of the six subjects occurred between 1 and 2 h ranging from 0.9 to 2.3 ng/mL. Valerenic acid serum concentrations were measurable for at least 5 h after the valerian dose. One subject showed a peak plasma value at 1 h and a second peak at 5 h. The elimination half-life (T(1/2)) for valerenic acid was 1.1 +/- 0.6 h. The area under the concentration time curve (AUC) as a measure of valerenic acid exposure was variable (4.80 +/- 2.96 microg/mL. h) and not correlated with subject's age or weight. CONCLUSIONS: Assuming that valerenic acid serum concentrations correlate with the pharmacological activity of valerian, the timing of the valerenic acid peak concentration is consistent with the standard dosage recommendation to take valerian 30 min to 2 h before bedtime. Ongoing studies are evaluating the relationship between valerenic acid serum concentrations and objective measures of sleep in patients.

Development of diagnostic criteria for defining sleep disturbance in Alzheimer's disease.

This article proposes new standards for identifying, defining, and naming sleep/wake cycle disturbances associated with Alzheimer's disease (AD) to aid in more effective research, including the development and testing of potential treatments. Many AD patients develop sleep/wake cycle disturbances associated with distress, depression, and sleep disturbances in the caregiver, as well as early nursing home placement for the patient. The Food and Drug Administration Psychopharmacological Drugs Advisory Committee has emphasized the need for a comprehensive diagnostic system. A key point made by the committee was that behavioral problems associated with dementia (including sleep and chronobiological disturbances) are scientifically and clinically valid targets of pharmacologic treatment. However, current diagnostic criteria preclude development of FDA-acceptable studies of pharmacological interventions because they do not include the required specific indications for treatment. This article attempts to develop better-defined provisional criteria with the goal of promoting epidemiological, physiological, and, especially, pharmacological research on sleep/wake disturbances.