Thanks so much @drmelaniechandler ! We're excited to grow and appreciate being a part of the larger HABIT team!
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Quality sleep is so important for all of us for so many reasons: emotional health, immune system efficiency, daytime energy, just to name a few. But sleep is especially important for those of you living with Mild Cognitive Impairment (MCI) because bad sleep impacts your thinking efficiency during the day. Not to mention that it contributes to moodiness, fights with our spouses, low motivation, and generally feeling poorly during the day. About a year ago, I posted a two part story on sleep apnea. The first part reviewed the importance of treating sleep apnea–important for many of same reasons it is important to maximize quality sleep in general! The second part provided some tips for adjusting to a CPAP device, which can be tough.
Today, I wanted to provide some tips to maximize the chance of good quality sleep whether or not you have a sleep disorder like sleep apnea. This is sometimes referred to as “healthy sleep habits” or “sleep hygiene”. These are habits that essentially tell your brain reliably that it is time to sleep and allow you to naturally experience all phases of your sleep cycle most reliably so you get deep restorative sleep. We discuss these in our HABIT program as our top 10 behaviors for healthy sleep and I’d like to share them with you!
These first habits are about building a good sleep routine. Basically the routine about how you get to bed and when:
1.Stick to a sleep schedule. Do your best. If you get to bed late one day–try to make yourself get up as the same time and get back to the schedule the next day.
2.Use the bedroom only for sleep and intimacy. Do you exercise in your bedroom? Watch TV? Pay bills? Try to do as many of these activities as possible in other rooms of your home. The goals is to have your brain pair your bedroom with sleep. That association, along with other good sleep habit routines, will help your brain release melatonin–the sleep hormone–at the right time.
3.No TV in the bedroom. In addition to the reason in #2 above, TV is stimulating and disruptive to the sleep cycle.
4.Have a relaxation activity as part of your bedtime routine. Try listening to relaxing music as you get ready for bed, a meditation activity, a breathing exercise, or saying your prayers (if that is your practice)–these relaxing activities help to lower your sympathetic nervous system (your fight or flight response) and activate your parasympathetic nervous system (your rest and digest system).
5.Discontinue screen time 1 hour before bed. Our brain interprets most light from electronics as sunlight which delays release of melatonin as our brains think it is still day time. However, I have recently seen research articles such as this one that suggest that using amber lenses to block the blue tone light may help.
6. Have a memory notebook handy at the bedside for those last minute thoughts of things that need to get done the next day that might keep you awake. Write them down so that you know you’ll be able to deal with them tomorrow. If you find that worrying about things you can’t control becomes an issue, you may benefit from seeing a psychologist to help you develop alternative thinking patterns for those times.
These last habits are more about how you structure the rest of your day and environment and how that may help improve your sleep.
7. Get physical exercise daily, especially earlier in the day. This is always my #1 tip when my patients tell me they feel tired during the day. Getting exercise in the morning activates your brain and sets it off on the proper cycle. Your body is more ready for rest and sleep with activity in the day.
8. Sunshine in the morning. This is the companion recommendation to avoiding electronics in the evening. Get sunshine in the morning so your brain gets the message it is time to be awake!
9. Check your environment. How long have you had that mattress? Is your pet in the bed with you? Review that the mattress and pillows are comfortable, the temperature is cool enough, you have the right blankets, your beloved Fido or Tiger has their own sleeping space, you have curtains that block out light that might bother you, the TV is off, etc. Pets can certainly be reassuring, but they unfortunately do disrupt the sleep cycle in bed with you. Having them on their own bed in your room, may be a good solution.
10. Avoid alcohol, caffeine, and heavy meals before bed. These all disrupt your body’s ability to sleep soundly and move fluidly through all the phases of sleep as desired through the night.
It can be difficult to implement all of the above tips and you may feel like your sleep is worse before it gets better. There are psychologists who specialize in helping treat sleep problems using cognitive behavioral therapy for insomnia. They will help you implement many of the above routines and more to help you maximize your sleep quality.
I hope you can try out some of these tips—and give them a little time for your body to adjust. Please feel free to comment on your experiences or provide any other tips you’ve found helpful!
On this Living with Mild Cognitive Impairment (MCI) newsfeed, we’ve primarily focused on topics that might be of help or interest to individuals who have been diagnosed with MCI and find our page. However, when I saw this recent newsletter from Banner Alzheimer’s Institute, I realized that some of you may find us because you’ve searched terms such as “memory loss” or “short term memory problems.” The article, authored by Dr. David Weidman, a Neurologist at Banner, gives guidance for individuals who may be worried about memory changes. I’d encourage you to check it out as well as their 10 warning signs related to memory loss. I agree with their final advice–“when in doubt, check it out!” I assure you that your primary care doctor, neurologist, or neuropsychologist (or all three!) love nothing better than evaluating individuals and being able to say–“Nope, this is just normal forgetfulness. No worries!” But, if you are evaluated and do receive a diagnosis of MCI, just know that there is support for you. Come back and check out our HABIT program information for starters!
At the same time I received this newsletter from Banner, I also received a newsletter from the Alzheimer’s Association. In that newsletter was a related article “Communicating with your doctor about memory loss.” If you are worried about your memory and know you want to bring it up with your doctor, their article can help you frame how you’d move forward–from advice about what to bring to the appointment to questions to ask. The article also provides information on the types of providers you may see in the evaluation process as well as helpful resources to help you prepare for your visit (such as a format for listing symptoms and questions or organizing medications). There are also resources that may be helpful to you after your doctors visit.
I hope these resources help you move forward with getting those memory concerns evaluated!
Hi @bonniep! I like your alternative plan. Sounds like you've found something that will give Denny a challenge that will adjust over time. And I like that you guys are planning to do this together. We've started playing around with some board games like Boggle, Scattegories, and Telestrastions in our HABIT class. I'm not convinced that these have the same brain exercise impact as the processing speed based adaptive computer games, but these games do have some time pressure involved and can be a challenge. So, if brain games just aren't feasible these may also be some other options, but I don't have official data on that. But something is likely better than nothing!
At present, HABIT is only available at one of the Mayo campuses (Arizona, Florida, or Midwest) and the University of Florida. It is our goal to help support providers at other institutions also launch HABIT programs, but that has not happened yet.
Last week, I highlighted some research by the HABIT team evaluating the comparative impact of the 5 components of the HABIT program: Cognitive rehabilitation, cognitive training, yoga, support group, and wellness. We concluded that the topic is complicated and that no one intervention is “best.” Multi-component interventions are likely to continue to be most helpful for patients with MCI. I did, however, mention that in evaluating the outcomes of quality of life, mood, anxiety, and self-efficacy, eliminating cognitive training did not negatively impact those outcomes.
Does this mean we think you can stop doing those brain games? Not so fast. I noted that we have not yet evaluated our cognitive outcome data to see if cognitive training may make a difference there. Because of this, I thought it an opportune time to highlight another recent study, this time from researchers in China, specifically evaluating the cognitive impact of cognitive training. Here are some details and summary, but you can read the study here if you like.
This study was conducted in patients diagnosed with “vascular cognitive impairment no dementia”. This is essentially another way of saying Mild Cognitive Impairment (MCI) but with a known underlying etiology (cause) of vascular disease. As we discuss in HABIT, MCI is a syndrome that describes the loss of cognitive ability (memory, word finding, or executive functioning for example) but with relatively good day-to-day functioning. There are many diseases that may cause MCI. Alzheimer’s disease is one, but vascular disease (i.e., small strokes or impaired blood flow in blood vessels of the brain) is another. In HABIT, we see patients with MCI with all etiologies and we may not even be sure of the disease. However, in this specific study, researchers limited the sample to patients with evidence of cognitive impairment (but not dementia) with evidence significant small vessel ischemic disease (i.e., vascular disease, primarily based on MRI scan–taking a picture of the brain and seeing evidence of small strokes).
Patients were randomly assigned to one of two possible interventions. The training group received a computerized, multidomain, adaptive training program for 7 weeks. They completed 30 minutes of training per day 5 days per week. When patients completed tasks with high accuracy, they upgraded to a higher difficulty level. The active control group received speed and attention tasks, also 30 minutes per day, 5 days per week for 7 weeks. In this group, they completed tasks at the same difficulty level throughout the study. This is a key difference between the interventions--the exercises got progressively more difficult as the participants got better at them in the training group.
The researchers collected data on measures of cognitive functioning (pencil and paper cognitive measurements) as well as measurements of brain functioning on brain scans (MRI and functional MRI). These measures are mean to evaluate changes in size of memory-important areas of the brain and evaluate the integrity and efficiency of the connections in the brain. They conducted these measurements prior to the intervention, at the end of the interventions, and 6 months later.
The found a significant improvement on pencil and paper cognitive measurements in the training group compared to the active control group. Unfortunately, this effect went away by 6 months after stopping the intervention. They did not find any change in the size of various brain structures with training compared to the active control, but the did see an increase in brain connections. Again, this improvement went away by 6 months after stopping the intervention.
Overall, I usually emphasize to my patients that we need to understand the benefits of cognitive exercise more. Ongoing research seems to suggest that cognitive exercises are not all created equal, and any potential benefits are only sustained with ongoing exercise. I’m optimistic enough about the benefits given studies like these, that we do routinely recommend brain exercise and help our patients create a habit during our treatment program. If you’ve been successful in creating a cognitive exercise habit, I’d love to hear more about what you are doing and how you maintain the habit!
This week, I want to highlight a recent research publication from our team, led by Dr. Melanie Chandler, director of the HABIT program in Florida. For those of you who have followed our newsfeed for a while, you’ve seen our references to the HABIT program already. However, I want to include some description here for any newcomers to our newsfeed. HABIT Healthy Action to Benefit Independence and Thinking ® is Mayo Clinic’s cognitive rehabilitation and wellness program for patients diagnosed with Mild Cognitive Impairment. You can find more detail on our information tab, but briefly, our program has 5 components: cognitive rehabilitation (memory compensation training), cognitive training (brain fitness), yoga, wellness, and support group. There is supportive research literature showing the benefit of each these five components individually, which is why HABIT evolved to include all 5 components in the first place. What we didn’t know, was whether our patients needed all 5 components. That is, could you get just as much benefit from just 4 parts of HABIT because some of the benefits of some pieces of the program overlap? And related to this question is understanding how each of the 5 components is helpful. Which outcomes are helped by which intervention?
For example, perhaps the cognitive rehabilitation piece helps people function better day to day with memory tasks, perhaps cognitive training improves measurements of cognitive function, support group helps improve mood or lessen anxiety, perhaps yoga improves relaxation and physical functioning, and perhaps wellness classes help people change lifestyle habits (e.g. diet and exercise) and also helps with functioning and mood. In our research trial, we attempted to answer these questions.
We first asked our HABIT alumni to tell us which outcomes were most important, out of 13 possible outcomes that included both patient outcomes (e.g., performance on memory testing, daily functioning in memory related activities, mood, confidence, physical functioning, quality of life, etc.) and partner outcomes (e.g., partner quality of life, burden, mood, anxiety, etc.). That survey showed that the highest priority should be patient quality of life and that all patient outcomes were valued by both patients and partners higher than partner outcomes. Dr. Chandler’s recent publication therefore, focused on this primary outcome as well as mood, self-efficacy (i.e., confidence), and memory-based daily functioning as these were the next most highly rated outcomes.
In this trial, supported by funding from the Patient Centered Outcomes Research Institute, nearly 300 couples agreed to be part of this research study in which they went through the HABIT program, but received just 4 of the components. The 5th component was randomly selected to be left out. The patients did not get to choose or know ahead of time which treatment would be left out. With this type of study, we compared which people had better or worse outcomes by evaluating the cost of not getting the one withheld intervention even if receiving another 4.
In reviewing the primary patient outcomes, Dr. Chandler and our team found that all combinations of four treatments improved quality of life at the end of treatment in our patients. At one year, wellness class had a greater impact on patient mood than cognitive training, and yoga had a greater impact on memory related daily functioning than support groups one year after treatment. Overall, the loss of computerized brain exercise did not negatively impact these primary outcomes. However, the literature on cognitive training suggests that it is most likely to impact cognitive measures, not the measures we’ve evaluated in this study—quality of life, mood, anxiety, or self-efficacy. We collected cognitive measurements in this trial and analyses of those data are ongoing. We also continue to evaluate partner outcomes.
Overall, these results are the first of several making an effort to compare various behavioral interventions (non-medication approaches) for patients with MCI. The topic is complicated, and there is still more to understand, but we can already say that it is likely that no one behavioral intervention is “best”. Different interventions impact different outcomes for patients (and likely partners), such that patients are likely to continue to be best served overall by multi-component interventions like HABIT.
We wish to express our gratitude to the patients and partners who agreed to be a part of this study and follow with us over time!! We could not do this without you, and we are forever thankful and humbled that we get to work with such special and courageous people. We also wish to acknowledge all the sites who participated in the trial, including Mayo Clinic Arizona, Florida, and Minnesota as well as the University of Washington. If you wish to read Dr. Chandler’s full academic paper, you can find that here!