The Fatigue Prescription: Four Steps to Renewing your Energy, Health, and Life

Posted By SHL Librarian

Presented by: Linda Hawes Clever, MD
Clinical Professor of Medicine, UCSF
Thursday, November 4, 2010

Modern life is full of annoyances, irritations, frustrations, and demands. There are the big concerns like work and family and health, and there are the little things like traffic, dishes, barking dogs, and lost to-do lists. These stresses, great and small, can take a heavy toll, and for many people the constant barrage causes a real drain-physically, emotionally, and spiritually.

Chronic exhaustion can undermine your day-to-day functioning, said Linda Hawes Clever, MD, a clinical professor of medicine at University of California, San Francisco, at a presentation sponsored by the Stanford Health Library. Dr. Clever wrote a book called The Fatigue Prescription: Four Steps to Renewing Your Energy, Health, and Life, which provides some tips she has developed to treat physical and spiritual exhaustion. The trick is to develop tools to keep you going while you stick to your values, personal strength, and inner motivation.

Dr. Clever’s insights come from personal experience. Fifteen years ago she was barraged by bad luck: both of her parents died, she lost two jobs, and her husband was diagnosed with cancer-all in the span of 18 months. She took her years of expertise as a clinician and researcher, interviewed thousands of people about how they maintained their energy, and came up with four steps to put her theories of personal renewal into practice.

“We tend to take better care of our cars than we do of ourselves,” she said. “We need to find ways to renew and refresh ourselves. The way to do that is to find meaning in your life. By that I mean getting back in touch with your basic values and organizing your life around them.”

Whether your stress and fatigue come from dramatic events or just from the daily grind, Dr. Clever said one key is to identify the activities that refresh your spirit and to make room on your calendar to take part in them. Her approach involves personal reflection to help you rediscover your lost energy.

“Most of us want to have meaning in our lives,” she said. “Happiness comes from finding meaning, not from looking to be happy. In our search for purpose we can also find ways to renew, which replenishes our ability to be creative, optimistic, and energized.”

One of Dr. Clever’s tools is called a Renew-O-Meter, a series of questions designed to measure how well you juggle your commitments. Questions range from how many sit-down dinners did you have with your family or friends in the past week to when did you feel bold enough to take a risk to how many times did you really laugh yesterday?

Rating a high score in your willingness to take a risk reflects on your self-esteem and personal efficacy-feelings that can pervade all aspects of your daily life. In that way the meter can help raise self-knowledge, she said.

She highlighted four basic steps that can be used to renew your energy:

  • Awareness assesses the nature of your fatigue and its external and internal causes.
  • Reflection enables you to probe the sources of your feelings and to identify the positive people, activities, and experiences that support you.
  • Conversation creates opportunities for heartfelt openness in communication and feedback from loved ones and associates; it implies a willingness to share and to learn.
  • Plan-and-act allows you to develop a process of systematic change made up of small steps.

“Most of us tend to want to act but don’t love change,” she said, “so we need to change incrementally. By making a plan with small steps, your change is like stepping off a curb, not jumping out of an airplane.”

It’s important to note what aspects of your nature or habits can stop you from changing, and to be aware that resisting change can actually cause more fatigue. Your guidepost should be your personal values-the things that give you direction and satisfaction. Dr. Clever said a good way to define your values is to think about what you want written up in your obituary.

“Think about how you would like to be described. By living your values you can find meaning and have joy in your life,” she said. “Talk about them with your partner or family-shared values keep a family or community together and create common ground.”

She also discussed five traits of people who consider themselves capable of dealing with the vagaries of a stressful life. These people tend to:

  • Have close relationships with family and friends
  • Have a strong sense of spirituality or religious beliefs
  • Take care of their health
  • Like what they do for a living
  • Have a certain level of acceptance of their situation: They feel they can play the hand that’s dealt them.

“We can learn to exert power over ourselves,” said Dr. Clever. “You can find the freedom to choose your attitude, and that will energize and sustain you.”

About the Speaker
Linda Hawes Clever, MD, is a clinical professor of medicine at University of California, San Francisco, and the founder of RENEW, a nonprofit dedicated to helping people find purpose and direction. She received her medical degree from Stanford, where she completed her residency and fellowships, and she now serves as the medical school’s associate dean for alumni affairs. Dr. Clever is board certified in internal medicine and occupational medicine.

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Changing Sleep Patterns As We Age

Posted By SHL Librarian

Presented by: Mehrdad Ayati, MD
Clinical Instructor, Internal Medicine
Stanford University Medical Center
April 19, 2012

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You go to bed, only to start tossing and turning, with no rest in sight. Or you fall asleep, only to wake up at 3 am. Having trouble falling asleep—or staying asleep—is a common problem, especially among older people.

But what is sleep exactly? And why does it become so elusive as we age? The reasons can range from physiological factors, such as chronic pain, hormones, or gastrointestinal problems, to environmental elements like light or noise, according to Mehrdad Ayati, MD, a clinical instructor of medicine, who spoke at a presentation sponsored by the Stanford Health Library.

We spend about eight hours a day, 56 hours a week, and 2,920 hours a year sleeping—almost a full third of our lives. But though sensory activity and voluntary muscles are on low, our brains are still quite active.

“Sleep is still a mystery,” said Dr. Ayati, “but we are understanding more about its function and what factors can affect our ability to sleep.”

Series of Cycles
Sleep involves a series of cycles triggered by a complex group of neurochemicals that respond to cues from the body and the environment. This sleep pattern follows an alternating cycle throughout the night. The first phase is called slow wave sleep, which is the deepest and most restorative stage. Slow brain waves occur at the beginning of the night, with a deep drop of consciousness. As we get older, however, there is a marked drop in these stages of our deepest sleep.

About 25 percent of sleep involves rapid eye movement (REM), the second cycle, which is associated with dreaming. REM sleep is sometimes called paradoxical sleep because the brain is still quite active. Blood pressure is low and muscles are inactive during REM sleep to prevent us from acting out our dreams. REM phases can last from five to 30 minutes, and most people can recall at least snatches of their dreams if they are wakened from this cycle. People with dementia tend to have more REM sleep and can develop REM sleep behavior disorders like sleepwalking.

Sleep is regulated by a complex network driven by several neurotransmitters, including acetylecholine, which appears to affect dreams; dopamine, which enhances wakefulness and alertness; and histamine, which can induce wakefulness (which is why many antihistamines cause drowsiness).

These neurotransmitters work in conjunction with our circadian clock, a biological time keeper that synchronizes our chemicals, hormones, body temperature, and sleep patterns. The circadian clock is also involved in the production of melatonin, a hormone produced by the pineal gland in the brain that is suppressed by light. Among other influences, melatonin regulates the core body temperature and circulation.

Together these processes control when we sleep and how deeply we sleep, said Dr. Ayati. For example, younger people spend more time sleeping and a greater percentage of sleep in a REM state compared with adults. He also described a typical wake-sleep cycle: Highest melatonin rates occur around 9 pm and production stops at 7:30 am; highest body temperature and blood pressure take place around 7 pm; deepest sleep takes place at 2 am, followed by lowest body temperature at 4:30 am.

Factors that can Affect Sleep
But as we get older, more internal and external factors can make sleep elusive or less satisfying. We spend more time in bed but more time awake, and the kind of sleep we get is the lighter stage. Dr. Ayati said close to 40 percent of older women develop sleep problems, usually related to hormone changes associated with menopause.

Sleep can also be affected by COPD and other respiratory problems; gastrointestinal ailments like irritable bowel syndrome; blood sugar fluctuations from diabetes; and chronic pain stemming from fibromyalgia and arthritis. There is a strong association between cardiovascular disease and sleep problems: people with sleep apnea, for example, are at a higher risk for heart attack.

But simply getting older may be the biggest cause of problematic sleep patterns. About 40 percent of older adults report having trouble falling asleep, and 30 percent report waking up in the middle of the night. About half use medication to help induce sleep, and more than half report experiencing daytime drowsiness. Almost two-thirds have some physical condition that can affect sleep.

Dr. Ayati said a key problem is that circadian rhythms change, causing sleep to become more fragmented, with disruptions from tossing and turning, and trips to the bathroom (a condition called nocturnia). For many people this change might be due to lifestyle changes, such as losing a loved one or limited social contact, which can cause anxiety. Because of physiological changes, medications, alcohol, and stimulants can also exert more influence over sleep patterns. Common prescriptions like antidepressants can actually make matters worse, he added.

“Older people are awake longer and more susceptible to changes in routine,” he said. “Over time the circadian cycle will change by itself.”

In hospitals and nursing homes, circadian cycles are affected by daytime napping, inactivity, noise, medication, and changes in routine.

Management and Treatment
A change in sleep hygiene is the best first step to managing and treating sleep problems.

“You can help yourself find your own circadian rhythm,” Dr. Ayati said. ”Go to bed the same time every day—even on weekends—and never go to bed unless you are sleepy. The bed is not the place to read, watch TV, or think.”

Though not a big proponent of naps, he did say that short naps of 15-20 minutes can be helpful for some people. He also suggested:

  • Stay in bed only when asleep and get up as soon as you awaken
  • Exercise daily but not just before bedtime
  • Relax mentally before getting ready for bed
  • A light snack is OK unless you have reflux
  • Cut out caffeine, alcohol, and nicotine
  • Control the noise, light, and temperature in your bedroom
  • If you can’t sleep after 30 minutes, get up but keep lights low

He also recommends using cognitive behavioral therapy, a psychotherapeutic approach designed to influence behaviors and perceptions by modifying mental processes. Other approaches may include bright light therapy to enhance melatonin production and relaxation techniques. Prescription or over-the-counter medications can help but only as a short-term remedy since they can cause even more sleeping problems, he said.

About the Speaker
Mehrdad Ayati, MD, is a clinical instructor of internal medicine with a special focus in geriatric medicine. He received his medical degree from the Iran University of Medical Sciences. He completed his internship and residency at the University of California, Davis, and his fellowship at Stanford.

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