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Iftikhar S, Sameer HM, Zainab. Significant potential of melatonin therapy in Parkinson's disease - a meta-analysis of randomized controlled trials. Front Neurol 2023; 14:1265789. [PMID: 37881313 PMCID: PMC10597669 DOI: 10.3389/fneur.2023.1265789] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023] Open
Abstract
Objective Since its discovery as an antioxidant, melatonin has been increasingly recognized for its therapeutic potential beyond sleep disturbances in neurodegenerative disorders. This study aims to evaluate efficacy of various melatonin doses, treatment durations, and formulations, in alleviating motor symptoms and sleep disturbances in Parkinson's disease, the second most common neurodegenerative disorder worldwide. Methods PubMed, Cochrane Library, ClinicalTrials.gov and other databases were systematically searched to retrieve randomized controlled trials (RCTs) administrating melatonin to Parkinson's disease patients until June 10th, 2023. Outcomes including Unified Parkinson Disease Rating Scale (UPDRS) scores and Pittsburgh Sleep Quality Index (PSQI) scores, were pooled and reported as mean differences (MD) with 95% confidence intervals (CIs). Meta-analysis was performed using an inverse variance random-effects model in Review Manager 5.4 software. Trial Sequential Analysis was performed to avoid false-positive results from random errors. Results Five RCTs with a total of 155 patients were included. Statistically significant reductions in UPDRS total scores were observed in groups receiving Melatonin ≥10 mg/day (MD = -11.35, 95% CI: -22.35 to -0.35, I2 = 0%, p = 0.04) and immediate release formulations (MD = -11.35, 95% CI: -22.35 to -0.35, I2 = 0%, p = 0.04). No significant effects on individual UPDRS II, III, and IV scores were observed, regardless of melatonin dosage and treatment duration. Moreover, significant improvements in PSQI scores were observed with only immediate-release melatonin formulations (MD = -2.86, 95% CI: -4.74 to -0.97, I2 = 0%, p = 0.003). Conclusion Melatonin ≥10 mg/day for a minimum duration of ≥12 weeks in immediate-release formulations consistently demonstrated significant therapeutic potential in improving motor symptom and sleep disturbances in Parkinson disease. However, further trials are warranted to investigate its impact when initiated early in the disease course to fully explore its true therapeutic potential. Systematic review registration Unique identifier: CRD42023427491 (PROSPERO).
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Affiliation(s)
- Sadaf Iftikhar
- Department of Neurology, King Edward Medical University/Mayo Hospital, Lahore, Pakistan
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2
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Choi K, Lee YJ, Park S, Je NK, Suh HS. Efficacy of melatonin for chronic insomnia: Systematic reviews and meta-analyses. Sleep Med Rev 2022; 66:101692. [PMID: 36179487 DOI: 10.1016/j.smrv.2022.101692] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/29/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022]
Abstract
We conducted systematic reviews and meta-analyses to evaluate the efficacy of melatonin versus placebo or other hypnotic agents in improving sleep quality and quantity in patients with chronic insomnia. A literature search on Ovid-MEDLINE, EMBASE, and the Cochrane Library was performed up to November 2020. Sleep onset latency, total sleep time, sleep efficiency, sleep quality and quality of life were examined as outcomes. We identified 24 randomized controlled trials of chronic insomnia including four studies of patients with comorbid insomnia. All studies were compared with placebo. Due to heterogeneity, we conducted subgroup analyses by age group. In non-comorbid insomnia, melatonin was only significantly effective in sleep onset latency and total sleep time in children and adolescents. In adults group, melatonin was not significantly effective in improving sleep onset latency, total sleep time, and sleep efficiency. In comorbid insomnia, melatonin significantly improved sleep onset latency in all age groups, but there was only one study in adults group. In conclusion, melatonin did not appear to be effective in adults but might be effective in children and adolescents with chronic insomnia for both comorbid insomnia and non-comorbid insomnia. Further studies are needed to establish the efficacy and safety of melatonin by age groups.
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Affiliation(s)
- Kyungseon Choi
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, South Korea; College of Pharmacy, Kyung Hee University, Seoul, South Korea
| | - Yu Jeong Lee
- College of Pharmacy, Pusan National University, Busan, South Korea; Department of Pharmacy, Pusan National University Hospital, Busan, South Korea
| | - Seonyoung Park
- College of Pharmacy, Pusan National University, Busan, South Korea
| | - Nam Kyung Je
- College of Pharmacy, Pusan National University, Busan, South Korea
| | - Hae Sun Suh
- Department of Regulatory Science, Graduate School, Kyung Hee University, Seoul, South Korea; College of Pharmacy, Kyung Hee University, Seoul, South Korea.
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3
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Essential Oils and Melatonin as Functional Ingredients in Dogs. Animals (Basel) 2022; 12:ani12162089. [PMID: 36009679 PMCID: PMC9405278 DOI: 10.3390/ani12162089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/07/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
Simple Summary Phytogenics are plant-based compounds with beneficial actions in feed technology and/or animal health. These so-called plant secondary metabolites are very diverse and with wide possible applications in humans and animals. Among them, essential oils (EOs) are the most used in feed for livestock and pets. Lately, melatonin has acquired new and interesting applications in dogs. Recent studies using EOs and/or melatonin in dog feeding and their involvement in health aspects are presented. Abstract The use of nutraceuticals or functional ingredients is increasingly widespread in human food; their use is also widespread in animal feed. These natural compounds generally come from plant materials and comprise a wide range of substances of a very diverse chemical nature. In animals, these compounds, so-called phytogenics, are used to obtain improvements in feed production/stability and also as functional components with repercussions on animal health. Along with polyphenols, isoprenoid compounds represent a family of substances with wide applications in therapy and pet nutrition. Essential oils (EOs) are a group of complex substances with fat-soluble nature that are widely used. Melatonin is an indolic amine present in all living with amphiphilic nature. In this work, we present a review of the most relevant phytogenics (polyphenol, isoprenoid, and alkaloid compounds), their characteristics, and possible uses as nutraceuticals in dogs, with special emphasis on EOs and their regulatory aspects, applied in foods and topically. Additionally, a presentation of the importance of the use of melatonin in dogs is developed, giving physiological and practical aspects about its use in dog feeding and also in topical application, with examples and future projections. This review points to the combination of EOs and melatonin in food supplements and in the topical application as an innovative product and shows excellent perspectives aimed at addressing dysfunctions in pets, such as the treatment of stress and anxiety, sleep disorders, alopecia, and hair growth problems, among others.
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4
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Effect of melatonin supplementation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. J Neurol 2022; 269:205-216. [PMID: 33417003 DOI: 10.1007/s00415-020-10381-w] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The Present study was conducted to systematically review the effect of the melatonin on sleep quality. We summarized evidence from randomized clinical trials (RCTs) that investigated the effects of melatonin on sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) in adults with various diseases. METHODS The literature searches of English publications in MEDLINE and EMBASE databases were performed up June 2020. Results were summarized as mean differences (MD) with 95% confidence intervals (CI) using random effects model (DerSimonian-Laird method). Heterogeneity among studies was evaluated by the Cochrane Q test and I-squared (I2). To determine the predefined sources of heterogeneity, subgroup analysis was performed. RESULTS Of 2642 papers, 23 RCTs met inclusion criteria. Our results indicated that melatonin had significant effect on sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) (WMD: - 1.24; 95% CI - 1.77, - 0.71, p = 0.000). There was significant heterogeneity between studies (I2 = 80.7%, p = 0.000). Subgroup analysis based on health status and kind of intervention were potential between-study heterogeneity. Subgroup analysis based on health status revealed melatonin intervention in subjects with Respiratory diseases (WMD: - 2.20; 95% CI - 2.97, - 1.44, p = 0.000), Metabolic disorders (WMD: - 2.74; 95% CI - 3.48, - 2.00, p = 0.000) and sleep disorders (WMD: - 0.67; 95% CI - 0.98, - 0.37, p = 0.000) has significant effect on sleep quality. CONCLUSION We found that the treatment with exogenous melatonin has positive effects on sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) in adult. In adults with respiratory diseases, metabolic disorders, primary sleep disorders, not with mental disorders, neurodegenerative diseases and other diseases.
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5
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Naveed M, Li LD, Sheng G, Du ZW, Zhou YP, Nan S, Zhu MY, Zhang J, Zhou QG. Agomelatine: An astounding sui-generis antidepressant? Curr Mol Pharmacol 2021; 15:943-961. [PMID: 34886787 DOI: 10.2174/1874467214666211209142546] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/09/2021] [Accepted: 06/25/2021] [Indexed: 11/22/2022]
Abstract
Major depressive disorder (MDD) is one of the foremost causes of disability and premature death worldwide. Although the available antidepressants are effective and well tolerated, they also have many limitations. Therapeutic advances in developing a new drug's ultimate relation between MDD and chronobiology, which targets the circadian rhythm, have led to a renewed focus on psychiatric disorders. In order to provide a critical analysis about antidepressant properties of agomelatine, a detailed PubMed (Medline), Scopus (Embase), Web of Science (Web of Knowledge), Cochrane Library, Google Scholar, and PsycInfo search was performed using the following keywords: melatonin analog, agomelatine, safety, efficacy, adverse effects, pharmacokinetics, pharmacodynamics, circadian rhythm, sleep disorders, neuroplasticity, MDD, bipolar disorder, anhedonia, anxiety, generalized anxiety disorder (GAD), and mood disorders. Agomelatine is a unique melatonin analog with antidepressant properties and a large therapeutic index that improves clinical safety. It is a melatonin receptor agonist (MT1 and MT2) and a 5-HT2C receptor antagonist. The effects on melatonin receptors enable the resynchronization of irregular circadian rhythms with beneficial effects on sleep architectures. In this way, agomelatine is accredited for its unique mode of action, which helps to exert antidepressant effects and resynchronize the sleep-wake cycle. To sum up, an agomelatine has not only antidepressant properties but also has anxiolytic effects.
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Affiliation(s)
- Muhammad Naveed
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Lian-Di Li
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Gang Sheng
- Key Laboratory of Cardiovascular and Cerebrovascular Medicine, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Zi-Wei Du
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Ya-Ping Zhou
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Sun Nan
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Ming-Yi Zhu
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Jing Zhang
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
| | - Qi-Gang Zhou
- Department of Clinical Pharmacology, School of Pharmacy, Nanjing Medical University, Nanjing 211166. China
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Nishimon S, Nishino N, Nishino S. Advances in the pharmacological management of non-24-h sleep-wake disorder. Expert Opin Pharmacother 2021; 22:1039-1049. [PMID: 33618599 DOI: 10.1080/14656566.2021.1876665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Introduction: Melatonin, a hormone that regulates circadian rhythms and the sleep-wake cycle, is produced mainly during the dark period in the pineal gland and is suppressed by light exposure. Patients with non-24-h sleep-wake disorder (non-24) fail to entrain the master clock with the 24-h light-dark cycle due to the lack of light perception to the suprachiasmatic nucleus typically in totally blind individuals or other organic disorders in sighted individuals, causing a progressive delay in the sleep-wake cycle and periodic insomnia and daytime sleepiness.Areas covered: Herein, the authors review the pharmacological therapies including exogenous melatonin and melatonin receptor agonists for the management of non-24. They introduce a historical report about the effects of melatonin on the phase shift and entrainment for blind individuals with the free-running circadian rhythm.Expert opinion: Orally administered melatonin entrains the endogenous circadian rhythm and improves nighttime sleep and daytime alertness for non-24. Currently, tasimelteon is the only approved medication for non-24 by the US Food and Drug Administration and the European Medicines Agency. Treatments that focus only on sleep problems are insufficient for the treatment of non-24, and aids to entrain the free-running rhythm with the light-dark cycle are needed.
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Affiliation(s)
- Shohei Nishimon
- Sleep and Circadian Neurobiology Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, USA.,Department of Psychiatry and Behavioral Science, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Naoya Nishino
- Sleep and Circadian Neurobiology Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, USA
| | - Seiji Nishino
- Sleep and Circadian Neurobiology Laboratory, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, USA
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Greten S, Müller-Funogea JI, Wegner F, Höglinger GU, Simon N, Junius-Walker U, Gerbel S, Krause O, Klietz M. Drug safety profiles in geriatric patients with Parkinson's disease using the FORTA (Fit fOR The Aged) classification: results from a mono-centric retrospective analysis. J Neural Transm (Vienna) 2020; 128:49-60. [PMID: 33263172 PMCID: PMC7815558 DOI: 10.1007/s00702-020-02276-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022]
Abstract
To reduce potentially inappropriate medications, the FORTA (Fit fOR The Aged) concept classifies drugs in terms of their suitability for geriatric patients with different labels, namely A (indispensable), B (beneficial), C (questionable), and D (avoid). The aims of our study were to assess the medication appropriateness in PD inpatients applying the FORTA list and drug-drug interaction software, further to assess the adequacy of FORTA list for patients with PD. We retrospectively collected demographic data, comorbidities, laboratory values, and the medication from the discharge letters of 123 geriatric inpatients with PD at the university hospital of Hannover Medical School. Patients suffered on average from 8.2 comorbidities. The majority of the medication was labeled A (60.6% of PD-specific and 40.9% of other medication) or B (22.3% of PD-specific and 26.9% of other medication). Administered drugs labeled with D were amantadine, clozapine, oxazepam, lorazepam, amitriptyline, and clonidine. Overall, 545 interactions were identified, thereof 11.9% severe interactions, and 1.7% contraindicated combinations. 81.3% of patients had at least one moderate or severe interaction. The FORTA list gives rational recommendations for PD-specific and other medication, especially for general practitioners. Considering the demographic characteristics and the common multimorbidity of geriatric PD patients, this study underlines the importance of awareness, education, and preventive interventions to increase drug safety.
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Affiliation(s)
- S Greten
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - J I Müller-Funogea
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - F Wegner
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - G U Höglinger
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - N Simon
- Centre for Information Management (ZIMT), Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - U Junius-Walker
- Department of General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - S Gerbel
- Centre for Information Management (ZIMT), Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - O Krause
- Department of General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - M Klietz
- Department of Neurology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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8
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Ahn JH, Kim M, Park S, Jang W, Park J, Oh E, Cho JW, Kim JS, Youn J. Prolonged-release melatonin in Parkinson's disease patients with a poor sleep quality: A randomized trial. Parkinsonism Relat Disord 2020; 75:50-54. [PMID: 32480307 DOI: 10.1016/j.parkreldis.2020.03.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The present study was a randomized, double-blind, placebo-controlled, multi-center trial to evaluate the efficacy and safety of prolonged-release melatonin (PRM) in Parkinson's disease (PD) patients with poor sleep quality. METHODS PD patients with a global Pittsburgh Sleep Quality Index (PSQI) score > 5 were included. Patients were assessed using the PSQI, a rapid eye movement sleep behavior disorder screening questionnaire, the Epworth Sleepiness Scale, Non-Motor Symptoms Scale (NMSS), Parkinson's Disease Quality of Life-39 (PDQ-39), and Unified Parkinson's Disease Rating Scale (UPDRS)-III at the beginning of the study and after 4 weeks of treatment with 2 mg of PRM. Partial correlation analysis was performed to investigate the relationship between PSQI score and the other scales. RESULTS Thirty-four PD patients with poor sleep quality were enrolled and divided into 2 groups based on medication; PRM (n = 16) and placebo (n = 18). Regarding efficacy, PSQI was significantly improved in the PRM group compared to the control group. Improvement in the NMSS and PDQ-39 summary index were observed in the PRM but not in the placebo group; UPDRS-III score was not significantly changed in either group. PSQI improvement correlated with improvement in NMSS score and PDQ-39 summary index. Regarding safety, all enrolled subjects did not complain of side effects due to PRM. CONCLUSION PRM is an effective and safe treatment option for subjective sleep quality in PD patients and beneficial effects on sleep quality are associated with improved non-motor symptoms and quality of life in PD patients.
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Affiliation(s)
- Jong Hyeon Ahn
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Neuroscience Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Minkyeong Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Neuroscience Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Hospital, Seoul, Republic of Korea
| | - Wooyoung Jang
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Republic of Korea
| | - Jinse Park
- Department of Neurology, Haeundae Paik Hospital, Inje University, Busan, Republic of Korea
| | - Eungseok Oh
- Department of Neurology, Chungnam National University Hospital, College of Medicine, Daejun, Republic of Korea
| | - Jin Whan Cho
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Neuroscience Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Ji Sun Kim
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Neuroscience Center, Samsung Medical Center, Seoul, Republic of Korea.
| | - Jinyoung Youn
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; Neuroscience Center, Samsung Medical Center, Seoul, Republic of Korea.
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Development of a Phytomelatonin-Rich Extract from Cultured Plants with Excellent Biochemical and Functional Properties as an Alternative to Synthetic Melatonin. Antioxidants (Basel) 2020; 9:antiox9020158. [PMID: 32079061 PMCID: PMC7070989 DOI: 10.3390/antiox9020158] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022] Open
Abstract
Melatonin is a pleiotropic molecule with multiple and various functions. In recent years, there has been a considerable increase in the consumption of melatonin supplements for reasons other than those related with sleep (as an antioxidant, for anti-aging, and as a hunger regulator). Although the chemical synthesis of melatonin has recently been improved, several unwanted by-products of the chemical reactions involved occur as contaminants. Phytomelatonin, melatonin of plant origin, was discovered in several plants in 1995, and the possibility of using raw plant material as a source to obtain dietary supplements rich in phytomelatonin instead of synthetic melatonin, with its corresponding chemical by-products was raised. This work characterizes the phytomelatonin-rich extract obtained from selected plant material and determines the contents in phytomelatonin, phenols, flavonoids, and carotenoids. Additionally, the antioxidant activity was measured. Finally, a melatonin-specific bioassay in fish was carried out to demonstrate the excellent biological properties of the natural phytomelatonin-rich extract obtained.
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Low TL, Choo FN, Tan SM. The efficacy of melatonin and melatonin agonists in insomnia - An umbrella review. J Psychiatr Res 2020; 121:10-23. [PMID: 31715492 DOI: 10.1016/j.jpsychires.2019.10.022] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 10/25/2019] [Accepted: 10/31/2019] [Indexed: 01/19/2023]
Abstract
We conducted an umbrella review to summarize all available systematic reviews and meta-analyses investigating the efficacy of melatonin and melatonin agonists in primary and comorbid insomnia disorders. Two independent reviewers conducted a search of Pubmed, EMBASE, Cochrane Database of Systematic Reviews, Google Scholar, PROSPERO and grey literature from inception to July 2018. Methodological quality was assessed using the revised Assessment of Multiple Systematic Reviews Instrument. Eighteen studies were found, with methodological quality ranging from Moderate to Critically Low. Of the twelve papers evaluating melatonin, there is statistically significant improvement in sleep latency and total sleep time, with a lack of consensus on whether these are clinically meaningful. Similar results are observed across the three reviews on ramelteon. The evidence for other melatonin agonists is sparse. We conclude that existing evidence is limited by disparate methodological quality of the papers, as well as a lack of consensus regarding the type, definition and interpretation of outcome measures in the evaluation of efficacy for insomnia.
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Affiliation(s)
- Tian Ling Low
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, 119228, Singapore.
| | - Faith Nadine Choo
- Yong Loo Lin School of Medicine, National University of Singapore, 1E Kent Ridge Road, 119228, Singapore
| | - Shian Ming Tan
- Department of Psychiatry, Sengkang General Hospital, 110 Sengkang E Way, 544886, Singapore
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11
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Elsabagh HH, Moussa E, Mahmoud SA, Elsaka RO, Abdelrahman H. Efficacy of Melatonin in prevention of radiation-induced oral mucositis: A randomized clinical trial. Oral Dis 2020; 26:566-572. [PMID: 31869853 DOI: 10.1111/odi.13265] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/26/2019] [Accepted: 12/17/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Evaluating the effectiveness of melatonin in prevention of radiation-induced oral mucositis. MATERIAL AND METHODS A randomized controlled clinical study was conducted on forty head and neck cancer (HNC) patients undergoing radiotherapy at the Department of Clinical Oncology, Alexandria University, Egypt. Patients were assigned equally to either control group who received conventional treatment or test group who received 20 mg of melatonin along with the conventional treatment. All patients were clinically evaluated for oral mucositis severity and pain at three and six weeks after the start of radiotherapy. Additionally, the total antioxidant capacity (TAC) in patients' saliva samples was assessed at the start of radiotherapy and six weeks later. RESULTS 92.5% of all patients have experienced oral mucositis with more severity reported in the control group (30%) compared with the test group (5%). Mean pain scores decreased significantly, in the second assessment, in test group rather than the controls. TAC values showed a significant difference between the test and controls with a significant decrease in TAC in the control group. CONCLUSION The administration of melatonin with conventional treatment has reduced severe oral mucositis development. It aided in decreasing pain and hindering the reduction of TAC resulting from radiotherapy among the test group compared with controls.
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Affiliation(s)
- Hossam H Elsabagh
- Oral Medicine, Periodontology, Oral Diagnosis and Oral Radiology Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Eglal Moussa
- Oral Medicine, Periodontology, Oral Diagnosis and Oral Radiology Department, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
| | - Sabah A Mahmoud
- Medical Biochemistry Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Rasha O Elsaka
- Clinical Oncology and Nuclear Medicine department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hams Abdelrahman
- Pediatric Dentistry and Dental Public Health, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
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12
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Salas-Crisóstomo M, Torterolo P, Veras AB, Rocha NB, Machado S, Murillo-Rodríguez E. Therapeutic Approaches for the Management of Sleep Disorders in Geriatric Population. Curr Med Chem 2019; 26:4775-4785. [PMID: 30182852 DOI: 10.2174/0929867325666180904113115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/25/2017] [Accepted: 08/16/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Aging is a natural biological phenomenon that occurs in human beings. With increasing of age, there is an appearance of deleterious changes related to progression onto pathological conditions, including hypertension, heart disease, diabetes, hearing and vision impairments, as well as sleep disorders. It is important to recognize that some sleep disturbances reported by aged subjects include insomnia, obstructive sleep apnea, restless legs syndrome, among others. Moreover, accumulating evidence indicates that coexistence of medical issues with sleep disorders constitutes clinical challenges for treatment of comorbidities in elderly. Here, we have attempted to review and summarize the available literature that assesses the sleep disturbances in aging. In addition, we highlight the management of sleep disorders associated with aging. Due to the particular health condition of aged adults, the development of effective pharmacological interventions for sleep disorders treatment in aging is warranted. METHODS Review of studies retrieved from the PubMed. RESULTS The sleep-wake cycle includes abnormalities classified as sleep disorders. Comorbidity between sleep disturbances and aging-related health issues will represent a public health challenge to be addressed in the near future. Moreover, this scenario will suggest an area that requires further drug investigation and design of new pharmacological and pharmaceutical strategies to treat sleep disorders in the elderly population. CONCLUSION The review highlights the sleep disturbances in aging. We focus on current knowledge in medicinal chemistry and further design of new treatments tools for managing sleep disturbances in the aged population.
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Affiliation(s)
- Mireille Salas-Crisóstomo
- Laboratorio de Neurociencias Moleculares e Integrativas. Escuela de Medicina División Ciencias de la Salud. Universidad Anáhuac Mayab, Mérida, Yucatán, México.,Grupo de Investigacion en Envejecimiento. Division Ciencias de la Salud, Universidad Anahuac Mayab. Merida, Yucatan, Mexico.,Intercontinental Neuroscience Research Group, Montevideo, Uruguay
| | - Pablo Torterolo
- Intercontinental Neuroscience Research Group, Montevideo, Uruguay.,Laboratorio de Neurobiologia del Sueno. Depto. de Fisiologia, Facultad de Medicina, Universidad de la Republica, Montevideo, Uruguay
| | - André Barciela Veras
- Intercontinental Neuroscience Research Group, Montevideo, Uruguay.,Institute of Psychiatry. Federal University of Rio de Janeiro. Rio de Janeiro, Brazil.,Dom Bosco Catholic University. Campo Grande, Mato Grosso del Sur, Brazil
| | - Nuno Barbosa Rocha
- Intercontinental Neuroscience Research Group, Montevideo, Uruguay.,Health School Sciences, Polytechnic Institute of Porto, Porto, Portugal
| | - Sérgio Machado
- Intercontinental Neuroscience Research Group, Montevideo, Uruguay.,Laboratory of Panic and Respiration, Institute of Psychiatry of Federal University of Rio de Janeiro, Rio de Janeiro. Brazil.,Physical Activity Neuroscience Laboratory, Physical Activity Sciences Postgraduate Program of Salgado de Oliveira University. Niterói, Brazil
| | - Eric Murillo-Rodríguez
- Laboratorio de Neurociencias Moleculares e Integrativas. Escuela de Medicina División Ciencias de la Salud. Universidad Anáhuac Mayab, Mérida, Yucatán, México.,Grupo de Investigacion en Envejecimiento. Division Ciencias de la Salud, Universidad Anahuac Mayab. Merida, Yucatan, Mexico.,Intercontinental Neuroscience Research Group, Montevideo, Uruguay
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Abstract
PURPOSE OF REVIEW To explore the evidence for using exogenous melatonin in the treatment of sleep disorders, both primary and secondary, in children and adults. RECENT FINDINGS A number of recently published meta-analyses have shown that there is evidence for the efficacy of exogenously administered melatonin in a number of sleep disorders. However, melatonin is likely to be prescribed largely for reasons of perceived minimal side-effect profile and very low cost in situations in which high-quality evidence for its usefulness is not forthcoming. SUMMARY There is evidence for the efficacy of melatonin in the management of insomnia and some intrinsic disorders of circadian rhythm in adults and children as well as in reducing sleep onset latency in jet-lag and shift work disorder in adults. Melatonin is used routinely in the treatment of rapid-eye movement sleep-behaviour disorder despite limited trial evidence. Increasingly, dual melatonin receptor agonists are being trialled in a variety of sleep disorders. Long-term adverse effects are currently not fully identified.
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Amaral FGD, Andrade-Silva J, Kuwabara WMT, Cipolla-Neto J. New insights into the function of melatonin and its role in metabolic disturbances. Expert Rev Endocrinol Metab 2019; 14:293-300. [PMID: 31192707 DOI: 10.1080/17446651.2019.1631158] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Melatonin is a pineal hormone that has acquired several unique modes of regulating the physiological effects in mammals due to its characteristic phylogenetic history. While melatonin exhibits immediate nocturnal effects, it also has next-day prospective effects that take place in the absence of this hormone. Besides that, the daily repetition and the annual variation in the duration of its synthesis determine its circadian and seasonal effects that characterize melatonin as a chronobiotic, a molecule that encodes time to the internal environment. Additionally, it presents transgenerational effects that are important for fetal programming, leading to a balanced energy metabolism in the adult life. AREAS COVERED Physiology, pathophysiology and therapeutic value of melatonin in metabolism and metabolic disorders. EXPERT OPINION The typical mechanisms of action of melatonin (immediate, prospective, chronobiotic and transgenerational) should be considered to adequately understand its physiological effects on the regulation of metabolism in humans and, as a result, to understand the metabolic pathophysiological consequences caused by its synthesis and/or signaling disturbances. That points to the importance of a broader understanding of melatonin actions, besides the classical endocrinological point of view, that would allow the clinician/research to proper interpret its role in health maintenance.
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Affiliation(s)
| | - Jéssica Andrade-Silva
- b Department of Physiology and Biophysics , Institute of Biomedical Sciences, University of São Paulo , São Paulo , Brazil
| | - Wilson M T Kuwabara
- b Department of Physiology and Biophysics , Institute of Biomedical Sciences, University of São Paulo , São Paulo , Brazil
| | - José Cipolla-Neto
- b Department of Physiology and Biophysics , Institute of Biomedical Sciences, University of São Paulo , São Paulo , Brazil
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15
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16
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Nishimon S, Nishimon M, Nishino S. Tasimelteon for treating non-24-h sleep-wake rhythm disorder. Expert Opin Pharmacother 2019; 20:1065-1073. [DOI: 10.1080/14656566.2019.1603293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Shohei Nishimon
- Sleep and Circadian Neurobiology Laboratory, Psychiatry and Behavior Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mari Nishimon
- Sleep and Circadian Neurobiology Laboratory, Psychiatry and Behavior Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Seiji Nishino
- Sleep and Circadian Neurobiology Laboratory, Psychiatry and Behavior Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
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17
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Jun JS, Kim R, Byun JI, Kim TJ, Lim JA, Sunwoo JS, Lee ST, Jung KH, Park KI, Chu K, Kim M, Lee SK, Jung KY. Prolonged-release melatonin in patients with idiopathic REM sleep behavior disorder. Ann Clin Transl Neurol 2019; 6:716-722. [PMID: 31019996 PMCID: PMC6469244 DOI: 10.1002/acn3.753] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 01/30/2019] [Accepted: 02/07/2019] [Indexed: 11/10/2022] Open
Abstract
Objective We investigated the effects of prolonged-release melatonin (PRM) on idiopathic rapid eye movement (REM) sleep behavior disorder (iRBD). Methods In this 4-week, randomized, double-blind, placebo-controlled pilot study, 30 participants with polysomnography-confirmed iRBD were assigned to receive PRM 2 mg per day, PRM 6 mg per day, or placebo. Medication was administered orally 30 min before bedtime. Primary outcomes included scores from the Clinical Global Impression-Improvement (CGI-I) and the Korean version of the RBD questionnaire-Hong Kong (RBDQ-KR). The secondary outcomes included RBDQ-KR factor 1 and factor 2 subscores, the Pittsburgh Sleep Quality Index score, the Epworth Sleepiness Scale score, the Short Form Health Survey version 2 score, and the frequency of dream-enacting behaviors assessed using a sleep diary. Results After 4 weeks, there were no differences in the proportions of patients with a CGI-I score of much improved or very much improved among the study groups. In addition, RBDQ-KR scores and secondary outcomes were not improved in all groups at 4 weeks, and there were no differences between the groups. Conclusion Our findings suggest that PRM may not be effective in treating RBD-related symptoms within the dose range used in this study. Further studies using doses higher than 6 mg per day are warranted.
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Affiliation(s)
- Jin-Sun Jun
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea.,Department of Neurosurgery Seoul National University Hospital Seoul Republic of Korea
| | - Ryul Kim
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Jung-Ick Byun
- Department of Neurology Kyung Hee University Hospital at Gangdong Seoul Republic of Korea
| | - Tae-Joon Kim
- Department of Neurology Ajou University School of Medicine Suwon Republic of Korea
| | - Jung-Ah Lim
- Department of Neurology Kangnam Sacred Heart Hospital Hallym University College of Medicine Seoul Republic of Korea
| | - Jun-Sang Sunwoo
- Department of Neurology Soonchunhyang University Seoul Hospital Seoul Republic of Korea
| | - Soon-Tae Lee
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Keun-Hwa Jung
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Kyung-Il Park
- Department of Neurology Seoul National University Healthcare System Gangnam Center Seoul Republic of Korea
| | - Kon Chu
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Manho Kim
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Sang Kun Lee
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
| | - Ki-Young Jung
- Department of Neurology Seoul National University Hospital Seoul Republic of Korea
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18
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Frase L, Nissen C, Riemann D, Spiegelhalder K. Making sleep easier: pharmacological interventions for insomnia. Expert Opin Pharmacother 2018; 19:1465-1473. [DOI: 10.1080/14656566.2018.1511705] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Lukas Frase
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Nissen
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
- University Hospital of Psychiatry and Psychotherapy, University Psychiatric Services, Bern, Switzerland
| | - Dieter Riemann
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Kai Spiegelhalder
- Department of Psychiatry and Psychotherapy, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Abstract
PURPOSE OF REVIEW Neurologists, along with all health care providers, commonly encounter patients with insomnia, which is a condition that impacts patients' underlying neurologic conditions in a bidirectional manner. While chronic insomnia is one of the most common sleep disturbances, only a small proportion of individuals with this condition discuss their sleep problems with their providers. When insomnia is described, it is more often in relationship to another medical problem, as opposed to an independent condition. In neurology practice, multiple factors including pain, movement disorders, sleep apnea, and medications that act on the central nervous system often contribute to insomnia. An all-inclusive approach is necessary when evaluating sleep problems in patients with insomnia. RECENT FINDINGS The US Food and Drug Administration (FDA) has approved several medications for the treatment of insomnia that target specific receptor systems in the brain and incorporate several unique pharmacodynamic and pharmacokinetic profiles that can represent customized therapy for specific insomnia phenotypes. FDA-approved medications for insomnia include γ-aminobutyric acid (GABA)-modulating benzodiazepine receptor agonists, a melatonin receptor agonist, a histamine receptor antagonist, and the newest approved option, a hypocretin (orexin) receptor antagonist. SUMMARY This article provides an evidence-based multidisciplinary approach to the treatment of insomnia, highlighting the rationale and utility of cognitive-behavioral therapy and pharmacologic interventions. Neurologists should be proactive in assessing the impact of underlying comorbidities on insomnia, particularly in the setting of psychiatric conditions such as depression, sleep disorders such as circadian rhythm disorders, and medical problems such as nocturia.
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20
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Paemanee A, Hitakarun A, Roytrakul S, Smith DR. Screening of melatonin, α-tocopherol, folic acid, acetyl-L-carnitine and resveratrol for anti-dengue 2 virus activity. BMC Res Notes 2018; 11:307. [PMID: 29769094 PMCID: PMC5956857 DOI: 10.1186/s13104-018-3417-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 05/09/2018] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE Infections with the mosquito transmitted dengue virus (DENV) are a significant public health burden in many parts of the world. Despite the introduction of a commercial vaccine in some parts of the world, the majority of the populations at risk of infection remain unprotected against this disease, and there is currently no treatment for DENV infection. Natural compounds offer the prospect of cheap and sustainable therapeutics to reduce the disease burden during infection, and thus potentially alleviate the risk of more severe disease. This study evaluated the potential anti-DENV 2 activity of five natural compounds namely melatonin, α-tocopherol, folic acid, acetyl-L-carnitine and resveratrol in two different cell lines. RESULTS Screening of the compounds showed that one compound (acetyl-L-carnitine) showed no effect on DENV infection, three compounds (melatonin, α-tocopherol and folic acid) slightly increased levels of infection, while the 5th compound, resveratrol, showed some limited anti-DENV activity, with resveratrol reducing virus output with an EC50 of less than 25 μM. These results suggest that some commonly taken natural compounds may have beneficial effects on DENV infection, but that others may potentially add to the disease burden.
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Affiliation(s)
- Atchara Paemanee
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, Salaya Campus, 25/25 Phuttamonthol Sai 4, Salaya, Nakorn Pathom, 73170, Thailand.,Proteomics Research Laboratory, Genome Technology Research Unit, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency, 113 Thailand Science Park, Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand
| | - Atitaya Hitakarun
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, Salaya Campus, 25/25 Phuttamonthol Sai 4, Salaya, Nakorn Pathom, 73170, Thailand
| | - Sittiruk Roytrakul
- Proteomics Research Laboratory, Genome Technology Research Unit, National Center for Genetic Engineering and Biotechnology, National Science and Technology Development Agency, 113 Thailand Science Park, Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathumthani, 12120, Thailand
| | - Duncan R Smith
- Molecular Pathology Laboratory, Institute of Molecular Biosciences, Mahidol University, Salaya Campus, 25/25 Phuttamonthol Sai 4, Salaya, Nakorn Pathom, 73170, Thailand.
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21
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Mischoulon D. Popular Herbal and Natural Remedies Used in Psychiatry. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2018; 16:2-11. [PMID: 31975894 PMCID: PMC6519573 DOI: 10.1176/appi.focus.20170041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Natural and herbal remedies, also known as "alternative" or "complementary" medicines, have grown tremendously in popularity over the past two decades, becoming a major component of health care and general wellness in the United States and worldwide. The ready availability of these remedies over the counter and their generally good tolerability and safety contribute to this popularity, and many people have benefited from them, often in cases when conventional treatments have failed or caused intolerable side effects. Despite many Food and Drug Administration (FDA)-approved psychotropic medications on the market, efficacy has been inconsistent for some, and many treatment responders will eventually relapse. Continued research on the efficacy and safety of these alternative therapies is, therefore, important. This article reviews six of the most commonly used natural remedies for psychiatric conditions, including the antidepressants St. John's wort, omega-3 fatty acids, and S-adenosyl methionine (SAMe); the sedative-hypnotics valerian and melatonin; and the nootropic ginkgo biloba. We outline the general indications for use, suggested doses, possible mechanisms, and adverse effects to give clinicians a good summary of the benefits and liabilities of each. Although there is growing evidence of efficacy and safety to support the use of these remedies, clinicians must be aware of the limitations of the evidence base and take that into account with all the other factors that contribute to clinical decision making.
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Affiliation(s)
- David Mischoulon
- Dr. Mischoulon is the director of the Depression Clinical and Research Program, Massachusetts General Hospital; and professor of psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston
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22
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Over-the-counter medications containing diphenhydramine and doxylamine used by older adults to improve sleep. Int J Clin Pharm 2017; 39:808-817. [PMID: 28466395 PMCID: PMC5541127 DOI: 10.1007/s11096-017-0467-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/17/2017] [Indexed: 12/11/2022]
Abstract
Background The unintentional misuse of over-the-counter sleep aids among older adults is an important public health problem and a focus of Healthy People 2020. Accordingly, the 2015 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults recommends that individuals 65 years or older avoid use of diphenhydramine and doxylamine; however, many over-the-counter sleep products contain these active ingredients. Objective To identify the proportion of older adults using an over-the-counter medication containing diphenhydramine or doxylamine, and compare their characteristics with older adults using an over-the-counter medication that does not contain these ingredients. Setting Study participants were recruited from the Community Registry of the Pittsburgh Claude D. Pepper Older Americans Independence Center. Method The study sample was taken from a larger survey of 1025 participants on sleep health and over-the-counter sleep medication use conducted from February to April 2015. A subset of 169 participants aged 65 and older reporting taking at least one over-the-counter product to improve sleep within the past 30 days (16.5%) were selected for our analysis on associations between participant characteristics and potentially inappropriate use of over-the-counter sleep medications. Main outcome measure The proportion and characteristics of older adults taking at least one over-the-counter medication containing diphenhydramine or doxylamine. Results Of the 223 over-the-counter sleep medications listed by participants, 115 (52%) contained diphenhydramine or doxylamine. Using the Beers Criteria, we found that more than half of participants (59%) had used a potentially inappropriate over-the-counter medication containing diphenhydramine or doxylamine to improve sleep within the past 30 days. Participants taking at least one diphenhydramine or doxylamine containing medication were less likely to be aware of any safety risks in taking over-the-counter sleep medications than participants not taking these products (38 vs 49%, p = 0.016). Conclusion A majority of older adults in a limited sample from the United States taking an over-the-counter medication to improve sleep are taking a product containing diphenhydramine or doxylamine, both of which are classified as potentially inappropriate for older adults. Awareness of the safety risks of over-the-counter medications and addressing conditions that impact sleep quality could be facilitated through consultation with pharmacists and other healthcare providers.
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23
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Frohnhofen H, Schlitzer J, Netzer N. Schlaf und Schlafstörungen beim alten Menschen. SOMNOLOGIE 2017. [DOI: 10.1007/s11818-017-0102-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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24
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Bougea A, Spantideas N, Lyras V, Avramidis T, Thomaidis T. Melatonin 4 mg as prophylactic therapy for primary headaches: a pilot study. FUNCTIONAL NEUROLOGY 2016; 31:33-7. [PMID: 27027892 DOI: 10.11138/fneur/2016.31.1.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
There is growing evidence that headaches are connected to melatonin secretion. Our aim was to assess the potential effectiveness of melatonin for primary headache prevention. Forty-nine patients (37 with migraine and 12 with chronic tension-type headache, TTH) were prescribed oral melatonin, 4 mg, 30 minutes before bedtime for six months. Forty-one (83.6%) of the 49 patients completed the study, while eight dropped out for personal reasons. A statistically significant reduction in headache frequency was found between baseline and final follow-up after six months of treatment (p=0.033 for TTH patients and p<0.001 for migraineurs). The Headache Impact Test score was significantly reduced in both groups of headache patients (p=0.002 and p<0.001, respectively). At baseline, melatonin levels, measured both during a headache attack and a pain-free period, did not differ between patients with TTH and migraineurs (p=0.539 and p=0.693, respectively), and no statistically significant differences in Hamilton Depression Rating Scale scores were found between the two groups. This pilot study shows promising results, in terms of headache frequency reduction and daily quality of life improvement, in both groups.
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25
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Effects of melatonin in the treatment of asthenia in aneurysmal subarachnoid hemorrhage. Neurochirurgie 2016; 62:295-299. [PMID: 27865517 DOI: 10.1016/j.neuchi.2016.06.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/09/2016] [Accepted: 06/20/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVES Survivors of aneurysmal subarachnoid hemorrhage (aSAH) commonly experience sleep disorders resulting in asthenia. The objective of this prospective study was to determine, in a cohort of patients with treated ruptured intracranial aneurysm (IA), the proportion of asthenia at 2months, in a cohort of patients treated with melatonin and in a control cohort. PATIENTS AND METHODS Twenty consecutive patients admitted for the treatment of ruptured IA and able to answer a standardized questionnaire were included in the study. After evaluation for fatigue at discharge, we divided our population into 2 cohorts of 10 patients: the first cohort was treated with melatonin for a period of 2months; the second cohort had no specific treatment for fatigue. The primary endpoint was the proportion of asthenia at 2months in both groups. Confounding factors, such as depression, autonomy and apathy were evaluated at the same time. RESULTS At discharge, there was no significant difference observed between both groups in terms of mean age and initial clinical status (WFNS, Rankin Scale and Fatigue Severity Scale). At 2months, the mean FSS score in the control group was of 4.7±1.0 versus 3.8±0.9 in the melatonin group (P=0.03). The mean MADRS score in the control group was of 1.1±1.45 versus 2.7±2.5 in the melatonin group (P=0.10). The mean LARS score in the control group was of -32.5±1.7 versus -31.7±1.9 in the melatonin group (P=0.24). DISCUSSION In a prospective evaluation of post-aSAH fatigue, we suggest that melatonin could decrease fatigue. There is no significant impact on depression and apathy. Further studies would be necessary to improve our comprehension of fatigue physiopathology in a context of aSAH.
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26
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Auld F, Maschauer EL, Morrison I, Skene DJ, Riha RL. Evidence for the efficacy of melatonin in the treatment of primary adult sleep disorders. Sleep Med Rev 2016. [PMID: 28648359 DOI: 10.1016/j.smrv.2016.06.005] [Citation(s) in RCA: 181] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Melatonin is a physiological hormone involved in sleep timing and is currently used exogenously in the treatment of primary and secondary sleep disorders with empirical evidence of efficacy, but very little evidence from randomised, controlled studies. The aim of this meta-analysis was to assess the evidence base for the therapeutic effects of exogenous melatonin in treating primary sleep disorders. An electronic literature review search of MEDLINE (1950-present) Embase (1980- present), PsycINFO (1987- present), and Scopus (1990- present), along with a hand-searching of key journals was performed in July 2013 and then again in May 2015. This identified all studies that compared the effect of exogenous melatonin and placebo in patients with primary insomnia, delayed sleep phase syndrome, non 24-h sleep wake syndrome in people who are blind, and rapid eye movement-behaviour disorder. Meta-analyses were performed to determine the magnitude of effect in studies of melatonin in improving sleep. A total of 5030 studies were identified; of these citations, 12 were included for review based on the inclusion criteria of being: double or single-blind, randomised and controlled. Results from the meta-analyses showed the most convincing evidence for exogenous melatonin use was in reducing sleep onset latency in primary insomnia (p = 0.002), delayed sleep phase syndrome (p < 0.0001), and regulating the sleep-wake patterns in blind patients compared with placebo. These findings highlight the potential importance of melatonin in treating certain first degree sleep disorders. The development of large-scale, randomised, controlled trials is recommended to provide further evidence for therapeutic use of melatonin in a variety of sleep difficulties.
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Affiliation(s)
- Fiona Auld
- Department of Sleep Medicine, Royal Infirmary Edinburgh, 51 Little France Crescent, Little France EH16 4SA, Scotland, United Kingdom
| | - Emily L Maschauer
- Department of Sleep Medicine, Royal Infirmary Edinburgh, 51 Little France Crescent, Little France EH16 4SA, Scotland, United Kingdom
| | - Ian Morrison
- Department of Sleep Medicine, Royal Infirmary Edinburgh, 51 Little France Crescent, Little France EH16 4SA, Scotland, United Kingdom; Department of Neurology, Ninewells Hospital, Dundee DD1 9SY, Scotland, United Kingdom
| | - Debra J Skene
- Chronobiology, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7XH, England, United Kingdom
| | - Renata L Riha
- Department of Sleep Medicine, Royal Infirmary Edinburgh, 51 Little France Crescent, Little France EH16 4SA, Scotland, United Kingdom.
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Chung S, Youn S, Park B, Lee S, Kim C. The Effectiveness of Prolonged-Release Melatonin in Primary Insomnia Patients with a Regular Sleep-Wake Cycle. SLEEP MEDICINE RESEARCH 2016. [DOI: 10.17241/smr.2016.00017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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28
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Gregg JA, Tyson RL, Cook D. Benzodiazepines and Geriatrics: What Clinical Practice Strategies Can Be Used to Reduce the Inappropriate Prescribing? Rehabil Nurs 2016; 41:270-5. [DOI: 10.1002/rnj.288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 02/06/2023]
Affiliation(s)
- Jason A. Gregg
- College of Nursing; University of Cincinnati; Cincinnati OH USA
| | - Ronald L. Tyson
- College of Nursing; University of Cincinnati; Cincinnati OH USA
| | - Donna Cook
- College of Nursing; University of Cincinnati; Cincinnati OH USA
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Interventions for Neuropsychiatric Symptoms in Neurocognitive Impairment Due to Alzheimer's Disease: A Review of the Literature. Harv Rev Psychiatry 2015; 23:377-93. [PMID: 26332220 DOI: 10.1097/hrp.0000000000000097] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neurocognitive impairment due to Alzheimer's disease (previously termed Alzheimer's dementia) (AD) is the most common form of cognitive impairment worldwide. Given the anticipated increase in the population aged 65 and over, the prevalence of persons with AD is expected to increase exponentially during the next 30 years. Noncognitive neuropsychiatric symptoms (NPS) commonly occur in AD and are associated with adverse outcomes for patients and their caregivers. This review summarizes randomized, controlled trials (RCTs) published between 2004 and 2014 with a primary outcome measure of change in symptom severity for NPS in AD. Of the 388 articles initially identified through a literature search, 33 trials met inclusion criteria. Fifteen of these studies had agitation/aggression as a targeted symptom. Twenty-eight evaluated pharmacologic treatments, including psychotropics, cognitive enhancers, stimulants, and nutraceuticals. Nonpharmacologic interventions included bright light, music, exercise, and cognitive-stimulation therapies. Among the pharmacologic interventions, modest efficacy was reported with aripiprazole, citalopram, trazodone, methylphenidate, and scheduled analgesics. Significant reduction in symptom severity was reported with nearly all the nonpharmacologic interventions. Variations in methodology such as inclusion criteria, study setting, and outcome measures limit the generalizability of these results. Barriers to the implementation of nonpharmacologic interventions in clinical settings include resource and training limitations. Electroconvulsive therapy and dronabinol are promising as emerging treatment strategies. Randomized clinical trials are needed in order to validate the utility of electroconvulsive therapy and dronabinol, including where and with whom these interventions will prove most valuable.
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Saksvik-Lehouillier I, Harrison SL, Marshall LM, Tranah GJ, Ensrud K, Ancoli-Israel S, Clemons A, Redline S, Stone KL, Schernhammer ES. Association of Urinary 6-Sulfatoxymelatonin (aMT6s) Levels and Objective and Subjective Sleep Measures in Older Men: The MrOS Sleep Study. J Gerontol A Biol Sci Med Sci 2015; 70:1569-77. [PMID: 26265731 DOI: 10.1093/gerona/glv088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/27/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Sleep and melatonin have been associated with healthy aging. In this study, we examine the association between melatonin levels and sleep among older men. METHODS Cross-sectional study of a community-dwelling cohort of 2,821 men aged 65 years or older recruited from six U.S. centers. First morning void urine samples were collected to measure melatonin's major urinary metabolite, 6-sulfatoxymelatonin (aMT6s). We also assessed objective and subjective sleep parameters. We used logistic regression models to calculate multivariate (MV) odds ratios (ORs), and 95% confidence intervals (CIs) adjusted for important demographic variables and comorbidities. RESULTS In the overall sample, the only significant finding in fully adjusted models was that aMT6s levels were inversely associated with subjectively measured daytime sleepiness (sleepiness mean score of 5.79 in the top aMT6s quartile, and 6.26 in the bottom aMT6s quartile, MV OR, 1.32; 95% CI, 0.95-1.84; p trend ≤ .02). When restricting to men without β-blocker use (a known melatonin suppressant), aMT6s levels were significantly associated with shorter sleep time, that is, less than 5 hours (MV OR, = 1.90; 95% CI, 1.21-2.99; p trend = .01), and worse sleep efficiency, that is, less than 70% (MV OR, 1.58; 95% CI, 1.28-2.65; p trend < .001). aMT6s were not associated with subjective sleep quality or respiratory disturbance in any of our analyses. CONCLUSION Lower nocturnal melatonin levels were associated with worsened daytime sleepiness, sleep efficiency, and shorter sleep time in older men. The role of circadian interventions, and whether melatonin levels are a modifiable risk factor for poor sleep in older men, warrants further study.
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Affiliation(s)
| | | | - Lynn M Marshall
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland. Department of Medicine, Bone and Mineral Unit, Oregon Health & Science University, Portland
| | - Greg J Tranah
- Research Institute, California Pacific Medical Center, San Francisco
| | - Kristine Ensrud
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minnesota. Department of Medicine, University of Minnesota, Minneapolis. Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis
| | - Sonia Ancoli-Israel
- Department of Psychiatry and Department of Medicine, University of California, San Diego, La Jolla
| | - Aaron Clemons
- Oregon Clinical and Translational Research Institute (OCTRI) Core Laboratory, Oregon Health & Science University, Portland
| | - Susan Redline
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts. Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
| | - Katie L Stone
- Research Institute, California Pacific Medical Center, San Francisco
| | - Eva S Schernhammer
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts. Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts. Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
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Schlitzer J, Heubaum S, Frohnhofen H. [Sleep and sleep disorders in the elderly. Part 2: therapy]. Z Gerontol Geriatr 2015; 47:611-8; quiz 619-20. [PMID: 25277109 DOI: 10.1007/s00391-014-0810-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Sleep disorders need to be treated if they affect the quality of life, lead to functional problems in daily life or unfavorably affect self-sufficiency. The large number of sleep disorders is reflected in the number of different and varied available therapeutic procedures. The basic therapeutic procedure for any sleep disorder is the use of sleep hygiene. Sleeplessness (insomnia) is most effectively treated through behavioral therapy, with stimulus control and sleep restriction as the most effective measures, whereas pharmacotherapy is considerably less effective and has side effects. Sleep-disordered breathing is also the most common cause of hypersomnia in the elderly and is most effectively treated by nocturnal positive pressure breathing.
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Affiliation(s)
- J Schlitzer
- Kliniken Essen Mitte, Knappschaftskrankenhaus, Akademisches Lehrkrankenhaus der Universität Essen-Duisburg, Am Deimelsberg 34a, 45276, Essen, Deutschland
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Stern AL, Naidoo N. Wake-active neurons across aging and neurodegeneration: a potential role for sleep disturbances in promoting disease. SPRINGERPLUS 2015; 4:25. [PMID: 25635245 PMCID: PMC4306674 DOI: 10.1186/s40064-014-0777-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 12/23/2014] [Indexed: 12/13/2022]
Abstract
Sleep/wake disturbance is a feature of almost all common age-related neurodegenerative diseases. Although the reason for this is unknown, it is likely that this inability to maintain sleep and wake states is in large part due to declines in the number and function of wake-active neurons, populations of cells that fire only during waking and are silent during sleep. Consistent with this, many of the brain regions that are most susceptible to neurodegeneration are those that are necessary for wake maintenance and alertness. In the present review, these wake-active populations are systematically assessed in terms of their observed pathology across aging and several neurodegenerative diseases, with implications for future research relating sleep and wake disturbances to aging and age-related neurodegeneration.
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Affiliation(s)
- Anna L Stern
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Nirinjini Naidoo
- Center for Sleep and Circadian Neurobiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Abstract
Maintaining a stable and adequate sleeping pattern is associated with good health and disease prevention. As a restorative process, sleep is important for supporting immune function and aiding the body in healing and recovery. Aging is associated with characteristic changes to sleep quantity and quality, which make it more difficult to adjust sleep–wake rhythms to changing environmental conditions. Sleep disturbance and abnormal sleep–wake cycles are commonly reported in seriously ill older patients in the intensive care unit (ICU). A combination of intrinsic and extrinsic factors appears to contribute to these disruptions. Little is known regarding the effect that sleep disturbance has on health status in the oldest of old (80+), a group, who with diminishing physiological reserve and increasing prevalence of frailty, is at a greater risk of adverse health outcomes, such as cognitive decline and mortality. Here we review how sleep is altered in the ICU, with particular attention to older patients, especially those aged ≥80 years. Further work is required to understand what impact sleep disturbance has on frailty levels and poor outcomes in older critically ill patients.
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Affiliation(s)
- Roxanne Sterniczuk
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada ; Division of Geriatric Medicine, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Benjamin Rusak
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada ; Department of Psychiatry, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
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Romero A, Ramos E, de Los Ríos C, Egea J, Del Pino J, Reiter RJ. A review of metal-catalyzed molecular damage: protection by melatonin. J Pineal Res 2014; 56:343-70. [PMID: 24628077 DOI: 10.1111/jpi.12132] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 03/11/2014] [Indexed: 12/31/2022]
Abstract
Metal exposure is associated with several toxic effects; herein, we review the toxicity mechanisms of cadmium, mercury, arsenic, lead, aluminum, chromium, iron, copper, nickel, cobalt, vanadium, and molybdenum as these processes relate to free radical generation. Free radicals can be generated in cells due to a wide variety of exogenous and endogenous processes, causing modifications in DNA bases, enhancing lipid peroxidation, and altering calcium and sulfhydryl homeostasis. Melatonin, an ubiquitous and pleiotropic molecule, exerts efficient protection against oxidative stress and ameliorates oxidative/nitrosative damage by a variety of mechanisms. Also, melatonin has a chelating property which may contribute in reducing metal-induced toxicity as we postulate here. The aim of this review was to highlight the protective role of melatonin in counteracting metal-induced free radical generation. Understanding the physicochemical insights of melatonin related to the free radical scavenging activity and the stimulation of antioxidative enzymes is of critical importance for the development of novel therapeutic strategies against the toxic action of these metals.
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Affiliation(s)
- Alejandro Romero
- Departamento de Toxicología y Farmacología, Facultad de Veterinaria, Universidad Complutense de Madrid, Madrid, Spain
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Hu ZP, Fang XL, Fang N, Wang XB, Qian HY, Cao Z, Cheng Y, Wang BN, Wang Y. Melatonin ameliorates vascular endothelial dysfunction, inflammation, and atherosclerosis by suppressing the TLR4/NF-κB system in high-fat-fed rabbits. J Pineal Res 2013; 55:388-98. [PMID: 24006943 DOI: 10.1111/jpi.12085] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2013] [Accepted: 08/05/2013] [Indexed: 01/28/2023]
Abstract
Vascular endothelial dysfunction (VED) and inflammation contribute to the initiation and progression of atherosclerosis. Melatonin (MLT) normalizes lipid profile, improves endothelial function, and possesses anti-inflammatory properties. However, the precise mechanisms are still unclear. This study investigated whether MLT could ameliorate VED, inflammation, and atherosclerosis by suppressing the Toll-like receptor 4 (TLR4)/nuclear factor kappa B (NF-κB) system in high-fat-fed rabbits. Rabbits were randomly divided into three groups that received a standard diet (control group), high-cholesterol diet (atherosclerosis group), or high-cholesterol diet plus 10 mg/kg/day MLT (MLT group) for 12 wk. After treatment, high-fat diet significantly increased serum lipid and inflammatory markers in rabbits in atherosclerosis group compared with that in control group. In addition, high-fat diet also induced VED and typical atherosclerotic plaque formation and increased intima/media thickness ratio, which were significantly improved by MLT therapy as demonstrated in MLT group. Histological and immunoblot analysis further showed that high-fat diet enhanced the expressions of TLR4, myeloid differentiation primary response protein (MyD88), and NF-κB p65, but decreased inhibitor of NF-κB (IκB) expression. By contrast, MLT therapy decreased the expressions of TLR4, MyD88, and NF-κB p65 and increased IκB expression. This study has demonstrated that MLT ameliorates lipid metabolism, VED, and inflammation and inhibits the progression of atherosclerosis in high-fat-fed rabbits. Moreover, our study indicates for the first time that suppression of the TLR4/NF-κB system in local vasculature with atherosclerotic damage is important for the protective effects of MLT.
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Affiliation(s)
- Ze-Ping Hu
- Department of Cardiology, the First Affiliated Hospital, Anhui Medical University, Hefei, China
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Maggio M, Colizzi E, Fisichella A, Valenti G, Ceresini G, Dall’Aglio E, Ruffini L, Lauretani F, Parrino L, Ceda GP. Stress hormones, sleep deprivation and cognition in older adults. Maturitas 2013; 76:22-44. [DOI: 10.1016/j.maturitas.2013.06.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 06/05/2013] [Indexed: 12/20/2022]
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Lyseng-Williamson KA. Melatonin prolonged release: a guide to its use in the treatment of insomnia in patients aged ≥55 years. DRUGS & THERAPY PERSPECTIVES 2013. [DOI: 10.1007/s40267-013-0031-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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