Treating Sleep Disorders in Alzheimer's Patients
by R. Hargrave, MD; http://www.psychiatryadvisor.com; 4/17/2015
Alzheimer's disease (AD), the commonest source of dementia, is associated with sleep disturbances among 25% to 35% of men and women with all the illness. Sleep disorders in AD end in significant caregiver distress, increased health care costs and increased rates of institutionalization.
AD related sleep complaints include sleep fragmentation, increased sleep latency (time taken up retire for the night), nocturnal wandering and increased daytime sleepiness. Many patients with AD also experience 'sun downing', which is confusion and agitation inside late afternoon and evening which decreases during hours of sunlight.
Sleep disturbances in AD are caused by multiple factors including physiologic changes associated with the degenerative brain disease, physiological changes relevant to normal aging, primary sleep issues(e.g. Sleep apnea, restless legs syndrome), comorbid medical and psychiatric conditions and environmental and behavioral factors (e.g. poor “sleep hygiene.”).
Medications can also adversely affect sleep. Cognitive enhancers like donepezil, an acetylcholinesterase inhibitor, could cause nighttime agitation and nightmares.1 Atypical antipsychotics (e.g. olanzapine or risperidone) can increase daytime fatigue and somnolence. Anxiolytics and antidepressants could potentially cause daytime sleepiness and increased risk for falls in older adults.
A various medications are widely-used within the treating problems with sleep in AD including atypical antipsychotics, benzodiazepines, non- benzodiazepine hypnotics (e.g. zolpidem, zopiclone, and zaleplon), melatonin, sedating antidepressants and antihistamines. However, up to now, there is certainly limited research around the safety and efficacy of such medications in patients with AD.
A meta-analysis by McCleery, et al reported that there were no random controlled trials on most in the medications employed to treat sleep problems in AD including benzodiazepine and non-benzodiazepine hypnotics. They found no evidence that melatonin or ramelton had beneficial effects on problems with sleep in moderate to severe AD. A small randomized, control trials of patients with AD addressed with trazodone reported significantly longer nocturnal total sleep some time to greater sleep efficiency.
Many with the medications accustomed to treat problems with sleep in AD are associated with adverse events. Sedating antipsychotics (e.g. quetiapine or olanzapine) are already linked with increased mortality as well as other serious side effects.
Benzodiazepines and non-benzodiazepine hypnotics, sedating antidepressants and antihistamines (often within over-the-counter sleep aids) may improve some elements of sleep but may produce daytime sleepiness, rebound insomnia, confusion, amnesia and increased fall risk for falls. Current research demonstrates that pharmacological treatments ought to be avoided as first-line strategy for sleep issue in older adults, especially from the context of cognitive impairment.
Treatment Without Medication
Non-pharmacological treatments present you with a different method of the procedure of sleep problem in AD. Non-pharamcological approaches include light therapy, exercising, behavioral and environmental interventions. But there may be limited research about the efficacy of such interventions in patients with AD.
Light therapy happens to be a frequent intervention for insomnia since contact light affects the complex metabolic processes associated together with the sleep-wake cycle. Current practice guidelines claim that older adults whose sleep is phase-advanced (i.e., people who drift off to sleep inside the early evening and awaken too soon inside morning) ought to be come across bright light inside evenings. Older adults whose sleep is phase-delayed (i.e., those whose sleep onset and final awakening occurs later within the day) needs to have bright light exposure early inside morning.
Regular exercising continues to be regarding more restful sleep in older adults. Several studies report that elderly care facility residents with dementia who be involved in nonstrenuous daytime activities can offer improved sleep quality. Although regular exercising might also enhance the sleep of folks with dementia, no published controlled trials have examined the isolated results of exercise on sleep in dementia.
Behavioral, nutritional and environment interventions are already accustomed to reduce insomnia. Behavioral strategies include maintaining regular bedtimes and rising times, limiting daytime napping, and restricting time during sex. Nutritional approaches include establishing consistent meal times; avoiding alcohol, nicotine, and caffeine; and emptying the bladder several hours before bedtime. Environmental methods to reducing insomnia include maintaining a cushty room temperature in sleep environment and reducing excessive ambient light and noise.
Sleep disturbances in older adults with AD are standard and they are the actual result of numerous factors including normal and pathological changes within the aging brain, environment factors, medical or psychiatric morbidity, and medication unwanted side effects. Because in the multifaceted nature of sleep disturbances and fragility of older adult patients with dementia, nonpharmacologic interventions are recommended because the first-line treatment modality. Pharmacologic agents can useful, but medication selections really should be made cautiously and consider potential adverse events need to be considered as part from the diagnostic and treatment planning.