Table 1. Recommended clinical approach to sleep disorders in dementia.
Assessment or Treatment | Details | Benefits | Cons | Notes |
---|---|---|---|---|
Clinical Assessments | ||||
History | Collateral source is critical Collect information about symptoms of primary sleep disorders, sleep habits/hygiene, co-morbidities, medications, dementia-specific symptoms Assess for depression and anxiety |
Time-intensive | Obtain information about caregiver burden | |
Sleep scales and questionnaires | General: Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia severity index, etc Dementia-specific: Sleep Disturbance Inventory, SCOPA sleep scale, etc |
Use serially to determine response to treatment | ||
Actigraphy | Several days to weeks To assess circadian phase and amplitude To assess nocturnal sleep variables |
Non-invasive, able to get data in patient's usual setting | Usually not reimbursed by insurers | Obtain concurrent sleep log Use serially to determine response to treatment |
Polysomnogram | For suspected obstructive sleep apnea, periodic limb movement disorder, RBD (or other parasomnia) | Gold standard diagnosis | Inconvenient Demented patients may have confusion/agitation |
Caregiver should stay with patient if possible Ambulatory (home) studies may have high failure rate in dementia |
Treat primary sleep disorder | ||||
Obstructive sleep apnea | Positive airway pressure | Slower cognitive decline Less snoring, improved sleep, improved daytime alertness |
Patients may not be able to tolerate PAP Caregiver burden | Common in AD, vascular dementia No data on non-PAP treatments |
Restless legs syndrome | Iron supplementation Dopamine agonists, gabapentin, other typical RLS medications |
Improve symptoms | Sleep attacks and compulsive/addictive behavior with dopamine agonists Sedation with gabapentin |
Common in PD Coordinate dopamine agonists with PD doctor |
REM sleep behavior disorder | Clonazepam or melatonin Safety precautions |
Reduced risk of injury | Sedation with clonazepam | In DLB and PDD |
Hypersomnia | Stimulants, sodium oxybate, anti-cataplectic agents | Improve alertness | Cardiovascular risk, irritability, risk of abuse/dependence Sedation with sodium oxybate |
Common in DLB and PDD Only for true primary hypersomnia such as narcolepsy |
Optimize co-morbidities and medications | ||||
Treat mood and anxiety disorders | Anti-depressants, psychotherapy, anxiolytics | Improve psychiatric and sleep symptoms (usually insomnia) | May cause sedation and worse cognition Worse RLS Time-intensive |
Coordinate with other physicians and healthcare professionals |
Treat pain, and other co-morbidites causing disrupted sleep | Varies | Improve sleep | Pain and bladder medications may cause sedation and worse cognition Varies by co-morbidity Time-intensive |
Coordinate with other physicians and healthcare professionals |
Minimize or adjust medications causing sleep disruption or hypersomnia | Dementia and Parkinsomnism medications Pain medications, stimulants, β2 agonist inhalers, anti-hypertensives, bladder medications, anti-retrovirals, steroids, etc |
Improve sleep | Varies by medication Time-intensive | Coordinate with other physicians and healthcare professionals |
Behavioral sleep treatments | ||||
Sleep hygiene education | See text Frequently used in MMT | Modest improvement in TST in one study (43) | Caregiver and patient burden | May be difficult to implement in institutionalized setting |
Physical activity | 3-5 times per week, 30-60 minutes, vigorous Can use in MMT |
Neutral effect on actigraphy measures (42,49,50) Vigorous activity showed modest improvements in subject sleep scales in one study (51) |
Caregiver and patient burden Discomfort or cardiovascular risk for patients with co-morbidities |
Ideally with professional therapist or trainer |
Social activity | Unknown Better in MMT with physical activity |
One small study showed improvement in TST and reduced daytime sleep (48) | Caregiver and patient burden | No standard |
Bright light therapy (BLT) | Morning, 2500-10000 lux, 1-2 hours Can use in MMT | Reduced night-time awakenings (meta-analysis; 54) Increased total sleep time if patients have pre-existing sleep complaint (meta-analysis; 66) |
Caregiver and patient burden Eyestrain | Ideally assess circadian phase, and time therapy to shift phase appropriately |
Complementary and alternative modalities | Varies, see text | No large RCT | Varies | If no adverse effects and low cost, reasonable to try with close monitoring |
Pharmacological sleep treatments | ||||
Melatonin | Studies support 2-5 mg immediate release, at bedtime. Recommended starting dose 1.5mg, increase by 1-2 mg every few days; additional benefit unlikely above 10mg. Can use in MMT particularly with BLT |
~25 minutes total sleep time (meta-analysis; 83) | One study showed increased depressive symptoms. Sedating effect may be more pronounced in elderly or demented patients, therefore assess for risk of falls/injuries. |
No data on dosing other times of day |
Sedating anti-depressants | Study supports Trazodone 50mg, at bedtime. Recommend starting dose 25mg, increase by 25mg increments. Max 200mg. Taper gradually if >50mg. | 42.5 minutes total sleep time in one study (90) | May cause sedation and increased risk of falls/injuries. particularly in elderly/demented Worse cognition,. in dementia Worse RLS |
|
NBBRA | No data to support specific treatment Typical doses for elderly: zolpidem 2.5-5 mg, eszopiclone 0.5-2mg, zaleplon 5-10mg. |
No large RCT | May cause sedation and worse cognition Falls/injuries, especially in elderly Parasomnias | |
Benzodiazepines | No data to support specific treatment | No large RCT | May cause sedation and worse cognition Falls/injuries Risk of abuse/dependence |
|
Stimulants | No data to support specific treatment | No large RCT | Cardiovascular risk, irritability, risk of abuse/dependence |
MMT = Multi-modality treatment
RCT = Randomized controlled trial
RLS = Restless legs syndrome
NBBRA = Non-benzodiazepine benzodiazepine receptor agonists
BLT = Bright light therapy