Table 1. Recommended clinical approach to sleep disorders in dementia.

Current existing evidence and expert guidelines on the evaluation and treatment of sleep disorders in dementia are summarized. The approach should proceed in the listed order, starting with “Clinical Assessments,” and proceeding downward only if symptoms persist. “Benefits” listed for sleep treatments include only RCT's and meta-analyses.

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