Sleep disturbance, including reduced sleep time, fragmented sleep, nighttime wandering, increased sleep latency, and daytime sleepiness and fatigue, are common concerns related to dementia. It is estimated that 1/3 of patients with Alzheimer’s dementia suffer from a sleep disturbance. The goal of this article is to review treatment options for sleep disturbance in patients with dementia.
In order to discuss appropriate treatment, it is first important to understand the causes of sleep disturbance in this population. The causes of sleep disturbance in patients with dementia include: (1) physiologic changes that occur as part of dementia as well as normal aging; (2) primary sleep disorders such as sleep apnea and restless leg syndrome that can occur co-morbidly; (3) medication side effects; (4) environmental and behavioral factors, including poor sleep hygiene practices; and (5) a combination of the above. With Alzheimer’s dementia, the sleep disturbance is thought to be a result of a progressive deterioration and decrease in the number of neurons in the suprachiasmatic nucleus (SCN), which lead to fluctuations in neurohormones that are important in the homeostatic stability of the circadian rhythm.
It is often difficult to determine the exact cause for an older patient presenting with insomnia. Older adults are at risk for a variety of age-related comorbid conditions, such as ischemic heart disease, diabetes, depression, renal failure, arthritis and pulmonary disorder, which can
further exacerbate sleep disturbances. To make things more complicated, many of the medications used to treat these chronic diseases can have varying effects on sleep. For example, narcotic analgesics that are used to treat chronic pain can cause excessive daytime somnolence, and bronchodilators that are used commonly for pulmonary disorders can have nighttime stimulating effects.
Often, patients with dementia need medication to manage their behavioral symptoms. Medications that are commonly used to treat the behavioral disturbances seen in dementia can have a negative impact on a patient’s sleep. Acetylcholinesterase inhibitors can cause nighttime activation and dream disturbances. Antipsychotic medications can cause daytime sleepiness and somnolence. When using these medications, it is important to individualize the treatment and assess for risks and benefits related to a medication.
Part 2 of this article will discuss treatment options, both non-pharmacological and pharmacological, for patients with insomnia related to dementia.