Non-pharmacologic treatment of insomnia in persons with dementia

/Home/Caregiving and Alzheimer's/Caregiving Tips for Coping with Symptoms/Alzheimer's and Sleep Disturbances

The prevalence of insomnia increases with age
and affects up to 35% of community-dwelling
adults with dementia. Sleep disturbances and
associated cognitive and behavioral symptoms
in this patient population can be a significant
contributor to morbidity, mortality, and caregiver
burden. Despite the frequency with which sleep
disorders are encountered in primary care, few
evidence-based guidelines are available to guide
physician treatment plans. Sedative-hypnotic
medications are commonly prescribed but are
associated with significant adverse effects and
have limited efficacy data. non-pharmacologic
treatments can be safe and effective adjuncts
or alternatives to medications but are often
underused in clinical practice. This article reviews
practical applications of modalities such as light
therapy, exercise, and sleep-hygiene modification
in treating insomnia in persons with dementia.

Shub D, Darvishi R, Kunik ME. Non-pharmacologic treatment of
insomnia in persons with dementia. Geriatrics. 2009;64(2):22-26.

Key words: aging, circadian rhythm, dementia,
insomnia, light therapy, sleep hygiene

Drugs discussed: zolpidem, mirtazapine

Insomnia is an important problem encountered in the
geriatric population. In addition to sleep changes
that normally occur with aging, the neurodegenera-
tive changes of dementia further compound the problem
by increasing the frequency and severity of sleep distur-
bances and associated behavioral disruptions. A com-
munity-residing, population-based study of individuals
with Alzheimer’s disease suggests that 35% of subjects
are affected,1 which is likely much lower than in clinic
and nursing-home populations. Sleep disturbances can
be a significant contributor to caregiver burden, and they
are often a reason caregivers cite for their decision to
institutionalize.2

Chronic insomnia in older patients is
also an independent predictor of cognitive decline, falls,
and increased 2-year mortality.3-5

Primary care physicians are often faced with an ardu-
ous task of addressing these sleep problems, frequently
by prescribing sedative-hypnotic or other sedating psy-
chotropic medications. Up to 36% of patients with severe
sleep, cognitive, functional, and behavioral impairments
take a sedative-hypnotic, anxiolytic, antipsychotic, or
antidepressant medication.1 Although judicious use of
medications may be helpful in addressing sleep and as-
sociated neuropsychiatric disturbances, their excess use
may also lead to increased risk of cognitive adverse ef-
fects, falls, and even death in patients with dementia.6,7
On the other hand, non-pharmacologic interventions are
safe and effective adjuncts or alternatives for treatment
of insomnia.

Physicians often receive information on use of phar-
macologic interventions (an evidence-based review may
be found within the American Psychiatric Association
Practice Guideline for the Treatment of Patients with
Alzheimer’s Disease and Other Dementias),8 but fewer
resources are available on non-pharmacologic alterna-
tives. This article will briefly review the initial presenta-
tion of insomnia in persons with dementia and focus on the
practical application of non-pharmacologic treatments to
dementia patients encountered in primary care practice.


Phenomenology and assessment

Sleep disturbances in persons with dementia have var-
ied clinical presentations. Changes
in sleep architecture normally occur
with age and are accentuated in de-
mentia. More time is spent in lighter
stages of sleep (stages 1 and 2) with
a significant decrease in slow-wave
(stages 3 and 4), rapid eye move-
ment, and total sleep time.9,10 These
changes in sleep structure manifest
in increased sleep fragmentation
and arousals, with resultant exces-
sive daytime sleepiness and napping.
Damage of neuronal pathways in the
suprachiasmatic nucleus of the hypo-
thalamus, the area believed to initiate
and maintain sleep as well as changes
in the circadian rhythm, may further
disrupt sleep in persons with demen-
tia and lead to shifts or complete day/
night sleep-pattern reversals.9 In a
population-based sample of Alzheim-
er’s disease patients, the most com-
mon sleep-related behavior problems
reported by caregivers were sleeping
more than usual (40%) and awakening
early (31%), whereas being awakened
at night (24%) was the most distress-
ing problem for caregivers.1

Clinical assessment of individuals
with insomnia must always include
screening for secondary causes,
including medical and psychiat-
ric conditions (eg, depression) and
medication side effects, as well as
specific sleep disorders. Although
this article will emphasize treatment
of primary insomnia, a discussion of
comorbidities (eg, sleep-disordered
breathing, periodic limb movements
in sleep, and restless-leg syndrome)
can be found elsewhere.10,11 Objec-
tive baseline measure of the patient’s
sleep disturbance may be helpful in
identifying specific target areas and
gauging the efficacy of a proposed
intervention. Because performing a
sleep study with polysomnography
is impractical and self-report is un-
reliable in this patient population, a
sleep diary filled out by the caregiver
is often the best alternative. A sample
2-week sleep diary is available online
from the American Academy of Sleep
Medicine (Table).

________
Table

American Academy
of Sleep Medicine:
http://www.sleepeducation.com/pdf/sleepdiary.pdf

National Institute on Aging:
http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/

Alzheimer’s Disease
Education and Referral
Center of the National
Institute on Aging:
http://www.nia.nih.gov/Alzheimers/

Alzheimer’s Association:
http://www.alz.org/national/documents/brochure_activities.pdf

Popular books in print include:
The 36-Hour Day: A Family Guide to Caring
for People with Alzheimer Disease, Other
Dementias, and Memory Loss in Later Life,
by Nancy L. Mace and Peter V. Rabins, from
The Johns Hopkins University Press.
________


When initial evaluation
fails to identify another
medical or psychiatric
condition as the cause of
insomnia, it is prudent to
consider non-pharmaco-
logic treatments as a first-
line intervention. Three modalities
will be emphasized here—light ther-
apy, exercise, and sleep hygiene—that
were chosen on the basis of avail-
able evidence and applicability to
patients typically seen in outpatient
primary care practice. All 3 were
components of a comprehensive sleep
education program in the Nighttime
Insomnia Treatment and Education
for Alzheimer’s Disease (NITE-AD)
study, the first clinical trial to date,
funded by the National Institute of
Mental Health, to have examined the
efficacy of non-pharmacologic thera-
pies for treating sleep disturbances
in community-dwelling patients with
Alzheimer’s disease.12


Light therapy

Exposure to light of sufficient intensity
and duration can have marked effects
on an individual’s mood and sleep.
Bright-light therapy has a proven indi-
cation for treatment of winter depres-
sion, or seasonal affective disorders.
It is also one of the most widely stud-
ied non-pharmacologic interventions
for sleep and behavioral symptoms
in dementia patients. NITE-AD, the
randomized, controlled trial using
light exposure as part of its research
protocol, demonstrated significant,
32% reductions from baseline in
nighttime awakenings and total time
awake at night compared with con-
trol subjects who worsened on both
measures.12 Patients and caregivers
found this treatment feasible, with
high compliance with the daily light
box recommendation during two 3-
week active treatment periods and at
6-month follow-up.

Physicians must overcome several
challenges in recommending and
implementing home-based light treat-
ment. First, light therapy requires a
light source of sufficient luminosity
to affect circadian phase-shift, with
most studies exposing patients to 1000
to 10,000 lux for 30 to 90 minutes, far
greater than can be achieved with or-
dinary home lighting. Thus, it is nec-
essary to purchase specialized light
equipment, ie, a “light box.” These
are readily available from online re-
tailers and they range from around
$130 for a smaller lamp to $300 for
the unit used in the NITE-AD study.
Although this upfront cost may seem
prohibitive to some patients and their
caregivers, it is comparable to costs of
pharmacologic treatment, given that a
month’s supply of zolpidem (Ambien)
costs $130.


___
There are more than a dozen handouts
on sleep disorders available online at
modernmedicine.com that can be shared
with caregivers.
www.geri.com/disorders
___


Another potential limitation is that
a demented patient may not be able to
understand and follow light therapy
treatment instructions. A caregiver is
usually necessary to ensure that the
patient remains seated and faces the
light source, which should be placed
at a distance of 2 to 3 feet within a
45º visual field. It is imperative that
the patient does not sleep or nap dur-
ing treatment because light must fall
onto the retina to influence the circa-
dian system. Patients can participate
in other activities such as reading,
eating, conversing, or watching tele-
vision (the light box can be placed
on top of the television) during light-
treatment sessions. Light exposure
treatment should be within a 3-hour
window before the patient’s habitual
bedtime, except for patients who al-
ready have extremely late bedtimes.
In the NITE-AD study, patients used
a light box delivering approximately
2,500 lux of full-spectrum light for 1
hour each day.

Caregivers who are struggling to
ensure at least a 30-minute seated
treatment time may need assistance to
identify and plan sedentary activities
to help keep patients in position during
light-therapy sessions. Resources are
available from the Alzheimer’s Asso-
ciation and the Alzheimer’s Disease
Education and Referral Center of the
National Institute on Aging (Table).
Caregivers may also find helpful in-
formation in several popular books
in print.


Exercise

Physical exercise is an important com-
ponent of non-pharmacologic therapy
for sleep disturbances. In addition to
the benefit of improving sleep, evi-
dence from a randomized, controlled
trial suggests that a home-based exer-
cise program combined with behav-
ioral management can reduce func-
tional dependence, improve physical
health and depression, and delay
institutionalization among patients
with Alzheimer’s disease.12,13 A su-
pervised exercise program in commu-
nity-dwelling individuals is
feasible. Most persons with
dementia were able to walk
for 30 or more minutes per
day in one study.12

A variety of other exer-
cise protocols have been
used in clinical trials for pa-
tients with dementia. These protocols
ranged from walking to more compre-
hensive programs including aerobic/
endurance activities, strength train-
ing, balance, and flexibility training.
The main challenge to implementing
these, as with all behavioral interven-
tions, is the required caregiver time.
Nevertheless, a primary care clinic
can be an ideal setting for encourag-
ing patients to increase their physical
activity level. Tailored exercise pre-
scriptions delivered in the primary
care practice setting have been shown
to improve physical fitness and ex-
ercise adherence in older (age > 65
years), community-dwelling adults.14
Patients with dementia and caregiv-
ers should be instructed to walk for
exercise daily for 30 minutes, prefer-
ably outside in natural light, weather
permitting.12 Frail patients can start
with shorter walking intervals and
gradually build up over time.

Information regarding exercise
safety, as well as sample endurance,
strength, balance, and stretching ex-
ercises, is available in the Exercise
Guide distributed by the National
Institute on Aging (Table). Primary
care physicians can encourage pa-
tients to try a new exercise from the
guide every day.


Sleep hygiene

Sleep hygiene refers to an individual’s
sleep habits and routines. It is often
believed that establishing good sleep
practices is the first-line treatment for
all patients with insomnia. There is
now ample clinical and empirical evi-
dence to suggest that behavioral inter-
ventions, aimed at improving sleep
hygiene, can be helpful in treating
sleep and nighttime disturbances in
dementia patients.12,15,16 The feasibil-
ity of changing sleep routines in com-
munity-dwelling dementia patients
hinges on the primary care provider’s
help in developing an individualized
behavioral plan tailored to the care-
giver’s particular situation. In the
NITE-AD study, compared with the
patients whose caregivers received
only educational materials, patients
whose caregivers received active as-
sistance in setting up and implementing a sleep-hygiene
program were more likely to maintain a consistent bed-
time (83% vs 38%) and rising time (96% vs 59%) sched-
ule, and were less likely to nap during the daytime (70%
vs 28%).16

Prior to formulating an individualized sleep-hygiene
program, it is worthwhile to screen for patients who would
benefit the most from intensive behavioral intervention.
Primary care physicians may start by obtaining details
on the patient’s baseline sleeping habits, using either
caregiver reports or, ideally, a sleep-data diary kept for
at least 1 week.

Patients who need to make changes in their bedtime, ris-
ing time, or daytime napping schedules are candidates for
sleep-hygiene changes and should receive further instruc-
tion.16 Caregivers may require assistance in identifying de-
sirable bed and rising times and in adhering to these within
a 30-minute leeway. Caregivers should be encouraged to
limit patients’ naps to 30 minutes or less and to eliminate
naps after 1 pm altogether. Effort should also be devoted to
identifying triggers for nighttime awakenings and to devise
strategies for eliminating them. Common culprits include
things such as nighttime noise and light, and incontinence.
Some helpful behavioral strategies to address these are
keeping sleeping areas dark, turning off the television at
night, avoiding excessive fluid intake, and restricting caf-
feinated beverages in the evening. A more comprehensive
list of educational information on sleep hygiene, including
environmental, dietary, and health guidelines, such as that
given to all subjects participating in the NITE-AD project,
can be found in McCurry et al.15, 16

The main obstacle to implementing sleep-hygiene
changes in persons with dementia is the requirement for
significant time and effort from caregivers, which may
contribute to caregiver burden. As already alluded to,
it is crucial for primary care providers to make specific
suggestions and to troubleshoot problems that arise in
caregivers’ attempts to change sleep and activity routines,
as opposed to having them rely on written educational
materials alone. For example, it could be very challeng-
ing to keep individuals from napping without a concrete
plan for keeping them occupied, active, and awake dur-
ing daytime. Scheduling a long walk or another type of
physical activity in the afternoon may be helpful, but
any plan must take into account the caregiver’s ability
to follow through with the recommendation, and there
must be collaboration on possible alternatives.


Conclusion

Treatment of insomnia in persons with dementia presents
a number of challenges for caregivers and primary care
physicians. Despite the ubiquitous
nature of sleep disturbances in de-
mentia patients, few evidence-based
guidelines exist to address this im-
portant problem. In clinical practice
it often becomes necessary to com-
bine several approaches, including
behavioral and environmental inter-
ventions, as well as pharmacologic
therapies. If other neuropsychiatric
comorbidities are present, medica-
tions with sedative properties such
as mirtazapine (Remeron) for depres-
sion can be prescribed at bedtime.8
Pharmacologic treatments could
also be considered for primary sleep
disturbance when other approaches
have failed, but there are few data
on the efficacy of specific agents.8
Although more large-scale, random-
ized, controlled trials are also needed
on non-pharmacologic interventions,
preliminary evidence from studies
such as NITE-AD demonstrates that
even brief trials of light therapy, ex-
ercise, and sleep-hygiene changes are
efficacious and feasible with com-
munity-dwelling patients who suffer
from dementia.


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