Pharmacological options include benzodiazepines, non-benzodiazepines, antidepressants and antihistamines. There is limited evidence on their long-term safety particularly with cognitively-impaired older adults. For this reason, it is important to use these medications with caution, for the shortest period of time as needed, and to follow the motto “start low and go slow”. Benzodiazepines are commonly used, but they have little effect on the sleep maintenance problems that are most commonly seen in older adults with dementia. In addition, they can have problematic side effects, including sedation, confusion, anterograde amnesia, and rebound insomnia, which can make the behavioral disturbance seen with dementia worse. The newer generation non-benzodiazepines have shorter half-lives and fewer side effects, but there is limited data on their use in older patients with dementia.

Antidepressants, including Trazodone, the SSRIs and Remeron, are sometimes used to help with sleep problems, in some cases to take advantage of their side effect of sedation and in other cases because there is concern about co-morbid depression. Trazodone has been found in small studies to be helpful short-term with improving total sleep time and sleep efficiency. Antihistamines are commonly used in this situation, partly because of the availability over-the-counter, but there are side effect concerns, including sedation, cognitive impairment, and anticholinergic responses. Because of these side effect risks, they should be avoided as first-like agents in older patients. Supplemental melatonin has not been found to be helpful as a stand-alone treatment for insomnia in patients with dementia in studies, but ramelteon, a melatonin agonist, has been shown some promising results in general studies, to improve sleep efficiency and increase total sleep time. In addition, it is not associated with side effects that are seen with other medications used for sleep disturbance, like cognitive impairment and daytime sleepiness. It would be helpful for more studies to be done with this agent in older patients.

It is our hope that this article has been helpful in addressing the common issue of sleep disturbance in patients with dementia, to begin thinking about how to determine the cause and the best treatment approach.

Reference: Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.

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.

Reference:
Current Treatments for Sleep Disturbances in Individuals with Dementia. Cynthia L Deschenes, MSN, CCRN and Susan M. McCurry, PhD. Curr Psychiatry Rep 2009, Feb.