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nocturnal sleep of patients suffering from various forms of dementia is often impaired by nocturnal agitation or nocturnal wandering .
anticonvulsives such as carbamazepine or valproate are reported to have some therapeutic efficacy , but there is little information about other drugs suitable for treatment of this condition .
our patient , a 77-year - old czech woman with incipient vascular dementia , received gabapentin 400 mg at bedtime for 6 months and showed convincing improvement .
excessive motor activity during the night impairs the sleep of patients with various forms of dementia .
lack of sleep due to nocturnal agitation or nocturnal wandering is a significant burden on families of elderly demented patients and is the primary cause of institutionalization [ 14 ] .
nocturnal agitation may result from discomfort , pain or environmental factors ; hence , identification of these potential sources is crucial . for insomnia management ,
eliminating alcohol and restricting caffeine intake in the early morning may help in alleviating nocturnal agitation .
however , if necessary , atypical neuroleptics , anticonvulsives ( carbamazepine , valproate ) and benzodiazepines , as well as trazodone and chloral hydrate are recommended .
we present the case of a patient with incipient vascular dementia accompanied by nocturnal agitation , which was successfuly treated with gabapentin . to our best knowledge
, no controlled study has yet been conducted to prove its efficacy in this condition .
we present the case of a czech woman , now 77 years old , who was treated for ischemic heart disease , arterial hypertension , chronic obstructive pulmonary disease and migrainous cephalalgia .
the patient was referred to our center for sleep disorders for the first time in 2006 due to a history of 2 nocturnal episodes of confusion with abnormal behavior and retrograde amnesia .
the patient herself could not recall these episodes , and it was not possible to retrieve further objective history .
eeg showed a mild slowing of the background activity , but no epileptiform discharges were found .
as partial complex epileptic seizure was suspected , gabapentin ( 300 mg 3 times daily ) was administered and subsequently found to have brought the patient considerable relief .
gabapentin is generally not the first - choice drug in the cases of temporal lobe epilepsy ; nevertheless , we considered it appropriate because of diagnostic uncertainty and only sporadic occurrence of the episodes .
next , the patient consulted our department in may 2008 because of 3 episodes of syncope .
cardiologic examination excluded cardiac disease as the cause , which appeared to be of cerebrovascular etiology .
since our previous diagnosis of temporal lobe epilepsy was uncertain and with respect to the 4-year seizure - free period , gabapentin was discontinued in june 2008 .
two weeks after its withdrawal the nocturnal episodes of confusion with abnormal behavior reappeared . according to a room - mate
, the patient was agitated in the night , shuffled about in her apartment , did not know where she was , talked aloud and was sometimes verbally aggressive .
in the morning the patient could not recall the episodes , though these recurred several times during the night .
these nocturnal states of confusion were the reason for her admission and video - eeg monitoring at our department . during the monitoring , performed on 2 consecutive nights , the patient repeatedly sat up and attempted to get out of bed , but could not due to being attached to the monitor .
though confused , she reacted to the technician s statements appropriately , but with a delay . she complained of discomfort caused by the electrodes and the recurrent urge to void .
the technician repeatedly told her where she was , but she continued to ask the same question . during both nights we recorded the above - described episodes  during the first night every 20 minutes , and during the second night every 40 minutes .
the quality of the sleep was considerably impaired by fragmentation , by a higher percentage of stage 1nrem , and by a worse configuration of k - complexes and sleep spindles .
no epileptiform activity or respiratory disturbances or periodic leg movements were recorded . during follow - up clinical examination after the video - eeg monitoring , the patient complained of memory failures for the first time , and for this reason a psychological examination was performed , which revealed low - grade organic deterioration of cognitive functions with excursive thinking , impairment of encoding and retrieval of information and normal spatial orientation . the mini - mental state examination ( mmse )
score was 26 and the cohen - mansfield agitation inventory ( cmai - long form ) score was 39 .
with regard to the fact that the nocturnal episodes of confusion , sometimes accompanied by verbal aggression , were evoked by environmental influences and discomfort and by concomitant incipient vascular dementia , we concluded the case was nocturnal agitation ( nocturnal wandering ) .
we recommended elimination of the evoking factors , and following the recommended regimen with the goal of reducing the insomnia . in spite of the regimen precautions the episodes repeated several times during most nights and we decided to begin pharmacological treatment . since gabapentin had proved effective and well - tolerated before , we prescribed it again , with very satisfactory results . to date
, the patient has been taking 400 mg of gabapentin at bedtime for 9 months , with no recurrence of her former problems despite the relatively low dosage .
thus , we consider the effectiveness of gabapentin in this condition to be clearly demonstrated . we confirm that the patient was able to provide informed consent .
the use of gabapentin has thus far been only sporadically reported in this condition [ 710 ] .
therefore , we should like to call attention to our satisfactory experience of gabapentin in cases like ours . in particular , we found it suitable in geriatric patients for its minimal adverse effects and absence of pharmacokinetic interactions with respect to geriatric polymorbidity .
it is noted for its anti - anxiety and hypnotic effects in psychiatric patients . its positive effect on the structure / quality of sleep is well - known . while its mechanism of action is not yet fully understood
, it would appear to be via the modulation of glutamate - mediated excitatory synaptic transmission and gamma - aminobutyric acid ( gaba)-mediated inhibitory synaptic transmission .
unlike carbamazepine , it does not interfere with bone metabolism , nor does it have any adverse cardiac effects .
nevertheless , there are still limited data on its efficacy , and no controlled studies have been published to date on this topic . as we mentioned above , in most of the reviewed cases gabapentin is reported to be a well - tolerated and effective treatment for dementia - associated agitation
. however , several case reports in which gabapentin was used for agitation in dementia with lewy bodies question its appropriateness for all types of dementia - related agitation [ 1416 ] . indeed , paradoxical gabapentin - induced exacerbation of psychosis in a patient with schizophrenia has already been described .
the relevant literature recommends drugs such as benzodiazepines ; however , these can aggravate the cognitive deficit , a fact of importance in our patient .
we present the case of a patient with incipient vascular dementia accompanied by nocturnal agitation , which was successfully treated with gabapentin .
summarybackgroundnocturnal sleep of patients suffering from various forms of dementia is often impaired by nocturnal agitation or nocturnal wandering . 
 anticonvulsives such as carbamazepine or valproate are reported to have some therapeutic efficacy , but there is little information about other drugs suitable for treatment of this condition.case reportour patient , a 77-year - old czech woman with incipient vascular dementia , received gabapentin 400 mg at bedtime for 6 months and showed convincing improvement.conclusionsgabapentin was very effective in treating nocturnal agitation .