There are non-pharmacological and pharmacological options to treat sleep disturbance in patients with dementia. Non-pharmacological approaches include: light therapy, regular exercise, and behavioral treatment/sleep hygiene. In general, evening bright light treatment is helpful for sleep maintenance problems and morning light exposure is helpful for patients whose sleep is phase-delayed or who are suffering from a seasonal depressive disorder. However there is no identified standard of care for which light wavelengths are maximally safe and effective, which method of light delivery is optimal and how long it should be delivered. Physical activity has been linked to phase shifting of circadian rhythms and promotion of more restful sleep in older adults. Behavioral treatments for insomnia, including CBT for insomnia, can be very helpful for the motivated patient and it is important to have a discussion about healthy sleep hygiene practices even if a patient is going to be taking medication to help with insomnia. CBT for insomnia and other behavioral treatments for insomnia have been discussed in other e-weekly’s.
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.