Current Treatment Options in Neurology

, Volume 5, Issue 3, pp 261–272 | Cite as

Sleep dysfunction in Alzheimer’s disease and other dementias

  • Susan M. McCurry
  • Sonia Ancoli-Israel
Article

Opinion statement

Changes in sleep architecture and circadian rhythms, including increased sleep latency and nighttime awakenings, decreased slow-wave sleep, rapid eye movement sleep, and total sleep time, and increased daytime napping are widespread in people with dementia. In addition, cyclic agitation episodes (“sundowning”), nightmares or hallucinations, sleep attacks, and nocturnal behavioral outbursts are associated with specific dementia syndromes. Sleep hygiene recommendations, particularly those aimed at reducing daytime sleep and improving the sleep environment and routine, can offset the circadian disturbances of some dementia patients. However, they can be burdensome for caregivers to implement, and must be targeted to the specific patterns of sleep disturbances patients are experiencing. Pharmacologic treatments may be useful for symptomatic treatment of insomnia and nighttime behavioral disturbances in dementia patients, but there have been few controlled trials demonstrating their efficacy or long-term safety. Clonazepam is highly effective for treating the nighttime behaviors associated with rapid eye movement behavior disorder. For most dementia patients, however, the side effect risks of prolonged use of sedating medications must be weighed against the potential benefits. Dementia patients should be evaluated for common primary sleep disorders that may contribute to nighttime behavioral disturbances and impact treatment decisions. Continuous positive airway pressure, the gold standard for treating obstructive sleep apnea, can be tolerated by mild to moderately demented individuals with support from supervising caregivers. Increased daily light exposure and physical activity may help normalize circadian restactivity rhythms in some dementia patients, although the frequency and dose needed to maintain treatment effects is currently not known.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Hope T, Keene J, Gedling K, et al.: Predictors of institutionalization for people with dementia living at home with a carer. Int J Geriatr Psychiatry 1998, 13:682–690.PubMedCrossRefGoogle Scholar
  2. 2.
    Prinz PN, Poceta JS, McCurry S: Sleep in the dementing disorders. In Sleep Medicine. Edited by Lee-Chiong TL, Sateia MJ, Carskadon MA. Philadelphia: Hanley & Belfus, Inc.; 2002:497–507.Google Scholar
  3. 3.
    Bliwise DL, Hughes M, McMahon PM, Kutner N: Observed sleep/wakefulness and severity of dementia in an Alzheimer’s disease special care unit. J Gerontol Med Sci 1995, 50:M303-M306.Google Scholar
  4. 4.
    van Someren EJW: Circadian rhythms and sleep in human aging. Chronobiol Int 2000, 17:233–243.PubMedCrossRefGoogle Scholar
  5. 5.
    van Someren EJW: More than a marker: interaction between the circadian regulation of temperature and sleep, age-related changes, and treatment possibilities. Chronobiol Int 2000, 17:313–354. An overview of the neurobiologic mechanisms of sleep and circadian regulation identified in recent years. Ties findings to a proposed model for the effects of body temperature on sleep, and highlights treatment implications.PubMedCrossRefGoogle Scholar
  6. 6.
    Vitiello MV, Poceta JS, Prinz PN: Sleep in Alzheimer’s disease and other dementing disorders. Can J Psychol 1991, 45:221–239.PubMedGoogle Scholar
  7. 7.
    Ancoli-Israel S, Klauber MR, Jones DW, et al.: Variations in circadian rhythms of activity, sleep, and light exposure related to dementia in nursing-home patients. Sleep 1997, 20:18–23.PubMedGoogle Scholar
  8. 8.
    Boeve BF, Silber MH, Ferman TJ: Current management of sleep disturbances in dementia. Curr Neurol Neurosci Rep 2002, 2:169–177.PubMedCrossRefGoogle Scholar
  9. 9.
    Harper DG, Stopa EG, McKee AC, et al.: Differential circadian rhythm disturbances in men with Alzheimer disease and frontotemporal degeneration. Arch Gen Psychiatry 2001, 58:353–360.PubMedCrossRefGoogle Scholar
  10. 10.
    Volicer L, Harper DG, Manning BC, et al.: Sundowning and circadian rhythms in Alzheimer’s disease. Am J Psychiatry 2001, 158:704–711.PubMedCrossRefGoogle Scholar
  11. 11.
    Martin J, Marler MF, Shochat T, Ancoli-Israel S: Circadian rhythms of agitation in institutionalized Alzheimer’s disease patients. Chronobiol Int 2000, 17:405–418.PubMedCrossRefGoogle Scholar
  12. 12.
    Bliwise DL, Carroll JS, Lee KA, et al.: Sleep and “sundowning” in nursing home patients with dementia. Psychiatry Res 1993, 48:277–292.PubMedCrossRefGoogle Scholar
  13. 13.
    Autret A, Lucas B, Mondon K, et al.: Sleep and brain lesions: a critical review of the literature and additional new cases. Neurophysiol Clin 2001, 31:356–375.PubMedCrossRefGoogle Scholar
  14. 14.
    Larsen JP, Tandberg E: Sleep disorders in patients with Parkinson’s disease: Epidemiology and management. CNS Drugs 2001, 15:267–275.PubMedCrossRefGoogle Scholar
  15. 15.
    Boeve BF, Silber MH, Ferman TJ, et al.: Association of REM sleep behavior disorder and neurodegenerative disease may reflect an underlying synucleinopathy. Mov Disord 2001, 16:622–630.PubMedCrossRefGoogle Scholar
  16. 16.
    McCurry SM, Logsdon RG, Teri L, et al.: Characteristics of sleep disturbance in community-dwelling Alzheimer’s disease patients. J Geriatr Psychiatry Neurol 1999, 12:53–59.PubMedCrossRefGoogle Scholar
  17. 17.
    McCurry SM, Gibbons LE, Logsdon RG, Teri L: Anxiety and nighttime behavioral disturbances in Alzheimer’s disease. J Gerontol Nurs 2002, In press.Google Scholar
  18. 18.
    Ancoli-Israel S, Klauber MR, Butters N, et al.: Dementia in institutionalized elderly: relation to sleep apnea. J Am Geriatr Soc 1991, 39:258–263.PubMedGoogle Scholar
  19. 19.
    Ancoli-Israel S: Insomnia in the elderly: a review for the primary care practitioner. Sleep 2000, 23:S23-S30.PubMedGoogle Scholar
  20. 20.
    Schweitzer PK: Drugs that disturb sleep and wakefulness. In Principles and Practice of Sleep Medicine, edn 3. Edited by Kryger MH, Roth T, Dement WC. Philadelphia: WB Saunders; 2000:441–462.Google Scholar
  21. 21.
    McCurry SM, Gibbons LE, Logsdon RG, et al.: Training caregivers to change the sleep hygiene practices of patients with dementia: the NITE-AD Project. J Am Geriatr Soc 2003, In press.Google Scholar
  22. 22.
    Martin J, Shochat T, Ancoli-Israel S: Assessment and treatment of sleep disturbances in older adults. Clin Psychol Rev 2000, 20:783–805.PubMedCrossRefGoogle Scholar
  23. 23.
    NCSDR Working Group: Insomnia: assessment and management in primary care. Sleep 1999, 22:S402-S412.Google Scholar
  24. 24.
    Drugs and insomnia: the use of medications to promote sleep. NIH Consens Statement 1983, 4:1–19.Google Scholar
  25. 25.
    National Institutes of Health Consensus Group: National Institutes of Health Consensus Development Conference Statement: the treatment of sleep disorders of older people, March 26–28, 1990. Sleep 1991, 14:169–177.Google Scholar
  26. 26.
    Egan M, Moride Y, Wolfson C, Monette J: Long-term continuous use of benzodiazepines by older adults in Quebec: prevalence, incidence and risk factors. J Am Geriatr Soc 2000, 48:811–816.PubMedGoogle Scholar
  27. 27.
    Morgan K, Clarke D: Longitudinal trends in late-life insomnia: implications for prescribing. Age Ageing 1997, 26:179–184.PubMedCrossRefGoogle Scholar
  28. 28.
    Lonergan E, Luxenberg J, Colford J: Haloperidol for agitation in dementia. Cochrane Database Syst Rev 2002, 2:CD002852.PubMedGoogle Scholar
  29. 29.
    Raskind M: Psychopharmacology of noncognitve abnormal behaviors in Alzheimer’s disease. J Clin Psychiatry 1998, 56:28–32.Google Scholar
  30. 30.
    Tariot PN, Ryan JM, Porsteinsson AP, et al.: Pharmacologic therapy for behavioral symptoms of Alzheimer’s disease. Clin Geriatr Med 2001, 17:359–376.PubMedCrossRefGoogle Scholar
  31. 31.
    Wirz-Justice A, Cajochen C, Nussbaum P: A schizophrenic patient with an arrhythmic circadian rest-activity cycle. Psychiatry Res 1997, 73:83–90.PubMedCrossRefGoogle Scholar
  32. 32.
    Eccles M, Clarke J, Livingston M, et al.: North of England evidence based guidelines development project: guideline for the primary care management of dementia. BMJ 1998, 317:802–808.PubMedGoogle Scholar
  33. 33.
    Grace JB, Walker MP, McKeith IG: A comparison of sleep profiles in patients with dementia with Lewy bodies and Alzheimer’s disease. Int J Geriatr Psychiatry 2000, 15:1028–1033.PubMedCrossRefGoogle Scholar
  34. 34.
    Corey-Bloom J, Galasko D: Adjunctive therapy in patients with Alzheimer’s disease. Drugs Aging 1995, 7:79–87.PubMedCrossRefGoogle Scholar
  35. 35.
    Olde Rikkert MG, Rigaud AS: Melatonin in elderly patients with insomnia: a systematic review. Z Gerontol Geriatr 2001, 34:491–497.CrossRefGoogle Scholar
  36. 36.
    Zhdanova IV, Wurtman RJ, Regan MM, et al.: Melatonin treatment for age-related insomnia. J Clin Endrocrinol Metab 2001, 86:4724–4730.Google Scholar
  37. 37.
    Colling E, Wright M, Schaefer K, et al.: A large multicenter trial for the treatment of sleep disturbances in persons with Alzheimer’s disease: a progress report. Sleep 2000, 23:A340.Google Scholar
  38. 38.
    Singer C, Tractenberg R, Kaye J, et al.: The ADCS clinical trial of melatonin for the sleep disturbance of Alzheimer’s disease. Am J Geriatr Psychiatry 2002, 10:S65.Google Scholar
  39. 39.
    Gehrman PR, Connor D, Marler M, et al.: Bright light improves sleep but melatonin does not in severe Alzheimer’s disease. Sleep 2002, 25:A438–439.Google Scholar
  40. 40.
    Gehrman PR, Martin JL, Schochat T, et al.: Sleep disordered breathing and agitation in institutionalized adults with Alzheimer’s disease. Am J Geriatr Psychiatry 2002, In press.Google Scholar
  41. 41.
    Ancoli-Israel S, Cohen-Zion M, Palmer B, et al.: Effect of CPAP on cognitive functioning in patients with dementia and SDB: preliminary results. Sleep 2002, 25:A19-A20.Google Scholar
  42. 42.
    Ancoli-Israel S, Kripke DF, Klauber MR, et al.: Periodic limb movements in sleep in community-dwelling elderly. Sleep 1991, 14:496–500.PubMedGoogle Scholar
  43. 43.
    Wetter TC, Pollmacher T: Restless leg and periodic leg movements in sleep syndromes. J Neurol 1997, 244:S37-S45.PubMedCrossRefGoogle Scholar
  44. 44.
    Schenck CH, Mahowald MW: Polysomnographic, neurologic, psychiatric, and clinical outcome report on 70 consecutive cases with the REM sleep behavior disorder (RBD): sustained clonazepam efficacy in 89.5% of 57 treated patients. Cleve Clin J Med 1990, 57:S10-S24.Google Scholar
  45. 45.
    Olson EJ, Boeve BF, Silber MH: Rapid eye movement sleep behavior disorder: demographic, clinical and laboratory findings in 93 cases. Brain 2000, 123:331–339.PubMedCrossRefGoogle Scholar
  46. 46.
    Shochat T, Loredo J, Ancoli-Israel S: Sleep disorders in the elderly. Curr Treat Options Neurol 2001, 3:19–36.PubMedCrossRefGoogle Scholar
  47. 47.
    Chesson AL Jr., Anderson WM, Littner M, et al.: Practice parameters for the nonpharmacologic treatment of chronic insomnia. Sleep 1999, 22:1128–1133. Reviews evidence from 48 clinical trials and two meta-analyses on the efficacy of nonpharmacologic treatments for treating insomnia to develop American Academy of Sleep Medicine practice parameter recommendations.PubMedGoogle Scholar
  48. 48.
    Campbell SS, Kripke DF, Gillin JC, Hrubovcak JD: Exposure to light in healthy elderly subjects and Alzheimer’s patients. Physiol Behav 1988, 42:141–144.PubMedCrossRefGoogle Scholar
  49. 49.
    Shochat T, Martin J, Marler M, Ancoli-Israel S: Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res 2000, 9:373–379.PubMedCrossRefGoogle Scholar
  50. 50.
    McCurry SM, Reynolds CF, Ancoli-Israel S, et al.: Treatment of sleep disturbance in Alzheimer’s disease. Sleep Med Rev 2000, 4:603–608.PubMedCrossRefGoogle Scholar
  51. 51.
    Ancoli-Israel S, Martin JL, Kripke DF, et al.: Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. J Am Geriatr Soc 2002, 50:282–289. Largest published clinical controlled trial to date examining the treatment of sleep and circadian rhythm disturbances in persons with dementia.PubMedCrossRefGoogle Scholar
  52. 52.
    Ancoli-Israel S, Gehrman PR, Martin JL, et al.: Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer’s disease patients. Behav Sleep Med 2003, 1:22–36.PubMedCrossRefGoogle Scholar
  53. 53.
    Sumaya IC, Rienzi BM, Deegan JF, Moss DE: Bright light treatment decreases depression in institutionalized older adults: a placebo-controlled crossover study. J Gerontol Med Sci 2001, 56A:M356-M360.Google Scholar
  54. 54.
    van Someren EJW, Kessler A, Mirmiran M, Swaab DF: Indirect bright light improves circadian rest-activity rhythm disturbances in demented patients. Biol Psychiatry 1997, 41:955–963.PubMedCrossRefGoogle Scholar
  55. 55.
    Colenda CC, Cohen W, McCall WV, Rosenquist PB: Phototherapy for patients with Alzheimer disease with disturbed sleep patterns: results of a communitybased pilot study. Alz Dis Assoc Disord 1997, 11:175–178.CrossRefGoogle Scholar
  56. 56.
    van Someren EJW, Hagebeuk EEO, Lijzenga C, et al.: Circadian rest-activity rhythm disturbances in Alzheimer’s disease. Biol Psychiatry 1996, 40:259–270.PubMedCrossRefGoogle Scholar
  57. 57.
    Morgan K, Clarke D: Risk factors for late-life insomnia in a representative general practice sample. Br J Gen Pract 1997, 47:166–169.PubMedGoogle Scholar
  58. 58.
    van Someren EJ, Lijzenga C, Mirmiran M, Swaab DF: Long-term fitness training improves the circadian rest-activity rhythm in healthy elderly males. J Biol Rhythms 1997, 12:146–156.PubMedCrossRefGoogle Scholar
  59. 59.
    Arkin SM: Elder rehab: A student-supervised exercise program for Alzheimer’s patients. Gerontologist 1999, 39:729–735.PubMedGoogle Scholar
  60. 60.
    Brill PA, Drimmer AM, Morgan LA, Gordon NF: The feasibility of conducting strength and flexibility programs for elderly nursing home residents with dementia. Gerontologist 1995, 35:263–266.PubMedGoogle Scholar
  61. 61.
    Teri L, McCurry SM, Buchner DM, et al.: Exercise and activity level in Alzheimer’s disease: a potential treatment focus. J Rehabil Res Dev 1998, 35:411–419.PubMedGoogle Scholar
  62. 62.
    Lazowski D-A, Ecclestone NA, Myers AM, et al.: A randomized outcome evaluation of group exercise programs in long-term care institutions. J Gerontol Med Sci 1999, 54A:M621-M628.Google Scholar
  63. 63.
    Alessi CA, Yoon EJ, Schnelle JF, et al.: A randomized trial of a combined physical activity and environmental intervention in nursing home residents: do sleep and agitation improve? J Am Geriatr Soc 1999, 47:784–791.PubMedGoogle Scholar
  64. 64.
    Naylor E, Penev PD, Orbet L, et al.: Daily social and physical activity increases slow-wave sleep and daytime neuropsychological performance in the elderly. Sleep 2000, 23:87–95.PubMedGoogle Scholar
  65. 65.
    Ancoli-Israel S, Clopton P, Klauber MR, et al.: Use of wrist activity for monitoring sleep-wake in demented nursing-home patients. Sleep 1997, 20:24–27.PubMedGoogle Scholar
  66. 66.
    van Someren EJ, Swaab DF, Colenda CC, et al.: Bright light therapy: improved sensitivity to its effects on rest-activity rhythms in Alzheimer patients by application of nonparametric methods. Chronobiol Int 1999, 16:505–518.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc 2003

Authors and Affiliations

  • Susan M. McCurry
  • Sonia Ancoli-Israel
    • 1
  1. 1.Department of PsychiatryUniversity of California San Diego School of Medicine, Veterans Affairs San Diego Healthcare SystemSan DiegoUSA

Personalised recommendations