Diagnosis and treatment of sleep disorders in dementia
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Diagnosis and Treatment of Sleep Disorders in Dementia. Subhash Bashyal , M.D. George T. Grossberg , M.D. Samuel W. Fordyce Professor Department of Neurology & Psychiatry Saint Louis University School of Medicine. Disclosures. Dr. Bashyal – None Dr. Grossberg

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Diagnosis and treatment of sleep disorders in dementia
Diagnosis and Treatment of Sleep Disorders in Dementia

SubhashBashyal, M.D.

George T. Grossberg, M.D.

Samuel W. Fordyce Professor

Department of Neurology & Psychiatry

Saint Louis University School of Medicine


Disclosures
Disclosures

Dr. Bashyal – None

Dr. Grossberg

Consultant – Baxter Bioscience; Bristol-Myers, Squibb; Forest Labs; Novartis; Lundbeck; Otsuka

Research Support: Baxter Bioscience; Janssen; Novartis; Pfizer; NIH

Safety Monitoring Committee - Merck


Dementia
Dementia

  • Characterized by cognitive decline resulting in functional impairment.

  • Major types:

    Alzheimer's Dementia

    Lewy Body Dementia

    Vascular dementia

    Parkinson’s Dementia

    Frontotemporal dementia


Epidemiology
Epidemiology

  • 1/8 older Americans has Alzheimer’s disease (AD)

  • 5.4 million Americans with AD and other dementias

  • Estimated to cost 200 billion USD (Alzheimer’ s Association 2012)

  • Risk increased in the presence of cardiac disease, hypertension, and cerebrovascular disease, but presence of dementia alone has been associated with decrease in mean survival.

Ref: Alzheimer’s Disease Facts and Figures – 2012

www.alz.org


Normal sleep
Normal Sleep

  • NREM: Stages 1, 2, 3 and 4.

  • Stages 3 and 4 also known collectively as deep sleep, delta sleep, slow wave sleep.

  • REM sleep

  • Cycle occurs approximately every 90 mins.

  • Regulated by circadian rhythm, homeostatic sleep drive.

Ref: Weldemichael DA, Grossberg GT, Int J AlzheimersDis, 2010


Sleep changes in the elderly
Sleep changes in the Elderly

  • Difficulty in sleep initiation

  • Decrease in total sleep time

  • Reduced sleep efficiency

  • Decrease in slow wave and REM sleep and an increase in Stage 1 and 2

  • Increased fragmentation of sleep.


Ref: Kate Crowley, Neuropsychol Rev 2011


Changes in sleep in patients with alzheimer s disease
Changes in sleep in patients with Alzheimer's disease

  • Poorer sleep efficiency

  • Longer sleep latency, increase in Stage 1

  • Frequent awakenings, and decrease in REM sleep, decrease in sleep spindles and K complexes

  • Frequent day time naps

  • Circadian rhythm disturbance, sundowning

  • Phase delay


Dementia and sleep
Dementia and Sleep

  • Sleep disordered breathing associated with cognitive impairment.( Yaffe et al)

  • REM-sleep behavior disorders associated more with Lewy Body dementia.(Bliwise et al )

  • Nocturnal sleep disturbance associated with more advanced Alzheimer's disease

  • Poor sleep leading to increased wandering with risk for injury and care giver burden, and frequently is a factor for increase in level of care .

Ref: Yaffe K, Laffan AM, Harrison SL, et al, JAMA 2011

Bliwise DL, Mercaldo ND, Avidan AY, et al, Dement GeriatrCognDisord.


Causes of sleep disturbance in dementia
Causes of sleep disturbance in dementia

  • Apolipiprotein E associated with sleep disturbance (in Alzheimer’s disease)

  • Sleep related breathing disorders

  • Circadian rhythm disorders

  • Medications

  • Comorbid depression / anxiety

  • Medical problems: Pain, cardiovascular, respiratory, GI and urological problems.

  • Environmental Factors.


Evaluation
Evaluation

History (from sleep partner if available):

Evaluate for common causes

Patient’s medications, including over the counter and herbal supplements

History of snoring/ periodic cessation of breathing, kicking during sleep

Physical examination / Mental Status Examination

Lab tests

Sleep study / sleep clinic


Obstructive sleep apnea
Obstructive sleep Apnea

  • Higher prevalence in elderly with dementia, and also higher with severity of dementia

  • Similar comorbid factors as Alzheimer’s dementia: Increasing age, cardiovascular parameters (hypertension, cardiac disease, stroke) and Apolipoprotein E genotype

  • Managed by weight loss, avoidance of alcohol, sedatives and hypnotics

  • Treated with Continuous Positive Airway Pressure (CPAP)


Restless leg syndrome rls
Restless Leg syndrome(RLS)

  • Characterized by distressing, deep sensations in the limbs ( predominantly lower), and an urge to move them (mostly at night)

  • More frequent in women

  • Associated with conditions such as low serum ferritin, renal failure, rheumatoid arthritis, anti depressant use

  • Treated with dopamine agonists (pramipexole, ropinirole, L-Dopa/Carbidopa – off label)

  • Periodic limb movements(PLMs): Often co exist with RLS, no treatment recommended if alone (w/0 RLS)

Ref: Neikrug AB, Ancoli-Israel S, Gerontology 2010


Treatment of insomnia in patients with dementia
Treatment of Insomnia in patients with dementia

  • Non pharmacological methods:

  • Bright light therapy:

    Some benefit with reductions in night time sleep fragmentation, increase in sleep period

  • Behavioral methods :(increase in daytime physical activity, daily sunlight exposure, decreased night time noise and light)

    Some benefit with reductions in sleep fragmentation, but mixed results overall

    Ref: Neikrug AB, Ancoli-Israel S, Gerontology 2010


Pharmacological treatment
Pharmacological treatment

  • Sedative Hypnotics: Non-Benzodiazepines ( Zolpidem Zaleplon) preferred to Benzodiazepines, with decreased risk of disorientation and memory loss

  • Melotonin: Mixed results but mostly ineffective ; effect better when combined with bright light therapy.

  • Acetylcholinesterase Inhibitors: Some positive results with Donepezil in AD.

  • Antipsychotics: Few studies evaluating sleep, more helpful for agitation. Increased sensitivity in patient’s with Lewy Body Dementia, use with caution in elderly

  • Anti depressants: Mirtazepine and Trazodone

    Ref: Wilson SJ, Nutt DJ, Alford C, et al. J Psychopharmacol 2010


Other contributing factors
Other Contributing factors

  • Low stimulus non distracting environment

  • Avoid frequent interruptions (e.g. Vitals check at night while in a nursing home)

  • Sleep Hygiene

  • Treatment of pain/ urinary issues

  • Treatment of sleep apnea, restless legs syndrome

  • Treatment of medical problems


Summary
Summary

  • Sleep problems in patients with dementia have been known to cause impaired daytime functioning ,and are frequently responsible for the requirement of a higher level of care

  • Alzheimer’s disease has been associated with circadian rhythm disorders, sleep breathing disorders, which can further impair cognition and contribute to behavioral problems

  • Behavioral management is associated with the least side effects, while the use of medication needs more research.


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