Dementia and Sleep Disturbance C. Andrew Class, MD St. Vincent Stress Center

This speaker has no conflict of interest to disclose.

Age Related Sleep Changes Decrease in total sleep time Lighter and more fragmented Decreased REM sleep and deep sleep Increased prevalence of sleep disorders: Insomnia, OSA, RLS, REM Sleep Behavior Disorder, Periodic Limb Movement Disorder Chronic disease and poor health probably account for much of the decline

Sleep Disturbance More common in patients with neuro-degenerative dementias Changes in sleep quality vary based on the dementia etiology May be a risk factor for cognitive decline May result in mood disturbance, fatigue, and increase fall risk Along with behavioral disturbances are most common causes of institutionalization

Circadian Rhythms Regulated by hypothalamic suprachiasmatic nucleus (SCN) Zeitgebers – exogenous stimuli that entrain the circadian rhythm (which is slightly greater than 24 hours) to the 24 hour day Light is most important Physical activity Meals Social contact

Circadian Rhythms in Patients with Dementia Disturbances more prominent Phase delays in activity rhythms and core body temperature Sundowning related to circadian rhythm abnormalities Related to the neuro-degenerative process, changes in the retinal photoreceptors and SCN (disregulation of melatonin secretion) and environmental changes

REM Sleep Behavior Disorder Prevalent in neurodegenerative dementias associated with alpha-synuclein pathology (PD, DLB, Multiple system atrophy) Parasomnia caused by loss of muscle atonia during REM sleep Results in “acting out” dreams May emerge before overt signs/symptoms of the dementia Predominate during 2nd half of sleep period (REM most prevalent) Associated with risk of injury to patients and bed partners Treatment includes physical safeguards Melatonin 3-12mg qHS or Clonazepam

Nocturnal Stridor Type of respiratory dysfunction seen with Multiple system atrophy Associated with partial obstruction of the larynx Associated with high pitched wheezing sound which is diagnostic Can be treated with CPAP and without treatment can become life threatening

Restless Leg Syndrome Urge to move the legs Uncomfortable sensations In patients with dementia may result in rubbing of limbs, frequent limb movements or restlessness May be worsened by serotonergic antidepressants and dopamine antagonists May be associated with decreased iron stores Might benefit from exercise and leg massage Pharmacotherapy includes dopamine agonists or gabapentinoids

Obstructive Sleep Apnea Increasingly common with age, as well as central sleep apneas Other risk factors include excess weight/thick neck, use of alcohol, smoking Symptoms include snoring, apneic periods, nocturnal choking or gasping, daytime sleepiness, nocturia and AM headaches If severe can further decrease cognitive function CPAP may benefit, some tolerate

Nonpharmacological Treatment Environmental restructuring Minimizing polypharmacy (stimulants, respiratory meds, antihypertensives and decongestants in particular) and consider timing Manage pain/discomfort Encourage exercise at least 30 minutes, walks outside ideal Reduce time in bed and use only for sleep Maintain consistent sleep/wake schedule Bright light therapy

Pharmacological Treatments Melatonin Trazodone Ramelteon Other antidepressants Hypnotics Antipsychotics

Bibliography Ancoli-Israel S, Palmer BW, Cooke JR, et al. Cognitive effects of treating obstructive sleep apnea in Alzheimer’s disease: a randomized controlled study. J Am Geriatr Soc 2008; 56:2076. Bloom HG, Ahmed I, Alessi CA et al. Evidence-based recommendations for the assessment and management of sleep disorders in older persons. J AM Geriatr Soc 2009; 57:761. Kinnunen KM, Vikhanova A, Livingston G. The management of sleep disorders in dementia: an update. Curr Opin Psychiatry. 2017; 6:491-497. McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbance in Alzheimer’s disease. Chochrane Database Syst Rev. 2014; 3:CD009178. Richards K, Shue VM, Beck CK, et al. Restless legs syndrome risk factors, behaviors and diagnosis in persons with early to moderate dementia and sleep disturbance. Behave Sleep Med 2010; 8:48. Urrestarazu E, Iriarte J. Clinical management of sleep disturbances in Alzheimer’s disease: current and emerging strategies. Nat Sci Sleep. 2016; 8:21-23.