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

2. This speaker has no conflict of interest to disclose.

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Pharmacological Treatments
Melatonin
Trazodone
Ramelteon
Other antidepressants
Hypnotics
Antipsychotics

13. 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:
McCleery J, Cohen DA, Sharpley AL. Pharmacotherapies for sleep disturbance in Alzheimer’s disease. Chochrane Database Syst Rev. 2014; 3:CD
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.