Question: My wife with Alzheimer’s disease is up wandering around the house all night, and then naps all day. Can’t my doctor prescribe a sleeping pill?
Answer: Hopefully not! Sleep problems in patients with Alzheimer’s disease and other dementias are extremely common and probably occur in up to 50 per cent of patients. In normal aging adults, sleep becomes lighter and there are more frequent awakenings. In patients with dementia however, these changes tend to be more severe, with problems falling asleep and maintaining sleep. More rarely, but common in dementia with Lewy bodies, there can be unusual sleep behaviours including the acting out of dreams. Some patients can exhibit complete day-night reversal, where they are up all night and sleep most of the day. It is not hard to imagine how sleep problems in patients with dementia lead to increased caregiver distress, depression and increase the risk of institutionalization.
Sleep hygiene
Insomnia in dementia is extremely difficult to treat. Typically, treatment begins with sleep hygiene techniques which include avoiding day-time napping, following regular bed and rising times, ensuring a quiet and comfortable sleep environment, avoiding caffeine etc. Unfortunately, these techniques which work so well in otherwise healthy elderly adults, are often insufficient to improve sleep in patients with dementia. Increasing daytime activities and exercise can be helpful. Bright light therapy, using specialized bulbs or light panels, might also be helpful for some patients, but this has not been confirmed in large rigorous clinical trials.
Medications
Medications are unfortunately used far too frequently to treat insomnia in dementia, even though their effectiveness is largely unproven and their potential side effects are considerable. Patients with dementia should not be treated with standard sleeping pills. The sleeping pills that are available over the counter in pharmacies are typically made with sedating antihistamines which have a prominent side-effect called “anticholinergic” effects which can worsen memory in patients with Alzheimer’s disease and actually counteract the effects of the standard anti-dementia drugs. The most common prescription sleeping drugs are benzodiazepines (drugs like Valium and Ativan). Besides being addictive and leading to falls in the elderly, they too can lead to worsening of memory and cognition in patients with Alzheimer’s disease.
Another increasingly common and problematic treatment for insomnia in patients with dementia is the use of antipsychotic drugs, especially quetiapine (Seroquel). These drugs are completely unproven as sleeping medications for dementia, and carry with them the risks of stroke and even death. Some physicians will use sedating antidepressants like mirtazapine (Remeron) or trazodone. While there is one small positive trial of trazodone, use of these antidepressants may also increase the risk of falls in the elderly with dementia.
Finally, the use of melatonin – a hormone associated with sleep and wakefulness regulation and can be taken in the form of supplements – remains somewhat controversial. While a recent review of the small number of published trials in dementia suggested some benefit and good tolerability, most clinicians have not found it very helpful.
Exercise and activities
Insomnia and sleep disorders in patients with dementia are common problems that can have prominent negative effects on caregivers. At present, the best recommendations suggest that drugs should be avoided, and patients should be treated by instituting good sleep hygiene, increasing daytime exercise and activities, and ensuring exposure to lots of natural daytime sunshine.
