Non-pharmacologic treatment of insomnia in persons with dementia
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Non-pharmacologic treatment of insomnia
in persons with dementia
Denis Shub, MD; Roham Darvishi, MD; Mark E. Kunik, MD, MPH
The prevalence of insomnia increases with age
and affects up to 35% of community-dwelling
adults with dementia. Sleep disturbances and
associated cognitive and behavioral symptoms
I nsomnia is an important problem encountered in the
geriatric population. In addition to sleep changes
that normally occur with aging, the neurodegenera-
tive changes of dementia further compound the problem
by increasing the frequency and severity of sleep distur-
in this patient population can be a significant
contributor to morbidity, mortality, and caregiver
bances and associated behavioral disruptions. A com-
burden. Despite the frequency with which sleep
munity-residing, population-based study of individuals
disorders are encountered in primary care, few with Alzheimer’s disease suggests that 35% of subjects
evidence-based guidelines are available to guide are affected,1 which is likely much lower than in clinic
physician treatment plans. Sedative-hypnotic and nursing-home populations. Sleep disturbances can
medications are commonly prescribed but are be a significant contributor to caregiver burden, and they
associated with significant adverse effects and are often a reason caregivers cite for their decision to
have limited efficacy data. Non-pharmacologic institutionalize.2 Chronic insomnia in older patients is
treatments can be safe and effective adjuncts also an independent predictor of cognitive decline, falls,
or alternatives to medications but are often and increased 2-year mortality.3-5
underused in clinical practice. This article reviews Primary care physicians are often faced with an ardu-
practical applications of modalities such as light ous task of addressing these sleep problems, frequently
therapy, exercise, and sleep-hygiene modification by prescribing sedative-hypnotic or other sedating psy-
in treating insomnia in persons with dementia. chotropic medications. Up to 36% of patients with severe
Shub D, Darvishi R, Kunik ME. Non-pharmacologic treatment of sleep, cognitive, functional, and behavioral impairments
insomnia in persons with dementia. Geriatrics. 2009;64(2):22-26.
take a sedative-hypnotic, anxiolytic, antipsychotic, or
Key words: aging, circadian For rhythm,
Client Review Only. All Rights Reserved.antidepressant
dementia, Advanstar Communications Inc. 2005
medication. 1
Although judicious use of
insomnia, light therapy, sleep hygiene
medications may be helpful in addressing sleep and as-
Drugs discussed: zolpidem, mirtazapine sociated neuropsychiatric disturbances, their excess use
may also lead to increased risk of cognitive adverse ef-
fects, falls, and even death in patients with dementia.6,7
On the other hand, non-pharmacologic interventions are
Dr Shub is a resident, Menninger Department of safe and effective adjuncts or alternatives for treatment
Psychiatry and Behavioral Sciences, Baylor College of of insomnia.
Medicine, Houston, Texas. Physicians often receive information on use of phar-
Dr Darvishi is a staff physician, Michael E. DeBakey macologic interventions (an evidence-based review may
Veterans Affairs Medical Center, Houston, and assistant
professor, Department of Medicine, Baylor College of
be found within the American Psychiatric Association
Medicine. Practice Guideline for the Treatment of Patients with
Dr Kunik is Associate Director, Houston Center for Alzheimer’s Disease and Other Dementias),8 but fewer
Quality of Care & Utilization Studies; Associate Direc- resources are available on non-pharmacologic alterna-
tor, Research Training, VA South Central Mental Illness tives. This article will briefly review the initial presenta-
Research, Education & Clinical Center; Professor, Men-
ninger Department of Psychiatry and Behavioral Sci-
tion of insomnia in persons with dementia and focus on the
ences, Baylor College of Medicine. practical application of non-pharmacologic treatments to
Disclosure: The authors report no conflicts of interest. dementia patients encountered in primary care practice.
This work was supported in part by the Houston VA
HSR&D Center of Excellence (HFP90-020) Phenomenology and assessment
Sleep disturbances in persons with dementia have var-
22 Geriatrics February 2009 Volume 64, Number 2 w w w.g e r i . c o mied clinical presentations. Changes
in sleep architecture normally occur
Table Resources for caregivers
with age and are accentuated in de-
American Academy http://www.sleepeducation.com/pdf/
mentia. More time is spent in lighter of Sleep Medicine: sleepdiary.pdf
stages of sleep (stages 1 and 2) with
http://www.nia.nih.gov/HealthInformation/
a significant decrease in slow-wave National Institute on Aging:
Publications/ExerciseGuide/
(stages 3 and 4), rapid eye move- Alzheimer’s Disease
ment, and total sleep time.9,10 These Education and Referral
http://www.nia.nih.gov/Alzheimers/
changes in sleep structure manifest Center of the National
Institute on Aging:
in increased sleep fragmentation
http://www.alz.org/national/documents/
and arousals, with resultant exces- Alzheimer’s Association:
brochure_activities.pdf
sive daytime sleepiness and napping. The 36-Hour Day: A Family Guide to Caring
Damage of neuronal pathways in the for People with Alzheimer Disease, Other
Popular books in print
suprachiasmatic nucleus of the hypo- Dementias, and Memory Loss in Later Life,
include:
by Nancy L. Mace and Peter V. Rabins, from
thalamus, the area believed to initiate The Johns Hopkins University Press.
and maintain sleep as well as changes
Created for Geriatrics
in the circadian rhythm, may further
disrupt sleep in persons with demen-
tia and lead to shifts or complete day/ identifying specific target areas and pies for treating sleep disturbances
night sleep-pattern reversals.9 In a gauging the efficacy of a proposed in community-dwelling patients with
population-based sample of Alzheim- intervention. Because performing a Alzheimer’s disease.12
er’s disease patients, the most com- sleep study with polysomnography
mon sleep-related behavior problems is impractical and self-report is un- Light therapy
reported by caregivers were sleeping reliable in this patient population, a Exposure to light of sufficient intensity
more than usual (40%) and awakening sleep diary filled out by the caregiver and duration can have marked effects
early (31%), whereas being awakened is often the best alternative. A sample on an individual’s mood and sleep.
at night (24%) was the most distress- 2-week sleep diary is available online Bright-light therapy has a proven indi-
ing problem for caregivers.1 from the American Academy of Sleep cation for treatment of winter depres-
Medicine (Table). sion, or seasonal affective disorders.
When initial evaluation It is also one of the most widely stud-
NITE-AD used For Clientlight
Review Only. All Rights Reserved.
fails Advanstaranother
to identify Communications
ied Inc. 2005
non-pharmacologic interventions
therapy, sleep hygiene, medical or psychiatric for sleep and behavioral symptoms
condition as the cause of in dementia patients. NITE-AD, the
and exercise. insomnia, it is prudent to randomized, controlled trial using
consider non-pharmaco- light exposure as part of its research
logic treatments as a first- protocol, demonstrated significant,
Clinical assessment of individuals line intervention. Three modalities 32% reductions from baseline in
with insomnia must always include will be emphasized here—light ther- nighttime awakenings and total time
screening for secondary causes, apy, exercise, and sleep hygiene—that awake at night compared with con-
including medical and psychiat- were chosen on the basis of avail- trol subjects who worsened on both
ric conditions (eg, depression) and able evidence and applicability to measures.12 Patients and caregivers
medication side effects, as well as patients typically seen in outpatient found this treatment feasible, with
specific sleep disorders. Although primary care practice. All 3 were high compliance with the daily light
this article will emphasize treatment components of a comprehensive sleep box recommendation during two 3-
of primary insomnia, a discussion of education program in the Nighttime week active treatment periods and at
comorbidities (eg, sleep-disordered Insomnia Treatment and Education 6-month follow-up.
breathing, periodic limb movements for Alzheimer’s Disease (NITE-AD) Physicians must overcome several
in sleep, and restless-leg syndrome) study, the first clinical trial to date, challenges in recommending and
can be found elsewhere.10,11 Objec- funded by the National Institute of implementing home-based light treat-
tive baseline measure of the patient’s Mental Health, to have examined the ment. First, light therapy requires a
sleep disturbance may be helpful in efficacy of non-pharmacologic thera- light source of sufficient luminosity
w w w.g e r i . c o m February 2009 Volume 64, Number 2 Geriatrics 23Running_head
Insomnia & dementia
to affect circadian phase-shift, with 2,500 lux of full-spectrum light for 1 care practice setting have been shown
most studies exposing patients to 1000 hour each day. to improve physical fitness and ex-
to 10,000 lux for 30 to 90 minutes, far Caregivers who are struggling to ercise adherence in older (age > 65
greater than can be achieved with or- ensure at least a 30-minute seated years), community-dwelling adults.14
dinary home lighting. Thus, it is nec- treatment time may need assistance to Patients with dementia and caregiv-
essary to purchase specialized light identify and plan sedentary activities ers should be instructed to walk for
equipment, ie, a “light box.” These to help keep patients in position during exercise daily for 30 minutes, prefer-
are readily available from online re- light-therapy sessions. Resources are ably outside in natural light, weather
tailers and they range from around available from the Alzheimer’s Asso- permitting.12 Frail patients can start
$130 for a smaller lamp to $300 for ciation and the Alzheimer’s Disease with shorter walking intervals and
the unit used in the NITE-AD study. Education and Referral Center of the gradually build up over time.
Although this upfront cost may seem National Institute on Aging (Table). Information regarding exercise
prohibitive to some patients and their Caregivers may also find helpful in- safety, as well as sample endurance,
caregivers, it is comparable to costs of formation in several popular books strength, balance, and stretching ex-
pharmacologic treatment, given that a in print. ercises, is available in the Exercise
month’s supply of zolpidem (Ambien) Guide distributed by the National
costs $130. Exercise Institute on Aging (Table). Primary
care physicians can encourage pa-
Physical exercise is an important com-
Network ponent of non-pharmacologic therapy tients to try a new exercise from the
guide every day.
for sleep disturbances. In addition to
the benefit of improving sleep, evi-
There are more than a dozen handouts dence from a randomized, controlled Sleep hygiene
on sleep disorders available online at
modernmedicine.com that can be shared
trial suggests that a home-based exer- Sleep hygiene refers to an individual’s
with caregivers. cise program combined with behav- sleep habits and routines. It is often
www.geri.com/disorders ioral management can reduce func- believed that establishing good sleep
tional dependence, improve physical practices is the first-line treatment for
health and depression, and delay all patients with insomnia. There is
Another potential limitation is that institutionalization among patients now ample clinical and empirical evi-
a demented patient may not be able to with Alzheimer’s disease.12,13 A su- dence to suggest that behavioral inter-
understand and follow light therapy pervised exercise program in commu- ventions, aimed at improving sleep
treatment instructions. A caregiver For Client Review Only. All Rights Reserved.
is nity-dwelling Advanstar
individuals is Communications Inc. 2005
usually necessary to ensure that the feasible. Most persons with
patient remains seated and faces the dementia were able to walk Behavioral interventions
light source, which should be placed for 30 or more minutes per
at a distance of 2 to 3 feet within a day in one study.12 can be helpful in treating
45º visual field. It is imperative that A variety of other exer-
the patient does not sleep or nap dur- cise protocols have been nighttime disturbances.
ing treatment because light must fall used in clinical trials for pa-
onto the retina to influence the circa- tients with dementia. These protocols hygiene, can be helpful in treating
dian system. Patients can participate ranged from walking to more compre- sleep and nighttime disturbances in
in other activities such as reading, hensive programs including aerobic/ dementia patients.12,15,16 The feasibil-
eating, conversing, or watching tele- endurance activities, strength train- ity of changing sleep routines in com-
vision (the light box can be placed ing, balance, and flexibility training. munity-dwelling dementia patients
on top of the television) during light- The main challenge to implementing hinges on the primary care provider’s
treatment sessions. Light exposure these, as with all behavioral interven- help in developing an individualized
treatment should be within a 3-hour tions, is the required caregiver time. behavioral plan tailored to the care-
window before the patient’s habitual Nevertheless, a primary care clinic giver’s particular situation. In the
bedtime, except for patients who al- can be an ideal setting for encourag- NITE-AD study, compared with the
ready have extremely late bedtimes. ing patients to increase their physical patients whose caregivers received
In the NITE-AD study, patients used activity level. Tailored exercise pre- only educational materials, patients
a light box delivering approximately scriptions delivered in the primary whose caregivers received active as-
24 Geriatrics February 2009 Volume 64, Number 2 w w w.g e r i . c o mInsomnia & dementia
sistance in setting up and implementing a sleep-hygiene
program were more likely to maintain a consistent bed-
time (83% vs 38%) and rising time (96% vs 59%) sched-
ule, and were less likely to nap during the daytime (70%
vs 28%).16
Prior to formulating an individualized sleep-hygiene
program, it is worthwhile to screen for patients who would
benefit the most from intensive behavioral intervention.
Primary care physicians may start by obtaining details
on the patient’s baseline sleeping habits, using either
caregiver reports or, ideally, a sleep-data diary kept for
at least 1 week.
Patients who need to make changes in their bedtime, ris-
ing time, or daytime napping schedules are candidates for
sleep-hygiene changes and should receive further instruc-
tion.16 Caregivers may require assistance in identifying de-
sirable bed and rising times and in adhering to these within
a 30-minute leeway. Caregivers should be encouraged to
limit patients’ naps to 30 minutes or less and to eliminate
naps after 1 pm altogether. Effort should also be devoted to
identifying triggers for nighttime awakenings and to devise
strategies for eliminating them. Common culprits include
things such as nighttime noise and light, and incontinence.
Some helpful behavioral strategies to address these are
keeping sleeping areas dark, turning off the television at
night, avoiding excessive fluid intake, and restricting caf-
feinated beverages in the evening. A more comprehensive
list of educational information on sleep hygiene, including
environmental, dietary, and health guidelines, such as that
given to all subjects participating in the NITE-AD project,
can be found in McCurry etForal.Client
15, 16 Review Only. All Rights Reserved. Advanstar Communications Inc. 2005
The main obstacle to implementing sleep-hygiene
changes in persons with dementia is the requirement for
significant time and effort from caregivers, which may
contribute to caregiver burden. As already alluded to,
it is crucial for primary care providers to make specific
suggestions and to troubleshoot problems that arise in
caregivers’ attempts to change sleep and activity routines,
as opposed to having them rely on written educational
materials alone. For example, it could be very challeng-
ing to keep individuals from napping without a concrete
plan for keeping them occupied, active, and awake dur-
ing daytime. Scheduling a long walk or another type of
physical activity in the afternoon may be helpful, but
any plan must take into account the caregiver’s ability
to follow through with the recommendation, and there
must be collaboration on possible alternatives.
Conclusion
Treatment of insomnia in persons with dementia presents
a number of challenges for caregivers and primary care
February 2009 Volume 64, Number 2 Geriatrics 25Insomnia & dementia
physicians. Despite the ubiquitous munity-dwelling patients who suffer D, Rovner B, et al. American Psychiatric
Association practice guideline for the treat-
nature of sleep disturbances in de- from dementia. ment of patients with Alzheimer’s disease
and other dementias. Second edition. Am J
mentia patients, few evidence-based Psychiatry. 2007;164(12 Suppl):5-56.
guidelines exist to address this im- 9. Vitiello MV, Borson S. Sleep disturbances
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