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Assessing and Promoting Assessing and Promoting Better Sleep in Elders Better Sleep in Elders Joe Lasek, MD Joe Lasek, MD Medical Director, Counseling Service of Addison Medical Director, Counseling Service of Addison County County Clinical Assistant Professor, UVM College of Medicine Clinical Assistant Professor, UVM College of Medicine
Objectives Objectives • Briefly review epidemiology of sleep Briefly review epidemiology of sleep problems in the elderly problems in the elderly • Review sleep changes in elderly Review sleep changes in elderly • Briefly review insomnia evaluation Briefly review insomnia evaluation • Briefly review pharmacologic Briefly review pharmacologic interventions for insomnia in the elderly interventions for insomnia in the elderly • Review non-pharmacologic Review non-pharmacologic interventions for insomnia in the elderly interventions for insomnia in the elderly
Epidemiology of Sleep Problems Epidemiology of Sleep Problems for Elders for Elders • Up to 80% of elderly report sleep changes Up to 80% of elderly report sleep changes (increases as a function of age, higher in (increases as a function of age, higher in institutional settings) institutional settings) • When defined as diff falling or staying asleep When defined as diff falling or staying asleep or non restorative: 60-90% report problems or non restorative: 60-90% report problems • When defined more strictly, i.e. chronic When defined more strictly, i.e. chronic insomnia that causes distress or impairment: insomnia that causes distress or impairment: 12-20% 12-20% • 6-29% report hypersomnia 6-29% report hypersomnia • Women report more sleep problems than men Women report more sleep problems than men (lower melatonin levels, >vasomotor sx) (lower melatonin levels, >vasomotor sx)
Impact of Insomnia in the Impact of Insomnia in the Elder Population Elder Population • Independent predictor of: Independent predictor of: – Cognitive decline (effect bidirectional: Cognitive decline (effect bidirectional: cognitive decline predicts worsening sleep) cognitive decline predicts worsening sleep) – Falls Falls – Increased 2 year mortality Increased 2 year mortality • Significant contributor to caregiver Significant contributor to caregiver burden, often a reason for burden, often a reason for institutionalization institutionalization
Risk Factors for Developing Risk Factors for Developing Dementia Dementia • Daytime sleepiness Daytime sleepiness • Restless sleep Restless sleep • Increased use of sleep medication Increased use of sleep medication • Sleep problems may be the single Sleep problems may be the single strongest predictor of Alzheimer’s strongest predictor of Alzheimer’s • Also predictive of Parkinson’s and Also predictive of Parkinson’s and Huntington’s Huntington’s
Types of Insomnia Types of Insomnia • Primary Insomnia (minority of cases) Primary Insomnia (minority of cases) • Adjustment Insomnia (due to stress) Adjustment Insomnia (due to stress) • Inadequate Sleep Hygiene Inadequate Sleep Hygiene • Insomnia due to a Drug or Substance Insomnia due to a Drug or Substance • Insomnia due to a Psychiatric Disorder Insomnia due to a Psychiatric Disorder • Insomnia due to a Medical Condition Insomnia due to a Medical Condition – Pain Disorders Pain Disorders – Ocular Disorders: Macular degeneration/ Ocular Disorders: Macular degeneration/ cataracts/diabetes cataracts/diabetes
Primary Sleep Disorders Primary Sleep Disorders • All of the following more common with age All of the following more common with age • All impact sleep and have specific All impact sleep and have specific treatment treatment • Obstructive Sleep Apnea (OSA) Obstructive Sleep Apnea (OSA) • Restless Leg Syndrome (RLS) Restless Leg Syndrome (RLS) • Periodic Limb Movements of Sleep (PLMS) Periodic Limb Movements of Sleep (PLMS) • REM Sleep Behavior Disorder (RSBD) REM Sleep Behavior Disorder (RSBD)
Dementia and Obstructive Sleep Dementia and Obstructive Sleep Apnea (OSA) Apnea (OSA) • Prevalence of OSA in dementia: 33%-70% Prevalence of OSA in dementia: 33%-70% • 90% of patients with mod-severe Alzheimer’s 90% of patients with mod-severe Alzheimer’s have >5 apneic events/hr have >5 apneic events/hr • OSA increases risk of dementia and vice versa OSA increases risk of dementia and vice versa • Persistent hypoxia (low oxygen) from apnea Persistent hypoxia (low oxygen) from apnea intensifies cognitive/mood symptoms (less intensifies cognitive/mood symptoms (less effective clearance of B-amyloid?) effective clearance of B-amyloid?) • Increased cardio-pulmonary disease Increased cardio-pulmonary disease • Treatment: CPAP, dental appliance, surgery Treatment: CPAP, dental appliance, surgery
Sleep Changes as We Age Sleep Changes as We Age • Advanced sleep phase (“Early to bed, Advanced sleep phase (“Early to bed, early to rise”) early to rise”) • Longer time to sleep Longer time to sleep • Increasingly fragmented sleep Increasingly fragmented sleep • Decreased sleep efficiency (more time Decreased sleep efficiency (more time awake in bed) awake in bed) • Decreased slow wave (restorative) sleep Decreased slow wave (restorative) sleep & decreased REM sleep & decreased REM sleep
Neurobiology of Sleep Neurobiology of Sleep Changes Changes • Circadian rhythm changes (sleep phase shifts Circadian rhythm changes (sleep phase shifts earlier bc of earlier melatonin production) earlier bc of earlier melatonin production) • Decreased neuron activity in supra-chiasmatic Decreased neuron activity in supra-chiasmatic nucleus (SCN)- central circadian pacemaker nucleus (SCN)- central circadian pacemaker (decreased variability in core temperature) (decreased variability in core temperature) • Decreased pineal gland-SCN connections Decreased pineal gland-SCN connections • Decreased light transmission (pupils smaller, Decreased light transmission (pupils smaller, lenses cloudier, decreased retina receptors) lenses cloudier, decreased retina receptors) • Decreased pineal gland melatonin production Decreased pineal gland melatonin production
Sleep Problems in Dementia Sleep Problems in Dementia • Progressively decreased REM & slow wave sleep Progressively decreased REM & slow wave sleep • Decreased efficiency: 40% of time in bed may be Decreased efficiency: 40% of time in bed may be spent awake spent awake • Daytime sleepiness Daytime sleepiness • Nighttime confusion/agitation (sundowning) Nighttime confusion/agitation (sundowning) • Nighttime waking/wandering (rated most Nighttime waking/wandering (rated most distressing symptom by caregivers) distressing symptom by caregivers) • Irregular Sleep Wake Disorder (ISWD): normal Irregular Sleep Wake Disorder (ISWD): normal amount of sleep dispersed in 3 or more variable amount of sleep dispersed in 3 or more variable periods through out day periods through out day
Neurobiology of insomnia in Neurobiology of insomnia in dementia dementia • Progressive damage to Supra Progressive damage to Supra Chiasmatic Nucleus & SCN-pineal gland Chiasmatic Nucleus & SCN-pineal gland pathways (greater melatonin decrease) pathways (greater melatonin decrease) • Progressive damage to basal forebrain Progressive damage to basal forebrain and reticular formation in brainstem and reticular formation in brainstem (part of central circadian rhythm (part of central circadian rhythm pacemaker) pacemaker)
Medications & Impaired Medications & Impaired Cognition Cognition • Anti-cholinergic medications Anti-cholinergic medications – TCAs (amitriptyline, nortriptyline) TCAs (amitriptyline, nortriptyline) – Antihistamines (benadryl, zyrtec, claritin, pepcid, Antihistamines (benadryl, zyrtec, claritin, pepcid, zantac) zantac) – Bladder agents (ditropan, detrol) Bladder agents (ditropan, detrol) • Benzodiazepines (valium, klonopin, ativan) Benzodiazepines (valium, klonopin, ativan) • Benzo receptor agonists (ambien, sonata, Benzo receptor agonists (ambien, sonata, lunesta) lunesta) • Opioids (morphine, oxycodone, hydrocodone) Opioids (morphine, oxycodone, hydrocodone) • Muscle relaxants (flexeril, robaxin, baclofen) Muscle relaxants (flexeril, robaxin, baclofen) • Anti-psychotics (seroquel, rispridone, haldol) Anti-psychotics (seroquel, rispridone, haldol) • Anti-epileptics (depakote, tegretol) Anti-epileptics (depakote, tegretol)
Medications Can Cause Medications Can Cause Insomnia Insomnia • Any med can cause SEs & worsen sleep Any med can cause SEs & worsen sleep • Antidepressants (prozac, zoloft, effexor, Antidepressants (prozac, zoloft, effexor, cymbalta, wellbutrin) cymbalta, wellbutrin) • Beta-blockers (propranolol, atenolol, metoprolol) Beta-blockers (propranolol, atenolol, metoprolol) • Bronchodilators (albuterol) Bronchodilators (albuterol) • Pro-Cholinergics (aricept) Pro-Cholinergics (aricept) • Corticosteroids (prednisone) Corticosteroids (prednisone) • Diuretics (lasix, hydrochlorothiazide) Diuretics (lasix, hydrochlorothiazide) • Stimulants/decongestants (amphetamine, Stimulants/decongestants (amphetamine, pseudophedrine) pseudophedrine)
Delirium: get help quick! Delirium: get help quick! • Sudden change in mental status Sudden change in mental status • Confusion (disorientation) about time or place Confusion (disorientation) about time or place • Changes in alertness, level of consciousness (usually Changes in alertness, level of consciousness (usually more alert in the morning, less alert at night) more alert in the morning, less alert at night) • Changes in sleep patterns, drowsiness Changes in sleep patterns, drowsiness • Changes in attention, memory; disorganized thought Changes in attention, memory; disorganized thought • Perceptual disturbances (visual, tactile > auditory) Perceptual disturbances (visual, tactile > auditory) • Emotional or personality changes (increased paranoia) Emotional or personality changes (increased paranoia) • Changes in movement (either slowed or hyperactive) Changes in movement (either slowed or hyperactive) • Treatment: Always due to a medical condition Treatment: Always due to a medical condition requiring emergent medical treatment requiring emergent medical treatment
Depression, Sleep & Cognition Depression, Sleep & Cognition • Mood affected by sleep and sleep/cognition Mood affected by sleep and sleep/cognition worsen with depressed mood worsen with depressed mood • MDD occurs in 4% of elders (dep sx occur in MDD occurs in 4% of elders (dep sx occur in up to 16% of elderly) and up to 18% of those up to 16% of elderly) and up to 18% of those with Alzheimer’s with Alzheimer’s • Non-depressed elders with insomnia have up Non-depressed elders with insomnia have up to 2x risk of developing depression (though to 2x risk of developing depression (though only study with objective measures showed only study with objective measures showed no relationship) no relationship)
Depression, Sleep & Cognition Depression, Sleep & Cognition • Studies show that circadian rhythm & Studies show that circadian rhythm & sleep disrupted in those with depression sleep disrupted in those with depression – Delayed sleep onset Delayed sleep onset – Early morning awakening Early morning awakening – Decreased slow wave sleep Decreased slow wave sleep – Decreased REM latency (unique to Decreased REM latency (unique to depression) depression) • Better sleep quality post-treatment Better sleep quality post-treatment associated with lower relapse associated with lower relapse
Assessment Assessment & & Treatment Treatment of of Sleep Problems Sleep Problems
Evaluating Insomnia Evaluating Insomnia • Quantity of sleep alone does not Quantity of sleep alone does not constitute insomnia constitute insomnia • DSM-IV diagnosis for primary insomnia is DSM-IV diagnosis for primary insomnia is a subjective clinical diagnosis a subjective clinical diagnosis • Ideally, diagnosis would be subjective and Ideally, diagnosis would be subjective and objective objective • Referral for a sleep study should be Referral for a sleep study should be reserved for special cases (eg confirm reserved for special cases (eg confirm OSA) OSA)
An Approach to Evaluating An Approach to Evaluating Chronic Insomnia (>4 weeks) Chronic Insomnia (>4 weeks) • Medical/Psychiatric Evaluation Medical/Psychiatric Evaluation – Medical problems that may impact sleep Medical problems that may impact sleep – Psychiatric sx that may impact sleep: depression, anxiety, etc Psychiatric sx that may impact sleep: depression, anxiety, etc • Carefully review Carefully review – Sleep patterns (time to bed, lights out, wake up, Sleep patterns (time to bed, lights out, wake up, etc) etc) – Sleep hygiene (habits that may effect sleep) Sleep hygiene (habits that may effect sleep) – Substance use (drugs, caffeine, alcohol, nicotine) Substance use (drugs, caffeine, alcohol, nicotine) – Medication use Medication use – Sources of increased stress Sources of increased stress
First things first: gather info First things first: gather info • Start with a 2 week sleep diary Start with a 2 week sleep diary – Dr. L’s version (see handout) Dr. L’s version (see handout) – http://yoursleep.aasmnet.org/pdf/sleepdiar y.pdf • Have caregiver provide collateral if Have caregiver provide collateral if available available
First steps in treatment First steps in treatment • Diagnose and treat underlying conditions Diagnose and treat underlying conditions – Medication side effects Medication side effects – Infection Infection – Depression/anxiety Depression/anxiety – Pain Pain – Incontinence Incontinence • Treat primary sleep disorders when present Treat primary sleep disorders when present – OSA: CPAP (at least 5 hrs/night) may slow OSA: CPAP (at least 5 hrs/night) may slow progression of cognitive impairment in dementia progression of cognitive impairment in dementia – RLS/RSBD: standard medications, start lower and RLS/RSBD: standard medications, start lower and go slower go slower
Make the environment safe Make the environment safe • Remove dangerous objects Remove dangerous objects • Generally: avoid bed rails Generally: avoid bed rails • Lock door and windows Lock door and windows • Use gates to block off dangerous areas Use gates to block off dangerous areas (e.g. stairs) (e.g. stairs) • Use night light if needed Use night light if needed
Cognitive Behavioral Cognitive Behavioral Therapies vs Medications Therapies vs Medications • Medications appear to interfere with Medications appear to interfere with the effectiveness of CBT (especially the effectiveness of CBT (especially BZDs and BZD receptor drugs) BZDs and BZD receptor drugs) • CBT effective in helping taper CBT effective in helping taper medications (including in older patients) medications (including in older patients) • CBT as effective in secondary insomnia CBT as effective in secondary insomnia as in primary insomnia as in primary insomnia
Sleep Medication Sleep Medication • Up to 36% of patients with insomnia & Up to 36% of patients with insomnia & cognitive impairment use sedatives cognitive impairment use sedatives • Some studies: no effect (some limited effect) Some studies: no effect (some limited effect) • Sedating medications increase risks Sedating medications increase risks – Daytime sleepiness Daytime sleepiness – Cognitive impairment (including risk for dementia) Cognitive impairment (including risk for dementia) – Falls/accidents/broken hips Falls/accidents/broken hips – All cause mortality All cause mortality • If using sedatives, should be low doses & If using sedatives, should be low doses & time-limited time-limited
CBT in Elders CBT in Elders • Substantial evidence that CBT most effective Substantial evidence that CBT most effective – Cognitive restructuring: decatastrophizing insomnia Cognitive restructuring: decatastrophizing insomnia – Sleep scheduling: regular wake and sleep time Sleep scheduling: regular wake and sleep time – Stimulus control: bed only for sleep Stimulus control: bed only for sleep – Relaxation training Relaxation training – Sleep hygiene (more on this in a moment) Sleep hygiene (more on this in a moment) • Less effective for advanced sleep phase probs Less effective for advanced sleep phase probs • Social rhythm therapy: Social rhythm therapy: Regular scheduling of Regular scheduling of sleep, meals, social activity, etc. sleep, meals, social activity, etc.
Melatonin Melatonin • May help with sleep, behavioral problems and May help with sleep, behavioral problems and cognitive impairment (largest clinical trial showed cognitive impairment (largest clinical trial showed no benefit) no benefit) • May have benefit in sundowning May have benefit in sundowning • May reduce neurotoxicity of B-amyloid May reduce neurotoxicity of B-amyloid • Less effective in late Alzheimer’s Less effective in late Alzheimer’s • One study with BZDs: BZD dose decreased 25-66% One study with BZDs: BZD dose decreased 25-66% • One study: helped sleep in Alzheimer’s/depression One study: helped sleep in Alzheimer’s/depression • Min. benefit in Inconsistent Sleep-Wake Disorder Min. benefit in Inconsistent Sleep-Wake Disorder • Dose 0.5 mg – 3mg 1-4 hours before bed Dose 0.5 mg – 3mg 1-4 hours before bed • If not effective, stop it If not effective, stop it
Light Light • In elders, melatonin peaks earlier in day In elders, melatonin peaks earlier in day • Elders go to sleep and awaken earlier Elders go to sleep and awaken earlier – Exposure to bright early morning light Exposure to bright early morning light accentuates earlier phase accentuates earlier phase – Avoiding early light can be helpful Avoiding early light can be helpful • Brighter light in afternoon in or out of Brighter light in afternoon in or out of home helps home helps • Keep bedroom as dark as possible for Keep bedroom as dark as possible for sleep sleep
Light Therapy Light Therapy • 1000 to 2500 lux light for 60 min/d maximally 1000 to 2500 lux light for 60 min/d maximally suppresses melatonin suppresses melatonin • Bright light (2500-10000 lux) for 1 hr between Bright light (2500-10000 lux) for 1 hr between 7-9pm helps delay sleep phase in those with 7-9pm helps delay sleep phase in those with Advanced Sleep Phase D.O. Advanced Sleep Phase D.O. • In ISWD in those with dementia, morning In ISWD in those with dementia, morning bright light (2500-5000 lux) for 2 hrs over 4 bright light (2500-5000 lux) for 2 hrs over 4 wks found to be beneficial wks found to be beneficial • In double blind RCT elderly pts with MDD with In double blind RCT elderly pts with MDD with no other tx: 7500 lux for 1 hr for 3 wks no other tx: 7500 lux for 1 hr for 3 wks improved mood, sleep efficiency and improved mood, sleep efficiency and melatonin circadian rhythm melatonin circadian rhythm
Exercise Exercise • Evidence from studies: Evidence from studies: – Improves health/stamina Improves health/stamina – Improves functional independence Improves functional independence – Improves depression Improves depression – Delays institutionalization Delays institutionalization • One study on tai chi: improved sleep quality One study on tai chi: improved sleep quality • Many studies showing positive effects on Many studies showing positive effects on sleep sleep • Ideally during morning or about 4-5 hrs Ideally during morning or about 4-5 hrs before bedtime (in natural light) to maximize before bedtime (in natural light) to maximize rise & then fall in body temperature rise & then fall in body temperature
Sleep Hygiene Sleep Hygiene • Stay out of bed until ready to turn off lights Stay out of bed until ready to turn off lights • Limit caffeine to 1 cup of coffee before noon Limit caffeine to 1 cup of coffee before noon • Avoid alcohol and nicotine Avoid alcohol and nicotine • Minimize time in front of TV especially within Minimize time in front of TV especially within 4 hrs of bedtime 4 hrs of bedtime • Avoid sugar, liquids and big meals within 2 Avoid sugar, liquids and big meals within 2 hrs of bed hrs of bed • A small snack of complex carbs with protein A small snack of complex carbs with protein can help sleep (1 hr before sleep) can help sleep (1 hr before sleep)
Sleep Hygiene Sleep Hygiene • A 30 minute bath improves sleep 1 hour A 30 minute bath improves sleep 1 hour before bedtime before bedtime • Avoid noise (though for some white noise Avoid noise (though for some white noise or instrumental music may be needed) or instrumental music may be needed) • Cooler temperatures improve sleep Cooler temperatures improve sleep • Use a conditioned stimulus (transitional Use a conditioned stimulus (transitional object) present only at bedtime: blanket, object) present only at bedtime: blanket, stuffed animal, etc stuffed animal, etc
NITE-AD NITE-AD • Small but well done RCT Small but well done RCT • Community dwelling, predominantly white Community dwelling, predominantly white • Age 63-93, avg. 5.8 yrs with dementia Age 63-93, avg. 5.8 yrs with dementia • Moderate dementia (mean MMSE 11.8) Moderate dementia (mean MMSE 11.8) • Intervention administered by caregivers Intervention administered by caregivers • NITE-AD & controls both received six 1 hr NITE-AD & controls both received six 1 hr sessions sessions • All participants had 1 hr sleep hygiene ed All participants had 1 hr sleep hygiene ed • NITE-AD subjects: 3 sessions of ed/3 session f/u NITE-AD subjects: 3 sessions of ed/3 session f/u
NITE-AD Interventions NITE-AD Interventions • Sleep hygiene Sleep hygiene – Individualized using baseline sleep diaries Individualized using baseline sleep diaries – Setting regular waking/bedtimes +/- 30 mins Setting regular waking/bedtimes +/- 30 mins – Identifying night time wake triggers Identifying night time wake triggers – No nap after 1pm; naps <30 mins No nap after 1pm; naps <30 mins – Reduce light in sleeping environment Reduce light in sleeping environment • Exercise: walk for 30 mins/day (outdoors) Exercise: walk for 30 mins/day (outdoors) • Light therapy Light therapy – 2500 lux, 45 deg from visual field, 1 hr/day 2500 lux, 45 deg from visual field, 1 hr/day – 3 hrs before bedtime (unless bedtime late) 3 hrs before bedtime (unless bedtime late) – Can eat, read, watch TV, play games/puzzles Can eat, read, watch TV, play games/puzzles
NITE-AD Results NITE-AD Results • Compliance with recommendations 80% Compliance with recommendations 80% • Those in treatment arm Those in treatment arm – 83% (vs 38%) had consistent bedtimes 83% (vs 38%) had consistent bedtimes – 96% (vs 59%) had regular wake times 96% (vs 59%) had regular wake times – 70% (vs 28%) avoided naps 70% (vs 28%) avoided naps • 32% reduction (36 min) in time awake during 32% reduction (36 min) in time awake during night night • 32% fewer (5.3) fewer awakenings 32% fewer (5.3) fewer awakenings • Those with 85% (normal) sleep efficiency Those with 85% (normal) sleep efficiency – NITE AD group: 38%->69% NITE AD group: 38%->69% – CONT: 50% -> 38% CONT: 50% -> 38%
NITE-AD Results NITE-AD Results • Significantly more exercise Significantly more exercise • Decreased depression Decreased depression • Decreased daytime sleepiness Decreased daytime sleepiness • At 6 month f/u: NITE AD less time awake, fewer At 6 month f/u: NITE AD less time awake, fewer awakenings, more exercise & less depression awakenings, more exercise & less depression • NITE AD caregivers: improved sleep time/sleep NITE AD caregivers: improved sleep time/sleep efficiency, decreased awakenings at 2 & 6 months efficiency, decreased awakenings at 2 & 6 months • May have delayed institutionalization May have delayed institutionalization • Intervention appeared to help those with more Intervention appeared to help those with more problems at beginning problems at beginning
Depression Treatment Depression Treatment • Sometimes treating depression with Sometimes treating depression with therapy or medication will improve sleep therapy or medication will improve sleep • May consider sedating antidepressants May consider sedating antidepressants (mirtazapine, trazodone, tricyclic (mirtazapine, trazodone, tricyclic antidepressants) but all have risks antidepressants) but all have risks • May temporarily add low dose, short May temporarily add low dose, short acting BZD medications (zolpidem, acting BZD medications (zolpidem, zaleplon) but risky zaleplon) but risky
Conclusions Conclusions • Insomnia in elderly is a significant, pervasive and Insomnia in elderly is a significant, pervasive and progressive health related problem progressive health related problem • Insomnia has predictable underlying Insomnia has predictable underlying neurobiologic causes but is very responsive to neurobiologic causes but is very responsive to environmental conditions even in dementia environmental conditions even in dementia • Insomnia requires prompt, thorough evaluation Insomnia requires prompt, thorough evaluation • Ideally, CBT and environmental interventions are Ideally, CBT and environmental interventions are first line treatment for most forms of insomnia first line treatment for most forms of insomnia • CBT safer & more efficacious than medication for CBT safer & more efficacious than medication for treatment of insomnia medium & long term treatment of insomnia medium & long term
Resources Resources • Exercise Guide: Exercise Guide: http://www.nia.nih.gov/health/publicati on/exercise-physical-activity • Activities Guide: Activities Guide: https://www.alz.org/national/document s/brochure_activities.pdf • The 36-Hour Day: A Family Guide to The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Caring for People Who Have Alzheimer Disease, Related Dementias, and Disease, Related Dementias, and Memory Loss Memory Loss
Sources Sources Costa et al. Aging, circadian rhythms & Costa et al. Aging, circadian rhythms & depressive disorders: a review. Am J depressive disorders: a review. Am J Neurodegener Dis. 2013; 2(4): 228-46 Neurodegener Dis. 2013; 2(4): 228-46 McCurry et al. Nighttime Insomnia Treatmennt McCurry et al. Nighttime Insomnia Treatmennt and Education for Alz Dis: a RCT. J Am Geriatr and Education for Alz Dis: a RCT. J Am Geriatr Soc. 2005; 53 (5): 793-802. Soc. 2005; 53 (5): 793-802. Shub et al. Non-pharmacologic treatment of Shub et al. Non-pharmacologic treatment of insomnia in persons with dementia. insomnia in persons with dementia. Geriatrics; 64(2): 22-26. Geriatrics; 64(2): 22-26.

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Assessing-and-Promoting-Better-Sleep-for-Elders.ppt

  • 1.
    Assessing and Promoting Assessingand Promoting Better Sleep in Elders Better Sleep in Elders Joe Lasek, MD Joe Lasek, MD Medical Director, Counseling Service of Addison Medical Director, Counseling Service of Addison County County Clinical Assistant Professor, UVM College of Medicine Clinical Assistant Professor, UVM College of Medicine
  • 2.
    Objectives Objectives • Briefly reviewepidemiology of sleep Briefly review epidemiology of sleep problems in the elderly problems in the elderly • Review sleep changes in elderly Review sleep changes in elderly • Briefly review insomnia evaluation Briefly review insomnia evaluation • Briefly review pharmacologic Briefly review pharmacologic interventions for insomnia in the elderly interventions for insomnia in the elderly • Review non-pharmacologic Review non-pharmacologic interventions for insomnia in the elderly interventions for insomnia in the elderly
  • 3.
    Epidemiology of SleepProblems Epidemiology of Sleep Problems for Elders for Elders • Up to 80% of elderly report sleep changes Up to 80% of elderly report sleep changes (increases as a function of age, higher in (increases as a function of age, higher in institutional settings) institutional settings) • When defined as diff falling or staying asleep When defined as diff falling or staying asleep or non restorative: 60-90% report problems or non restorative: 60-90% report problems • When defined more strictly, i.e. chronic When defined more strictly, i.e. chronic insomnia that causes distress or impairment: insomnia that causes distress or impairment: 12-20% 12-20% • 6-29% report hypersomnia 6-29% report hypersomnia • Women report more sleep problems than men Women report more sleep problems than men (lower melatonin levels, >vasomotor sx) (lower melatonin levels, >vasomotor sx)
  • 4.
    Impact of Insomniain the Impact of Insomnia in the Elder Population Elder Population • Independent predictor of: Independent predictor of: – Cognitive decline (effect bidirectional: Cognitive decline (effect bidirectional: cognitive decline predicts worsening sleep) cognitive decline predicts worsening sleep) – Falls Falls – Increased 2 year mortality Increased 2 year mortality • Significant contributor to caregiver Significant contributor to caregiver burden, often a reason for burden, often a reason for institutionalization institutionalization
  • 5.
    Risk Factors forDeveloping Risk Factors for Developing Dementia Dementia • Daytime sleepiness Daytime sleepiness • Restless sleep Restless sleep • Increased use of sleep medication Increased use of sleep medication • Sleep problems may be the single Sleep problems may be the single strongest predictor of Alzheimer’s strongest predictor of Alzheimer’s • Also predictive of Parkinson’s and Also predictive of Parkinson’s and Huntington’s Huntington’s
  • 6.
    Types of Insomnia Typesof Insomnia • Primary Insomnia (minority of cases) Primary Insomnia (minority of cases) • Adjustment Insomnia (due to stress) Adjustment Insomnia (due to stress) • Inadequate Sleep Hygiene Inadequate Sleep Hygiene • Insomnia due to a Drug or Substance Insomnia due to a Drug or Substance • Insomnia due to a Psychiatric Disorder Insomnia due to a Psychiatric Disorder • Insomnia due to a Medical Condition Insomnia due to a Medical Condition – Pain Disorders Pain Disorders – Ocular Disorders: Macular degeneration/ Ocular Disorders: Macular degeneration/ cataracts/diabetes cataracts/diabetes
  • 7.
    Primary Sleep Disorders PrimarySleep Disorders • All of the following more common with age All of the following more common with age • All impact sleep and have specific All impact sleep and have specific treatment treatment • Obstructive Sleep Apnea (OSA) Obstructive Sleep Apnea (OSA) • Restless Leg Syndrome (RLS) Restless Leg Syndrome (RLS) • Periodic Limb Movements of Sleep (PLMS) Periodic Limb Movements of Sleep (PLMS) • REM Sleep Behavior Disorder (RSBD) REM Sleep Behavior Disorder (RSBD)
  • 8.
    Dementia and ObstructiveSleep Dementia and Obstructive Sleep Apnea (OSA) Apnea (OSA) • Prevalence of OSA in dementia: 33%-70% Prevalence of OSA in dementia: 33%-70% • 90% of patients with mod-severe Alzheimer’s 90% of patients with mod-severe Alzheimer’s have >5 apneic events/hr have >5 apneic events/hr • OSA increases risk of dementia and vice versa OSA increases risk of dementia and vice versa • Persistent hypoxia (low oxygen) from apnea Persistent hypoxia (low oxygen) from apnea intensifies cognitive/mood symptoms (less intensifies cognitive/mood symptoms (less effective clearance of B-amyloid?) effective clearance of B-amyloid?) • Increased cardio-pulmonary disease Increased cardio-pulmonary disease • Treatment: CPAP, dental appliance, surgery Treatment: CPAP, dental appliance, surgery
  • 9.
    Sleep Changes asWe Age Sleep Changes as We Age • Advanced sleep phase (“Early to bed, Advanced sleep phase (“Early to bed, early to rise”) early to rise”) • Longer time to sleep Longer time to sleep • Increasingly fragmented sleep Increasingly fragmented sleep • Decreased sleep efficiency (more time Decreased sleep efficiency (more time awake in bed) awake in bed) • Decreased slow wave (restorative) sleep Decreased slow wave (restorative) sleep & decreased REM sleep & decreased REM sleep
  • 10.
    Neurobiology of Sleep Neurobiologyof Sleep Changes Changes • Circadian rhythm changes (sleep phase shifts Circadian rhythm changes (sleep phase shifts earlier bc of earlier melatonin production) earlier bc of earlier melatonin production) • Decreased neuron activity in supra-chiasmatic Decreased neuron activity in supra-chiasmatic nucleus (SCN)- central circadian pacemaker nucleus (SCN)- central circadian pacemaker (decreased variability in core temperature) (decreased variability in core temperature) • Decreased pineal gland-SCN connections Decreased pineal gland-SCN connections • Decreased light transmission (pupils smaller, Decreased light transmission (pupils smaller, lenses cloudier, decreased retina receptors) lenses cloudier, decreased retina receptors) • Decreased pineal gland melatonin production Decreased pineal gland melatonin production
  • 12.
    Sleep Problems inDementia Sleep Problems in Dementia • Progressively decreased REM & slow wave sleep Progressively decreased REM & slow wave sleep • Decreased efficiency: 40% of time in bed may be Decreased efficiency: 40% of time in bed may be spent awake spent awake • Daytime sleepiness Daytime sleepiness • Nighttime confusion/agitation (sundowning) Nighttime confusion/agitation (sundowning) • Nighttime waking/wandering (rated most Nighttime waking/wandering (rated most distressing symptom by caregivers) distressing symptom by caregivers) • Irregular Sleep Wake Disorder (ISWD): normal Irregular Sleep Wake Disorder (ISWD): normal amount of sleep dispersed in 3 or more variable amount of sleep dispersed in 3 or more variable periods through out day periods through out day
  • 13.
    Neurobiology of insomniain Neurobiology of insomnia in dementia dementia • Progressive damage to Supra Progressive damage to Supra Chiasmatic Nucleus & SCN-pineal gland Chiasmatic Nucleus & SCN-pineal gland pathways (greater melatonin decrease) pathways (greater melatonin decrease) • Progressive damage to basal forebrain Progressive damage to basal forebrain and reticular formation in brainstem and reticular formation in brainstem (part of central circadian rhythm (part of central circadian rhythm pacemaker) pacemaker)
  • 14.
    Medications & Impaired Medications& Impaired Cognition Cognition • Anti-cholinergic medications Anti-cholinergic medications – TCAs (amitriptyline, nortriptyline) TCAs (amitriptyline, nortriptyline) – Antihistamines (benadryl, zyrtec, claritin, pepcid, Antihistamines (benadryl, zyrtec, claritin, pepcid, zantac) zantac) – Bladder agents (ditropan, detrol) Bladder agents (ditropan, detrol) • Benzodiazepines (valium, klonopin, ativan) Benzodiazepines (valium, klonopin, ativan) • Benzo receptor agonists (ambien, sonata, Benzo receptor agonists (ambien, sonata, lunesta) lunesta) • Opioids (morphine, oxycodone, hydrocodone) Opioids (morphine, oxycodone, hydrocodone) • Muscle relaxants (flexeril, robaxin, baclofen) Muscle relaxants (flexeril, robaxin, baclofen) • Anti-psychotics (seroquel, rispridone, haldol) Anti-psychotics (seroquel, rispridone, haldol) • Anti-epileptics (depakote, tegretol) Anti-epileptics (depakote, tegretol)
  • 15.
    Medications Can Cause MedicationsCan Cause Insomnia Insomnia • Any med can cause SEs & worsen sleep Any med can cause SEs & worsen sleep • Antidepressants (prozac, zoloft, effexor, Antidepressants (prozac, zoloft, effexor, cymbalta, wellbutrin) cymbalta, wellbutrin) • Beta-blockers (propranolol, atenolol, metoprolol) Beta-blockers (propranolol, atenolol, metoprolol) • Bronchodilators (albuterol) Bronchodilators (albuterol) • Pro-Cholinergics (aricept) Pro-Cholinergics (aricept) • Corticosteroids (prednisone) Corticosteroids (prednisone) • Diuretics (lasix, hydrochlorothiazide) Diuretics (lasix, hydrochlorothiazide) • Stimulants/decongestants (amphetamine, Stimulants/decongestants (amphetamine, pseudophedrine) pseudophedrine)
  • 16.
    Delirium: get helpquick! Delirium: get help quick! • Sudden change in mental status Sudden change in mental status • Confusion (disorientation) about time or place Confusion (disorientation) about time or place • Changes in alertness, level of consciousness (usually Changes in alertness, level of consciousness (usually more alert in the morning, less alert at night) more alert in the morning, less alert at night) • Changes in sleep patterns, drowsiness Changes in sleep patterns, drowsiness • Changes in attention, memory; disorganized thought Changes in attention, memory; disorganized thought • Perceptual disturbances (visual, tactile > auditory) Perceptual disturbances (visual, tactile > auditory) • Emotional or personality changes (increased paranoia) Emotional or personality changes (increased paranoia) • Changes in movement (either slowed or hyperactive) Changes in movement (either slowed or hyperactive) • Treatment: Always due to a medical condition Treatment: Always due to a medical condition requiring emergent medical treatment requiring emergent medical treatment
  • 17.
    Depression, Sleep &Cognition Depression, Sleep & Cognition • Mood affected by sleep and sleep/cognition Mood affected by sleep and sleep/cognition worsen with depressed mood worsen with depressed mood • MDD occurs in 4% of elders (dep sx occur in MDD occurs in 4% of elders (dep sx occur in up to 16% of elderly) and up to 18% of those up to 16% of elderly) and up to 18% of those with Alzheimer’s with Alzheimer’s • Non-depressed elders with insomnia have up Non-depressed elders with insomnia have up to 2x risk of developing depression (though to 2x risk of developing depression (though only study with objective measures showed only study with objective measures showed no relationship) no relationship)
  • 18.
    Depression, Sleep &Cognition Depression, Sleep & Cognition • Studies show that circadian rhythm & Studies show that circadian rhythm & sleep disrupted in those with depression sleep disrupted in those with depression – Delayed sleep onset Delayed sleep onset – Early morning awakening Early morning awakening – Decreased slow wave sleep Decreased slow wave sleep – Decreased REM latency (unique to Decreased REM latency (unique to depression) depression) • Better sleep quality post-treatment Better sleep quality post-treatment associated with lower relapse associated with lower relapse
  • 19.
  • 20.
    Evaluating Insomnia Evaluating Insomnia •Quantity of sleep alone does not Quantity of sleep alone does not constitute insomnia constitute insomnia • DSM-IV diagnosis for primary insomnia is DSM-IV diagnosis for primary insomnia is a subjective clinical diagnosis a subjective clinical diagnosis • Ideally, diagnosis would be subjective and Ideally, diagnosis would be subjective and objective objective • Referral for a sleep study should be Referral for a sleep study should be reserved for special cases (eg confirm reserved for special cases (eg confirm OSA) OSA)
  • 21.
    An Approach toEvaluating An Approach to Evaluating Chronic Insomnia (>4 weeks) Chronic Insomnia (>4 weeks) • Medical/Psychiatric Evaluation Medical/Psychiatric Evaluation – Medical problems that may impact sleep Medical problems that may impact sleep – Psychiatric sx that may impact sleep: depression, anxiety, etc Psychiatric sx that may impact sleep: depression, anxiety, etc • Carefully review Carefully review – Sleep patterns (time to bed, lights out, wake up, Sleep patterns (time to bed, lights out, wake up, etc) etc) – Sleep hygiene (habits that may effect sleep) Sleep hygiene (habits that may effect sleep) – Substance use (drugs, caffeine, alcohol, nicotine) Substance use (drugs, caffeine, alcohol, nicotine) – Medication use Medication use – Sources of increased stress Sources of increased stress
  • 22.
    First things first:gather info First things first: gather info • Start with a 2 week sleep diary Start with a 2 week sleep diary – Dr. L’s version (see handout) Dr. L’s version (see handout) – http://yoursleep.aasmnet.org/pdf/sleepdiar y.pdf • Have caregiver provide collateral if Have caregiver provide collateral if available available
  • 23.
    First steps intreatment First steps in treatment • Diagnose and treat underlying conditions Diagnose and treat underlying conditions – Medication side effects Medication side effects – Infection Infection – Depression/anxiety Depression/anxiety – Pain Pain – Incontinence Incontinence • Treat primary sleep disorders when present Treat primary sleep disorders when present – OSA: CPAP (at least 5 hrs/night) may slow OSA: CPAP (at least 5 hrs/night) may slow progression of cognitive impairment in dementia progression of cognitive impairment in dementia – RLS/RSBD: standard medications, start lower and RLS/RSBD: standard medications, start lower and go slower go slower
  • 24.
    Make the environmentsafe Make the environment safe • Remove dangerous objects Remove dangerous objects • Generally: avoid bed rails Generally: avoid bed rails • Lock door and windows Lock door and windows • Use gates to block off dangerous areas Use gates to block off dangerous areas (e.g. stairs) (e.g. stairs) • Use night light if needed Use night light if needed
  • 25.
    Cognitive Behavioral Cognitive Behavioral Therapiesvs Medications Therapies vs Medications • Medications appear to interfere with Medications appear to interfere with the effectiveness of CBT (especially the effectiveness of CBT (especially BZDs and BZD receptor drugs) BZDs and BZD receptor drugs) • CBT effective in helping taper CBT effective in helping taper medications (including in older patients) medications (including in older patients) • CBT as effective in secondary insomnia CBT as effective in secondary insomnia as in primary insomnia as in primary insomnia
  • 26.
    Sleep Medication Sleep Medication •Up to 36% of patients with insomnia & Up to 36% of patients with insomnia & cognitive impairment use sedatives cognitive impairment use sedatives • Some studies: no effect (some limited effect) Some studies: no effect (some limited effect) • Sedating medications increase risks Sedating medications increase risks – Daytime sleepiness Daytime sleepiness – Cognitive impairment (including risk for dementia) Cognitive impairment (including risk for dementia) – Falls/accidents/broken hips Falls/accidents/broken hips – All cause mortality All cause mortality • If using sedatives, should be low doses & If using sedatives, should be low doses & time-limited time-limited
  • 27.
    CBT in Elders CBTin Elders • Substantial evidence that CBT most effective Substantial evidence that CBT most effective – Cognitive restructuring: decatastrophizing insomnia Cognitive restructuring: decatastrophizing insomnia – Sleep scheduling: regular wake and sleep time Sleep scheduling: regular wake and sleep time – Stimulus control: bed only for sleep Stimulus control: bed only for sleep – Relaxation training Relaxation training – Sleep hygiene (more on this in a moment) Sleep hygiene (more on this in a moment) • Less effective for advanced sleep phase probs Less effective for advanced sleep phase probs • Social rhythm therapy: Social rhythm therapy: Regular scheduling of Regular scheduling of sleep, meals, social activity, etc. sleep, meals, social activity, etc.
  • 28.
    Melatonin Melatonin • May helpwith sleep, behavioral problems and May help with sleep, behavioral problems and cognitive impairment (largest clinical trial showed cognitive impairment (largest clinical trial showed no benefit) no benefit) • May have benefit in sundowning May have benefit in sundowning • May reduce neurotoxicity of B-amyloid May reduce neurotoxicity of B-amyloid • Less effective in late Alzheimer’s Less effective in late Alzheimer’s • One study with BZDs: BZD dose decreased 25-66% One study with BZDs: BZD dose decreased 25-66% • One study: helped sleep in Alzheimer’s/depression One study: helped sleep in Alzheimer’s/depression • Min. benefit in Inconsistent Sleep-Wake Disorder Min. benefit in Inconsistent Sleep-Wake Disorder • Dose 0.5 mg – 3mg 1-4 hours before bed Dose 0.5 mg – 3mg 1-4 hours before bed • If not effective, stop it If not effective, stop it
  • 29.
    Light Light • In elders,melatonin peaks earlier in day In elders, melatonin peaks earlier in day • Elders go to sleep and awaken earlier Elders go to sleep and awaken earlier – Exposure to bright early morning light Exposure to bright early morning light accentuates earlier phase accentuates earlier phase – Avoiding early light can be helpful Avoiding early light can be helpful • Brighter light in afternoon in or out of Brighter light in afternoon in or out of home helps home helps • Keep bedroom as dark as possible for Keep bedroom as dark as possible for sleep sleep
  • 30.
    Light Therapy Light Therapy •1000 to 2500 lux light for 60 min/d maximally 1000 to 2500 lux light for 60 min/d maximally suppresses melatonin suppresses melatonin • Bright light (2500-10000 lux) for 1 hr between Bright light (2500-10000 lux) for 1 hr between 7-9pm helps delay sleep phase in those with 7-9pm helps delay sleep phase in those with Advanced Sleep Phase D.O. Advanced Sleep Phase D.O. • In ISWD in those with dementia, morning In ISWD in those with dementia, morning bright light (2500-5000 lux) for 2 hrs over 4 bright light (2500-5000 lux) for 2 hrs over 4 wks found to be beneficial wks found to be beneficial • In double blind RCT elderly pts with MDD with In double blind RCT elderly pts with MDD with no other tx: 7500 lux for 1 hr for 3 wks no other tx: 7500 lux for 1 hr for 3 wks improved mood, sleep efficiency and improved mood, sleep efficiency and melatonin circadian rhythm melatonin circadian rhythm
  • 31.
    Exercise Exercise • Evidence fromstudies: Evidence from studies: – Improves health/stamina Improves health/stamina – Improves functional independence Improves functional independence – Improves depression Improves depression – Delays institutionalization Delays institutionalization • One study on tai chi: improved sleep quality One study on tai chi: improved sleep quality • Many studies showing positive effects on Many studies showing positive effects on sleep sleep • Ideally during morning or about 4-5 hrs Ideally during morning or about 4-5 hrs before bedtime (in natural light) to maximize before bedtime (in natural light) to maximize rise & then fall in body temperature rise & then fall in body temperature
  • 32.
    Sleep Hygiene Sleep Hygiene •Stay out of bed until ready to turn off lights Stay out of bed until ready to turn off lights • Limit caffeine to 1 cup of coffee before noon Limit caffeine to 1 cup of coffee before noon • Avoid alcohol and nicotine Avoid alcohol and nicotine • Minimize time in front of TV especially within Minimize time in front of TV especially within 4 hrs of bedtime 4 hrs of bedtime • Avoid sugar, liquids and big meals within 2 Avoid sugar, liquids and big meals within 2 hrs of bed hrs of bed • A small snack of complex carbs with protein A small snack of complex carbs with protein can help sleep (1 hr before sleep) can help sleep (1 hr before sleep)
  • 33.
    Sleep Hygiene Sleep Hygiene •A 30 minute bath improves sleep 1 hour A 30 minute bath improves sleep 1 hour before bedtime before bedtime • Avoid noise (though for some white noise Avoid noise (though for some white noise or instrumental music may be needed) or instrumental music may be needed) • Cooler temperatures improve sleep Cooler temperatures improve sleep • Use a conditioned stimulus (transitional Use a conditioned stimulus (transitional object) present only at bedtime: blanket, object) present only at bedtime: blanket, stuffed animal, etc stuffed animal, etc
  • 34.
    NITE-AD NITE-AD • Small butwell done RCT Small but well done RCT • Community dwelling, predominantly white Community dwelling, predominantly white • Age 63-93, avg. 5.8 yrs with dementia Age 63-93, avg. 5.8 yrs with dementia • Moderate dementia (mean MMSE 11.8) Moderate dementia (mean MMSE 11.8) • Intervention administered by caregivers Intervention administered by caregivers • NITE-AD & controls both received six 1 hr NITE-AD & controls both received six 1 hr sessions sessions • All participants had 1 hr sleep hygiene ed All participants had 1 hr sleep hygiene ed • NITE-AD subjects: 3 sessions of ed/3 session f/u NITE-AD subjects: 3 sessions of ed/3 session f/u
  • 35.
    NITE-AD Interventions NITE-AD Interventions •Sleep hygiene Sleep hygiene – Individualized using baseline sleep diaries Individualized using baseline sleep diaries – Setting regular waking/bedtimes +/- 30 mins Setting regular waking/bedtimes +/- 30 mins – Identifying night time wake triggers Identifying night time wake triggers – No nap after 1pm; naps <30 mins No nap after 1pm; naps <30 mins – Reduce light in sleeping environment Reduce light in sleeping environment • Exercise: walk for 30 mins/day (outdoors) Exercise: walk for 30 mins/day (outdoors) • Light therapy Light therapy – 2500 lux, 45 deg from visual field, 1 hr/day 2500 lux, 45 deg from visual field, 1 hr/day – 3 hrs before bedtime (unless bedtime late) 3 hrs before bedtime (unless bedtime late) – Can eat, read, watch TV, play games/puzzles Can eat, read, watch TV, play games/puzzles
  • 36.
    NITE-AD Results NITE-AD Results •Compliance with recommendations 80% Compliance with recommendations 80% • Those in treatment arm Those in treatment arm – 83% (vs 38%) had consistent bedtimes 83% (vs 38%) had consistent bedtimes – 96% (vs 59%) had regular wake times 96% (vs 59%) had regular wake times – 70% (vs 28%) avoided naps 70% (vs 28%) avoided naps • 32% reduction (36 min) in time awake during 32% reduction (36 min) in time awake during night night • 32% fewer (5.3) fewer awakenings 32% fewer (5.3) fewer awakenings • Those with 85% (normal) sleep efficiency Those with 85% (normal) sleep efficiency – NITE AD group: 38%->69% NITE AD group: 38%->69% – CONT: 50% -> 38% CONT: 50% -> 38%
  • 37.
    NITE-AD Results NITE-AD Results •Significantly more exercise Significantly more exercise • Decreased depression Decreased depression • Decreased daytime sleepiness Decreased daytime sleepiness • At 6 month f/u: NITE AD less time awake, fewer At 6 month f/u: NITE AD less time awake, fewer awakenings, more exercise & less depression awakenings, more exercise & less depression • NITE AD caregivers: improved sleep time/sleep NITE AD caregivers: improved sleep time/sleep efficiency, decreased awakenings at 2 & 6 months efficiency, decreased awakenings at 2 & 6 months • May have delayed institutionalization May have delayed institutionalization • Intervention appeared to help those with more Intervention appeared to help those with more problems at beginning problems at beginning
  • 38.
    Depression Treatment Depression Treatment •Sometimes treating depression with Sometimes treating depression with therapy or medication will improve sleep therapy or medication will improve sleep • May consider sedating antidepressants May consider sedating antidepressants (mirtazapine, trazodone, tricyclic (mirtazapine, trazodone, tricyclic antidepressants) but all have risks antidepressants) but all have risks • May temporarily add low dose, short May temporarily add low dose, short acting BZD medications (zolpidem, acting BZD medications (zolpidem, zaleplon) but risky zaleplon) but risky
  • 39.
    Conclusions Conclusions • Insomnia inelderly is a significant, pervasive and Insomnia in elderly is a significant, pervasive and progressive health related problem progressive health related problem • Insomnia has predictable underlying Insomnia has predictable underlying neurobiologic causes but is very responsive to neurobiologic causes but is very responsive to environmental conditions even in dementia environmental conditions even in dementia • Insomnia requires prompt, thorough evaluation Insomnia requires prompt, thorough evaluation • Ideally, CBT and environmental interventions are Ideally, CBT and environmental interventions are first line treatment for most forms of insomnia first line treatment for most forms of insomnia • CBT safer & more efficacious than medication for CBT safer & more efficacious than medication for treatment of insomnia medium & long term treatment of insomnia medium & long term
  • 40.
    Resources Resources • Exercise Guide: ExerciseGuide: http://www.nia.nih.gov/health/publicati on/exercise-physical-activity • Activities Guide: Activities Guide: https://www.alz.org/national/document s/brochure_activities.pdf • The 36-Hour Day: A Family Guide to The 36-Hour Day: A Family Guide to Caring for People Who Have Alzheimer Caring for People Who Have Alzheimer Disease, Related Dementias, and Disease, Related Dementias, and Memory Loss Memory Loss
  • 41.
    Sources Sources Costa et al.Aging, circadian rhythms & Costa et al. Aging, circadian rhythms & depressive disorders: a review. Am J depressive disorders: a review. Am J Neurodegener Dis. 2013; 2(4): 228-46 Neurodegener Dis. 2013; 2(4): 228-46 McCurry et al. Nighttime Insomnia Treatmennt McCurry et al. Nighttime Insomnia Treatmennt and Education for Alz Dis: a RCT. J Am Geriatr and Education for Alz Dis: a RCT. J Am Geriatr Soc. 2005; 53 (5): 793-802. Soc. 2005; 53 (5): 793-802. Shub et al. Non-pharmacologic treatment of Shub et al. Non-pharmacologic treatment of insomnia in persons with dementia. insomnia in persons with dementia. Geriatrics; 64(2): 22-26. Geriatrics; 64(2): 22-26.