Elsevier

Sleep Medicine

Volume 5, Issue 4, July 2004, Pages 373-377
Sleep Medicine

Original article
Treatment of sleep and nighttime disturbances in Alzheimer's disease: a behavior management approach

https://doi.org/10.1016/j.sleep.2003.11.003Get rights and content

Abstract

Background and purposes

Sleep and nighttime behavioral disturbances are widespread in community-dwelling dementia patients, but little is known about the usefulness of behavioral interventions for treating them. This article presents data from three cases enrolled in an ongoing study of sleep problems in community-dwelling Alzheimer's disease (AD) patients: nighttime insomnia treatment and education for Alzheimer's disease.

Patients and methods

All subjects received written materials describing age- and dementia-related changes in sleep, and standard principles of good sleep hygiene. Caregivers also received education about dementia, listings of relevant community resources, and general support. Subjects' sleep–wake activity was measured at baseline, post-test (2 months), and 6-month follow-up using an Actillume wrist-movement recorder, which was worn continuously for 1 week.

Results

Post-test actigraphic improvements in sleep quantity and sleep efficiency, number of nighttime awakenings, and amount of daytime sleep, as well as subjective sleep ratings were observed. One subject maintained improvements at 6-month follow-up. Subjects varied widely in the type of sleep problems reported and behavioral strategies implemented by family caregivers, illustrating the complexity that characterizes nighttime behavioral disturbances in AD.

Conclusions

This paper provides clinical and empirical evidences that behavioral strategies including standard sleep hygiene recommendations can be helpful in treating sleep and nighttime behavioral disturbances in dementia patients.

Introduction

In persons with Alzheimer's disease (AD), sleep and nighttime behavioral disturbances such as wandering, day/night confusion, getting up repeatedly during the night, and nightmares or hallucinations are a significant source of caregiver burden and a primary cause of patient institutionalization [1], [2], [3]. Sedative/hypnotic medications are frequently prescribed to treat sleep problems in AD [4], [5], but there are few controlled trials demonstrating their efficacy [6] and medication side-effect risks are greater among elderly persons with dementia than among younger, cognitively intact adults [7], [8]. Thus, non-pharmacological strategies are needed to supplant or augment pharmacological treatments.

Most research on the use of non-pharmacological interventions to improve sleep in dementia has been conducted with nursing home residents, and has focused on physiological/circadian therapies such as increasing light exposure and physical activity [9]. Little is known about the impact of behavioral interventions on the sleep of dementia patients living at home in the community. Caregivers are frequently told to reduce patient daytime sleep and are given generic suggestions on how to improve the sleeping environment [10], [11]. However, caregivers who are concerned about adding to their caregiving burden or are skeptical about their ability to change sleep habits and environments may be reluctant to try such strategies [12].

This article presents three case studies from an ongoing study of sleep problems in community-dwelling AD patients: nighttime insomnia treatment and education for Alzheimer's disease (NITE-AD). The NITE-AD study is designed to develop a comprehensive, systematic treatment for improving sleep disturbance in patients with AD, and then to empirically evaluate the efficacy of this intervention. All subjects in NITE-AD receive general sleep hygiene education, including information about sleep habits, and environmental, dietary, and health factors that can influence sleep quality (Appendix A). Caregivers also receive education about dementia, listings of relevant community resources, and general support. This article provides evidence of the potential utility of sleep hygiene recommendations and dementia education to reduce nighttime behavioral disturbances in persons with AD.

Section snippets

Study procedures

Subjects were recruited through newspaper ads, articles in caregiver and senior newsletters, and community mailings. Patients were required to have at least one sleep problem on the Neuropsychiatric Inventory (NPI) Nighttime Behavior scale occurring three or more times per week, and a diagnosis of AD from their primary physician. No subject had a pre-existing diagnosis of a primary sleep disorder.

NITE-AD subjects participated in six in-home treatment sessions over a 2-month period with a

Case #1

Mrs A was a 77-year-old, white, high school-educated homemaker. She lived at home with her 81-year-old husband, and had a 3-year history of memory loss. Her Mini-Mental State Examination (MMSE) score [13] was 12/30, indicating moderately severe cognitive impairment. Mrs A's sleep had been disturbed for approximately 2 years, and she took Aricept and Tylenol PM every night. Baseline problems reported by her husband included nightmares, nighttime wandering, and sleeping excessively during the

Discussion

This paper provides clinical and empirical evidence that behavioral strategies including standard sleep hygiene recommendations can be helpful in treating sleep and nighttime behavioral disturbances in dementia patients. These interventions yielded both quantifiable improvement at post-test in sleep quality and clinically meaningful improvements in subjective reports about patient sleep. However, only one patient sustained the improvements over time; one patient's sleep deteriorated to baseline

Acknowledgements

This study was supported by NIH grants MH01644, AG14777, MH01158, and an Alzheimer's Association Pioneer grant P10-1999-1800.

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