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