The author reports no relevant financial relationships.
Rancho/USC California Alzheimer’s Disease Center, Downey, CA; Keck School of Medicine of USC, Los Angeles, CA
A “good night’s sleep” has long been known to be important for good health. Sleep is important for memory, and lack of sleep impairs reasoning, problem-solving, and attention to detail.1 The counterpart to restorative sleep, sleep deprivation, can lead to a range of health issues, even psychotic symptoms.2 Insomnia is common, fueling the use of sleeping pills, both prescribed and over the counter.3
The relationship between sleep and cognition is gaining increased attention by researchers and clinicians.4,5 We have learned that it is during sleep when the cerebrospinal fluid (CSF), which bathes the brain, is active. The flow of CSF increases during sleep, and proteins that accumulate during normal physiologic activity of the brain are actively cleared out. A system of channels that drain waste products from the brain into the CSF has been identified.6 Some have equated this removal of toxins to a washing machine or a garbage truck effect.7
A connection between sleep disturbances, such as obstructive sleep apnea (OSA), and cognition is well-recognized.8 Sleep disturbances are common in patients with dementia, occurring in about a quarter of patients during the course of the disease.9 Disturbance of the circadian rhythm—the normal sleep-wake cycle—leads to sleep loss which then increases the disruption of normal daily functioning, not only of the person with dementia, but also of family members and others, leading to increased caregiver stress and often a decision for out-of-home placement.
Many older adults take prescription and nonprescription medications to help them sleep. Poor sleep, whether from insomnia, sleep deprivation, or OSA, is a known risk factor for cognitive impairment.10 The use of sleep medications on a regular basis (3 or more nights/wk) has been found to be a risk factor for developing dementia.11 Long-term use of anticholinergic drugs, which include antidepressants and antihistamines that are often used (prescribed and not) to aid sleep, have also been found to be associated with high risk for dementia.12 In persons with dementia, benzodiazepines, a common class of medications used for their sedating effect, are known to increase confusion and falls.13
What is a provider to do when a family member or long-term care facility requests medication for sleep? The first thing not to do is to immediately pull out the prescription pad or click on “order” in the electronic medical record for a new medication for the patient. Instead, begin by looking for anything that might have changed in the patient or their environment. Are vital signs normal? Have there been any recent changes in appetite, activity, or bladder/ bowel function? Is there a new roommate, or has there been a change in living situation? Answers to these questions may uncover underlying reasons for illness that is presenting as sleep disturbance. Staff should also clearly establish the symptoms of the patient. If a patient with dementia is “awake all night,” what does this mean? Are they truly awake from about 11pm to 5am, or are they waking up frequently, intermittently, through the night? In a facility where there is 24-hour staff, having the staff adjust to the patient, rather than sedating the patient, is preferable. Create a space where residents can sit with a staff person at night. At home it may be more challenging for someone to remain awake with the person.
A review of current medications is always prudent. Has there been a change in medication usage in the past days or weeks—maybe by another provider or the family introducing something over the counter? Donepezil, a medication commonly used in patients with Alzheimer disease, other dementia, and increasingly with mild cognitive impairment, can cause vivid dreams that may awaken the person.14 Beta- and alpha-blockers can also cause vivid dreams, nightmares, and insomnia. A recent increased dosage to better manage blood pressure may have the unintended consequence, a week or two later, of impairing a patient’s sleep; or, once awake and alert, it may be difficult for them to return to sleep. Some antidepressants can decrease rapid-eye movement (REM) sleep, leading to fractured sleep and awakenings particularly early in treatment.15 Nonsteroidal anti-inflammatory medications and opioid analgesics prescribed for pain also cause decreased sleep efficiency, sedation, and decrease REM sleep.16,17 Chronic use of alcohol, sometimes ingested for its sedating properties, can often go unreported and underreported by patients and families. This can contribute to cognitive impairment and increased confusion in patients with dementia, and also impact sleep function and quality.18
Simple sleep hygiene is important in promoting restorative nighttime sleep. Minimizing daytime sleeping by keeping the person awake and engaged in activities is a helpful strategy. Importantly, watching television is not considered active engagement; it is passive and often contributes to daytime sleeping, which then leads to poor sleep at night. Regular exercise, including walking and chair exercise participation, has multiple benefits including improved sleep. A regular bedtime routine, perhaps with a warm bath and/or massage with lotion and soft music in a dark room, are all essential elements that help promote restful sleep.
Realistic expectations of sleep in older adults by clinicians and family are important to keep in mind. Fractured sleep and frequent awakenings become more common with older age for a variety of reasons; urge or need to urinate and pain are two common conditions that can impair sleep. The expectation of 8 to 10 hours of solid sleep in older adults may not be realistic. For some older adults, 6 hours of sleep may be sufficient. Adjusting to the sleep pattern and needs of the person with dementia may oftentimes be a more realistic approach.
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