What is the relationship between insomnia and dementia?

From the Guidelines

Insomnia in dementia patients should be managed through non-drug approaches as the first line of treatment, prioritizing good sleep hygiene and addressing underlying causes of sleep disturbance, due to the potential harms and limited efficacy of pharmacologic interventions, as suggested by studies such as 1 and 1.

Management Approaches

To manage insomnia in dementia patients effectively, consider the following strategies:

• Establish good sleep hygiene by maintaining consistent sleep-wake times, limiting daytime napping, ensuring exposure to natural light during the day, creating a comfortable sleep environment, and avoiding caffeine and alcohol before bedtime.
• Promote physical activity during the day to help improve sleep quality.
• Address underlying causes of sleep disturbance, such as pain, urinary issues, or depression.

Medication Use

When medication is necessary, consider the following options:

• Low-dose melatonin (1-2mg) taken 1-2 hours before bedtime may help regulate sleep cycles with minimal side effects, as noted in studies like 1.
• Short-term use of trazodone (25-50mg at bedtime) can be effective, but its use should be carefully monitored due to potential side effects.

Avoiding Harmful Medications

It is crucial to avoid certain medications that can exacerbate insomnia or worsen dementia symptoms:

• Benzodiazepines and Z-drugs like zolpidem increase fall risk and may worsen confusion, as highlighted in 1 and 1.
• Antipsychotics should only be used as a last resort due to their serious side effects. Regular reassessment of the management approach is necessary, as sleep problems in dementia often result from disruption of the brain's sleep-wake regulation centers and may worsen as dementia progresses, as discussed in 1.

From the Research

Insomnia with Dementia

• Insomnia occurs in one-fourth to one-third of patients with dementia, leading to patient and caretaker distress and early institutionalization 2.
• Sleep disturbances in people with dementia are associated with significant carer distress, increased healthcare costs, and institutionalisation 3.
• Non-pharmacological interventions, such as light therapy, physical activities, social activities, and carer interventions, may have some positive effects on sleep-related outcomes in people with dementia 4.
• Pharmacological treatments, such as melatonin, trazodone, and orexin antagonists, have shown some beneficial effects on sleep outcomes, but the evidence is limited and more research is needed 3.

Non-Pharmacological Interventions

• Light therapy may have little or no effect on sleep-related outcomes in people with dementia 4, 3.
• Physical activities may slightly increase total nocturnal sleep time and sleep efficiency, and may reduce the total time awake at night and slightly reduce the number of awakenings at night 4.
• Social activities may slightly increase total nocturnal sleep time and sleep efficiency 4.
• Carer interventions may modestly increase total nocturnal sleep time, may slightly increase sleep efficiency, and may modestly decrease the total awake time during the night 4.

Pharmacological Interventions

• Melatonin doses up to 10 mg may have little or no effect on any major sleep outcome over eight to 10 weeks in people with Alzheimer's disease and sleep disturbances 3.
• Trazodone 50 mg for two weeks may improve total nocturnal sleep time and sleep efficiency in people with moderate-to-severe Alzheimer's disease 3.
• Orexin antagonists may increase total nocturnal sleep time and decrease time awake after sleep onset, but may have little or no effect on number of awakenings 3.

Treatment Approach

• A structured approach to the evaluation and treatment of sleep disorders in dementia is proposed, including the treatment of primary sleep disorders, management of comorbid conditions and medications, and the use of non-pharmacological and pharmacological treatments 5.
• Clinically effective, safe treatment of sleep disturbances in dementia remains an unresolved challenge, and well-designed controlled trials are needed to determine acceptable and cost-effective treatment strategies 6.