What are the recommended sleep medications for patients with dementia?

Sleep Medication Recommendations for Patients with Dementia

For patients with dementia and sleep disturbances, non-pharmacological interventions should be used as first-line treatment, and clinicians should avoid using sleep-promoting medications due to increased risks of adverse events in this population. 1

First-Line Approaches (Non-Pharmacological)

Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I has shown robust improvements in sleep quantity and quality for both young and older adults 1
• Components include:
  • Sleep restriction
  • Stimulus control
  • Cognitive restructuring
  • Sleep hygiene education
  • Relaxation techniques

Light Therapy

• Suggested for elderly patients with dementia who have irregular sleep-wake rhythm disorder (ISWRD) 1
• Protocol: White broad spectrum light therapy (2500-5000 lux) positioned ~1 meter from participants, 1-2 hours in duration, between 9:00-11:00 AM, for 4-10 weeks
• While evidence is very low quality, light therapy may improve behavioral symptoms even when total sleep time doesn't increase 1

Physical and Social Activities

• Physical activities may slightly increase total nocturnal sleep time and sleep efficiency 2
• Social activities may slightly improve total nocturnal sleep time 2
• Regular daytime physical activity should be encouraged to help regulate sleep-wake cycles 3

Sleep Medications to AVOID in Dementia

Strong Recommendation Against

• The American Academy of Sleep Medicine strongly recommends against using sleep-promoting medications to treat elderly patients with dementia who have ISWRD 1
• Hypnotic medications increase risks of falls, confusion, and other adverse events in this population 1
• Medications with anticholinergic properties should be minimized in older persons 1

Melatonin Considerations

• The evidence suggests clinicians should avoid using melatonin as a treatment for ISWRD in older people with dementia 1
• However, strategically timed melatonin is suggested for ISWRD in children/adolescents with neurologic disorders 1

Special Considerations

Sleep Apnea Assessment

• A careful sleep history, including assessment of sleep time and symptoms of sleep apnea, should be included in the assessment of any patient at risk for dementia 1
• Patients with suspected sleep apnea should be referred for polysomnography and/or sleep specialist consultation 1
• Adults with sleep apnea should be treated with continuous positive airway pressure (CPAP), which may improve cognition and decrease dementia risk 1

Sleep Hygiene Practices

• Maintain consistent sleep-wake schedules
• Create a sleep environment conducive to sleep (quiet, dark, comfortable temperature)
• Limit screen time before bed
• Avoid caffeine and alcohol close to bedtime
• Target 7-8 hours of sleep per night 1

Monitoring and Follow-up

• Assess sleep parameters within 2-4 weeks of starting any intervention 4
• Monitor for side effects, particularly daytime sedation, falls, and cognitive changes
• Consider referral to a sleep specialist if sleep disturbances persist 4

Pitfalls and Caveats

• Combining interventions that have sedating effects increases risk of falls, confusion, and respiratory depression 4
• Despite the inclusion of multiple randomized controlled trials, there is a lack of conclusive evidence for non-pharmacological interventions for sleep problems in people with dementia 2
• The multifactorial nature of sleep problems in dementia requires addressing primary sleep disorders, comorbid conditions, and medications that may impact sleep 3
• While non-pharmacological approaches are preferred, they may require more time and resources to implement effectively

In summary, for patients with dementia and sleep disturbances, non-pharmacological approaches should be prioritized, with particular emphasis on CBT-I, light therapy, and physical/social activities. Sleep medications should be avoided due to significant risks of adverse effects in this vulnerable population.