What can be prescribed for a 90-year-old patient with dementia experiencing sleep disturbances?

Management of Sleep Disturbances in a 90-Year-Old Patient with Dementia

For a 90-year-old patient with dementia experiencing sleep disturbances, non-pharmacological interventions should be implemented first, as sleep-promoting medications are strongly discouraged due to increased risks of adverse events in this vulnerable population. 1

First-Line Approach: Non-Pharmacological Interventions

Light Therapy

• Implement bright light therapy during morning hours (09:00-11:00) for 1-2 hours daily at 2,500-5,000 lux, positioned about 1 meter from the patient 1
• This helps regulate circadian rhythms and has been shown to decrease daytime napping and increase nighttime sleep in patients with dementia 1
• Avoid bright light exposure in the evening as it may disrupt sleep patterns 1

Environmental Modifications

• Create a sleep-conducive environment by reducing nighttime light and noise 1
• Improve incontinence care to minimize nighttime awakenings 1
• Establish a structured bedtime routine to provide temporal cues 1

Daytime Activity

• Encourage at least 30 minutes of sunlight exposure daily 1
• Increase physical and social activities during daytime hours 1
• Reduce time spent in bed during the day to consolidate nighttime sleep 1

Why Medications Should Be Avoided

Hypnotics and Sedatives

• The American Academy of Sleep Medicine strongly recommends against using sleep-promoting medications in elderly patients with dementia and irregular sleep-wake rhythm disorder 1
• Hypnotics increase risks of falls, cognitive decline, and other adverse outcomes in this population 1
• Altered pharmacokinetics in aging, especially with dementia, further increases these risks 1

Melatonin

• Evidence for melatonin in dementia patients with sleep disturbances is inconclusive 1
• Clinical trials have not shown significant improvements in total sleep time with melatonin supplementation 1
• The American Academy of Sleep Medicine suggests avoiding melatonin for sleep disturbances in older people with dementia 1

If Non-Pharmacological Approaches Fail

If non-pharmacological interventions are unsuccessful after adequate trial (4-10 weeks), and sleep disturbance significantly impacts quality of life:

Consider Trazodone with Extreme Caution

• Low-dose trazodone (25-50 mg at bedtime) may be considered as it has shown some benefit in improving total nocturnal sleep time in patients with moderate-to-severe Alzheimer's disease 1, 2
• A small study found trazodone 50 mg improved total sleep time by approximately 42 minutes and sleep efficiency by 8.5% 2
• Start with the lowest possible dose (25 mg) and monitor closely for side effects 3
• Be aware of potential risks including:
  • Dizziness and increased fall risk 3
  • QT prolongation and cardiac arrhythmias 3
  • Interactions with other medications 3

Monitoring and Follow-up

• Reassess sleep patterns regularly using caregiver reports 4
• Monitor for daytime sleepiness, confusion, or increased fall risk 1
• Discontinue any medication if adverse effects occur 3
• Continue to emphasize and reinforce non-pharmacological approaches 4, 5

Important Cautions

• Benzodiazepines should be strictly avoided due to high risk of falls, confusion, and worsening cognitive impairment 1
• Antipsychotics, while sometimes used for sleep in dementia, carry significant risks including increased mortality and should be avoided 5
• The risk-benefit ratio for any medication intervention must be carefully considered, with risks generally outweighing benefits in this population 1, 2

Remember that improving sleep in dementia requires a consistent approach with emphasis on environmental and behavioral modifications rather than medication 1, 4.