What is the latest treatment for sleep disturbances in individuals with dementia?

Treatment of Sleep Disturbances in Dementia

Begin with non-pharmacological interventions as first-line treatment, specifically bright light therapy combined with structured behavioral approaches, while strictly avoiding sleep-promoting medications and melatonin in elderly patients with dementia. 1, 2

Non-Pharmacological Interventions (First-Line Treatment)

Bright Light Therapy

• Implement morning bright light therapy at 2,500-5,000 lux for 1-2 hours daily (09:00-11:00), positioned approximately 1 meter from the patient. 2
• This approach regulates circadian rhythms, decreases daytime napping, and increases nighttime sleep consolidation in dementia patients. 2
• The American Academy of Sleep Medicine suggests light therapy for irregular sleep-wake rhythm disorder in elderly patients with dementia, though the evidence quality is very low. 1

Structured Behavioral Interventions

• Establish a consistent bedtime routine to provide temporal cues and encourage at least 30 minutes of daily sunlight exposure. 2
• Increase physical and social activities during daytime hours, which may slightly increase total nocturnal sleep time and sleep efficiency. 3
• Reduce time spent in bed during the day to consolidate nighttime sleep. 2
• Physical activities may slightly reduce total time awake at night and the number of awakenings. 3

Environmental Modifications

• Create a sleep-conducive environment by reducing nighttime light and noise exposure. 2
• Improve incontinence care to minimize nighttime awakenings. 2
• Remove potentially dangerous objects from the bedroom for safety. 2

Evidence-Based Multicomponent Program

• DREAMS-START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives) is the most recent evidence-based intervention showing clinical effectiveness. 4
• This six-session manualized intervention delivered to family carers reduced sleep disturbance scores by approximately 5 points on the Sleep Disorders Inventory at 8 months compared to usual care. 4
• The intervention covers understanding sleep in dementia, creating individualized plans incorporating light therapy, daytime activity structuring, managing difficult nighttime behaviors, and carer sleep strategies. 5, 4
• It can be delivered face-to-face or remotely by trained non-clinical graduates, making it practical for implementation. 4

Pharmacological Interventions (Generally NOT Recommended)

Sleep-Promoting Medications

• The American Academy of Sleep Medicine strongly recommends AGAINST using sleep-promoting medications (hypnotics) in elderly patients with dementia and irregular sleep-wake rhythm disorder. 1, 2
• Hypnotics increase risks of falls, cognitive decline, confusion, and worsening cognitive impairment in this population. 2
• Benzodiazepines should be strictly avoided due to high risk of adverse outcomes. 2
• Altered pharmacokinetics in aging, especially with dementia, further increases these risks. 2

Melatonin

• The American Academy of Sleep Medicine suggests avoiding melatonin for sleep disturbances in older people with dementia. 1, 2
• Evidence shows melatonin doses up to 10 mg have little or no effect on total nocturnal sleep time (mean difference 10.68 minutes) or sleep efficiency over 8-10 weeks. 6
• Clinical trials have not shown significant improvements in total sleep time with melatonin supplementation in dementia patients. 2
• The combination of light therapy with melatonin should also be avoided in demented elderly patients. 1

Trazodone

• Low-certainty evidence suggests trazodone 50 mg for two weeks may improve total nocturnal sleep time by approximately 42 minutes and sleep efficiency by 8.5% in people with moderate-to-severe Alzheimer's disease. 6
• However, this is based on a single small study (n=30) with no serious adverse effects reported. 6

Orexin Antagonists (Suvorexant, Lemborexant)

• Moderate-certainty evidence indicates orexin antagonists taken for four weeks probably increase total nocturnal sleep time by approximately 28 minutes and decrease time awake after sleep onset by 16 minutes in mild-to-moderate Alzheimer's disease. 6
• Adverse events were probably no more common than placebo in trials involving 323 participants. 6
• These represent the newest pharmacological option with the most favorable evidence profile, though still secondary to non-pharmacological approaches. 6

Critical Implementation Points

The risk-benefit ratio for any medication intervention must be carefully considered, with risks generally outweighing benefits in elderly dementia patients. 2

Address sleep disturbances comprehensively rather than in isolation, including hypersomnia, excessive motor activity at night, and behavioral problems, with active caregiver involvement. 2

Only 9% of participants in recent trials experienced deaths (unrelated to intervention), emphasizing the importance of careful monitoring in this vulnerable population. 4