II. Epidemiology
- Incidence in Alzheimer's Disease: 40-70%
III. Associated Conditions
- Results in sun-downing
- Risk of falls
- Wandering Behavior in Dementia
- Family exhausted by required nighttime supervision
- Strong factor in NH placement
IV. Pathophysiology
V. Management: Behavioral techniques
- Aggressive management necessary
- Increase awareness of time
- Frequent reality orientation
- Access to daylight
-
General Sleep Hygiene
- Restrict Caffeine and Stimulant Medications
- Restrict daytime naps
- Perform moderate Exercise early in the day
- Keep room cool and quiet
- Provide safe night-time environment
- Night light reduces confusion if patient awakens
- Reduce nighttime awakenings and potential wandering
- Provide nighttime Analgesic for arthritic pain
- Reduce Urinary urge and wetness at night
- Limit evening fluid intake
- Provide bedside commode
- Consider Condom catheter
- Use Incontinence garment
- Apply moisture barrier (Vaseline) to perineum
VI. Management: Medications
- Indications
- Failed response to behavioral techniques
- Preferred options
- Melatonin agents (preferred)
- Rozerum 8 mg
- Suvorexant (Belsomra)
- Orexin Receptor Antagonist that improves total sleep time without dependence
- Coleman (2017) Annu Rev Pharmacol Toxicol 57: 509-33 [PubMed]
- Antidepressants (especially for comorbid depression or need to stimulate appetite)
- Remeron 15 mg orally taken before bedtime
- Antipsychotic Medications
- NOT FDA approved for Insomnia, and increased mortality risk (see Antipsychotic Medication)
- Zyprexa 2.5 to 5 mg orally taken 1 hour before bedtime
- Seroquel 25 mg orally taken 1 hour before bedtime
- Melatonin agents (preferred)
- Adverse effects
- Ataxia with Fall Risk
- May worsen confusion due to Anticholinergic effects
- Avoid agents that worsen confusion
- Avoid Benzodiazepines
- Avoid Anticholinergic Medications
- Trazodone 50 mg orally at bedtime
- Has been commonly used for Insomnia, but has fallen out of favor due to adverse effects
- Risk of othostatic Hypotension and falls
- Obviously avoid these medications as well
- Do NOT Use these for Insomnia (listed for historical purposes)
- These medications were actually used for Insomnia at one time
- Should trigger pause in the use of contemporary medications for sleep (are we causing harm?)
- As with these medications, in which we now know risk far exceeds benefit
- Chloral Hydrate 500-1000 mg PO qhs
- Significant apnea risk
- Thioridazine 25-50 mg PO qhs
- Removed from U.S. market in 2005 due to Cardiac Arrhythmias
VII. References
- Howell in Duthie (1998) Geriatrics p. 295-305
- Ham (1997) Postgrad Med 101(6):57-70 [PubMed]
- Stewert (1995) Am Fam Physician 52(8):2311-22 [PubMed]