sleep well, think well: strategies for improving sleep in dementia · 2020. 5. 1. · sleep well,...

The University of Sydney

PROFESSOR SHARON NAISMITH, MAPS, CCN

NHMRC CAREER DEVELOPMENT FELLOW

LEONARD P ULLMAN CHAIR, CHARLES PERKINS CENTRE

HEAD, HEALTHY BRAIN AGEING PROGRAM, BRAIN & MIND CENTRE

Sleep well, think well:

Strategies for improving

sleep in dementia


The significance of sleep

– Important for:

– Mood

– Alertness

– Daytime functioning & cognition

– 2 key systems:

– Sleep system

– Circadian system


How does sleep change as we age?

– Shallow, fragmented

– Decreased deep sleep

– Decreased dreaming (REM) in second half of night

– Decreased sleep duration

– Daytime sleepiness

– Shift to earlier sleep and wake times

– Longer to recover from lack of sleep and changes in timing

– Elderly twice as likely to be prescribed sleeping pills than younger people


Why should we be concerned about sleep disturbance?

– Prodromal feature of:

– Mood disorders

– Neurodegenerative disorders

• Parkinsons Disease

• Dementia with Lewy Bodies

• Alzheimer’s Disease

– Bi-directional association between B-amyloid and poor sleep

– Predictive of:

– More rapid cognitive decline


How is sleep linked to cognitive decline?

Z Z

Z

Role of sleep

Impaired sleep

quality

Obstructive sleep

apnoea

• Clearance of toxins & waste

• Memory consolidation

• Immune/inflammatory regulation

• Support of new brain cells

• Common in dementia and MCI

• Predicts worse cognitive outcomes

• Fragmented sleep

• Hypoxemia


What happens to sleep in dementia?

Alzheimer’s

– 40-50% - sleep disturbance

– Excessive daytime sleepiness

– Light fragmented sleep, ~40% of nocturnal time awake

– Daytime napping

– Sleep apnoea 35-63% (48% have AHI>20)

Dementia with Lewy Bodies

– Disturbance may occur in up to 90% of patients

– Highly prodromal – poor sleep quality and REM Sleep Behaviour Disorder may occur 20 years before the onset

Vascular Dementia

Commonly associated with obstructive sleep apnoea

Bonanni et al, 2005; Cooke et al, 2006


How does poor sleep impact on functioning?

– Circadian delay

– Contributes to sundowning – agitation and confusion in the evening

– Difficulty sleeping at night

– Wandering can increase risk of injury and in turn medical problems and can lead to need for care

– Excessive sleepiness in daytime

– Poorer cognitive functioning

– Uncontrolled naps

– Impacts on driving

– Decreased engagement in socialisation and therapies


Sleep spindles

11-15Hz

NREM Sleep

Z Z

Z

SLEEP TO REMEMBER?

Impaired memory processing


Sleep

quality Sleep hygiene

Bed and wake times

Napping

Exercise

Body

temperature

Depression &

stress

Sleep expectations

Light exposure

Factors that impact sleep

-Needing to use bathroom

-Medications -TV

-Internet

External factors affecting sleep


Interventions for sleep-

wake disturbance in

ageing


Beware drugs!

Cholinesterase

Inhibitors

Benefits to dreaming (REM) sleep in some studies,

Donepezil – more Stage 2 and less Stage 1 sleep

Can cause insomnia, disturbing dreams, REM sleep

behaviour disorder, dosing could be moved to early in

daytime

Antidepressants

May suppress REM, insomnia, data lacking for efficacy in

sleep

Antipsychotics

May worsen sleep-wake disturbance in AD

Sedative hypnotics Less disruption to sleep architecture

No known data on cognitive effects in older people

Benzodiazepines Decrease SWS & REM, reduce latency & awakenings

Associated with sleepiness, falls, cognitive side-effects,

confusion, Short-term (1-2 weeks) use only

Clonazepam often effective for REM Sleep Behaviour

Disorder

Dopaminergic Can cause daytime sleepiness

Naismith, Rogers, Lewis (i2011); Cooke et al, 2006


Does melatonin work for sleep disturbance in AD?

– A powerful antioxidant & free radical scavenger

– Helps to clear harmful reactive oxygen species and reduce oxidative stress levels in brain tissue

– 14 melatonin studies in AD

– 8 reports (n=89), 6 double-blind RCTs (n=210)

– Doses: 1-9mg, evening or bedtime

– Duration: 2 weeks to 36 months

– Improvements in sleep quality, sundowning and cognition in 4/6 randomised controlled trials (N=143)

– Important to use melatonin manufactured in controlled settings e.g Circadin – speak to GP

– Combination of light and melatonin may have superior effects

Cardinali et al, 2010; Dowling et al, 2008; Riemersma et al, 2007


Light therapy

General principles:

– Evening exposure delays sleep

– Morning exposure advances sleep

– Magnitude of circadian shifts depends on intensity and duration -

brighter and longer duration produces larger shifts

– Short wavelength light (blue light) has greatest effects

Efficacy:

– Reduction in nightime awakenings in dementia

– Benefits best for morning light and if sleep complaints (latency,

efficiency, awakenings, total sleep time)

– May have broader effects on cognition and mood in AD

– 4wks bright light (1000lx) all day


Pay attention to snoring and

apnoea: CPAP treatment works!

– San Diego study, n = 39-52

– Less light sleep and awakenings, more deep sleep

– Reductions in excessive daytime sleepiness

– Improvements in memory

– Sustained effects of CPAP

– Cooke et al, 2009: n = 10, 1-year follow-up (CPAP n = 5 vs. no CPAP)

– Medium to large effect size improvements in executive functions, psychomotor speed, mood, daytime sleepiness

1

4 Ancoli-Israel et al., 2008; Chong et al, 2006; Cooke et al, 2009


Avoid contributors to sleep problems

– Avoid caffeine

Decreases slow wave ’deep’ sleep

Increases awakenings

Increases time to fall asleep

Can be helpful if wish to delay sleep

– Avoid alcohol

Sedative but disruptive

– Avoid heavy meals prior to bedtime

– Avoid heavy exercise prior to bedtime

– Avoid raising body temperature (hot baths)

– Consider medications

– sleeping medications are only effective for short-term use (<2 weeks)


Practice sleep-promoting activities

– Engage in daytime exercise

– Keep the brain active!

– Quiet and relaxing activities before bed

– Keep lights dim in the evening

– Get up at the same time everyday

– Ensure morning light exposure

– Manage depression and stress

– ?Naps


Use of Naps

› Prescribed ‘controlled napping’

• Duration is important!

• Nap less than 30minutes

• Nap earlier in day, not in evening

• Counts in your total sleep count

› May improve alertness, cognition, mood

› Can be associated with sleep inertia (feeling ‘groggy’) if nap for too long

› Consider effects on night-time sleep


If you can’t sleep!

– Get up!

– Relax in a different environment

• Dim lighting

• Do not stimulate the mind

– Do not try to make up for lost sleep

– Do not focus on the ‘perceived negative”

consequences of poor sleep

– Consider sleep expectations


Dealing with daytime sleepiness

› Limit the number of demanding activities you perform each day

› Schedule activities that are cognitively and physically demanding

for periods when you feel most alert

› Take regular rest breaks

› Ensure adequate light exposure


Summary

– Sleep is important for optimising brain health and consolidating memories overnight

– Improving sleep is best achieved using non-drug methods

– Implementing lifestyle changes, reducing sleeping pills, having a regular sleep routine, exposure to light and regular exercise, and considering sleep expectations will help


Concerns about cognition

or sleep?

– Neurosleep clinic

– Healthy Brain Ageing Clinic

– Brain and Mind Centre

– 94 Mallett Street, Camperdown

– Phone: 9114 4002

– Fax: 9351 0551

– Email: [email protected]

– http://sydney.edu.au/brain-mind/patient-services/clinics/healthy-brain-ageing.php

NEUROSLEEP NHMRC Centre of Research Excellence

– Healthy Brain, Healthy Sleep

– Postdoctoral Fellowships, Postgraduate Scholarships and Seed-funding available for projects across four themes

– [email protected]

mailto:[email protected]


Acknowledgements

FUNDING –NHMRC PRACTITIONER FELLOWSHIP (LEWIS)

–NHMRC ‘NEUROSLEEP’ CRE (GRUNSTEIN)

–NHMRC PROJECT GRANT (NAISMITH)

–ALZHEIMERS AUSTRALIA

–ANZ TRUSTEES (MASON FOUNDATION)

–PARKINSON’S NSW

–BEYOND BLUE

–NHMRC/ARC Dementia Fellowship Scheme

NEUROSLEEP NHMRC Centre of Research Excellence

– Healthy Brain, Healthy Sleep

– Postdoctoral Fellowships, Postgraduate Scholarships and Seed-funding available for projects across four themes

– [email protected]

TEAM –Prof Sharon Naismith Head, Neuropsychologist –Prof Ian Hickie Psychiatrist –Prof Simon Lewis Neurologist –Prof Jim Lagopoulos Neuroimaging –Prof Ron Grunstein Sleep physician –Ms Amelia English Clinical Trials Manager –Dr Shantel Duffy Postdoctoral Researcher –Dr Loren Mowzsowski Neuropsychologist –Dr Haley LaMonica Neuropsychologist –Dr Zoe Terpening Neuropsychologist –Dr Keri Diamond Neuropsychologist –Dr Rebekah Ahmed Neurologist –Dr Jerome Ip Geriatrician/Neurologist –Ms Tess Anderson Trials Nurse –Ms Stacey West Research Assistant –Ms Keshani Jayaweera PhD student –Mr Nathan Cross PhD student

sleep well, think well: strategies for improving sleep in dementia · 2020. 5. 1. · sleep well,...

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