Light Therapy
1 : 15 / 63 (23.8%) 1 : 7 2 : 8 : 6 / 86 (7%) 1, : 48 / 205 (23.4%) 1 : 43 2 : 5
Sleep in Geriatrics Prevalence NIH survey of 9000 american senior above age 65 ; 88% had sleep disturbances Difficult falling asleep and/or wake up too early (28%) Trouble maintaining asleep (29%) Early morning awakening (18%) Only 12% reported no sleep complaints. (Foley et al. 1995)
Sleep in Alzheimer s Disease Clinical Correlates Sleep in 108 patients with AD ; 21% had sleep disturbances Excessive awakening (23%) Morning awakening (11%) Excessive daytime sleepiness (10%) Napping more than an hour a day (14%) Rebok et al. 1991 205 patients with AD Hypersomnia (40%) Early morning awakening (31%) Night time awakening (24%) McCurry et al. 1999 Sleep disturbance was associated with behavioral problem & Severity of cognitive impairment. Disturbances in the patient s sleep and night time behavior most important factors of institutionalization of dementia patients
Changes with Age Normal sleep cycle Decreased NREM & REM sleep Increased awakenings and easy arousal less sleep : average 70-years old sleeps only 6 hr/d with often daytime nap (1-2hr) have greater difficulty falling asleep (increased sleep latency) have greater difficulty staying asleep (decreased sleep efficiency) have more medical condition (eg, nocturia, chronic pain, concomitant pulmonary disease, or psychiatric disease, particularly depression) may experience changes in circadian rhythms (which make them fall asleep earlier in the evening
Changes with Age Normal sleep cycle Sleep Medicine Reviews (2004) 8, 31 45
Sleep in Alzheimer s Disease Sleep-wake organization Sleep efficiency, stage 1, awakening TST, REM sleep, sleep spindle and K complex, sleep-wake rhythm disturbance Causes of disruption - Breakdown of wake-sleep pattern - Chronobiology change - Medication & medical problems - Coexisting psychological problems such as depression
Sleep in Alzheimer s Disease - Chronobiology (I) Excessive daytime sleepiness - Severity of dementia - A particular genotype (APO-E4) Circadian rhythm Environmental influences - Light level Minimal exposure to light Macular degeneration and optic n. degeneration - Social/institutional factors Reduced melatonin rhythm Dampening diurnal variability in HR & BP Phase delay of BT rhythm ; CNS drugs 2001;15:777-796 Clinical cornerstone 2004;6(spp1A):S16-S28 Associated with Sleep Behavior Cognition
Circadian rhythm Environmental cue(zeitgebers) + int. biological clock (SCN) SCN - in ant. Hypothalamus, internal generator 24 hrs rhythm ; free-running (absent of zeitbegers): 25 hrs Pacemaker
Sleep in Alzheimer s Disease Chronobiology (II) Deterioration in circadian rhythms - suprachiasmatic nucleus (SCN) Melatonin : tobacco, alchol, Medication (NSAIDs, Ca blocker, BZDs, fluoxetine, Steorids)
Sleep in Alzheimer s Disease Primary sleep disorders A 72 year-old man presents to his primary care physician complaining of early morning awakening and the inability to reinitiate sleep. Patient often becomes very tired around 6:00 pm and falls asleep around 8:00 pm. He has no problems falling asleep; however, when he wakes up around 2:30-3:00 am, he is unable to reinitiate sleep and stays awake in bed until around 7:00 am, when he finally gets up and begins his days. He denies any symptoms of depression such as mood disturbances. Diagnosis : Insomnia due to advanced sleep phase syndrome circadian rhythm abnormalities
Sleep in Alzheimer s Disease Primary sleep disorders Light before 5 AM phase delay Light after 5 AM phase advanced Cf) 5 AM : BT minimum 2,500lux 2 hours or 10,000luxfor 30 minutes (5:30-7:30PM / 9:30-11:30AM) SEMINARS IN NEUROLOGY vol24: 2004;315-25
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1. PDD
~ ^^ 2. AD
Sundowning 12 to 25% in institutionalised elderly patients 24 to 28% by home care-giver(bliwise et al. 2000) Begins later afternoon or early evening Travel behavior : 7 to 9 pm (Martino-Saltzman et al. 1991) Vocalization : 5 to 7 pm (Burgio et al. 1994) Wandering : 5 to 6 pm (Algase et al. 1999) Maladaptive behavior : 4 to 8 pm (O leary et al. 1993) Physical aggression : 4:30 to 11 pm (Cohen et al. 1992) Agitation : 4 to 9 pm (Kutner et al. 2000) Strongly associated with circadian rhythm abnormalities Mental decline, nocturnal insomnia, wanderring (Moe et al, 1995 Martin et al 2000)
Study characteristics of light therapy for behavioral and psychological symptoms of dementia B A A A A: ambient light B: dawn-dusk stimulation Others : conventional LT Int J Geriatr Psychiatry 2004; 19:516-522
Dawn simulator
Summary of review data of the efficacy of light treatment for BPSD Int J Geriatr Psychiatry 2004; 19:516-522
Sleep in Alzheimer s Disease Etiology (I) 1. Sundowning (12-25% in AD) 2. Behavioral and environmental factors : bedtime rituals and habits, amount of time in bed, ambient light level, night time noise. 3. Physical illness 1) Congestive heart failure : nocturnal respiratory distress or nocturnal diuresis 2) COPD : sleep apnea 3) Parkinson s disease nocturia, pain and stiffness, difficulty turning in the bed, REM sleep disorder Tx : sustained-release levodopa, nasal vasopressin, benzodiazepine antidepressants 4) Gastro-esophageal reflux ; bronchspasm or nocturnal asthma 5) Arthritic conditions
Sleep in Alzheimer s Disease Etiology (II) 6). Nocturnal polyuria - BPH - DM - CHF - Nocturnal polyuria syndrome (NPS) 3% of elderly population ; 24-hr diuresis is normal, but shift to night due to disturbance of the vasopressin system (lack of nocturnal increase in plasma vasopressin) ; restriction of fluid intake, desmopressin at bed time (journal of psychosomatic research, 2004;517-525) - UTI* - Autonomic sensory disturbance : anxiety, depression or neurological disease 4. Medications OTC medications (caffeine, nicotine, alcohol) 5. Delirium and other confusion state (Inouye et al. 1999) Poor nutritional status (serum albumin < 3.0 g/dl) Use of physical restraints Insertion of a bladder catheter Polypharmacy ( 4medications) Iatrogenic events (fecal impaction or acute infection) 6. Neuropsychiatric disorder : Depression (20% of AD, 32% of VD; Rebok et al 2000) day-time apathy, anxiety, agitation and aggression
Sleep in Alzheimer s Disease Primary sleep disorders 1. Sleep disordered breathing ; Obstructive sleep apnea syndrome 4% in total population 25% in geriatric population Clinical presentation 1. Snring 2. Breathing pauses 3. Excessive daytime sleepiness 4. Awake with gasping 5. Waking with a headache 6. Waking with heart racing 7. Frequent nocturnal urination Male & Obesity Complication 1. Heart failure, Arrhythmia 2. CVA 3. Hypertension Treatment : CPAP
Sleep in Alzheimer s Disease Primary sleep disorders 2. Restless leg syndrome ; 20% - 45% in geriatric population Etiology 1. Primary (a genetic predisposition?) - up to 60% report a positive family history. - autosomal dominant mode of inheritance 2. Secondary : - iron deficiency (31%) - pregnancy (20%) - end-stage renal disease (20-65%) - Neuropathy (5.2%,underestimated) - Rhematoid arthritis (25%) - Parkinson s disease (20%) -MS etc Arch Intern Med.2000
Sleep in Alzheimer s Disease Primary sleep disorders Treatment : - Lovedopa (Sinemet, 25/100 mg at bedtime) - Dopa-agonist (pramipexole, 0.125mg at bedtime) - Benzodiazepines (Clonazepam) Avoid substances - Nicotine, Caffeine, Alcohol - SSRI, TCA : intensify -Antihistamines -Mecperan - Antipsychotics
: 6 / 86 (7%) 1, : 48 / 205 (23.4%) 1 : 43 2 : 5
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Treatment- hypnotics for insomnia
Treatment- hypnotics (benzodiazepine receptor)
Treatment- antidepressants
Treatment- antipsychotics Dement Geriatr Cogn Disrod 2004;17:78-90