sleep well, think well: strategies for improving sleep in dementia · 2020. 5. 1. · sleep well,...
TRANSCRIPT
The University of Sydney Page 1
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 University of Sydney Page 2
The significance of sleep
– Important for:
– Mood
– Alertness
– Daytime functioning & cognition
– 2 key systems:
– Sleep system
– Circadian system
The University of Sydney Page 3
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
The University of Sydney Page 4
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
The University of Sydney Page 5
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
The University of Sydney Page 6
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
The University of Sydney Page 7
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
The University of Sydney Page 8
Sleep spindles
11-15Hz
NREM Sleep
Z Z
Z
SLEEP TO REMEMBER?
Impaired memory processing
The University of Sydney Page 9
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
The University of Sydney Page 10
Interventions for sleep-
wake disturbance in
ageing
The University of Sydney Page 11
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
The University of Sydney Page 12
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
The University of Sydney Page 13
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
The University of Sydney Page 14
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
The University of Sydney Page 15
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)
The University of Sydney Page 16
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
The University of Sydney Page 17
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
The University of Sydney Page 18
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
The University of Sydney Page 19
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
The University of Sydney Page 20
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
The University of Sydney Page 21
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
The University of Sydney Page 22
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
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