Sleep well, think well: Strategies for improving sleep in dementia

Transcription

1 Sleep well, think well: Strategies for improving sleep in dementia PROFESSOR SHARON NAISMITH, MAPS, CCN NHMRC CAREER DEVELOPMENT FELLOW LEONARD P ULLMAN CHAIR, CHARLES PERKINS CENTRE HEAD, HEALTHY BRAIN AGEING PROGRAM, BRAIN & MIND CENTRE The University of Sydney Page 1

2 The significance of sleep Important for: Mood Alertness Daytime functioning & cognition 2 key systems: Sleep system Circadian system The University of Sydney Page 2

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 3

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 4

5 How is sleep linked to cognitive decline? Z Z Z Role of sleep Clearance of toxins & waste Memory consolidation Immune/inflammatory regulation Support of new brain cells Impaired sleep quality Common in dementia and MCI Predicts worse cognitive outcomes Obstructive sleep apnoea Fragmented sleep Hypoxemia The University of Sydney Page 5

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 The University of Sydney Page 6 Bonanni et al, 2005; Cooke et al, 2006

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 7

8 SLEEP TO REMEMBER? Z Z NREM Sleep Z 11-15Hz Sleep spindles Impaired memory processing The University of Sydney Page 8

9 External factors affecting sleep Factors that impact sleep Napping Exercise Bed and wake times Body temperature Sleep quality Sleep hygiene Depression & stress -TV -Internet Sleep expectations Light exposure -Needing to use bathroom -Medications The University of Sydney Page 9

10 Interventions for sleepwake disturbance in ageing The University of Sydney Page 10

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 Antipsychotics May suppress REM, insomnia, data lacking for efficacy in sleep May worsen sleep-wake disturbance in AD Sedative hypnotics Benzodiazepines Less disruption to sleep architecture No known data on cognitive effects in older people 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 The University of Sydney Page 11 Naismith, Rogers, Lewis (i2011); Cooke et al, 2006

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 The University of Sydney Page 12 Cardinali et al, 2010; Dowling et al, 2008; Riemersma et al, 2007

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 13

14 Pay attention to snoring and apnoea: CPAP treatment works! San Diego study, n = 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 The University of Sydney Page 14 Ancoli-Israel et al., 2008; Chong et al, 2006; Cooke et al,

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 15

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 16

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 17

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 18

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 19

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 20

21 Concerns about cognition or sleep? Neurosleep clinic Healthy Brain Ageing Clinic Brain and Mind Centre 94 Mallett Street, Camperdown Phone: Fax: 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 21

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 TEAM Prof Sharon Naismith Prof Ian Hickie Prof Simon Lewis Prof Jim Lagopoulos Prof Ron Grunstein Ms Amelia English Dr Shantel Duffy Dr Loren Mowzsowski Dr Haley LaMonica Dr Zoe Terpening Dr Keri Diamond Dr Rebekah Ahmed Dr Jerome Ip Ms Tess Anderson Ms Stacey West Ms Keshani Jayaweera Mr Nathan Cross Head, Neuropsychologist Psychiatrist Neurologist Neuroimaging Sleep physician Clinical Trials Manager Postdoctoral Researcher Neuropsychologist Neuropsychologist Neuropsychologist Neuropsychologist Neurologist Geriatrician/Neurologist Trials Nurse Research Assistant PhD student PhD student NEUROSLEEP NHMRC Centre of Research Excellence Healthy Brain, Healthy Sleep Postdoctoral Fellowships, Postgraduate Scholarships and Seed-funding available for projects across four themes neurosleep@woolcock.org.au The University of Sydney Page 22