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You may have noted, as I have, the recent reports in the news media about the significant increase in the suicide rate since the end of the 1990s. The rate increased more than 25% between 1999 and 2016 with increases in 49 of 50 states. I believe that some of the factors underlying this increase have to do with the increasing materialism and lack of meaning that many experience in our society. Whatever the cause, suicide can be extremely difficult to predict on the part of mental health professionals and is devastating to close family and friends who lose a loved one to suicide. It has been my experience that psychotherapy aimed at helping these family members and friends can be some of the most challenging work a therapist will ever do. While thinking about this, I recalled the tragic suicide of Robin Williams. He had struggled with depression and apparently learning that he had the early stages of dementia was so overwhelming that he chose to take his own life. For his family and many fans this was a devastating event.
Getting a diagnosis of mild cognitive impairment or dementia can be devastating to patients and their family members. Mild cognitive impairment is diagnosed when people are getting older and have more frequent cognitive problems than those experienced by people of the same age. It includes such problems as more frequently forgetting recently learned information, forgetting important events like doctors’ appointments, feeling overwhelmed by having to make decisions, and having increasingly poor judgment. These changes are significant enough that friends and family note them. Mild cognitive impairment can be a precursor to Alzheimer’s disease and probably often occurs due to the same kind of changes taking place in the brain during the development of dementia.
Mild cognitive impairment is an intermediate state of cognitive dysfunction between that seen in normal aging and actual dementia (Petersen, R. C., 2011). Typically, memory declines with age, but not to the degree that it impairs the normal ability to function. A very small number of people, around one in 100, may be able to go through life without any cognitive decline whatsoever. The rest of us are less fortunate. Mild cognitive impairment is diagnosed when the declining cognitive functioning is greater than what would be expected on the basis of aging alone. Among people over 65 years of age between 10% and 20% meet the criteria for mild cognitive impairment. Unfortunately, studies have indicated that most people with mild cognitive impairment are at increased risk for developing dementia. For those with mild cognitive impairment, activities such as paying bills and going shopping become increasingly difficult. I have often noted the significant distress that this cognitive impairment causes patients.
A literature review conducted by Da Silva (2015) found that sleep disturbances frequently occur in dementia and predict cognitive decline in older individuals with dementia. It is possible that identifying and treating sleep disorders in individuals with mild cognitive impairment and dementia may help preserve cognition, and monitoring sleep disturbances in patients with mild cognitive impairment may help identify the initial symptoms of dementia. Cassidy-Eagle & Siebern (2017) note that nearly 40% of people over 65 years of age report some form of sleep disorder and 70% of those over 65 years of age have four or more co-morbid illnesses. As people age, sleep becomes more fragmented and deep sleep declines. As they get older, people tend to become less active and less healthy, which in turn contributes to an increase in problems such as insomnia. These changes occur more frequently and more severely in individuals with mild cognitive impairment. Spending more time in bed awake and taking longer to fall asleep have been associated with increased risk of developing mild cognitive impairment or dementia in older individuals.
Fortunately, cognitive behavioral therapy has been found to be as effective in treating insomnia in older individuals as it is with younger ones. Many older individuals find cognitive behavioral therapy to be more acceptable than pharmacological treatment, in part, because it does not have the side effects associated with medication management of insomnia. Cassidy-Eagle & Siebern (2017) used a cognitive behavioral intervention provided by a psychologist to 28 older adults with a mean age of 89.36 years, who met criteria for both insomnia and mild cognitive impairment. This treatment intervention resulted in improvement in sleep and improved measures of executive functioning such as planning and memory. This indicates that cognitive behavioral therapy may be a helpful intervention for patients suffering with mild cognitive impairment. Further research will be needed to fully explore the potential benefits of cognitive therapy for insomnia in these patients.
The major types of dementia are Alzheimer’s disease, Parkinson’s disease with dementia, dementia with Lewy bodies, vascular dementia, Huntington’s disease, Creutzfeldt-Jakob disease, and frontotemporal dementia. Most people are familiar with Alzheimer’s disease and Parkinson’s disease with dementia. In fact, Alzheimer’s disease is the greatest cause of dementia in old age. Parkinson’s disease is well-known and is often associated with dementia. Approximately 80% of Parkinson’s patients will develop some degree of dementia within eight years. Between 40% and 60% of patients with dementia are affected by insomnia. Insomnia is just one of a number of sleep problems that can complicate the lives and treatment of patients with dementia. It is also known that increasing sleep disturbance, and the EEG changes that can be seen on polysomnography, tend to worsen along with the progression of dementia.
Alzheimer’s disease is a neurodegenerative disorder with progressive decline in memory and cognitive functioning over time. Up to 25% of patients with mild to moderate Alzheimer’s and 50% with moderate to severe disease have some diagnosable sleep disorder. These include insomnia and excessive daytime sleepiness. Perhaps the most serious of these sleep-related problems is the circadian linked phenomenon of “sundowning”, during which, patients in the evening hours regularly begin to have a delirium-like state with confusion, anxiety, agitation, and aggressive behavior with potential for wandering away from home. Indeed, sleep difficulty in these patients is a major contributor to early institutionalization, and wandering frequently results in the need for these patients to stay on locked units.
Parkinson’s disease with dementia is associated with significant sleep problems including hallucinations that may be related to REM sleep features emerging during wakefulness, REM sleep behavior disorder during which people act out dreams, and decreased quality of sleep. These problems can be extremely difficult for patients, their families, and their caregivers.
The primary sleep problems that patients with all forms of dementia experience are insomnia, excessive daytime sleepiness, altered circadian rhythms, and excessive movement during the night such as leg kicks, acting out dreams, and wandering. A first step in helping treat these problems is for their physicians to identify additional sleep or medical disorders so that they can be treated to potentially help ameliorate these difficulties. For example, patients may have restless leg syndrome, sleep apnea, depression, pain, or bladder problems, all of which can disturb sleep. Treatment of these disorders can help reduce insomnia and excessive daytime sleepiness. Various medical problems and the medications used to treat them can contribute to sleep problems in patients with dementia. An example would be the potential for increased insomnia caused by using activating antidepressant medications to treat depression.
It should be noted that behavioral techniques can be extremely helpful and should be implemented early in the treatment of sleep problems in patients with dementia. These can be very simple and straightforward and include taking steps such as ensuring good sleep hygiene by keeping regular bedtime schedules and routines, limiting intake of caffeine and alcohol, avoiding prolonged daytime naps, and increasing activity levels during the day. Bright light therapy may also have a role in helping patients be more alert during the day and in decreasing awake time during the night. Likewise, bright light therapy as well as melatonin may have a role in helping regularize the circadian rhythm in patients with dementia and thus in decreasing evening wandering. With regard to excessive motor activity during the night, behavioral approaches such as ensuring a safe bed environment are important. For example, removing potentially dangerous objects such as firearms from the home or placing mattresses on the floor at bedside to cushion any falls.
Medication management typically plays an important role in treating these sleep related problems. A strong reason for considering behavioral interventions for many of these problems as well is that some pharmacological interventions such as sedative medications to treat insomnia may unfortunately increase daytime cognitive dysfunction. Maximizing behavioral interventions can reduce the need to over rely on medications alone.
Mild cognitive impairment and dementia represent significant challenges for patients and their families. Awareness of sleep habits and the changes that occur over time may help doctors better recognize the progression of neurodegenerative disease and help slow that progression. Behavioral techniques when implemented humanely and carefully can contribute to improved sleep for many patients with these disorders.
Cassidy-Eagle, E.L. & Siebern, A. (2017). Sleep and mild cognitive impairment, Sleep Science and Practice, 1:15, DOI 10.1186/s41606-017-0016-5
Da Silva, R. A. P. C. (2015). Sleep disturbances and mild cognitive impairment: A review. Sleep Science, 8(1), 36–41. http://doi.org/10.1016/j.slsci.2015.02.001
Petersen, R. C., (2011). Mild Cognitive Impairment. New England Journal of Medicine, 364, p. 2227 - 2234.
Petit, D., Montplaisir, J., St. Louis, E.K., & Boeve, B.F., (2017). Alzheimer Disease and Other Dementias, in Kryger, M., Roth, T., Dement, W.C. (Eds.), (2017). Principles and Practice of Sleep Medicine Sixth Edition, Philadelphia, PA: Elsevier.
