Other Sleep Disorders
Restless legs syndrome should also be considered among sleep disorders in the nursing home population. “Perhaps all the pacing that we see in the nursing home residents with Alzheimer’s disease might be a result of restless legs,” Dr. Ancoli-Israel suggested. She cited research by Kathy Richards, PhD, RN, and colleagues, who looked at probable RLS and sleep apnea in relation to agitation in older adults with dementia.
They found probable RLS in 24% of their community sample. Agitation was associated with severe cognitive impairment but low apnea. So “RLS may be something we might want to examine a little more carefully in these patients,” said Dr. Ancoli-Israel. “If you can’t make the diagnosis, it might not be such a bad idea to just go ahead and try treating it and see if the treatment can be used in a diagnostic fashion. You may see improvement in pacing and agitation in this group.”
Environment Plays a Role
Apart from physiologic factors, environment also has a great influence in poor sleep and poor circadian rhythms. “In the nursing home, we found that patients are exposed to very little light,” Dr. Ancoli-Israel reported. Her own group has done research showing that the median daily exposure to light above 1,000 lux in a nursing home population was one minute. And at night the reverse is often true—not enough darkness. “Not getting enough light during the day and getting too much light at night are contributing to the poor rhythms and fragmented sleep that we see in this population.”
Likewise, sound has also been shown to contribute to poor sleep in the nursing home setting. “Reminding the staff to speak quietly,” Dr. Ancoli-Israel suggested, “might in itself help patients sleep better at night.”
Research with bright light therapy has shown that it may slightly decrease agitative behavior, consolidate the sleep/wake cycle, and increase the strength of the rest/activity rhythm, “but none of these results in any of these studies has been really robust,” Dr. Ancoli-Israel said. Trials with melatonin also have yielded weak results.
The Next Steps
“Where do we go from here? I think we still need some very good randomized, controlled trials examining the efficacy of both pharmacologic and behavioral treatments on sleep and circadian rhythms in Alzheimer’s disease and … other neurodegenerative diseases. We need to look at combinations of treatments, and light, exercise, and sleeping pills, if necessary,” said Dr. Ancoli-Israel.
She also advocated treating related disorders such as sleep apnea and RLS. “We need to include mortality in our outcome measures—that’s an end point that’s important to look at,” Dr. Ancoli-Israel said. “And we need to perhaps start earlier in our treatments. Let’s not wait until the patients are severely demented. Let’s not wait until they are institutionalized. Perhaps if we intervene earlier with some of these behavioral or pharmacologic treatments we might be able to influence activity rhythms. We might be able to decrease the risk of cognitive impairment or at least slow down deterioration. If we could show in our epidemiologic studies poor rhythms in people at risk for developing MCI or dementia, then maybe we should be doing something to fix those rhythms before they get to that point.”
—Glenn S. Williams