by Cheryl Dawes
Getting a good night’s sleep is a high priority for most people. However, for those with Alzheimer’s disease (AD) and their caregivers, an uninterrupted night’s sleep can be an unusual luxury. Sleep disturbances such as wandering, repeatedly getting out of bed, and day-night confusion are common among people with dementia. Dealing with these disturbances is tough on family caregivers. Sleep problems are a major factor in decisions to move AD patients away from their homes and family members in the community into institutions.
Finding ways to help AD patients sleep better is a chief focus for ADRC investigator Dr. Susan McCurry. Through her research, she hopes to provide relief for family caregivers who are frequently awakened at night to attend to their loved ones’ needs. Sedating medications are often prescribed to improve sleep, but few studies show such medications are effective and, in older adults with dementia, there is a greater risk of side-effects than among younger healthy individuals. For this reason, McCurry’s research centers on behavioral interventions that can be an alternative or supplement to sleeping medications. Preliminary findings are promising, she says. Providing sleep education to caregivers and active assistance in setting up a regular program for good sleep practices may help to reduce sleep disturbances in AD patients.
In a study funded by the National Institute of Mental Health, McCurry enrolled 36 community-dwelling AD patients who had one or more sleep problems that were occurring three or more times a week, and who lived with a family caregiver that could monitor their sleep and put treatment recommendations into practice. The ongoing project, known as Nighttime Insomnia Treatment and Education for Alzheimer’s Disease (NITE-AD), is a comprehensive sleep education program that teaches caregivers about good sleep practices, trains them in behavior management skills, and helps them increase patients’ daytime activity and exposure to light.
To evaluate the NITE-AD intervention, McCurry and her colleagues conducted a randomized controlled trial to compare outcomes for participants who received active treatment with control subjects who received only sleep education handouts and caregiver support. Caregivers kept a daily sleep diary, and both patients and caregivers wore wrist-movement recorders that provided objective sleep estimates at the beginning of the study, at the end of the two-month treatment period, and at a six-month follow-up.
Participants were randomly assigned to the active treatment group or the control group. All participants received six in-home treatment sessions over a two-month period. Sessions included written information about good sleep habits, sleep changes associated with normal aging and dementia, and basic strategies for improving sleep problems in persons with AD.
In addition, the active treatment group received individualized treatment recommendations, training in behavior management strategies, and assistance in setting up a daily walking and increased light exposure program. In contrast, the control group received non-directive caregiver support throughout the treatment period, and general information about dementia care and community resources.
Overall, caregivers in the active treatment group were able to help patients change sleep scheduling, napping, and walking routines and to reach sleep goals they had set for the patient. Caregivers in the control group set fewer goals for changing sleep practices, and were markedly less successful at meeting goals they had set.
Although final outcome results of the study are still pending, preliminary data show a reduction in the number and duration of patient nighttime awakenings in the active treatment group. These findings suggest that behavioral strategies can help in managing sleep disturbances in patients with AD, explains McCurry. However, these strategies take some time and effort to implement, and caregivers often need help figuring out what will work in their unique situations, she points out.
"What NITE-AD has shown us is that simply providing general information and written materials about sleep often wasn’t enough to empower caregivers to change the sleep practices of their loved ones with dementia," says McCurry. "Changes occurred when caregivers were given individualized suggestions and concrete help in implementing those recommendations."