Effect of an 18-Month Walking Intervention on the Rest-Activity Rhythm of Older Adults With Mild-Moderate Dementia

The objective of this 18-month walking intervention was to evaluate the effect on rest-activity rhythm (RAR) for older adults with mild-to-moderate dementia (65.8% female; aged M = 82.4 [SD = 6.5]). The intervention group (n = 44) was intended to walk 30 min, five times per week for 18 months. The control group (n = 35) received sedentary activities or usual care. RAR was measured at baseline to after 18 months and five times in between actigraphy outcome variables (interdaily stability, intradaily variability, relative amplitude, activity 10 most active hours, and activity 5 least active hours). Hierarchical mixed model analyses revealed no significant intervention effects (with or without baseline confounders as covariate) on RAR. However, participants in the intervention group were able to significantly increase their daily life activity (activity 10 most active hours) from the onset of the preceding measurement, b = 0.10, t(239.32) = 2.36, p = .019. More research is warranted to study the effect of regular walks on older persons with dementia whose RAR is worst at baseline.

Clinical and cost-effectiveness of DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives) for people living with dementia and their carers: a study protocol for a parallel multicentre randomised controlled trial

INTRODUCTION

Many people living with dementia experience sleep disturbance and there are no known effective treatments. Non-pharmacological treatment options should be the first-line sleep management. For family carers, relatives' sleep disturbance leads to interruption of their sleep, low mood and breakdown of care. Our team developed and delivered DREAMS START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives), a multimodal non-pharmacological intervention, showing it to be feasible and acceptable. The aim of this randomised controlled trial is to establish whether DREAMS START is clinically cost-effective in reducing sleep disturbances in people living with dementia living at home compared with usual care.

METHODS AND ANALYSIS

We will recruit 370 participant dyads (people living with dementia and family carers) from memory services, community mental health teams and the Join Dementia Research Website in England. Those meeting inclusion criteria will be randomised (1:1) either to DREAMS START or to usual treatment. DREAMS START is a six-session (1 hour/session), manualised intervention delivered every 1-2 weeks by supervised, non-clinically trained graduates. Outcomes will be collected at baseline, 4 months and 8 months with the primary outcome being the Sleep Disorders Inventory score at 8 months. Secondary outcomes for the person with dementia (all proxy) include quality of life, daytime sleepiness, neuropsychiatric symptoms and cost-effectiveness. Secondary outcomes for the family carer include quality of life, sleep disturbance, mood, burden and service use and caring/work activity. Analyses will be intention-to-treat and we will conduct a process evaluation.

ETHICS AND DISSEMINATION

London-Camden & Kings Cross Ethics Committee (20/LO/0894) approved the study. We will disseminate our findings in high-impact peer-reviewed journals and at national and international conferences. This research has the potential to improve sleep and quality of life for people living with dementia and their carers, in a feasible and scalable intervention.

TRIAL REGISTRATION NUMBER

ISRCTN13072268.

Research advances in the study of sleep disorders, circadian rhythm disturbances and Alzheimer’s disease

Although there are still no satisfactory answers to the question of why we need to sleep, a better understanding of its function will help to improve societal attitudes toward sleep. Sleep disorders are very common in neurodegenerative diseases and are a key factor in the quality of life of patients and their families. Alzheimer’s disease (AD) is an insidious and irreversible neurodegenerative disease. Along with progressive cognitive impairment, sleep disorders and disturbances in circadian rhythms play a key role in the progression of AD. Sleep and circadian rhythm disturbances are more common in patients with AD than in the general population and can appear early in the course of the disease. Therefore, this review discusses the bidirectional relationships among circadian rhythm disturbances, sleep disorders, and AD. In addition, pharmacological and non-pharmacological treatment options for patients with AD and sleep disorders are outlined.

How do care home staff use non-pharmacological strategies to manage sleep disturbances in residents with dementia: The SIESTA qualitative study

Background

Sleep disturbances affect 38% of care home residents living with dementia. They are often treated with medication, but non-pharmacological interventions may be safer and effective yet more difficult to implement. In the SIESTA study (Sleep problems In dEmentia: interviews with care home STAff) we explored care home staffs’ experience of managing sleep disturbances in their residents living with dementia.

Methods

We conducted one-to-one semi-structured interviews in four UK care homes, and purposively recruited a maximum variation sample of 18 nurses and care assistants, who were each interviewed once. We used a topic guide and audio-recorded the interviews. Two researchers independently analysed themes from transcribed interviews.

Results

Staff used a range of techniques that often worked in improving or preventing residents’ sleep disturbance. During the daytime, staff encouraged residents to eat well, and be physically active and stimulated to limit daytime sleep. In the evening, staff settled residents into dark, quiet, comfortable bedrooms often after a snack. When residents woke at night, they gave them caffeinated tea or food, considered possible pain and discomfort, and reassured residents they were safe. If residents remained unsettled, staff would engage them in activities. They used telecare to monitor night-time risk. Staff found minimising daytime napping difficult, described insufficient staffing at night to attend to reorient and guide awake residents and said residents frequently did not know it was night-time.

Conclusions

Some common techniques, such as caffeinated drinks, may be counterproductive. Future non-pharmacological interventions should consider practical difficulties staff face in managing sleep disturbances, including struggling to limit daytime napping, identifying residents’ night-time needs, day-night disorientation, and insufficient night-time staffing.

Development of a multi-component intervention to promote sleep in older persons with dementia transitioning from hospital to home

BACKGROUND

Hospitalised older persons with dementia are commonly discharged with intensified sleep disturbances. These disturbances can impede the recovery process. Nurses are well-positioned to assist persons with dementia and their family caregivers in managing sleep disturbances during the transition from hospital to home.

OBJECTIVES

To describe the development of a multi-component intervention to promote sleep.

METHODS

We applied three stages of the intervention mapping method to develop a non-pharmacological, multi-component sleep intervention. The first stage involved a review of the literature to generate an understanding of the determinants of sleep disturbances experienced by persons with dementia in hospital and home settings. The second stage consisted of a literature review to identify therapies for managing commonly reported determinants of sleep disturbances. The third stage entailed delineation of the intervention components.

RESULTS

The most common determinants of sleep disturbances experienced by persons with dementia in hospital and home settings were: physiological changes associated with ageing, sleep environments non-conducive to sleep, limited exposure to light and engagement in physical activity, stress and sleep-related beliefs and behaviours. Therapies found effective included: light therapy, physical activity therapy, sleep hygiene, and stimulus control therapy. These therapies were integrated into a multi-component sleep intervention to be provided using the teach-back technique, during and following hospitalisation.

DISCUSSION

Consistent with the principles of patient engagement, the multi-component sleep intervention will be evaluated for its acceptability and feasibility.

IMPLICATIONS FOR PRACTICE

The intervention has potentials to improve sleep during the transition from hospital to home.

Effects on sleep from group activity with a robotic seal for nursing home residents with dementia: a cluster randomized controlled trial

OBJECTIVES

Sleep disturbances are common in people with dementia and increase with the severity of the disease. Sleep disturbances are complex and caused by several factors and are difficult to treat. There is a need for more robust and systematic studies dealing with sleep disturbances in older people with dementia. The aim of this study was to investigate effects from robot-assisted (Paro) group activity on sleep patterns in nursing home (NH) residents with dementia.

DESIGN

A cluster randomized controlled trial.

SETTING

Special care units in 10 NH in Norway.

PARTICIPANTS

A total of 60 participants over 65 years with dementia were recruited. Thirty participants were recruited to the intervention group and 30 participants to the control group.

INTERVENTION

Participants participated in group activity with Paro for 30 minutes twice a week over 12 weeks or in control group (treatment as usual).

MEASUREMENTS

Sleep-wake patterns were assessed objectively by 7 days of wrist actigraphy before and after the intervention. Data were collected between March 2013 and September 2014. Data were analyzed using mixed models.

RESULTS

Positive effects on change in sleep were found in the intervention group as compared with the control group. The intervention group increased percentage of sleep efficiency, increased the amount of total sleep time and reduced number of nocturnal awakenings. In addition, a significant effect was found in reduced awakenings after sleep onset.

CONCLUSIONS

Social stimulation through engaging group activity could contribute to improved sleep in people with dementia in NH. Increased sleep efficiency and total sleep time, in addition to fewer night awakenings, affect central indicators of good sleep quality across the life span. Improved sleep quality will also affect quality of life and comorbidities in vulnerable groups. We believe group activity with Paro to be an accessible and feasible non-pharmacological treatment for those who enjoy Paro.

Non-pharmacological interventions a feasible option for addressing dementia-related sleep problems in the context of family care

Background

Sleep disturbances are challenging symptoms associated with mild cognitive impairment or dementia (MCIoD). This study assessed the feasibility of sleep monitoring and non-pharmacological interventions to improve the sleep of New Zealanders with MCIoD and their family carers.

Methods

A 5-week multi-modal intervention consisting of timed bright light therapy, physical activity, and sleep education was piloted. Sleep was monitored for a week at baseline and conclusion of the trial using actigraphy, diaries, and questionnaires alongside additional health and wellbeing information concerning both care recipients and carers.

Results

Fifteen pairs participated, 9 completed the trial. Patterns of attrition and participant feedback are discussed. Case studies showed that six of the care recipients had minor improvements to sleep efficiency. Some also had improved subjective sleep ratings and quality of life. Changes did not clearly translate to family carers. However, five of them also showed some improvements in sleep status and mental health. Health deterioration of care recipients may mask the effects of the intervention.

Conclusions

It is feasible to use non-pharmacological sleep interventions for people with MCIoD and their family carers. Given the limited treatment options, further consideration of such interventions in future research and clinical practice is warranted.

Trial registration

As this study was to assess the feasibility of proposed methods, it was an observational study without case-control groups nor a medical-based intervention, clinical registration was not required. A future full version of the trial would be registered with the Australian New Zealand Clinical Trails Registry.

Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies

BACKGROUND

Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia.

OBJECTIVES

To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance.

DESIGN

A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia.

DATA SOURCES

Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial.

SETTING

Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England.

PARTICIPANTS

Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively.

INTERVENTIONS

The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics.

MAIN OUTCOME MEASURES

Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance.

RESULTS

The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life.

LIMITATIONS

Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses.

CONCLUSIONS

We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed.

FUTURE WORK

More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia.

STUDY REGISTRATION

This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.

Therapy for Insomnia and Circadian Rhythm Disorder in Alzheimer Disease

PURPOSE OF THE REVIEW

There is strong evidence for a bidirectional association between sleep disorders and Alzheimer's disease (AD). In particular, insomnia may be a potentially modifiable risk factor for AD. The present review summarizes recent advances in treatment of sleep disorders in AD.

RECENT FINDINGS

Some studies investigated the efficacy and safety of hypnotic agents as ramelteon and mirtazapine to treat sleep disorders in AD but no significant therapeutic effects have been observed. Benzodiazepines are the most frequently used medication for treatment of insomnia but they may cause significant side effects in old subjects. Suvorexant, an orexin receptor antagonist, showed a positive effect on AD insomnia. Recent report suggests an association between trazodone use and delayed cognitive decline in AD. With respect to circadian rhythm disorders, non-pharmacological treatments, especially bright light therapy, could be useful and safe options for treatment in AD. Some pharmacological and non-pharmacological treatments might have benefits in AD patients with sleep disturbances, but further well-designed controlled trials are needed.

Non-pharmacological interventions for patients with dementia: A protocol for a systematic review and meta-analysis

BACKGROUND

This protocol for a systematic review describes the methods that will be used to evaluate the efficacy and safety of non-pharmacological interventions for patients with dementia.

METHODS

We will search ALOIS, the specialized register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG), without language or publication status restrictions. Additional separate searches will be run in many of the above six databases to ensure the most up-to-date results are retrieved.The study selection and data extraction will be performed independently by two authors and only randomized controlled trials will be included. The risk of bias will be assessed independently by two authors following the Cochrane Handbook for Systematic Reviews of Interventions. We will use RevMan software and random-effects models to assess the heterogeneity and data synthesis.If any plan for documenting important protocol amendments changes, the researchers will make a revision agreement and then register the modification on PROSPERO.

CONCLUSION

Through this systematic review, a comprehensive understanding of current non-pharmacological interventions on dementia will be available. Meanwhile, it will provide basic evidence for further clinical research.

ETHICS AND DISSEMINATION

Ethical approval is not required because no individual patient's data are included in this paper. This study will be disseminated through conference presentation.

PROSPERO REGISTRATION NUMBER

CRD42019136435.

Behavioral and psychological symptoms in Alzheimer's dementia and vascular dementia

Behavioral and psychological symptoms of dementia (BPSD) are highly prevalent and represent a significant burden for patients and their caregivers. Early recognition and management of these symptoms is crucial as they are associated with increased risk of institutionalization, impairments in daily functioning, reduced quality of life, and more rapid progression to severe dementia. This chapter will discuss the pathophysiology, proposed diagnostic criteria, clinical features, and management of BPSD, including apathy, depression, agitation/aggression, psychosis, and sleep disturbances. Apathy and depression are the most common overall, and apathy is associated with high symptom severity likely because of its greater persistence. Symptoms such as agitation, aggression, hallucinations, and delusions may be especially distressing and dangerous to patients and caregivers. Nonpharmacologic management should be considered first-line therapy in most cases due to the modest and inconsistent evidence base for pharmacologic agents and greater risk of harm. However, the judicious use of pharmacologic agents may be warranted when symptoms are dangerous and/or severely distressing.

Effects of creative expression therapy on Chinese elderly patients with dementia: an exploratory randomized controlled trial

Purpose: This study aimed to evaluate the effect of creative expression (CE) therapy on cognition, communication, emotion, and quality-of-life in people with dementia. Methods: One hundred individuals were included in this study, of whom 91 completed the study (mean age=84.33). The participants were randomly assigned to an intervention group (n=43) and a control group (n=48), and received the CE program or standard cognitive (SC) training twice a week for 6 weeks, respectively. Both groups were submitted to extensive neuropsychological tests, as follows - Mini-Mental State Examination (MMSE), Quality of Life-Alzheimer's Disease (QOL-AD), Cornell Scale for Depression in Dementia (CSDD), Functional Assessment of Communication Skills (FACS) at baseline, 1-, and 4 -weeks post-intervention, and the Observed Emotion Rating Scale (OERS) was measured during the intervention period at weeks 3 and 6. Results: The participants demonstrated significant improvements in cognitive function, quality-of-life, depression degree, communication ability, and emotion status (P<0.05) at post-intervention, which were maintained at 1-month follow-up. Conclusion: This study provides preliminary evidence that CE therapy developed in the study benefits elderly Chinese with dementia. The findings indicated that non-pharmacological intervention programs - CE therapy - can be applied in the management of neuropsychiatric symptoms of dementia.

A manual-based intervention for carers of people with dementia and sleep disturbances: an acceptability and feasibility RCT

BACKGROUND

It has been estimated that between 25% and 40% of people living with dementia suffer from sleep disturbances, and there are currently no known effective treatments. Sleep disturbances may be the direct result of dementia or due to other comorbidities, such as pain and limited mobility. If carers' sleep is also disturbed, carers too can become tired and stressed, and this sometimes results in the breakdown of care in the home.

OBJECTIVES

To design an evidence-based manualised non-pharmacological therapy for sleep disturbances and test it for feasibility and acceptability.

DESIGN

A single-blind, randomised, parallel-group feasibility trial, with participants randomised 2 : 1 to intervention or treatment as usual (TAU).

SETTING

Five memory services in two London NHS trusts and Join Dementia Research (JDR).

PARTICIPANTS

The study recruited people with dementia and sleep disturbances (who scored ≥ 4 on at least one question on the Sleep Disorders Inventory) and their primary family carers.

INTERVENTION

All participants were given an Actiwatch (CamNtech Ltd, Cambridge, UK) to wear to record their sleep patterns for 2 weeks before randomisation. The intervention group received Dementia RElAted Manual for Sleep; STrAtegies for RelaTives (DREAMS START). This was designed as a six-session, manual-based intervention for carers of people with dementia, delivered by trained and clinically supervised psychology graduates, based on evidence about managing sleep disturbance in people with dementia. It uses the structure of a previous manual-based treatment, STrAtegies for RelaTives (START). Family carers were consulted about structure, content and design. Sessions were interactive, and each involved techniques, tasks to practise between sessions, relaxation and a recapitulation on the previous session. The sessions covered understanding sleep and dementia, making a plan (incorporating information from Actiwatch read-outs and a light box to increase light), daytime activity and routine, difficult night-time behaviours, taking care of your own (carer's) sleep and using the strategies in the future. Carers kept their own manual, light box and relaxation recordings post intervention.

RANDOMISATION AND BLINDING

A statistician created an electronic randomisation list, stratified by site, using random permuted blocks. Those assessing the outcome were blinded to allocation; participants were not blinded.

MAIN OUTCOME MEASURES

Outcomes were assessed at 3 months. (1) Feasibility, defined as the percentage of eligible people who consented to the study recruitment, with an expected value of 50% [95% confidence interval (CI) 41% to 59%]. (2) Acceptability, defined as the percentage of intervention group participants attending ≥ 4 intervention sessions, with an expected value of 75% (95% CI 59% to 87%). The predetermined criterion for progression to the main trial was acceptability of ≥ 70%.

RESULTS

Of 95 eligible patients referred, 63 (66%, 95% CI 56% to 76%) consented between 4 August 2016 and 24 March 2017: 61 from memory clinics and two from JDR. Of these, 62 participants (65%, 95% CI 55% to 75%) were randomised: 42 to the intervention arm and 20 to the TAU arm. Thirty-seven out of 42 participants (88%, 95% CI 75% to 96%) adhered to the intervention.

CONCLUSIONS

The results show that the randomised controlled trial is feasible and that the intervention is acceptable. A higher than expected proportion of eligible patients referred consented to the study and adhered to the intervention.

LIMITATIONS

Participants were not blinded and were recruited only in London.

FUTURE WORK

The results of this trial indicate that a future efficacy trial is warranted.

TRIAL REGISTRATION

Current Controlled Trials ISCTRN36983298.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 71. See the NIHR Journals Library website for further project information. Funding was also provided by Camden and Islington NHS Foundation Trust and Barnet, Enfield and Haringey Mental Health NHS Trust to pay for excess treatment costs from therapist training and supervision and intervention delivery.

An intervention to improve sleep for people living with dementia: Reflections on the development and co-production of DREAMS:START (Dementia RElAted Manual for Sleep: STrAtegies for RelaTives)

Many people living with dementia experience sleep disturbances yet there are currently no known effective, safe and acceptable treatments. Working with those affected by dementia to co-produce interventions is increasingly promoted to ensure that approaches are fit for purpose and meet the specific needs of target groups. Our aim here is to outline and reflect upon the co-production of Dementia RElAted Manual for Sleep; STrAtegies for RelaTives (DREAMS:START), an intervention to improve sleep for people living with dementia. Our co-production team brought together experts in the development and testing of manualised interventions in dementia care and cognitive behavioural interventions for sleep disorders, with Alzheimer’s Society research network volunteers (ASRNVs) whose lives had been affected by dementia. Here we present the process of intervention development. We worked with (ASRNVs) at each stage of the process bringing together ‘experts by training’ and ‘experts by experience’. (ASRNVs)shared their experiences of sleep disturbances in dementia and how they had managed these difficulties, as well as suggestions for how to overcome barriers to putting the intervention into practice; making (DREAMS:START) more accessible and usable for those in need. In this paper we discuss both the benefits and challenges to this process and what we can learn for future work. Collaborating with ‘experts by experience’ caring for a relative with sleep difficulties helped us to develop a complex intervention in an accessible and engaging way which we have tested and found to be feasible and acceptable in a randomised controlled trial.

Circadian Rhythm and Alzheimer's Disease

Alzheimer’s disease (AD) is a neurodegenerative disorder with a growing epidemiological importance characterized by significant disease burden. Sleep-related pathological symptomatology often accompanies AD. The etiology and pathogenesis of disrupted circadian rhythm and AD share common factors, which also opens the perspective of viewing them as a mutually dependent process. This article focuses on the bi-directional relationship between these processes, discussing the pathophysiological links and clinical aspects. Common mechanisms linking both processes include neuroinflammation, neurodegeneration, and circadian rhythm desynchronization. Timely recognition of sleep-specific symptoms as components of AD could lead to an earlier and correct diagnosis with an opportunity of offering treatments at an earlier stage. Likewise, proper sleep hygiene and related treatments ought to be one of the priorities in the management of the patient population affected by AD. This narrative review brings a comprehensive approach to clearly demonstrate the underlying complexities linking AD and circadian rhythm disruption. Most clinical data are based on interventions including melatonin, but larger-scale research is still scarce. Following a pathophysiological reasoning backed by evidence gained from AD models, novel anti-inflammatory treatments and those targeting metabolic alterations in AD might prove useful for normalizing a disrupted circadian rhythm. By restoring it, benefits would be conferred for immunological, metabolic, and behavioral function in an affected individual. On the other hand, a balanced circadian rhythm should provide greater resilience to AD pathogenesis.

Feasibility of a Cognitive-Behavioral and Environmental Intervention for Sleep-Wake Difficulties in Community-Dwelling Cancer Patients Receiving Palliative Care

BACKGROUND

High rates of sleep-wake difficulties have been found in patients with cancer receiving palliative care. Pharmacotherapy is the most frequently used treatment option to manage these difficulties despite numerous adverse effects and the absence of empirical evidence of its efficacy and innocuity in palliative care.

OBJECTIVE

This pilot study aimed to assess the feasibility and acceptability of a cognitive-behavioral and environmental intervention (CBT-E) to improve insomnia and hypersomnolence in patients with a poor functioning level and to collect preliminary data on its effects.

METHODS

Six patients with cancer receiving palliative care (Eastern Cooperative Oncology Group score 2-3), who had insomnia and/or hypersomnolence, received 1 CBT-E individual session at home. They applied the strategies for 3 weeks. Patients completed the Insomnia Severity Index, the Epworth Sleepiness Scale, a daily sleep diary, and a 24-hour actigraphic recording (7 days) at pretreatment and posttreatment, in addition to a semistructured interview (posttreatment).

RESULTS

Participants found strategies easy to apply most of the time, and none was rated as impossible to use because of their health condition. However, their adherence and satisfaction toward CBT-E were highly variable. Results on the effects of CBT-E were heterogeneous, but improvements were observed in patients with a persistent insomnia disorder.

CONCLUSIONS

The CBT-E protocol tested among this highly selected sample was fairly well received and suggested positive outcomes in some patients, particularly those with an insomnia complaint alone.

IMPLICATIONS

Efforts should be pursued to adapt CBT-E and develop other nonpharmacological interventions, in order to provide an alternative to pharmacotherapy for sleep-wake difficulties in this population.

Disruptions in sleep-wake cycles in community-dwelling cancer patients receiving palliative care and their correlates

Significant disruptions in sleep-wake cycles have been found in advanced cancer patients in prior research. However, much remains to be known about specific sleep-wake cycle variables that are impaired in patients with a significantly altered performance status. More studies are also needed to explore the extent to which disrupted sleep-wake cycles are related to physical and psychological symptoms, time to death, maladaptive sleep behaviors, quality of life and 24-h light exposure. This study conducted in palliative cancer patients was aimed at characterizing patients' sleep-wake cycles using various circadian parameters (i.e. amplitude, acrophase, mesor, up-mesor, down-mesor, rhythmicity coefficient). It also aimed to compare rest-activity rhythm variables of participants with a performance status of 2 vs. 3 on the Eastern Cooperative Oncology Group scale (ECOG) and to evaluate the relationships of sleep-wake cycle parameters with several possible correlates. The sample was composed of 55 community-dwelling cancer patients receiving palliative care with an ECOG of 2 or 3. Circadian parameters were assessed using an actigraphic device for seven consecutive 24-h periods. A light recording and a daily pain diary were completed for the same period. A battery of self-report scales was also administered. A dampened circadian rhythm, a low mean activity level, an early mean time of peak activity during the day, a late starting time of activity during the morning and an early time of decline of activity during the evening were observed. In addition, a less rhythmic sleep-wake cycle was associated with a shorter time to death (from the first home visit) and with a lower 24-h light exposure. Sleep-wake cycles are markedly disrupted in palliative cancer patients, especially, near the end of life. Effective non-pharmacological interventions are needed to improve patients' circadian rhythms, including perhaps bright light therapy.

Effectiveness of Occupational Therapy Interventions to Enhance Occupational Performance for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to describe the evidence for the effectiveness of interventions designed to establish, modify, and maintain occupations for adults with Alzheimer's disease (AD) and related neurocognitive disorders.

METHOD

Titles and abstracts of 2,597 articles were reviewed, of which 256 were retrieved for full review and 52 met inclusion criteria. U.S. Preventive Services Task Force levels of certainty and grade definitions were used to describe the strength of evidence.

RESULTS

Articles were categorized into five themes: occupation-based, sleep, cognitive, physical exercise, and multicomponent interventions. Strong evidence supports the benefits of occupation-based interventions, physical exercise, and error-reduction learning.

CONCLUSION

Occupational therapy practitioners should integrate daily occupations, physical exercise, and error-reduction techniques into the daily routine of adults with AD to enhance occupational performance and delay functional decline. Future research should focus on establishing consensus on types and dosage of exercise and cognitive interventions.

Sleepiness in the Elderly

Excessive daytime sleepiness has pathologic causes and numerous adverse consequences; therefore, it requires medical attention in older adults. Excessive sleepiness in older adults is often multifactorial and may signal an underlying sleep disorder, chronic medical condition, undiagnosed mood disorder, or side effects of medications. It is associated with increased risk for cognitive decline and dementia in the elderly. Excessive sleepiness often requires a multi-method assessment in this age group. It is pertinent to take a systematic, step-by-step treatment approach geared toward the underlying cause, and to treat sleepiness directly, when the cause cannot be eliminated to prevent adverse outcomes.

Non-pharmacological interventions for managing dementia-related sleep problems within community dwelling pairs: A mixed-method approach

Dementia-related sleep problems can be complex and challenging. Environmental interventions which resynchronise the sleep/wake cycle have been trialled with promising results for people with dementia in institutionalised settings. However, there is less research concerning community-dwelling people with dementia and their family carers. This study involved a five-week feasibility study including timed light therapy, exercise and sleep education. Sleep and physical and mental functioning were measured at the beginning and end of the trial using objective measures, standardised questionnaires and structured participant feedback. Of 15 community-dwelling pairs who participated, nine completed the trial. The case studies presented here reveal that it is feasible for this population to use non-pharmacological interventions, with positive outcomes. However, there are also issues that can mask benefits or prevent compliance. The options for treating dementia are limited. Environmental interventions may help manage dementia-related sleep problems and further trials would be worthwhile to improve compliance and evaluate effectiveness.

Clinical management of sleep disturbances in Alzheimer's disease: current and emerging strategies

Sleep and circadian disorders in Alzheimer's disease (AD) are more frequent than in the general population and appear early in the course of the disease. Quality of sleep and quality of life are parallel in these patients, and such disorders also represent a heavy burden for caregivers. Although alterations in melatonin and hypocretins (orexins) seem to play a key role in the origin of these disturbances, the etiology of these disorders is multifactorial, including many factors such as environment, behavior, treatments, and comorbidities, among others. A comprehensive evaluation of sleep in each patient is essential in the design of the treatment that includes nonpharmacological and pharmacological approaches. One particularly interesting point is the possibility of a role of sleep disorders in the pathogenesis of AD, raising the possibility that treating the sleep disorder may alter the course of the disease. In this review, we present an update on the role of sleep disorders in AD, the bidirectional influence of sleep problems and AD, and treatment options. Behavioral measures, bright light therapy (BLT), melatonin, and other drugs are likely well known and correctly managed by the physicians in charge of these patients. In spite of the multiple treatments used, evidence of efficacy is scarce and more randomized double-blind placebo-controlled studies are needed. Future directions for treatment are the establishment of BLT protocols and the development of drugs with new mechanisms of action, especially hypocretin receptor antagonists, melatonin receptor agonists, and molecules that modulate the circadian clock.

Sleep disturbances and dementia

Sleep is a complex behavioural state, the ultimate functions of which remain poorly understood. It becomes more fragmented as we age, with more night-time awakenings and greater tendency for daytime sleep. The magnitude of disordered sleep among individuals affected by dementia has been clearly demonstrated, and disturbed sleep is a major clinical problem in dementia. Comorbid insomnia and other sleep disturbances are common in patients with neurodegenerative disorders, such Alzheimer's disease and other dementing disorders. How and when sleep problems manifest themselves can depend on the type of dementia involved as well as the stage of the dementia. However, differences in sleep pattern presentation show more variation during the initial stages of dementias than they do during the later stages. Effective, pragmatic interventions are largely anecdotal and untested.

Healthcare providers' knowledge of disordered sleep, sleep assessment tools, and nonpharmacological sleep interventions for persons living with dementia: a national survey

A large proportion of persons with dementia will also experience disordered sleep. Disordered sleep in dementia is a common reason for institutionalization and affects cognition, fall risk, agitation, self-care ability, and overall health and quality of life. This report presents findings of a survey of healthcare providers' awareness of sleep issues, assessment practices, and nonpharmacological sleep interventions for persons with dementia. There were 1846 participants, with the majority being from nursing and rehabilitation. One-third worked in long-term care settings and one-third in acute care. Few reported working in the community. Findings revealed that participants understated the incidence of sleep deficiencies in persons with dementia and generally lacked awareness of the relationship between disordered sleep and dementia. Their knowledge of sleep assessment tools was limited to caregiver reports, self-reports, and sleep diaries, with few using standardized tools or other assessment methods. The relationship between disordered sleep and comorbid conditions was not well understood. The three most common nonpharmacological sleep interventions participants identified using were a regular bedtime routine, increased daytime activity, and restricted caffeine. Awareness of other evidence-based interventions was low. These findings will guide evidence-informed research to develop and test more targeted and contextualized sleep and dementia knowledge translation strategies.

Time to Wake Up: Bridging the Gap between Theory and Practice for Sleep in Occupational Therapy

Sleep plays an essential role in physical, cognitive and emotional functioning, and in occupational performance and participation; it is now considered within the scope of occupational therapy practice. However, since sleep is not routinely assessed and addressed in standard practice, a practice gap exists. Interventions are available to optimize sleep and cope with the consequences of sleep disorders, but occupational therapists may overlook the effect of sleep on function, so missing opportunities to provide relevant management strategies. This opinon piece argues the benefits of including sleep within occupational therapy practice and provides suggestions to facilitate its inclusion within practice, education and research.