Published on December 1, 2007
Treating Sleep Disturbances in Persons with Dementia : Treating Sleep Disturbances in Persons with Dementia Susan McCurry, Ph.D. University of Washington School of Nursing Department of Psychosocial & Community Health Northwest Research Group on Aging Alzheimer’s Disease Research Center The Seattle Protocols Core Research Team: The Seattle Protocols Core Research Team Rebecca Logsdon, PhD Susan McCurry, PhD June van Leynseele, MA Amy Moore, MS Ken Pike, PhD David LaFazia, MSW Thom Walton, BS Lisa Bancroft, MSW Ray Houle, BA Margaret Sekijima, ARNP Cathy Blackburn, BA Cat Olcott And the many persons with dementia and family members who have shared their lives and experiences with us. Linda Teri, PhD Research on the Seattle Protocols has been funded by the National Institute of Mental Health, National Institute on Aging, the Alzheimer’s Association, and the University of Washington Seattle Behavioral Treatment Protocols: Seattle Behavioral Treatment Protocols Theoretically Grounded- Social Learning & Gerontological Theory Clinically Relevant- Clinical geropsychologists - need for practical solutions Ethically Sensitive- Respect for person with dementia and carer Commitment to supporting both Empirically Tested- Depression, Anxiety, Agitation Physical Inactivity Sleep Disturbances Slide5: What Kinds of Sleep Problems? Getting up during the night (not brief bathroom trips) Waking caregiver during the night Sleeping excessively during the day Wandering, pacing, or inappropriate activities at night Awakening too early in the morning Day/night confusion Difficulty falling asleep “Other” (incontinence/nocturia, hallucinating, talking/singing, snacking, repetitive movements) Sleep Problems in AD (N=205): Sleep Problems in AD (N=205) % McCurry, et al. 1999. Journal of Geriatric Psychiatry and Neurology, 12, 53-59. Slide7: Causes of Sleep Disturbances Age-related sleep changes Circadian rhythm disturbances Primary sleep disorders Brain changes from dementia Medical and psychiatric illnesses Medications / polypharmacy Behavioral and environmental factors Where Should We Intervene?: Physical health Life Events Physical Environment Social rhythms Sleep-related habits Physical fitness Nutrition Patient-caregiver interactions Supportive resources Gender Alzheimer’s disease: Dementia stage Functional status Cognitive level Sleep and circadian rhythms Age Psychiatric health Least modifiable Most modifiable Where Should We Intervene? McCurry, et al. 2002. Sleep Medicine Reviews, 4, 623-628. Seattle Protocolsfor Dementia Treatment: Seattle Protocols for Dementia Treatment Manuals provide structure and guidelines. Treatment is individualized—not rigid formula. Rationale for treatment. Realistic expectations. Communication skills. Fundamentals of behavior change (A-B-C’s). Increase pleasant events/behavioral activation. Caregiver support & community resources. Plans for maintenance and generalization. A-B-C Approach to Problem Solving: A-B-C Approach to Problem Solving Describe behavior in observable terms Identify antecedents & consequences Develop a reasonable plan to try for a week Identify who will carry out the plan Evaluate success Revise, try another plan or go on to the next problem A-B-Cs: Simple but Tricky: A-B-Cs: Simple but Tricky Behaviors can be influenced by more than one thing at a time The message being communicated is more important than the actual behavior Observation is critical and challenging Creative brainstorming is not easy The caregiver is the expert Case Example: Sleep Disturbances: Case Example: Sleep Disturbances Mrs. A is an 81 year old woman with Alzheimer’s disease who lives with her adult daughter. She is getting up during the night and dressing at about 3 - 4 am. She frequently removes her undergarments and leaves them in the toilet or in a fish tank that is near the bathroom. She recently left the house in a thin nightgown and was very chilled when her daughter got her back inside. The daughter is exhausted and thinking she may not be able to keep mom in her home. Slide13: Physical Causes Historical Environment Cognitive Poor sleep hygiene Dietary habits Preferred routines Brain changes from dementia Circadian rhythm changes Daytime napping Primary sleep disorders Medications Chronic pain or other physical illness Depression Day-night confusion Inability to tell time Sundowning Bedroom light exposure Noise Pets Temperature Uncomfortable bedding Season of year Boredom Caregiver sleep habits Changing the ABC’s of Behavior: Changing the ABC’s of Behavior “A”: Look for the antecedent Did anyone or anything trigger the event? “B”: Define and observe the problem Who does it happen around? What is the current behavior? Where does it happen most? How often does it occur? “C”: Identify the consequence What happened after the behavior? How did others react? The A-B-C’s of Problem Solving: The A-B-C’s of Problem Solving Activating Event (Antecedent) Behavior Consequence Always around 3 am Almost every night When mom’s alone in her room Gets up at night Inappropriate activities once up Upset with daughter Daughter scolds, argues with mom Brainstorming Ideas: Brainstorming Ideas Check with physician to see if any of mom’s medications or medical problems are waking her up at night. Install alarm system on outside doors. Eliminate late afternoon and evening napping. Move fish tank out of the hallway near the bathroom. Give mom a snack before bed so make sure she’s not hungry during the night. Switch to adult incontinence undergarments. Establish consistent bed, rising times. Increase daytime physical and social activity. A-B-C Approach: A-B-C Approach Set consistent 10 pm bed time Moved fish tank Started in adult day several days/week Eliminated evening naps Put child monitor in mom’s room Mom is redirected quickly back to bed Sleep improvements: Pre - 6.6 hrs sleep/night, 8 awakenings Post - 7.3 hrs/night, 1 awakening Daughter gets up when she hears mom go into bathroom Stopped scolding, using angry tone Slide18: Nighttime Insomnia Treatment and Education for Alzheimer’s Disease (NITE-AD) Funded by: National Institute of Mental Health (K01-MH01644) SM McCurry, LE Gibbons, RG Logsdon, & L Teri. (2005). Nighttime Insomnia Treatment and Education for Alzheimer’s Disease: A controlled trial. Journal of the American Geriatrics Society, 53, 793-802. Subjects (N=36): Subjects (N=36) Probable or possible AD Two or more sleep problems, occurring 3+ times/week No diagnosed primary sleep disorder (sleep apnea, restless legs syndrome, REM behavior disorder, periodic leg movement syndrome) Reside in community with caregivers Ambulatory Descriptive Data : Descriptive Data Slide22: Actigraphy: NITE-AD Dyad Caregiver Person with dementia Sleep/inactivity Wake/activity Time of day Changes in Total Wake Time: Changes in Total Wake Time p = .03 McCurry, et al. 2005. J Am Geriatr Soc, 53, 793-802. Changes in Night Awakenings: Changes in Night Awakenings p = .01 McCurry, et al. 2005. J Am Geriatr Soc, 53, 793-802. Slide25: Treatment Adherence 86% of enrolled subjects completed study Almost no caregivers (8%) reported the program required too much work or effort Compliance with scheduling, walking, and light box use was > 80% during active treatment During followup, 62% of subjects continued to walk, and 33% continued to use the light box No subject who completed active treatment had been institutionalized at 6 months Slide26: “Tomorrow ends the research that UW Hospital and Group Health have been doing with Dad to see if that helps people with dementia to sleep better. Obviously, with him, it was worked. He sleeps much, much better. There is less wandering (almost none) at night.” - Caregiver, April, 2007 Ongoing Studies: Ongoing Studies Community-based subjects N=136 Three active treatments: Walking only, light only, NITE-AD, Educational contact control Funded by National Institute of Mental Health (R01-MH072736) Residents of adult family homes N=48 Behavioral treatment vs. no treatment control Funded by the Alzheimer’s Association (IIRG-05-13293) Lessons from Research: Lessons from Research Providing education and written information alone is usually insufficient to achieve behavioral changes. Realistic expectations and good communication are foundations for all behavioral intervention. Behavioral interventions must be individualized for each dyad. We attempt to involve the person with dementia in each session. Lessons from Research: Lessons from Research Caregiver depression, anger, or burnout can sabotage behavioral interventions-must be recognized, acknowledged, and addressed. Family disagreement or conflict can also sabotage behavioral interventions and be distressing and disruptive for the person with dementia. Therapist experience, skill, and supervision are essential for the success of the intervention. Slide30: Related Readings McCurry SM, et al. (2003). Training caregivers to change the sleep practices of patients with dementia: The NITE-AD study. J Am Geriatr Soc, 51: 1455-1460. McCurry SM, et al. (2004). Treatment of sleep and nighttime disturbances in Alzheimer’s disease: A behavior management approach. Sleep Med, 5: 373-377. Logsdon RG, et al. (2005). A home health care approach to exercise for persons with Alzheimer’s disease. Care Manage J, 6, 90-97. Teri L, et al. (2005). The Seattle protocols: Advances in behavioral treatment of Alzheimer’s disease. In: Vellas B, et al. (Eds.), Research and practice in Alzheimer’s disease and cognitive decline, Volume 10, pp. 153-158. New York: Springer Publications. McCurry S. (2006). When a family member has dementia: Steps to becoming a resilient caregiver. Greenwood Publishing, Westport:CT. McCurry SM, et al. (2007). Sleep disturbances in caregivers of persons with dementia: Contributing factors and treatment implications. Sleep Med Rev, 11, 143-153.