Alzheimer's and Sleep

by Peter J. Dorsen M.D., LADC

Alzheimer's

"Novel treatment options: cognitive decline in Alzheimer’s disease" (Primary Psychiatry 17:1 (suppl 1). As we age, are afflicted with bipolar disorder, and might require a panel of mood stabilizers and more, we certainly can experience a decline in mental function (executive/cognitive as well?). Thirty million individuals will have (some form of ) dementia in 2010!

Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.

They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.

They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.

Sleep Problems

John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).

Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”

Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.

Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.

These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."

Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).

Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.