Background
People with dementia frequently experience sleep disturbances. These can include reduced sleep at night, frequent wakening, wandering at night, and sleeping excessively during the day.
These behaviours cause a lot of stress to carers, and may be associated with earlier admission to institutional care for people with dementia. They can also be difficult for care-home staff to manage.
Non-drug approaches to treatment should be tried first, However, these may not help and medicines are often used. Since the source of the sleep problems may be changes in the brain caused by dementia, it is not clear whether normal sleeping tablets are effective for people with dementia, and there are worries that the medicines could cause significant side effects (harms).
The purpose of this review
In this updated Cochrane review, we tried to identify the benefits and common harms of any medicine used to treat sleep problems in people with dementia.
Findings of this review
We searched up to February 2020 for well-designed trials that compared any medicine used for treating sleep problems in people with dementia with a fake medicine (placebo). We consulted a panel of carers to help us identify the most important outcomes to look for in the trials.
We found nine trials (649 participants) investigating four types of medicine: melatonin (five trials), trazodone (one trial), ramelteon (one trial), and orexin antagonists (two trials). Participants in all the trials had dementia due to Alzheimer's disease. The ramelteon trial, one melatonin trial, and both orexin antagonist trials were commercially funded. Overall, the evidence was moderate or low quality, meaning that further research is likely to affect the results.
Participants in the trazodone trial and most of those in the melatonin trials had moderate-to-severe dementia, while those in the ramelteon and orexin antagonist trials had mild-to-moderate dementia.
The five melatonin trials included 253 participants. We found no evidence that melatonin improved sleep in people with dementia due to Alzheimer's disease. The ramelteon trial had 74 participants. The limited information available did not provide any evidence that ramelteon was better than placebo. There were no serious harms for either medicine.
The trazodone trial had only 30 participants. It showed that a low dose of the sedative antidepressant trazodone, 50 mg, given at night for two weeks, may increase the total time spent asleep each night (an average of 43 minutes more in the trial) and may improve sleep efficiency (the percentage of time in bed spent sleeping). It may have slightly reduced the time spent awake at night after first falling asleep, but we could not be sure of this effect. It did not reduce the number of times the participants woke up at night. There were no serious harms reported.
The two orexin antagonist trials had 323 participants. We found evidence that an orexin antagonist probably has some beneficial effects on sleep. On average, participants in the trials slept 28 minutes longer at night and spent 15 minutes less time awake after first falling asleep. There was also a small increase in sleep efficiency, but no evidence of an effect on the number of times participants woke up. Side effects were no more common in participants taking the drugs than in those taking placebo.
The drugs that appeared to have beneficial effects on sleep did not seem to worsen participants' thinking skills, but these trials did not assess participants' quality of life, or look in any detail at outcomes for carers.
Shortcomings of this review
Although we searched for them, we were unable to find any trials of other sleeping medications that are commonly prescribed to people with dementia. All participants had dementia due to Alzheimer's disease, although sleep problems are also common in other forms of dementia. No trials assessed how long participants spent asleep without interruption, a high priority outcome to our panel of carers. Only four trials measured side effects systematically.
We concluded that there are significant gaps in the evidence needed to guide decisions about medicines for sleeping problems in dementia. More trials are required to inform medical practice. It is essential that trials include careful assessment of side effects.
Authors' conclusions:
We discovered a distinct lack of evidence to guide decisions about drug treatment of sleep problems in dementia. In particular, we found no RCTs of many widely prescribed drugs, including the benzodiazepine and non-benzodiazepine hypnotics, although there is considerable uncertainty about the balance of benefits and risks for these common treatments. We found no evidence for beneficial effects of melatonin (up to 10 mg) or a melatonin receptor agonist. There was evidence of some beneficial effects on sleep outcomes from trazodone and orexin antagonists and no evidence of harmful effects in these small trials, although larger trials in a broader range of participants are needed to allow more definitive conclusions to be reached. Systematic assessment of adverse effects in future trials is essential.
Read the full abstract...
Background:
Sleep disturbances, including reduced nocturnal sleep time, sleep fragmentation, nocturnal wandering, and daytime sleepiness are common clinical problems in dementia, and are associated with significant carer distress, increased healthcare costs, and institutionalisation. Although non-drug interventions are recommended as the first-line approach to managing these problems, drug treatment is often sought and used. However, there is significant uncertainty about the efficacy and adverse effects of the various hypnotic drugs in this clinically vulnerable population.
Objectives:
To assess the effects, including common adverse effects, of any drug treatment versus placebo for sleep disorders in people with dementia.
Search strategy:
We searched ALOIS (www.medicine.ox.ac.uk/alois), the Cochrane Dementia and Cognitive Improvement Group's Specialized Register, on 19 February 2020, using the terms: sleep, insomnia, circadian, hypersomnia, parasomnia, somnolence, rest-activity, and sundowning.
Selection criteria:
We included randomised controlled trials (RCTs) that compared a drug with placebo, and that had the primary aim of improving sleep in people with dementia who had an identified sleep disturbance at baseline.
Data collection and analysis:
Two review authors independently extracted data on study design, risk of bias, and results. We used the mean difference (MD) or risk ratio (RR) with 95% confidence intervals (CI) as the measures of treatment effect, and where possible, synthesised results using a fixed-effect model. Key outcomes to be included in our summary tables were chosen with the help of a panel of carers. We used GRADE methods to rate the certainty of the evidence.
Main results:
We found nine eligible RCTs investigating: melatonin (5 studies, n = 222, five studies, but only two yielded data on our primary sleep outcomes suitable for meta-analysis), the sedative antidepressant trazodone (1 study, n = 30), the melatonin-receptor agonist ramelteon (1 study, n = 74, no peer-reviewed publication), and the orexin antagonists suvorexant and lemborexant (2 studies, n = 323).
Participants in the trazodone study and most participants in the melatonin studies had moderate-to-severe dementia due to Alzheimer's disease (AD); those in the ramelteon study and the orexin antagonist studies had mild-to-moderate AD. Participants had a variety of common sleep problems at baseline. Primary sleep outcomes were measured using actigraphy or polysomnography. In one study, melatonin treatment was combined with light therapy. Only four studies systematically assessed adverse effects. Overall, we considered the studies to be at low or unclear risk of bias.
We found low-certainty evidence that melatonin doses up to 10 mg may have little or no effect on any major sleep outcome over eight to 10 weeks in people with AD and sleep disturbances. We could synthesise data for two of our primary sleep outcomes: total nocturnal sleep time (TNST) (MD 10.68 minutes, 95% CI –16.22 to 37.59; 2 studies, n = 184), and the ratio of day-time to night-time sleep (MD –0.13, 95% CI –0.29 to 0.03; 2 studies; n = 184). From single studies, we found no evidence of an effect of melatonin on sleep efficiency, time awake after sleep onset, number of night-time awakenings, or mean duration of sleep bouts. There were no serious adverse effects of melatonin reported.
We found low-certainty evidence that trazodone 50 mg for two weeks may improve TNST (MD 42.46 minutes, 95% CI 0.9 to 84.0; 1 study, n = 30), and sleep efficiency (MD 8.53%, 95% CI 1.9 to 15.1; 1 study, n = 30) in people with moderate-to-severe AD. The effect on time awake after sleep onset was uncertain due to very serious imprecision (MD –20.41 minutes, 95% CI –60.4 to 19.6; 1 study, n = 30). There may be little or no effect on number of night-time awakenings (MD –3.71, 95% CI –8.2 to 0.8; 1 study, n = 30) or time asleep in the day (MD 5.12 minutes, 95% CI –28.2 to 38.4). There were no serious adverse effects of trazodone reported.
The small (n = 74), phase 2 trial investigating ramelteon 8 mg was reported only in summary form on the sponsor's website. We considered the certainty of the evidence to below. There was no evidence of any important effect of ramelteon on any nocturnal sleep outcomes. There were no serious adverse effects.
We found moderate-certainty evidence that an orexin antagonist taken for four weeks by people with mild-to-moderate AD probably increases TNST (MD 28.2 minutes, 95% CI 11.1 to 45.3; 1 study, n = 274) and decreases time awake after sleep onset (MD –15.7 minutes, 95% CI –28.1 to –3.3: 1 study, n = 274) but has little or no effect on number of awakenings (MD 0.0, 95% CI –0.5 to 0.5; 1 study, n = 274). It may be associated with a small increase in sleep efficiency (MD 4.26%, 95% CI 1.26 to 7.26; 2 studies, n = 312), has no clear effect on sleep latency (MD –12.1 minutes, 95% CI –25.9 to 1.7; 1 study, n = 274), and may have little or no effect on the mean duration of sleep bouts (MD –2.42 minutes, 95% CI –5.53 to 0.7; 1 study, n = 38). Adverse events were probably no more common among participants taking orexin antagonists than those taking placebo (RR 1.29, 95% CI 0.83 to 1.99; 2 studies, n = 323).
FAQs
Medicines for sleep problems in dementia? ›
The main drugs used to treat RBD are melatonin and clonazepam. Melatonin tends to be prescribed more for people with dementia, as clonazepam may worsen other symptoms of dementia and leave the person feeling drowsy during the day.
What is the best drug for insomnia in Alzheimer's? ›Pharmacological treatment. The most commonly used drugs are melatonin, z-hypnotics such as zolpidem, sedating antidepressants, and antipsychotics. Usually benzodiazepines are avoided because they may worsen cognitive function. Cholinesterase inhibitors, the first-line treatment for AD, can also improve sleep quality.
What are the first-line interventions to treat sleep problems in patients with dementia? ›Because of the risk for sedating medication side effects, behavioral strategies are also commonly recommended as first-line treatment for sleep-disturbed individuals with dementia. Standard recommendations include maintaining regular bedtimes and rising times, limiting daytime napping, and restricting time in bed.
Why can't dementia patients sleep at night? ›The primary cause of sleepless nights for those with dementia seems to be the changes that take place in the brain. Leading experts believe that as dementia changes brain cells, it also affects a person's circadian rhythms. When circadian rhythms get disrupted, the individual often confuses morning and evening.
What is the safest sleeping pill for the elderly? ›In the elderly, should prescription medication be necessary, the first-line treatment is nonbenzodiazepines (e.g., zolpidem, eszopiclone, zaleplon, and ramelteon) as they have been found to be safer and better tolerated than tricyclic antidepressants, antihistamines, and benzodiazepines.
What is a strong sedative for dementia patients? ›- Lorazepam (brand name Ativan)
- Temazepam (brand name Restoril)
- Diazepam (brand name Valium)
- Alprazolam (brand name Xanax)
- Clonazepam (brand name Klonopin)
Melatonin secretion decreases in Alzheimer´s disease (AD) and this decrease has been postulated as responsible for the circadian disorganization, decrease in sleep efficiency and impaired cognitive function seen in those patients.
How can I help someone with dementia to sleep at night? ›- Maintain regular times for meals and for going to bed and getting up.
- Seek morning sunlight exposure.
- Encourage regular daily exercise, but no later than four hours before bedtime.
- Avoid alcohol, caffeine and nicotine.
- Treat any pain.
Donepezil (also known as Aricept), rivastigmine (Exelon) and galantamine (Reminyl) are used to treat the symptoms of mild to moderate Alzheimer's disease. Donepezil is also used to treat more severe Alzheimer's disease.
Which type of treatment has the best long term success for treating sleep disorders in older adults? ›Cognitive behavioral therapy, sometimes called CBT , can effectively treat long-term sleep problems like insomnia.
Can you give sleeping pills to dementia patients? ›
Sleep medication is not recommended for a person with dementia. However, some doctors may suggest trying it for a short period if the sleep problem is severe, and non-drug treatments have not worked. If the person does take sleep medication, they may become more confused and more likely to fall over the next day.
Can dementia patients take melatonin? ›Melatonin supplements are generally safe and are used to treat insomnia. They may modestly improve sleep, which could theoretically lead to long-term protection against Alzheimer's. However, other insomnia treatments may be more effective and experts do not recommend melatonin for elderly people with dementia.
What are the signs dementia is getting worse? ›Middle stage: A person develops more significant cognitive problems that may affect their ability to perform daily self-care or live alone. Late stage: The body begins to shut down. A person may not recognize others or speak. They may become incontinent and stop responding to their environment.
What is the new sleeping pill for the elderly? ›QUVIVIQ is a prescription medicine for adults who have trouble falling asleep or staying asleep (insomnia).
What is an alternative to Ambien? ›Pharmaceutical alternatives to Ambien include Lunesta, Restoril, Silenor, Rozerem, antidepressants and over-the-counter antihistamines. Melatonin is a natural sleep aid to discuss with your doctor.
What is the most prescribed drug for sleep? ›The benzodiazepines have been the most commonly used medications in the treatment of insomnia and are certainly safer than some of the older sleeping medications such as the barbiturates (Amytal, Nembutoal, Seconal).
Does CBD help dementia sleep? ›What Are the Benefits of CBD for Seniors with Dementia? CBD is commonly used to help with anxiety, insomnia, poor sleep, and even pain relief. Because CBD has been shown to help reduce anxiety and agitation, it is believed that it can help reduce these symptoms in seniors with dementia.
Why do they give Seroquel to dementia patients? ›There is some evidence that these drugs may also slightly reduce agitation in people with moderate-to-severe Alzheimer's disease. They may also help to reduce hallucinations and delusions in people with Lewy body dementia.
What calms dementia patients? ›Try gentle touching, soothing music, reading, or walks. Reduce noise, clutter, or the number of people in the room. Try to distract the person with a favorite snack, object, or activity. Limit the amount of caffeine the person drinks and eats.
How much melatonin should an elderly person with dementia take? ›If a trial of melatonin is considered, experts recommend low doses (as low as 0.3 mg up to 2 mg) given 1 h before bedtime.
What sleep position is linked to dementia? ›
To our knowledge, this study is the first to show a relationship between time spent in the supine sleep position and dementia.
What stage is restlessness in dementia? ›It can occur at any stage of the disease but it tends to peak in the middle stages of dementia and lessens as the disease progresses.
What is the 5 word memory test? ›Administration: The examiner reads a list of 5 words at a rate of one per second, giving the following instructions: “This is a memory test. I am going to read a list of words that you will have to remember now and later on. Listen carefully. When I am through, tell me as many words as you can remember.
What is the life expectancy of a person with dementia in their 80s? ›The average life expectancy figures for the most common types of dementia are as follows: Alzheimer's disease – around eight to 10 years. Life expectancy is less if the person is diagnosed in their 80s or 90s. A few people with Alzheimer's live for longer, sometimes for 15 or even 20 years.
What is the most common cause of death in dementia patients? ›One of the most common causes of death for people with dementia is pneumonia caused by an infection. A person in the later stages of dementia may have symptoms that suggest that they are close to death, but can sometimes live with these symptoms for many months.
What is the new dementia medication 2023? ›Lecanemab was approved by the US Food and Drug Administration (FDA) as a treatment for early Alzheimer's disease in January 2023. This means that it can now be given to patients with early Alzheimer's disease in the USA.
What is the 3 word memory test? ›The Mini-Cog test.
A third test, known as the Mini-Cog, takes 2 to 4 minutes to administer and involves asking patients to recall three words after drawing a picture of a clock. If a patient shows no difficulties recalling the words, it is inferred that he or she does not have dementia.
The following are used to temporarily improve dementia symptoms. Cholinesterase inhibitors. These medications — including donepezil (Aricept), rivastigmine (Exelon) and galantamine (Razadyne) — work by boosting levels of a chemical messenger involved in memory and judgment.
What medication is used for sleep anxiety? ›That said, here are some of the medications available to treat insomnia and sleep anxiety: Sleep aids: These include prescription medications such as eszopiclone (Lunesta), zolpidem (Ambien), zolpidem ER (Ambien CR), and zaleplon (Sonata). They can help you fall or stay asleep.
Should people with dementia take Ambien? ›All sleep medication, including zolpidem (Ambien™) can cause cognitive impairment including amnesia and should be used with caution in the elderly.
Does trazodone help dementia patients sleep? ›
[1] show that trazodone has a positive effect on dementia associated with Alzheimer's disease (AD) by slowing the rate of cognitive decline. The authors suggest that the beneficial effect of trazodone could be mediated through its effect on augmenting slow-wave sleep (SWS).
What does Benadryl do to dementia patients? ›Potential harm to the brain: Long-term anticholinergic use has been associated with increased dementia risk; diphenhydramine can impair many cognitive functions including memory.
What triggers dementia to get worse? ›other long-term health problems – dementia tends to progress more quickly if the person is living with other conditions, such as heart disease, diabetes or high blood pressure, particularly if these are not well-managed.
What is the fastest declining dementia? ›Creutzfeldt-Jakob disease causes a type of dementia that gets worse unusually fast. More common causes of dementia, such as Alzheimer's, dementia with Lewy bodies and frontotemporal dementia, typically progress more slowly.
What should you not do with dementia? ›I'm going to discuss five of the most basic ones here: 1) Don't tell them they are wrong about something, 2) Don't argue with them, 3) Don't ask if they remember something, 4) Don't remind them that their spouse, parent or other loved one is dead, and 5) Don't bring up topics that may upset them.
What is the name of the new sleeping medication? ›DAYVIGO is a prescription medicine for adults age 18 years and older who have trouble falling or staying asleep (insomnia).
What is the new sleep medication for 2023? ›The newest drugs for insomnia are classified as DORAs. Orexin-A and orexin-B are neuropeptides involved in, among other actions, arousal behavior and inducing wakefulness. DORAs act by blocking 2 orexin receptors: OX1R and OX2R.
What are the names of the new sleeping pills? ›And there are many different sleep aids available. But many medications are better for helping you fall asleep than helping you stay asleep. In January 2022, the FDA approved a new insomnia medication called daridorexant (Quviviq).
What is the safest prescription sleeping pill for the elderly? ›In the elderly, should prescription medication be necessary, the first-line treatment is nonbenzodiazepines (e.g., zolpidem, eszopiclone, zaleplon, and ramelteon) as they have been found to be safer and better tolerated than tricyclic antidepressants, antihistamines, and benzodiazepines.
What is a safer sleep aid than Ambien? ›Unlike Ambien, Lunesta is considered safe to be used long-term, which lends it to be highly effective for sleep maintenance.
What is the closest thing to Ambien over-the-counter? ›
- Diphenhydramine (e.g., Benadryl, Aleve PM, etc.): Diphenhydramine is a sedating antihistamine. ...
- Doxylamine (e.g., Unisom SleepMelts): Doxylamine is also a sedating antihistamine. ...
- Melatonin: The hormone melatonin helps control one's natural sleep-wake cycle.
"Through my research, I've found that the No. 1 sleep killer isn't social media or an uncomfortable mattress - it's rumination," Aric Prather writes in his essay. Dr Aric further mentioned in the essay, "Rumination is a sleep-blocker because it keeps your mind aroused, especially in bed, when it's dark and quiet.
What can I give my Alzheimer's patient to sleep? ›Consider melatonin.
Melatonin might help improve sleep and reduce sundowning in people with dementia.
However, trazodone uniquely improves the deeper phases of slow-wave sleep. Other sedative medications are generally associated with worse cognitive function over time, and they do not improve sleep characteristics as does trazodone.
Do sleeping pills work for Alzheimer's? ›Two doses of an FDA-approved sleeping pill reduced levels of Alzheimer's proteins in a small study of healthy volunteers led by researchers at Washington University School of Medicine in St. Louis.
What drugs are used to calm Alzheimer's patients? ›- Aripiprazole (Abilify®)
- Clozapine (Clozaril®)
- Haloperidol (Haldol®)
- Olanzapine (Zyprexa®)
- Quetiapine (Seroquel®)
- Risperidone (Risperdal®)
- Ziprasidone (Geodon®)
People with Alzheimer's should avoid Benadryl and other medications that contain diphenhydramine when possible. These medications may aggravate Alzheimer's symptoms, such as confusion. People with Alzheimer's may also be more likely to experience side effects when taking Benadryl.
What stage of dementia is Sundowning? ›This may continue into the night, making it hard for them to get enough sleep. This is sometimes known as 'sundowning' but is not necessarily linked to the sun setting or limited to the end of the day. Sundowning can happen at any stage of dementia but is more common during the middle stage and later stages.
Is it safe for dementia patients to take trazodone? ›However, there is a lack of controlled trials to suggest it is beneficial for primary insomnia or Alzheimer's disease. Neuroprotective Benefit: No evidence suggests that trazodone can prevent dementia or improve cognition in Alzheimer's patients; however, it may promote sleep in Alzheimer's patients.
Is Seroquel safe for dementia patients? ›Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death [see Warnings and Precautions (5.1)]. Seroquel is not approved for the treatment of patients with dementia-related psychosis [see Warnings and Precautions (5.1)].
Is trazodone good for sundowning? ›
Trazodone for Sundowning
Doctors often prescribe other medications, including antidepressants like trazodone, to help control sundowning. Trazodone may help to control sundowning in several ways, including: Improved sleep. Mild sedation, which can help manage aggression and irritability sometimes linked to sundowning.
A healthy sleep routine can help the person with dementia to feel better, be less confused, be more co-ordinated and have more energy in the daytime.
What are the new sleeping pills? ›Dayvigo and Quviviq are the newest sleep medications on the market and have shown promise in clinical trials. If you are struggling with insomnia, consult your doctor to see if these medications may be right for you.
What are 3 most commonly prescribed drugs for dementia? ›Donepezil (also known as Aricept), rivastigmine (Exelon) and galantamine (Reminyl) are used to treat the symptoms of mild to moderate Alzheimer's disease. Donepezil is also used to treat more severe Alzheimer's disease.
Is there anything you can give a dementia patient to calm them down? ›Anxiolytics, also known as anti-anxiety drugs, can be used to calm dementia patients. They may be used as a sleep aid as well. Similarly, antipsychotic medications are often prescribed to address aggression, hostility, delusions, and hallucinations.
How do you calm a dementia patient at night? ›Take a walk with the person to help reduce their restlessness. Talk to the person's doctor about the best times of day for taking medication. Try to limit daytime naps if the person has trouble sleeping at night. Reduce or avoid alcohol, caffeine and nicotine, which can all affect the ability to sleep.