Feb 19, 2018

Sleep Medications for Alzheimer's and Dementia Patients

I often have family caregivers request medications to help people living with Alzheimer's and related dementia to sleep.


Medications for Alzheimer's Patients who have trouble sleeping at night.

By Rita Jablonski
Alzheimer's Reading Room

Medications have their place in Alzheimer's care, but only AFTER all of the suggestions listed below have been followed.

It may seem exhausting to the caregiver to have to engage in all of these activities; but, the results could lessen exhaustion, frustration, and stress in a manner of days.

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Rule Out Physical Problems First


There are many medical conditions that contribute to problems sleeping.

Some of these medical conditions include:
  • over-active thyroid,
  • congestive heart failure,
  • and restless leg syndrome.
Check with your healthcare provider to see if there are medical problems that require attention.


Review Prescribed Medications


Likewise, a lot of medications can interfere with falling asleep and staying asleep.

These medications include:
  • high blood pressure pills 
  • and, some antihistamines (allergy medications). 
Reviewing your loved ones’ medications with a health professional is a good start. Medications that may interfere with sleep can be given earlier in the day or possibly swapped out with a similar medication that does not cause sleep problems.

Some medications, like anti-depressants, do cause sleepiness.
  • If they are prescribed for once-a-day, the family member usually gives them first thing in the morning. Then, the person with dementia winds up napping for a good part of the day and this messes up the sleep/wake cycle.

If you think this situation is going on with your loved one, check in with your health care provider and see if it would be OK to give these meds at bedtime … when sleepiness is a good thing!


What are the most effective sleep medications for Alzheimer's and dementia patients?


Over-the-counter Medications

Melatonin occurs naturally in our bodies. It is a hormone made by the pineal gland in the brain. As we age, we begin to produce less melatonin.

Melatonin can be given at bedtime to help the person with dementia naturally fall asleep. My pharmacology resources all recommend no more than 5 mg daily.

Even though melatonin is a hormone naturally produced by the body,
  • melatonin supplements have been linked to daytime sleepiness and irritability.
Diphenhydramine hydrochloride or Benadryl is the active ingredient in many over-the-counter sleep products, including pain medications with “PM” added to the name (for example, Tylenol PM).

The problems with this medication is that it is an “anticholinergic,” meaning it interferes with acetylcholine production in the brain.

In Alzheimer’s Disease, the drop in acetylcholine is what causes the memory problems. So why give a medication that interferes with memory in someone who is already losing theirs?


Prescription Medications

Trazodone (brand name, Desyrel) is an anti-depressant that is commonly used “off label” (meaning that the medication is being used to handle a condition for which it has not been officially approved by the FDA) for insomnia in all adults, including people with dementia.

The dosage is usually started at 25 to 50 mg at bedtime, then increased gradually to 100 mg at bedtime).
  • I use this a lot in my own practice, and the neurologists with whom I work prescribe this as well.
Z-drugs, which refer to a class of sleeping agents that all have “z” in their chemical names include:
  • zolpidem (brand name Ambien) 
  • and eszopiclone (band name, Lunesta) are two examples. 
Zolpidem’s side effects for everyone include:
These side effects can create even bigger problems for persons with dementia.
  • Eszopiclone can cause dizziness and loss of coordination, which spells “falls” for older adults with dementia.
  • Benzodiazepines like lorazepam (Ativan), clonazepam (Klonopin), and diazepam (Valium) are BIG NO-NO’s for persons with dementia (and are not great ideas for every one else). 
These drugs cause sedation and sleepiness and are often prescribed for anxiety.


First, dependence risk is high for these drugs. Second, when used over months and even years, these drugs mess up memory and other cognitive abilities.

The thinking is that these drugs, which work by blocking some neurotransmitters, cause problems with brain activity that, over time, become permanent.
  • In fact, there is some emerging evidence linking benzodiazepines and the Z-drugs with increased dementia risk. 

What Medications Can Be Used For Sleep in Persons with Dementia?


Before I recommend medication, I talk to the caregivers about these issues:
  • sufficient sunshine, 
  • daily activities, 
  • limited or no daytime napping
  • and bedtime routines. 
  • I’m a big fan of lavender essential oils used in diffusers and herbal teas (decaffeinated!) with chamomile, valerian, and/or lavender.
If nothing is working, or not working well enough, then I suggest medication.


In my practice, I suggest melatonin first.

I start at 1 mg about an hour before bedtime. It may need a couple of days use before you see anything. If nothing after 3 days, I increase the dosage to 2 mg an hour before bedtime. I tell the family members to increase by 1 mg every 3-4 days.

If melatonin is not effective, I then go to the trazadone.

I start with 25 mg at bedtime with very gradual increases (25 mg every 3-4 days). The recommended limit is 100 mg at bedtime, although some people seem to do OK with slightly higher dosages.

Unless other problems are happening, like hallucinations or delusions, this regimen is usually successful.

Citation

Alzheimer's Reading Room. Rita A. Jablonski, PhD, CRNP, FAAN, FGSA, Professor, School of Nursing, UAB
February, 2018. Sleep Medications for Alzheimer's and Dementia Patients
https://www.alzheimersreadingroom.com/2018/02/sleep-medications-for-alzheimers-and-dementia-patients.html



Dr. Rita Jablonski, PhD CRNP is an internationally recognized expert in dementia behaviors. She is tenured professor at the University of Alabama at Birmingham and a funded researcher, with over 50 publications and book chapters to her credit. She is a nurse practitioner in a Memory Disorders Clinic, where she helps people with dementia and their care partners. She shares her wisdom on her blog, Make Dementia Your B*tch.

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