Photo Credit: Katarzyna Bialasiewicz

Research finds a significant association between diagnosed insomnia and increased prevalence of behavioral symptoms in patients with Alzheimer’s Disease.

According to recent findings of a retrospective cohort analysis, which were published online in The Journal of Post-Acute and Long-Term Care Medicine, researchers found a significant association between diagnosed insomnia and increased prevalence of behavioral symptoms in patients with Alzheimer’s Disease (AD).

The team of researchers, led by Farid Chekani, PhD, identified 7,808 patients aged at least 50 years with newly diagnosed AD, categorized into insomnia and noninsomnia groups based on billing codes. The study team examined behavioral symptoms, including agitation/aggression, psychotic symptoms, anxiety/mood disorders, and delirium during baseline and a 12-month follow-up. The prevalence of these symptoms was notably higher among patients with insomnia both at baseline and follow-up compared with those without insomnia. The likelihood of being diagnosed with behavioral symptoms in the follow-up period was significantly higher in patients with insomnia (adjusted odds ratio, 2.7; 95% confidence interval, 2.4-3.1).

Physician’s Weekly spoke with geriatrician Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, adjunct assistant professor, Thomas Jefferson University, about the importance of this study.

PW: How would you integrate these findings to assess and manage patients newly diagnosed with AD?

Dr. Richard Stefanacci: The article points out something that a lot of geriatricians know about the importance of sleep—patients with more sleep issues are more likely to have cognitive impairment. Especially in the later stages of AD, more behavioral issues are expected, which is obviously going to be more of an issue for caregivers. The other aspect is that patients with AD are more likely to have sleep problems—so it goes both ways. I think the main takeaway is that clinicians should ask—as a part of normal routine screening—about any issues with sleep, and it should not just be a yes or no question.

Clinicians need to ask probing questions about sleep to find out if patients are napping during the day, and for some patients, clinicians should ask their caregivers about the issues they’re having.

PW: How would you approach a patient with AD who presents with behavioral symptoms?

Almost always, this patient population does not present themselves; a caregiver will present them. We as clinicians must be careful that we are not managing the caregiver and we are managing the patient.

Historically, there have been concerns with using antipsychotics and other treatments as chemical restraints for somebody who is having sleeping issues and agitation. Overall, it was not to treat the patient but to treat the caregivers and family members so they did not have to be up all night managing it.

Clinicians need to get the true information and ensure that it is valid and appropriate to treat the underlying causes and ensure that they are not treating issues that the family is having.

PW: How can collaboration with specialist caregivers provide a more comprehensive and coordinated treatment plan?

Now, with telemedicine, if the primary care provider can identify issues, we can easily pull in the right specialist. So, whether that’s a sleep specialist or a pulmonologist to do a sleep study, maybe the underlying problem is sleep apnea. If you can correct the sleep apnea and the insomnia, cognitive issues are improved.

It is important for primary care physicians to be able to identify the issue, refer the patient appropriately, and get that information from a specialist. The other aspect of it is that geriatrics is a team sport. Whether the patient is in the nursing home or the community, it is important to bring in caregivers to do what needs to get done.

One of the big issues with insomnia is that patients are not engaged during the day. They are napping all day, so they do not sleep at night. Once we get them more engaged during the day, that helps us determine treatment for their insomnia.

Even if we as primary care providers do not have the tools and cannot do a sleep apnea study, knowing who the appropriate parties are that we can refer to is most beneficial.

PW: Do you have anything else you would like to add?

I think the real-world implications of the study are to raise the awareness and importance of insomnia in both directions of care. Insomnia contributes to agitation challenges among patients who are cognitively impaired, and agitated patients are more likely to have sleeping issues.

Making sure that we refer to social determinants of health and understanding that there are other things outside of what we are normally engaged with—whether it is diet or the environment that somebody is living in—can contribute to insomnia.

The value of home visits is the last thing I would stress—because I still do it, and I know it is coming back a little, and it plays an important role here. When you have somebody in your office complaining about insomnia, you do not get a complete picture. You do a home visit, and you see the environment that they are in. If they are living in a noisy home and situation, insomnia is challenging. Correcting or making their home a better environment can improve that situation.