Non-pharmacological Treatment

Non-pharmacological treatment should always come first. Recent reviews have summarized steps of non-pharmacological treatment; the reader can follow some general guidelines published by the International Psychogeriatric Association (IPA) [15]. Kales et al. describe a very useful general approach [16]. Some more specific sleep disorder approaches and recommendations are of interest, for instance, from the American Academy of Sleep Medicine [10, 17] and, recently, from the Italian Dementia Research Association sleep study group [18].

Knowledge of previous personal sleep habits is crucial. Although the first recommended step in all programs and reviews is sleep hygiene [19], the clinician must understand that lifelong habits are hard or even impossible to change in people in their eighties or even in their sixties and seventies.

So, the clinician must be able to integrate and modulate recommendations to the personal sleep profile of the person sitting in front of them. Recommendations must then be made, but implementation and real utility depend on personal preferences and physical limitations. Some practical tips are given below.

Tips for Non-pharmacological Management:

  • • Adjust sleep routine to the patient’s previous sleep habits.
  • • Increase daytime light exposure.
  • • Increase physical activity, until 4-5 h before bedtime.
  • • Reduce daytime sleep.
  • • Implement a sleep routine.
  • • Restrict time in bed.
  • • Awakening in the next morning should be fixed, without changes in accordance with the quality of the previous night’s sleep.

Physical activity and light exposure over the day are frequently recommended [20]. In a recent randomized controlled trial conducted within a population of persons suffering from Alzheimer’s disease, higher levels of daytime physical activity and light exposure, either separated or in combination, were associated with an improvement in sleep [21]. However others could not confirm these results and a recent Cochrane review was unable to find statistical significance [22].

Timing of naps has been associated with poorer nocturnal sleep quality, so daytime naps should be reduced [23].

Sleep routine should be ideally started 1 hour before bedtime and be conducted similarly every day, with the minimum of changes (with the exception of acts or maneuvers that clearly are not tolerated by the patient) in consecutive nights. Physical activity and light exposure should be reduced, and repeated gestures should be given, to work as a cue that bedtime is approaching.

A light dinner is desired at night, but avoiding being hungry when going to bed is also of maximal importance. Frequently, the last evening meal comes with some tea or milk, namely, in nursing homes. Reducing liquid intake at the last meal (and also 3 or 4 h before bedtime) will reduce voiding during the night. This measure can only be effective if water and liquid consumption is adequately increased over the day.

Preferably, the patient should go to bed when feeling sleepy. If the patient is not sleepy at all, activities designed for relaxation should be included, according to patient preferences and caregiver resources. Naps near bedtime prior to going to bed must be carefully avoided. Persons without dementia benefit from getting up again after around 30 min in bed if they do not fall asleep and should wait until they feel sleepy. These measures are not always applicable in demented subjects, as it can be hard to restart the process, but relaxation techniques might be of help.

Awakenings should be fixed, irrespective of the sleep quality of the previous night. No “compensation” should be allowed, in order to foster the routine of the circadian rhythm, so the patient must get up at a previously defined fixed hour.

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