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Understanding Dementia

Sleep Disturbances

This is an excerpt from the book Understanding Dementia, which is meant to be a practical manual for primary care physicians and other health care professionals. Sleep disturbance in relation to severe dementia and the need for nursing home placement are discussed in the form of a case presentation, with a commentary to illustrate points of its diagnosis and management. This is an older case, so that drugs now not much used were employed, but the principles remain the same.


Chapter 2: case 1
Mr S, a 71-year-old man, presented with a reversal of his sleep-wake cycle. He was up all hours of the night, dressing himself and wandering about the house. At times he has believed it was time to go to work and tried to leave his home. When his wife explained to him that he was no longer working he became agitated. More than once his son had to be called to his home in the early morning hours to help calm Mr S. Over the two years prior to this presentation he had given up doing the taxes and the bills. After a motor vehicle accident his driver's license had been revoked.

He had difficulty dressing, often missing buttons and putting inappropriate combinations together. If not prompted by his wife he would not change his clothes or wash. At mealtimes he could no longer coordinate a knife and fork, and was unable to prepare even simple items like toast or tea. Although he watched television and read the newspaper, he did not retain any information and was unable to follow the thread of a plot.

His medical history was unremarkable. Aspirin was taken occasionally for pain associated with osteoarthritis .
Physical examination was unremarkable. Several primitive reflexes (glabellar tap, snout reflex) were positive. The rest of the neurological examination was normal. On cognitive exam he scored 5/30 on the Mini- Mental State Exam.

Commentary
The very low score on the Mini- Mental Sate Exam and significant loss of function are consistent with a severe dementia. The history of a two year decline is unusual with such severity, but perhaps his family minimized the cognitive impairment and dated his disease to the onset of functional impairment, which usually lags behind the onset of cognitive impairment by several years. Another explanation is that he has a dementia other than Alzheimer's disease ; the lack of suspicious findings on history or physical examination argues against this possibility. The important considerations in management are to ensure the safety of Mr S and his family's ability to cope.

Mrs S has obtained an enduring power of attorney . Information was provided to her on nursing home opportunities, and a contact was arranged with the local Alzheimer's Society . Because of his altered sleep-wake cycle and occasional agitation a medication , thioridazine, was ordered.

Commentary
Determining that Mrs S already has enduring power of attorney is crucial at this point, as otherwise Mr S's financial resources may become unavailable to him and his family. At this advanced stage of dementia it is unlikely that he could assign power of attorney, so a guardian would need to be appointed, which is a much more complicated process. His nursing needs will soon be beyond his wife's capabilities, and beginning the process of nursing home placement prior to a crisis situation makes the transition smoother and simpler. The alteration in his sleep-wake cycle disrupts his entire family and adds greatly to the strain of caring for him. A small dose of a sedating psychotropic agent, such as trazodone at bedtime, can help decrease this strain. He will need to be watched closely for side effects, especially over-sedation, orthostatic hypotension, akathisia (drug-induced motor restlessness), and Parkinsonism . This behavioural problem is consistent with the stage of his disease (stage congruent) and so unlikely to be due to a new acute illness.

Several months later Mr S moved into a nursing home. The move was associated with increased agitation, which was treated with escalating doses of loxapine. Mr S became virtually immobile. A much smaller dose of loxapine was found to control the agitation without severe Parkinsonism.

Commentary
The transition to a nursing home is often disruptive. Neuroleptics are frequently used to control these symptoms, but their use needs to be carefully monitored. Akathisia, or restlessness, is not an uncommon side effect, and can be misinterpreted as inadequate dosage of the neuroleptic. It is always important to consider that a neuroleptic may be making the agitation worse, and then switch to a different class of medication or reduce the dose of neuroleptic. The current role of neuroleptics in the treatment of behavioural disturbances associated with dementia is discussed in Chapter 10. After a year in the nursing home he had lost the ability to both walk and speak and did not recognize his family. He was incontinent of both urine and feces

Waste matter that is released by the bowels.

. After death his brain was donated to a Brain Bank. Alzheimer's disease was confirmed pathologically.


 

Taken from Understanding Dementia: A Primer of Diagnosis and Management
Kenneth Rockwood & Chris MacKnight, 2001
Chapter 2, pp 24-26

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