Disrupted Sleep, Neuroendocrine Status and the Behavioral Symptoms of AD
| Status: | Completed |
|---|---|
| Conditions: | Alzheimer Disease |
| Therapuetic Areas: | Neurology |
| Healthy: | No |
| Age Range: | 60 - 100 |
| Updated: | 12/14/2017 |
| Start Date: | September 2013 |
| End Date: | June 2015 |
Disrupted Sleep, Neuroendocrine Status and the Behavioral Symptoms of Alzheimer's Disease (AD)
Over 5 million Americans have Alzheimer's disease or a related dementia, a progressive and
irreversible neurodegenerative condition, affecting also close to 15 million family
caregivers (CG). Sleep efficiency in AD patients is severely impaired and complicated by
frequent night awakenings and nocturnal restlessness. Untreated sleep disruption in AD
patients is associated with increased rates of neuropsychiatric symptoms, daytime napping,
'sundowning' behaviors, cognitive and functional decline, and morbidity and mortality. The
added strain of sleep disruption is the primary reason family caregivers make the decision to
institutionalize AD patients. The circadian abnormalities in the sleep-wake cycle commonly
observed in AD patients occur more often in individuals with hypothalamic/ pituitary/adrenal
(HPA) axis hyperactivity. HPA axis hyperactivity may influence diurnal sleep-wake activity by
diminishing an AD patient's ability to respond to external zeitgebers which, in turn, can
further propagate HPA axis dysfunction. Thus, interventions to normalize diurnal HPA axis
patterns may be beneficial in treating sleep-wake disturbances. Nonpharmacologic treatments
are the first line therapy in AD patients with sleep wake problems, given the ineffective and
potentially harmful effects of pharmacologic agents. Current clinical sleep hygiene practices
in institutional (e.g., nursing home) settings holds promise for reducing disruptive sleep by
reestablishing circadian patterns in HPA functioning. These interventions include use of
timed and planned activities during daylight hours and creating a relaxing environment in the
evening. However little systematic work has been done to determine the efficacy of these
interventions in the home setting (where most individuals with AD reside).
We propose a pilot study to (a) characterize objective sleep parameters and behavioral
symptoms of sleep-wake disturbance, and biological indicators of diurnal HPA axis activity in
a sample of community residing older adults with AD: (b) examine the effects of timed and
planned activities on subjective and objective characteristics of sleep, behavioral symptoms,
and HPA status; and (c) evaluate measurement approaches in home-dwelling AD patients.
Subjective (CG questionnaires) and objective (wrist actigraphy) characteristics of sleep and
behavioral symptoms will be measured in fifty-four AD patients being cared for at home by a
family. Patients and CG with then be randomized to receive an intervention of timed, planned
activities (TPA) or attention control (AC) condition. We will also obtain diurnal measures of
HPA activity including salivary cortisol and alpha amylase.
irreversible neurodegenerative condition, affecting also close to 15 million family
caregivers (CG). Sleep efficiency in AD patients is severely impaired and complicated by
frequent night awakenings and nocturnal restlessness. Untreated sleep disruption in AD
patients is associated with increased rates of neuropsychiatric symptoms, daytime napping,
'sundowning' behaviors, cognitive and functional decline, and morbidity and mortality. The
added strain of sleep disruption is the primary reason family caregivers make the decision to
institutionalize AD patients. The circadian abnormalities in the sleep-wake cycle commonly
observed in AD patients occur more often in individuals with hypothalamic/ pituitary/adrenal
(HPA) axis hyperactivity. HPA axis hyperactivity may influence diurnal sleep-wake activity by
diminishing an AD patient's ability to respond to external zeitgebers which, in turn, can
further propagate HPA axis dysfunction. Thus, interventions to normalize diurnal HPA axis
patterns may be beneficial in treating sleep-wake disturbances. Nonpharmacologic treatments
are the first line therapy in AD patients with sleep wake problems, given the ineffective and
potentially harmful effects of pharmacologic agents. Current clinical sleep hygiene practices
in institutional (e.g., nursing home) settings holds promise for reducing disruptive sleep by
reestablishing circadian patterns in HPA functioning. These interventions include use of
timed and planned activities during daylight hours and creating a relaxing environment in the
evening. However little systematic work has been done to determine the efficacy of these
interventions in the home setting (where most individuals with AD reside).
We propose a pilot study to (a) characterize objective sleep parameters and behavioral
symptoms of sleep-wake disturbance, and biological indicators of diurnal HPA axis activity in
a sample of community residing older adults with AD: (b) examine the effects of timed and
planned activities on subjective and objective characteristics of sleep, behavioral symptoms,
and HPA status; and (c) evaluate measurement approaches in home-dwelling AD patients.
Subjective (CG questionnaires) and objective (wrist actigraphy) characteristics of sleep and
behavioral symptoms will be measured in fifty-four AD patients being cared for at home by a
family. Patients and CG with then be randomized to receive an intervention of timed, planned
activities (TPA) or attention control (AC) condition. We will also obtain diurnal measures of
HPA activity including salivary cortisol and alpha amylase.
Inclusion Criteria:
- The inclusion/exclusion criteria are designed to obtain a sample of moderate stage AD
patients because the sleep disruption we seek to assess occur most frequently at this
stage. AD patients must: 1) have a diagnosis of probable AD (physician generated); 2)
be over age 60; 3) be able to provide saliva samples; 4) be able to tolerate wrist
actigraphy per caregiver report. Family caregivers must: 1) be English speaking; 2)
have provided care for a minimum of 3 months; and 3) be the primary caregiver
(self-identifies as providing the most day-to-day care).
Exclusion Criteria:
- To minimize the contribution of extraneous variables, subjects will be excluded for
the following: regular use of medications with substantial known effects on the
measurement of alpha amylase and cortisol (e.g. corticosteroids, interferons,
beta-blockers, cytotoxic chemotherapy); major surgery in the past 3 months; history of
major psychiatric and/or personality disorder; history of heavy cigarette smoking
(e.g. >than 50 pack years); loss of a loved one in the past 3 months. Conditions known
to affect measurement of sleep will also be excluded: use of sedatives/ hypnotics,
Huntington's' disease, normal pressure hydrocephalus, Parkinson's disease, advanced
heart failure (New York Heart Stage 3-4), morbid obesity (BMI > 35), and indications
of restless legs syndrome or periodic limb movement disorder. We will exclude subjects
screening positive for sleep apnea (actigraph/pulse oximetry oxygen desaturation index
> 15).
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