Efficacy and safety of non-pharmacological interventions for sleep disturbance in dementia: a systematic review_Chinese Journal of Evidence-Based Medicine

Authors：

SI Yunfang ¹ , WEI Mingqing ¹ , NI Jingnian ¹ , LI Ting ¹ , SHI Jing ¹ , LIANG Xinzheng ^2,3 ,  TIAN Jinzhou ¹

1. Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, P.R.China;
2. School of Biological Science and Medical Engineering, Beihang University, Beijing 100083, P.R.China;
3. Health Service Department of the Guard Bureau of the General Office of the Central Committee of the Communist Party of China, Beijing 100017, P.R.China;

Corresponding author：

TIAN Jinzhou, Email: jztian@hotmail.com

Keywords：

Dementia; Sleep disturbance; Non-pharmacological treatment; Systematic review; Meta-analysis

DOI：

10.7507/1672-2531.202010058

Video：

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Objective To systematically review the efficacy and safety of non-pharmacological interventions for sleep disturbance in dementia, and to provide evidence for clinical practice.Methods Databases including CNKI, WanFang Data, VIP, PubMed, EMbase and The Cochrane Library were searched to collect randomized controlled trials (RCTs) on non-pharmacological interventions for sleep disturbance in dementia from inception to May 2020. Two reviewers independently screened literature, extracted data, and assessed risk of bias of included studies. Meta-analysis was then performed using RevMan 5.3 software.Results A total of 9 RCTs were included, involving 720 patients. Light therapy was the most commonly used treatment, followed by special activity and sleep education program. The results of meta-analysis showed that compared with the control intervention, light therapy could improve sleep efficiency (MD=2.21, 95%CI 1.09 to 3.33, P=0.0001) and the night-time sleep (MD=14.27, 95%CI 5.01 to 23.53, P=0.003) of patients with dementia in the community and nursing institutions, special activity could increase the night-time sleep (MD=29.74, 95%CI 20.44 to 39.04, P<0.00001), and sleep education program could also improve sleep efficiency (MD=6.19, 95%CI 5.22 to 7.16, P<0.00001) and night-time sleep (MD=33.95, 95%CI 25.40 to 42.50, P<0.00001). In addition, it was superior to obtain 120 or 60 minutes of light exposure than 30 minutes to improve the quality of sleep (RR=−2.62, 95%CI −3.56 to −1.68, P<0.001) and reduce daytime sleep (RR=−4.75, 95%CI −5.71 to −3.42, P<0.001). However, there was significant difference in incidence of adverse reactions between groups of 120 minutes and 30 minutes of light exposure (RR=2.57, 95%CI 1.44 to 4.58, P=0.001).Conclusions The current evidence shows that non-pharmacological intervention can improve sleep efficiency and night-time sleep in patients with dementia. Due to limited quantity and quality of the included studies, more high quality studies are required to verify above conclusions.

Citation： SI Yunfang, WEI Mingqing, NI Jingnian, LI Ting, SHI Jing, LIANG Xinzheng, TIAN Jinzhou. Efficacy and safety of non-pharmacological interventions for sleep disturbance in dementia: a systematic review. Chinese Journal of Evidence-Based Medicine, 2021, 21(4): 415-422. doi: 10.7507/1672-2531.202010058 Copy

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2.	Xu J, Murphy SL, Kockanek KD, et al. Mortality in the United States, 2018. NCHS Data Brief, 2020, (355): 1-8.
3.	Huang Y, Wang Y, Wang H, et al. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry, 2019, 6(3): 211-224.
4.	Jia J, Wei C, Chen S, et al. The cost of Alzheimer's disease in China and re-estimation of costs worldwide. Alzheimers Dement, 2018, 14(4): 483-491.
5.	Webster L, Costafreda Gonzalez S, Stringer A, et al. Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis. Sleep, 2020, 43(4): zsz251.
6.	Bliwise DL. Sleep in normal aging and dementia. Sleep, 1993, 16(1): 40-81.
7.	Mander BA, Marks SM, Vogel JW, et al. β-amyloid disrupts human NREM slow waves and related hippocampus-dependent memory consolidation. Nat Neurosci, 2015, 18(7): 1051-1057.
8.	Ju YS, Ooms SJ, Sutphen C, et al. Slow wave sleep disruption increases cerebrospinal fluid amyloid-β levels. Brain, 2017, 140(8): 2104-2111.
9.	Lysen TS, Luik AI, Ikram MK, et al. Actigraphy-estimated sleep and 24-hour activity rhythms and the risk of dementia. Alzheimers Dement, 2020, 16(9): 1259-1267.
10.	McCleery J, Sharpley AL. Pharmacotherapies for sleep disturbances in dementia. Cochrane Database Syst Rev, 2020, (11): CD009178.
11.	Ferini-Strambi L, Galbiati A, Casoni F, et al. Therapy for insomnia and circadian rhythm disorder in Alzheimer disease. Curr Treat Options Neurol, 2020, 22(2): 4.
12.	Vigen CL, Mack WJ, Keefe RS, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer's disease: outcomes from CATIE-AD. Am J Psychiatry, 2011, 168(8): 831-839.
13.	Saarelainen L, Taipale H, Koponen M, et al. The incidence of benzodiazepine and related drug use in persons with and without Alzheimer's disease. J Alzheimers Dis, 2016, 49(3): 809-818.
14.	Lee J, Jung SJ, Choi JW, et al. Use of sedative-hypnotics and the risk of Alzheimer's dementia: a retrospective cohort study. PLoS One, 2018, 13(9): e0204413.
15.	Figueiro MG, Plitnick B, Roohan C, et al. Effects of a tailored lighting intervention on sleep quality, rest-activity, mood, and behavior in older adults with Alzheimer disease and related dementias: arandomized clinical trial. J Clin Sleep Med, 2019, 15(12): 1757-1767.
16.	Christofoletti G, Oliani MM, Bucken-Gobbi LT, et al. Physical activity attenuates neuropsychiatric disturbances and caregiver burden in patients with dementia. Clinics (Sao Paulo), 2011, 66(4): 613-618.
17.	Shih YH, Pai MC, Huang YC, et al. Sundown syndrome, sleep quality, and walking among community-dwelling people with Alzheimer disease. J Am Med Dir Assoc, 2017, 18(5): 396-401.
18.	McCurry SM, LaFazia DM, Pike KC, et al. Development and evaluation of a sleep education program for older adults with dementia living in adult family homes. Am J Geriatr Psychiatry, 2012, 20(6): 494-504.
19.	McCurry SM, Gibbons LE, Logsdon RG, et al. Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. J Am Geriatr Soc, 2005, 53(5): 793-802.
20.	McCurry SM, Pike KC, Vitiello MV, et al. Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: results of a randomized, controlled trial. J Am Geriatr Soc, 2011, 59(8): 1393-1402.
21.	Dowling GA, Hubbard EM, Mastick J, et al. Effect of morning bright light treatment for rest-activity disruption in institutionalized patients with severe Alzheimer's disease. Int Psychogeriatr, 2005, 17(2): 221-236.
22.	Richards KC, Beck C, O'Sullivan PS, et al. Effect of individualized social activity on sleep in nursing home residents with dementia. J Am Geriatr Soc, 2005, 53(9): 1510-1517.
23.	Eggermont LH, Blankevoort CG, Scherder EJ. Walking and night-time restlessness in mild-to-moderate dementia: a randomized controlled trial. Age Ageing, 2010, 39(6): 746-749.
24.	Moyle W, Jones C, Murfield J, et al. Effect of a robotic seal on the motor activity and sleep patterns of older people with dementia, as measured by wearable technology: a cluster-randomised controlled trial. Maturitas, 2018, 110: 10-17.
25.	黄海华, 李明秋, 江皋轩, 等. 不同光照时间全光谱治疗对阿尔茨海默病患者睡眠障碍临床疗效的影响. 中华行为医学与脑科学杂志, 2015, 24(7): 629-632.
26.	兰莉. 光照时间对全光谱治疗阿尔茨海默病伴睡眠障碍患者临床效果的影响. 医疗装备, 2019, 32(8): 94-95.
27.	van Maanen A, Meijer AM, van der Heijden KB, et al. The effects of light therapy on sleep problems: a systematic review and meta-analysis. Sleep Med Rev, 2016, 29: 52-62.
28.	Forbes D, Blake CM, Thiessen EJ, et al. Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia. Cochrane Database Syst Rev, 2014, (2): CD003946.
29.	Ancoli-Israel S, Martin JL, Kripke DF, et al. Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. J Am Geriatr Soc, 2002, 50(2): 282-289.
30.	Landi F, Russo A, Bernabei R. Physical activity and behavior in the elderly: a pilot study. Arch Gerontol Geriatr Suppl, 2004, (9): 235-241.
31.	Brown RE, Basheer R, McKenna JT, et al. Control of sleep and wakefulness. Physiol Rev, 2012, 92(3): 1087-1187.
32.	Calkins AW, Hearon BA, Capozzoli MC, et al. Psychosocial predictors of sleep dysfunction: the role of anxiety sensitivity, dysfunctional beliefs, and neuroticism. Behav Sleep Med, 2013, 11(2): 133-143.
33.	Lucey BP, McCullough A, Landsness EC, et al. Reduced non-rapid eye movement sleep is associated with tau pathology in early Alzheimer's disease. Sci Transl Med, 2019, 11(474): eaau6550.
34.	Toh KL. Basic science review on circadian rhythm biology and circadian sleep disorders. Ann Acad Med Singap, 2008, 37(8): 662-668.
35.	Hoban TM, Lewy AJ, Sack RL, et al. The effects of shifting sleep two hours within a fixed photoperiod. J Neural Transm Gen Sect, 1991, 85(1): 61-68.
36.	Zhou L, Gao Q, Nie M, et al. Degeneration and energy shortage in the suprachiasmatic nucleus underlies the circadian rhythm disturbance in ApoE-/- mice: implications for Alzheimer's disease. Sci Rep, 2016, 6: 36335.
37.	Campbell SS, Kripke DF, Gillin JC, et al. Exposure to light in healthy elderly subjects and Alzheimer's patients. Physiol Behav, 1988, 42(2): 141-144.
38.	Shochat T, Martin J, Marler M, et al. Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res, 2000, 9(4): 373-379.
39.	Skriver K, Roig M, Lundbye-Jensen J, et al. Acute exercise improves motor memory: exploring potential biomarkers. Neurobiol Learn Mem, 2014, 116: 46-58.
40.	Dinas PC, Koutedakis Y, Flouris AD. Effects of exercise and physical activity on depression. Ir J Med Sci, 2011, 180(2): 319-325.
41.	Voss MW, Vivar C, Kramer AF, et al. Bridging animal and human models of exercise-induced brain plasticity. Trends Cogn Sci, 2013, 17(10): 525-544.
42.	Chennaoui M, Gomez-Merino D, Drogou C, et al. Effects of exercise on brain and peripheral inflammatory biomarkers induced by total sleep deprivation in rats. J Inflamm (Lond), 2015, 12: 56.
43.	Stranahan AM, Martin B, Maudsley S. Anti-inflammatory effects of physical activity in relationship to improved cognitive status in humans and mouse models of Alzheimer's disease. Curr Alzheimer Res, 2012, 9(1): 86-92.
44.	Bartfay E, Stewart P, Bartfay W, et al. Is there an association between physical activity and sleep in community-dwelling persons with dementia: an exploratory study using self-reported measures? Healthcare (Basel), 2019, 7(1): 6.
45.	Kredlow MA, Capozzoli MC, Hearon BA, et al. The effects of physical activity on sleep: a meta-analytic review. J Behav Med, 2015, 38(3): 427-449.
46.	Uchida S, Shioda K, Morita Y, et al. Exercise effects on sleep physiology. Front Neurol, 2012, 3: 48.
47.	Szuhany KL, Bugatti M, Otto MW. A meta-analytic review of the effects of exercise on brain-derived neurotrophic factor. J Psychiatr Res, 2015, 60: 56-64.
48.	McGinty D, Szymusiak R. Keeping cool: a hypothesis about the mechanisms and functions of slow-wave sleep. Trends Neurosci, 1990, 13(12): 480-487.
49.	Sellami M, Bragazzi NL, Slimani M, et al. The effect of exercise on glucoregulatory hormones: acountermeasure to human aging: insights from a comprehensive review of the literature. Int J Environ Res Public Health, 2019, 16(10): 1709.

1. Garre-Olmo J. Epidemiology of Alzheimer's disease and other dementias. Rev Neurol, 2018, 66(11): 377-386.
2. Xu J, Murphy SL, Kockanek KD, et al. Mortality in the United States, 2018. NCHS Data Brief, 2020, (355): 1-8.
3. Huang Y, Wang Y, Wang H, et al. Prevalence of mental disorders in China: a cross-sectional epidemiological study. Lancet Psychiatry, 2019, 6(3): 211-224.
4. Jia J, Wei C, Chen S, et al. The cost of Alzheimer's disease in China and re-estimation of costs worldwide. Alzheimers Dement, 2018, 14(4): 483-491.
5. Webster L, Costafreda Gonzalez S, Stringer A, et al. Measuring the prevalence of sleep disturbances in people with dementia living in care homes: a systematic review and meta-analysis. Sleep, 2020, 43(4): zsz251.
6. Bliwise DL. Sleep in normal aging and dementia. Sleep, 1993, 16(1): 40-81.
7. Mander BA, Marks SM, Vogel JW, et al. β-amyloid disrupts human NREM slow waves and related hippocampus-dependent memory consolidation. Nat Neurosci, 2015, 18(7): 1051-1057.
8. Ju YS, Ooms SJ, Sutphen C, et al. Slow wave sleep disruption increases cerebrospinal fluid amyloid-β levels. Brain, 2017, 140(8): 2104-2111.
9. Lysen TS, Luik AI, Ikram MK, et al. Actigraphy-estimated sleep and 24-hour activity rhythms and the risk of dementia. Alzheimers Dement, 2020, 16(9): 1259-1267.
10. McCleery J, Sharpley AL. Pharmacotherapies for sleep disturbances in dementia. Cochrane Database Syst Rev, 2020, (11): CD009178.
11. Ferini-Strambi L, Galbiati A, Casoni F, et al. Therapy for insomnia and circadian rhythm disorder in Alzheimer disease. Curr Treat Options Neurol, 2020, 22(2): 4.
12. Vigen CL, Mack WJ, Keefe RS, et al. Cognitive effects of atypical antipsychotic medications in patients with Alzheimer's disease: outcomes from CATIE-AD. Am J Psychiatry, 2011, 168(8): 831-839.
13. Saarelainen L, Taipale H, Koponen M, et al. The incidence of benzodiazepine and related drug use in persons with and without Alzheimer's disease. J Alzheimers Dis, 2016, 49(3): 809-818.
14. Lee J, Jung SJ, Choi JW, et al. Use of sedative-hypnotics and the risk of Alzheimer's dementia: a retrospective cohort study. PLoS One, 2018, 13(9): e0204413.
15. Figueiro MG, Plitnick B, Roohan C, et al. Effects of a tailored lighting intervention on sleep quality, rest-activity, mood, and behavior in older adults with Alzheimer disease and related dementias: arandomized clinical trial. J Clin Sleep Med, 2019, 15(12): 1757-1767.
16. Christofoletti G, Oliani MM, Bucken-Gobbi LT, et al. Physical activity attenuates neuropsychiatric disturbances and caregiver burden in patients with dementia. Clinics (Sao Paulo), 2011, 66(4): 613-618.
17. Shih YH, Pai MC, Huang YC, et al. Sundown syndrome, sleep quality, and walking among community-dwelling people with Alzheimer disease. J Am Med Dir Assoc, 2017, 18(5): 396-401.
18. McCurry SM, LaFazia DM, Pike KC, et al. Development and evaluation of a sleep education program for older adults with dementia living in adult family homes. Am J Geriatr Psychiatry, 2012, 20(6): 494-504.
19. McCurry SM, Gibbons LE, Logsdon RG, et al. Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. J Am Geriatr Soc, 2005, 53(5): 793-802.
20. McCurry SM, Pike KC, Vitiello MV, et al. Increasing walking and bright light exposure to improve sleep in community-dwelling persons with Alzheimer's disease: results of a randomized, controlled trial. J Am Geriatr Soc, 2011, 59(8): 1393-1402.
21. Dowling GA, Hubbard EM, Mastick J, et al. Effect of morning bright light treatment for rest-activity disruption in institutionalized patients with severe Alzheimer's disease. Int Psychogeriatr, 2005, 17(2): 221-236.
22. Richards KC, Beck C, O'Sullivan PS, et al. Effect of individualized social activity on sleep in nursing home residents with dementia. J Am Geriatr Soc, 2005, 53(9): 1510-1517.
23. Eggermont LH, Blankevoort CG, Scherder EJ. Walking and night-time restlessness in mild-to-moderate dementia: a randomized controlled trial. Age Ageing, 2010, 39(6): 746-749.
24. Moyle W, Jones C, Murfield J, et al. Effect of a robotic seal on the motor activity and sleep patterns of older people with dementia, as measured by wearable technology: a cluster-randomised controlled trial. Maturitas, 2018, 110: 10-17.
25. 黄海华, 李明秋, 江皋轩, 等. 不同光照时间全光谱治疗对阿尔茨海默病患者睡眠障碍临床疗效的影响. 中华行为医学与脑科学杂志, 2015, 24(7): 629-632.
26. 兰莉. 光照时间对全光谱治疗阿尔茨海默病伴睡眠障碍患者临床效果的影响. 医疗装备, 2019, 32(8): 94-95.
27. van Maanen A, Meijer AM, van der Heijden KB, et al. The effects of light therapy on sleep problems: a systematic review and meta-analysis. Sleep Med Rev, 2016, 29: 52-62.
28. Forbes D, Blake CM, Thiessen EJ, et al. Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia. Cochrane Database Syst Rev, 2014, (2): CD003946.
29. Ancoli-Israel S, Martin JL, Kripke DF, et al. Effect of light treatment on sleep and circadian rhythms in demented nursing home patients. J Am Geriatr Soc, 2002, 50(2): 282-289.
30. Landi F, Russo A, Bernabei R. Physical activity and behavior in the elderly: a pilot study. Arch Gerontol Geriatr Suppl, 2004, (9): 235-241.
31. Brown RE, Basheer R, McKenna JT, et al. Control of sleep and wakefulness. Physiol Rev, 2012, 92(3): 1087-1187.
32. Calkins AW, Hearon BA, Capozzoli MC, et al. Psychosocial predictors of sleep dysfunction: the role of anxiety sensitivity, dysfunctional beliefs, and neuroticism. Behav Sleep Med, 2013, 11(2): 133-143.
33. Lucey BP, McCullough A, Landsness EC, et al. Reduced non-rapid eye movement sleep is associated with tau pathology in early Alzheimer's disease. Sci Transl Med, 2019, 11(474): eaau6550.
34. Toh KL. Basic science review on circadian rhythm biology and circadian sleep disorders. Ann Acad Med Singap, 2008, 37(8): 662-668.
35. Hoban TM, Lewy AJ, Sack RL, et al. The effects of shifting sleep two hours within a fixed photoperiod. J Neural Transm Gen Sect, 1991, 85(1): 61-68.
36. Zhou L, Gao Q, Nie M, et al. Degeneration and energy shortage in the suprachiasmatic nucleus underlies the circadian rhythm disturbance in ApoE-/- mice: implications for Alzheimer's disease. Sci Rep, 2016, 6: 36335.
37. Campbell SS, Kripke DF, Gillin JC, et al. Exposure to light in healthy elderly subjects and Alzheimer's patients. Physiol Behav, 1988, 42(2): 141-144.
38. Shochat T, Martin J, Marler M, et al. Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res, 2000, 9(4): 373-379.
39. Skriver K, Roig M, Lundbye-Jensen J, et al. Acute exercise improves motor memory: exploring potential biomarkers. Neurobiol Learn Mem, 2014, 116: 46-58.
40. Dinas PC, Koutedakis Y, Flouris AD. Effects of exercise and physical activity on depression. Ir J Med Sci, 2011, 180(2): 319-325.
41. Voss MW, Vivar C, Kramer AF, et al. Bridging animal and human models of exercise-induced brain plasticity. Trends Cogn Sci, 2013, 17(10): 525-544.
42. Chennaoui M, Gomez-Merino D, Drogou C, et al. Effects of exercise on brain and peripheral inflammatory biomarkers induced by total sleep deprivation in rats. J Inflamm (Lond), 2015, 12: 56.
43. Stranahan AM, Martin B, Maudsley S. Anti-inflammatory effects of physical activity in relationship to improved cognitive status in humans and mouse models of Alzheimer's disease. Curr Alzheimer Res, 2012, 9(1): 86-92.
44. Bartfay E, Stewart P, Bartfay W, et al. Is there an association between physical activity and sleep in community-dwelling persons with dementia: an exploratory study using self-reported measures? Healthcare (Basel), 2019, 7(1): 6.
45. Kredlow MA, Capozzoli MC, Hearon BA, et al. The effects of physical activity on sleep: a meta-analytic review. J Behav Med, 2015, 38(3): 427-449.
46. Uchida S, Shioda K, Morita Y, et al. Exercise effects on sleep physiology. Front Neurol, 2012, 3: 48.
47. Szuhany KL, Bugatti M, Otto MW. A meta-analytic review of the effects of exercise on brain-derived neurotrophic factor. J Psychiatr Res, 2015, 60: 56-64.
48. McGinty D, Szymusiak R. Keeping cool: a hypothesis about the mechanisms and functions of slow-wave sleep. Trends Neurosci, 1990, 13(12): 480-487.
49. Sellami M, Bragazzi NL, Slimani M, et al. The effect of exercise on glucoregulatory hormones: acountermeasure to human aging: insights from a comprehensive review of the literature. Int J Environ Res Public Health, 2019, 16(10): 1709.

Chinese Journal of Evidence-Based Medicine

Efficacy and safety of non-pharmacological interventions for sleep disturbance in dementia: a systematic review

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