Introduction

A group of varied disorders known as frontotemporal and selective frontal lobe atrophy, early onset personality problems, and language and cognitive decline are the hallmarks of frontotemporal dementia (FTD).¹

Therapeutic approaches to sleep disorders in dementia

Sleep and circadian disruptions are common in all types of dementia. Because dementia-related sleep problems are complex, experts have recommended a rigorous approach to patient assessment and management. The most important thing to do is to address primary sleep problems such as obstructive sleep apnea. Drugs that interfere with sleep and your other existing conditions should be well managed to prevent negative effects on sleep.²

Patients and caregivers should follow good sleep hygiene practices and encourage daily social and physical activities. Since melatonin and bright light treatment are generally regarded as safe medicines, they ought to be tried first. When adding pharmacological therapy, care should be taken because there is a chance of falls, drowsiness, and cognitive adverse effects in older people and people with dementia. Regardless of the treatment strategy used, it is critical to continuously monitor patients with dementia and sleep issues by regularly checking each patient's response to the regimen.²

Dementia and excessive sleepiness problem

Oversleeping throughout the day can impair cognitive function, cause unintentional naps that jeopardise safety when driving, and diminish social and therapeutic engagement abilities. Effective therapies for sleep disturbances and circadian rhythm issues in dementia patients are much sought after, since they may reduce the strain on carers, improve patient quality of life, postpone institutionalisation, and maybe halt cognitive deterioration.²

Acquiring patient history from caregivers 

The initial stage in assessing sleep and circadian abnormalities in people with dementia is a comprehensive medical history. Caregivers' account of patient’s history is important since individuals with dementia may not recall their symptoms well. The clinical history should be reviewed to assess primary sleep disorder symptoms such as snoring, hypersomnia, observed apneas, parasomnias, restless legs syndrome (RLS), and leg movements during sleep.

It is important to find out when and how often people nap during the day, whether on purpose or by mistake, and how much sleep they get at night. In addition to the typical clinical questions for a sleep examination, you should ask about sundowning, hallucinations, falling asleep suddenly and without warning, dangerous parasomnias, and nighttime wandering in dementia patients.

After the dementia's underlying cause has been identified, the patient's medical history should be checked for common dementia symptoms, such as abnormal sleep-wake cycles. For instance, it is critical to determine the precise timing of the relationship between the dosage of dopaminergic drugs and RLS symptoms in individuals with Parkinson's disease. The whole cost of sleep disruptions for the patient and the caregiver should always be considered.²

Contributory problems to sleep disorders

It is essential to consider the evaluating factors that may contribute to sleep disturbances in people with dementia. These include:²

• Pain and discomfort-causing comorbidities (conditions that coexist with other conditions)
• Comorbidities that cause anxiety and depression
• Comorbidities that cause awakenings (e.g., prostatic enlargement causing frequent nocturia (frequent urination during the night)).
• Pharmaceuticals, such as over-the-counter medications and nutritional supplements
• The history and current usage of drugs, alcohol, cigarettes, and caffeine
• Rooms for sleeping and living
• Degree, regularity, and consistency of physical activity
• Participation in social and professional activities
• Regularity and schedule of meals
• Exposure to light and noise during the day and night

Medication approach to sleep problems in dementia

Like the general population, those with dementia who have trouble sleeping are given careful treatment to reduce the risk of damage, minimise the burden on caregivers, and avoid accelerating cognitive decline:²

• Firstly, it is important to identify and treat any primary sleep issues that are underlying
• Secondly, any anxiety and mood problems that co-occur must be treated
• Besides, pain, nocturia, and other concurrent conditions that interfere with sleep should be addressed to the greatest extent feasible to optimise sleep-wake functioning. Medication for the underlying dementing condition, in particular, that interferes with sleep should also be adjusted
• Similarly, the medication used to treat dopaminergic parkinsonism should be adjusted to reduce the sedative effects during the day
• Moreover, managing a patient's co-morbid illnesses and medications requires close coordination between the patient, caregiver, and other medical professionals. This process normally takes the longest when caring for people with dementia who have trouble sleeping
• Lastly, non-medicinal measures are recommended if sleep-wake issues continue because of the possibility of drowsiness, cognitive symptoms, falls, injuries, and drug interactions with pharmaceutical therapies²

Initiatives to therapy and effects of obstructive sleep apnea

When treating sleep disturbance in people with dementia, the first goal should always be to address any underlying sleep problems. Individuals with dementia and the elderly are more likely to experience sleep difficulties. In general, Obstructive Sleep Apnea (OSA) is linked to decreased mood, cognitive decline, insomnia, daytime hypersomnia, and fragmented sleep during the night. Therefore, it is expected that Obstructive Sleep Apnea will have similar, if not worse, effects in the population with mental illness.²

Obstructive sleep apnea and positive airway pressure

Positive airway pressure has not been the subject of any randomised trials; yet, Obstructive Sleep Apnea is equally common in vascular dementia. For those who are unable to use positive airway pressure, non-positive airway pressure treatments such as mandibular advancement devices may be a suitable alternative, even if they haven't been tested in randomised trials with dementia patients.²

Management of restless legs syndrome and periodic limb movement disorder in Lewy Body disease: a coordinated approach

Restless legs syndrome (RLS) and periodic limb movement disorder (PLMD) are common in Lewy Body Disease (LBD), especially Parkinson's disease with dementia (PDD). The treatment strategy is the same as that used for idiopathic restless leg syndrome and periodic limb movement disorder. Iron deficiency can increase restless legs syndrome and periodic limb movement disorder, which should be treated with supplements.

Dopamine agonists are commonly used for restless legs syndrome and periodic limb movement disorders and are effective in the elderly. However, treatment regimens should be coordinated by sleep medicine and dementia/movement disorders specialists. Treatment of REM sleep behavior disorder (RBD) symptoms does not appear to slow the progression of the underlying neurodegenerative condition.²

Behavioral variant frontotemporal dementia

Behavioural variant of frontotemporal dementia (BvFTD) is the most common type of frontotemporal dementia (FTLD). It is characterised by modest behavioural and psychological abnormalities, which usually manifest as emotional detachment and improper social conduct.^3,4

Behavioural variant frontotemporal dementia and semantic dementia comparison

Dementia is associated with sleep disruption and poor sleep quality for both patients and family caregivers. Little is known about the impact of frontotemporal dementia (FTD) on sleep. It is crucial to study the sleep habits of frontotemporal dementia patients and their caretakers. Researchers observed that people with BvFTD and Semantic Dementia (SD) spend more time in bed at night than their caregivers. Caregivers of bvFTD patients reported greater nocturnal activity, which was significantly associated with caregiver distress.⁵

Actigraphy data revealed that patients and caregivers experienced normal sleep efficiency and timing throughout the nocturnal sleep period. Caregivers of patients with BvFTD reported worse sleep quality than SD caregivers. More BvFTD caregivers than SD reported negative aspects of their sleep quality and used sleep medications more frequently. Thus, it appears that BvFTD's clinical symptoms have different and more distressing impacts on caregiver sleep quality than SD.⁵

Sleep disturbances in frontotemporal dementia and Alzheimer’s disease

Compared to healthy age-matched adults, patients with Frontotemporal Dementia (FTD) and Alzheimer's Disease (AD) reported significantly higher rates of excessive drowsiness during the day and difficulties falling or staying asleep at night. For almost 75% of FTD patients and more than half of AD patients, this was the situation. individuals with FTD were more likely to experience disrupted sleep episodes than individuals with AD. Patients with AD and FTD usually retired earlier and slept in bed considerably longer each night than older, healthier folks. Generally, the FTD group had extreme drowsiness during the day significantly more often than the AD group.⁶

Summary

A group of varied disorders known as frontotemporal and selective frontal lobe atrophy, early onset personality problems, and language and cognitive decline are the hallmarks of frontotemporal dementia (FTD).

Other disorders that can deteriorate the quality of life of dementia patients, like oversleeping. Along with that, many other evaluating factors contribute to disturbing the sleep pattern, such as pain, anxiety, and depression due to co-existing health issues; physical activity; diet schedule; alcohol or cigarette and/or alcohol consumption.

FTD is treated by finding the underlying condition, and then coexisting issues. Thereafter, non-medicinal approaches are considered to treat patients. It is vital to get the patients’ details from the caregivers, as patients might not recall the incidents exactly as they occurred.

Medicinal treatment is certainly the last option to opt for. When medicinal treatment is considered, patients should be dealt with extra care, as chances fall, drowsiness, and other conditions increase.