Ask the Expert: Managing Agitation and Insomnia
By Jennifer G. Goldman, MD, MS, Associate Professor, Section of Parkinson Disease and Movement Disorders, Department of Neurological Sciences, Rush University Medical Center
Q: What treatments can help with agitation and insomnia at night?
A: Agitation and insomnia may mean different things to different people, so defining the terms is a good place to start. Agitation can mean physical or emotional restlessness. A person may be exhibiting restlessness if they are unable to sit still or “get settled.” Other times, agitation may result in emotional responses such as tearfulness, irritability, or anxiety. Agitation in people with Lewy body dementia (LBD) may be the result of hallucinations or psychosis, depression, anxiety, fatigue or lack of sleep, and confusion.
There are other causes of agitation beyond the symptoms of LBD. If agitation appears rather suddenly and the person is having difficulty expressing himself or herself, it may be a sign of a medical problem such as infection, another illness, pain or medication side effects. Changes in environment or routine, fear or misunderstanding can also contribute to agitation. In some settings, agitation has been used to describe occurrences when the person does not cooperate with care or let people help him or her (e.g., getting upset with bathing or dressing, resisting these activities, etc). Like “sundowning,” agitation may worsen in the evening hours.
Insomnia refers to a sleep disorder with difficulty falling and/or staying asleep. People with insomnia can have trouble falling asleep, may awaken frequently during the night and/or have trouble going back to sleep, or wake up early in the morning. Insomnia can be due a number of different reasons, such as other sleep disorders (e.g., breathing-related problems, nightmares), medications, mood disorders (e.g., depression, anxiety), motor features of parkinsonism (e.g., stiffness, tremors, decreased ability to move in bed), or interferences in a normal, regular sleep schedule (e.g., day-night reversal, excessive daytime sleepiness).
Treating Agitation and Insomnia
Obtaining a thorough medical history from the patient and caregiver and conducting a physical/neurological examination are important to determine the cause and management of agitation and insomnia. Depending on the suspected cause and the patient’s evaluation, further testing may include laboratory studies or if needed, a sleep study.
Agitation may be reduced by behavioral and/or medication approaches. It is often helpful to create a calm and reassuring environment. Keep a regular schedule for activities, meals, and sleep. Avoid noisy and distracting environments and “scary” television programs before bedtime. Ask yes/no questions or give cues for answers, instead of providing multiple options.
Selecting the appropriate medications depends on the cause of the agitation. Antibiotics may be prescribed to treat an underlying infection, while antidepressants or anxiolytics would be used to treat depression or anxiety.
Sometimes medications for LBD or other medical conditions may need to be reduced or stopped under physician’s guidance if they are causing behavioral side effects. Certain antipsychotics with greater dopamine blocking properties (e.g., haloperidol, risperdone, olanzapine, and others) can worsen parkinsonism and should be avoided; patients with LBD may be very sensitive to these effects. If needed, medications can be used to treat hallucinations in LBD and include clozapine, quetiapine, or cholinesterase inhibitors such as donepezil, rivastigmine, or galantamine. Use of these medications should be discussed with one’s physician. Sometimes benzodiazepines, a type of sedative medication, can cause a “paradoxical” or opposite effect in LBD patients, leading to increased anxiety rather than a calming effect.
Treatments for insomnia also depend on the cause. Behavioral strategies include keeping a regular sleep-wake cycle, being active physically during the daytime, avoiding long and frequent naps in the daytime, and having a calming bedtime routine. Medications for insomnia vary greatly and should be tailored to the individual and specific needs for treating motor symptoms, depression, anxiety, pain, etc if also present. Melatonin and clonazepam have been used for sleep disorders in LBD, including insomnia and REM behavior disorder. One should note that medications for sleep that have strong anticholinergic effects (e.g., diphenhydramine) can produce confusion and hallucinations in LBD patients and should be avoided.