The Hidden Connection Between Poor Sleep and Cognitive Decline

Most people know sleep gets harder with age. What nobody tells you is that the sleep problems you're ignoring right now the insomnia, the restless nights, the medication you've been on for 20 years may be doing more damage than you think.

In this episode, Dr. Arun Karlamanga sits down with Dr. Cathy Alessi, Professor of Geriatric Medicine and Sleep Medicine at UCLA, to talk about what's actually happening with sleep in older adults and what clinicians and patients need to know but rarely hear. They cover why the sleeping pill that "worked" for two decades may have stopped working long ago, the surprisingly strong link between sleep disorders and cognitive decline, and the one question your doctor should be asking at every visit but probably isn't.

Transcript

SPEAKER_02 0:00

There is increasing evidence that sleep problems, including insomnia, including sleep medications, mental data's opinions, that are associated with cognitive decline.

SPEAKER_00 0:11

On this episode, Dr. Carlamunga sits down with Dr. Kathy Alesi, professor of geriatric medicine and sleep medicine. They're talking about sleep disorders in older adults.

SPEAKER_02 0:22

Sleep apnea is very common in older adults. You will find REM sleep behavior disorder in your primary care clinic if you ask about it. You probably have many patients who've been previously diagnosed with sleep apnea and are no longer using treatment. The best evidence for helping a patient who's been chronically on benzo dizent drug is the combination of tapering. And in addition, you provide alternative treatment. REM sleep behavior disorder may predate by years the presentation of an alpha genetisorder.

SPEAKER_01 0:56

Probably was mistakenly thinking that REM sleep disorder is related to confidences. But you're saying now that not only can we precede confidence, it can precede year of degeneration. I'm Erin Kudlamangla, Chief of Geriatrics at UCLA. I'm here today to talk with Dr. Kathy Alesi, who is a professor of internal medicine, geriatric medicine, and sleep medicine. She's one of those individuals who's uniquely qualified because she's boarded in all three fields. So, Dr. Alesi, there's been a lot going on in the field of sleep in older adults. What is a recent development that excites you the most?

SPEAKER_02 1:40

Well, first, Arun, thank you so much for having me here. I'm always thrilled to talk about sleep in older adults. You know, it's really hard to choose one thing as most exciting. There's been quite a bit of exciting work on treatment of sleep apnea. There's been wonderful work on behavioral treatment of insomnia in older adults with numerous comorbidities. So, you know, it's hard to choose one. And the whole field has just become more and more exciting.

SPEAKER_01 2:06

Let's talk about sleep apnea first, then. What do you like to tell us about sleep apnea and what's happening now and what clinicians need to know about treating sleep apnea in older adults?

SPEAKER_02 2:18

Well, I think it's first important to understand that sleep apnea is very common in older adults. In fact, older age is a common situation where you'll find sleep apnea. The other is that you probably have many patients who've been previously diagnosed with sleep apnea and are no longer using treatment. So I think it's really important to keep track of which of your patients have already been diagnosed, and majority of them will be treated with PAP therapy, positive airway pressure therapy. And so just ask them, you know, periodically ask them, are you using your PAP? And if they're not, ask them if they're interested in resuming their PAP, and then refer them back to sleep or do things, whatever you can to help them get back on treatment.

SPEAKER_01 3:03

So, what is the most common reason that people do not use their PAP machines?

SPEAKER_02 3:09

So, you know, I it's very difficult to answer that question. So I'm not really sure. Um, sometimes there it perhaps is uh some initial difficulty with adherence with PAP. You know, how well someone uses their PAP in the beginning, even within that first week that they've started on treatment, can predict long-term adherence. So that you know that it can be a problem. The other thing is that patients who have improvement in daytime symptoms with their PAP treatment tend to be more adherent. You know, they feel better when they when they use their PAP. And in fact, you likely have patients in your clinic who have sleep apnea who are using their PAP, and it's been life-altering. You know, I mean, just you probably can think of some patients who describe to you, oh, I always use my PAP. I feel so much better when I'm using my PAP. So I I think I think it's a mixed bag, if you know why people sometimes don't use their PAP. But I think that primary care providers, geriatricians, you know, we're the we can be the first line of defense in helping people in management of their sleep apnea.

SPEAKER_01 4:17

Can you say a few things about CBT for insomnia?

SPEAKER_02 4:21

Oh, sure, yeah. So uh CBTI, cognitive behavioral therapy for insomnia, is first line treatment for insomnia for adults of all ages. So not just older adults, but middle-aged, younger adults also. So first line treatment is CBTI, cognitive behavioral therapy for insomnia. And um the um now we've done quite a bit of work on uh research, you know, helping older adults, treating insomnia in older adults with CBTI. And if I could just back up a little bit, the you know, insomnia in older people, I like to think of it as it's generally chronic. So the majority of patients that we see in our geriatric clinics have had insomnia for a long time, if not years. So it's usually chronic. And it's almost always, or very typically comorbid, meaning patients don't just have insomnia, they have other comorbidities that are contributing to their insomnia and you know may have a bi-directional relationship between the insomnia. So sleep in older adults, insomnia, excuse me, in older adults is chronic and comorbid. And you know, just accept it. That's a situation. Uh and CBTI, again, is first-line treatment, and um, there are multiple ways that you can access CBTI for your patients. So I think we're in an era now where we no longer can assume that we're not going to be able to get CBTI for our patients. I think we can get it, uh, and and so that's really our first line of defense.

SPEAKER_01 5:54

Okay, so access is no longer an issue, or at least not as much an issue as it used to be.

SPEAKER_02 5:59

Well, I maybe I'm being a little optimistic there, but uh it it may vary with the health system that you're in. But but um CBTI can be has been research has clearly demonstrated that there's a multiple different ways that you can access CBTI. You know, there have been psychologists, behavioral sleep medicine specialists are uh sort of the the main way it originally was developed and provided, but nurses can provide it if they're trained. We've done some work with sleep coaches who are non-clinicians providing CBTI. So a variety of different people, types of people adequately trained can provide CBTI. Plus, there are many different ways of accessing CBTI. There's books, there are apps, websites, and so I think our job as clinicians, if we're recommending one of those types of approaches for CBTI for our patients, is maybe help them in steering them towards uh you know evidence-based, validated sources of CBTI.

SPEAKER_01 7:08

It sounds like you've done work trying to increase access to CBTI by by testing in studies how people other than uh psychologists can provide the treatment.

SPEAKER_02 7:22

That's true. One key thing about the work that we've done on that is is that we've um it's CBTI is provided by a non-psychologist, but they're supervised by in the work that we do, uh by a behavioral sleep medicine, meaning psychologists. You know, so we we do, you know, uh do generally the the interventions are manual based, so they're highly structured. The people providing it are trained and they're supervised. So they, you know, maybe once a week we'll get together with the behavioral sleep medicine psychologist and review the case and what's going on.

SPEAKER_01 7:58

So we spoke about access to CBTI.

SPEAKER_02 8:01

How about acceptance?

SPEAKER_01 8:02

Do you find that older adults are accepting of CBTI?

SPEAKER_02 8:07

You know, I haven't, uh I do. Yeah, I find they're accepting, and I really haven't found any difference in acceptability between middle-aged or younger adults and older adults. Although my practice is in geriatrics, you know, obviously it's primarily focused on older adults. Uh, and and as is the case with many things that we recommend for our patients where they may have same initial reluctance, over time, you know, you can convince them to give it a try. Ultimately, it'll be their choice and their decision and whether to participate in behavioral treatment, but it really is our primary, most well-validated, most potent way to treat insomnia.

SPEAKER_01 8:49

That's wonderful. So we replaced medication therapy as the primary treatment with CBTI. I still remember very well that when I was in training, the two choices of medications we had were trazodone and metazipine. So gone are those days. Now it's CBTI. So what are other medications one might use in conjunction with CBTI if it's needed?

SPEAKER_02 9:22

I I think that uh there are there likely are situations where medication treatment is warranted, typically for short-term use, uh, even in older adults. But it's always a matter of balancing risks and benefits. And and um so I I think that uh we can consider use of medications, and certainly I have many patients who typically they come to me on the sleeping pills. But you know, I think it is important to be very cautious and to avoid the potentially inappropriate medications, some medications that are on the beers list, for example, for treatment of insomnia. So benzodiazepines and the Z drugs, the non-benzodiazepine receptor agonists, um, use of anticholinergic medications for the side effect of sedation, you know, that we also avoid too. So, but um in patients, there there may be patients where in the outpatient setting we consider medications. Now, the issue with trazodone, as you mentioned, and mortazepine actually, are that you're really using those medicines for their side effect. You know, it's it's I I think it's always a good idea to take pause when a prescription medication is being used for a side effect, you know. So uh, and and with trazodone, for example, the sedating effects tend to wear off over time. And you may see that in your practice, you know, patients who've been on trazodone and the dose has increased and increased and increased, and that's a sign that it's not working, you know. Um the um now the other thing is we know in patients who, for example, are on benzodiazepine or non-benzodiazepine agents for sleep. And in geriatrics, we may see patients who've been on them for a very long time. Uh, and so I do have patients who typically they've come to me and they're on one of these uh agents, and I'll I'll just start having a conversation with them about the medicine. And and I'll say, you know, um, describe the well-known potential risks of this class of medicines and older adults. And and a patient, you know, in my experience, they'll say, Well, I've been on it for 20 years. So often what I try to do is I say, okay, uh, but you know, you're different now. Your body is different than it was 20 years ago, and what you know, what you could tolerate 20 years ago may not be the best choice right now. Uh so um, and also if they're still having sleep problems and they're on a medication for sleep, so my interpretation of that is that it's not working. So um rather than continue it, let's let's think about something else.

unknown 12:08

Okay.

SPEAKER_01 12:09

Now you have to be careful about tapering people off the benzodiazepines. Um there's been recent studies that show that um cognitive behavioral therapy may be helpful in doing that as well.

SPEAKER_02 12:23

Yeah. Um, right. So the best evidence for helping a patient who's been chronically on uh benzodiazepine or Z-drug is the combination of tapering. So you taper the medicine that they're on over time, and in addition, you provide alternative treatment, behavioral treatment with CBTI. So that's it seems to be where is the best evidence of effectiveness in helping a patient come off their uh potentially inappropriate medication. The combination of tapering plus um, something more effective, yeah.

SPEAKER_01 12:57

So we've talked about sleep apnea, we've talked about insomnia a little bit. There is so much more to talk about these subjects, these topics. Uh there'll be discussion and presentations on sleep disorders at the UCLA intensive course in September. Today let's talk a bit more about comorbidities because um I myself uh do work in dementia, and the relationship between sleep disorder as a risk factor for dementia is getting more and more recognized. Uh is there anything happening in that field that we need to know about?

SPEAKER_02 13:36

Oh, Arun, it's huge. Uh there's just been an explosion of work uh looking at sleep, sleep disorders, sleep problems, specific sleep disorders, and you know, sleep disturbance is more of a general topic, and cognitive decline and dementia. And we know uh clinically that there are nighttime complaints and sleep problems are common in our patients who have uh cognitive disorders, including dementia. Um, so the the bottom line is that I don't know that we really know the answers of how if what we're you know focused on is how to treat it. You know, it just really depends on the situation. Most of the patients that I treat that have dementia are in a geriatric clinic, are very complex. And so there are multiple issues that are I need to take into account when I think about how to help if they have a sleep complaint. So to be honest, I don't really have a simple quick answer for you other than yes. There is increasing evidence that sleep problems, including insomnia, including sleep medications, benzodiazepines, uh, including sleep apnea, uh, that are associated with cognitive decline. And so we, you know, we need to address these.

SPEAKER_01 14:56

I remember reading a study about how uh anticholinergic medications, for instance, not only do they cause cognitive problems while they're being taken. I'm thinking of medicines like Benadryl, which are used for its sedation side effect by people with who have insomnia, uh, that not only do they cause cognitive problems while you're in the medication, that they can cause long-lasting, irreversible um cognitive deficits as well. So um I I think it behooves us as geriatricians to tell our patients that it's not just a transient problem, the uh the side effect that there could be long-term risks from taking anticholinergic medications for their sedation side effects. Other comorbidities that go along with sleep uh uh that we need to be paying attention to?

SPEAKER_02 15:52

Um yeah, I'd actually like to chat about some of the other sleep problems that are common or important in older people. Um, so some of the uh prime primary quote-unquote sleep disorders are more common as people get older. So, for example, restless leg syndrome, which is an uncomfortable sensation of the legs that occur with rest or inactivity, can cause difficulty with falling asleep. It's very common in older people. You know, and interestingly, uh there is some evidence that some of the sundowning or you know, nighttime agitation that we see in patients with dementia, it may actually be unrecognized restless legs where the patient isn't able to report those symptoms, that uncomfortable sensation that they're having, uh, but they, you know, it is something to think about. So some clues might be a patient who has uh dementia, you know, has a major neurocognitive disorder, and they're uh agitated late in the day, rubbing their legs, you know, things that might be clues to you. Actually, that brings up another point, actually if you wouldn't mind. I go on. So when I have a patient in my primary care geriatric clinic that is talking, you know, mentions some trouble with their sleep, or they say something during the conversation that sort of piques my interest that there might be something going on at night or something related to their sleep, you know, I really hone in on that. I really try to try to uh focus on that during the during the visit. Uh to at least do some simple screening questions to try to find out more. So for example, you know, you might I I've had patients that I've identified evidence of REM sleep behavior disorder. You know, there is uh RAM sleep behavior disorder is uh sleep disorder characterized by dream enactment behavior, so people acting out their dreams with a lack of the muscle atonia, the paralysis that should normally occur in your muscles at night. And there may be clues. You know, you I'll have I'll be in clinic with a patient and they they'll they'll say something that kind of piques my interest, something happening at night usually, or the spouse no longer sleeps in the same bed with them, or they're calling out at night or striking out at night and say, Well, you know, tell me a little bit more about that. And the simple screener, such as, do you act out your dreams, it has been described as one potential way to screen for that problem, which is common in older adults. There's a very strong association between REM sleep behavior disorder and uh neurodegenerative disorders characterized by uh senucleinopathies, you know, so that's Parkinson's disease, Louis body dementia, multisystem atrophy. And the REM sleep behavior disorder may predate by years the presentation of their neurodegenerative disorder. So you will find REM sleep behavior disorder in your primary care clinic if you ask about it.

SPEAKER_01 18:55

Oh, good to know. Okay. So I um probably was mistakenly um thinking that REM sleep disorder is related to Parkinson's. Um is and that it can precede Parkinson's. Yes, absolutely. Yeah. Uh but you're saying now that not only can it precede Parkinson's, it can precede neurodegeneration.

SPEAKER_02 19:18

Right. So it it's associated with um neurodegenerative disorders, uh, the strongest association as far as I'm aware, that are characterized under the class of disorders called senucleinopathies. So alpha synuclein is the abnormal product in their brain that builds up. So Parkinson's disease is certainly one of the most common, just because it's a very common disorder. So there's a, you know, it's a REM sleep behavior disorder is associated with Parkinson's disease. And as you described, it can present well before the Parkinson's disease makes itself clinically. Um you know you become aware of it clinically. But there are, you know, Louis body dementia is another, and as I mentioned, multisystem atrophy is another.

SPEAKER_01 20:04

In in addition to benzodiazepines, um, older adults often use melatonin or uh its precursor remelteon. And there have been studies uh some supporting um their use and some not so supporting uh the use of melatonin and remelion to prevent delirium in a patient who's hospitalized as a prophylactic intervention. Um is that something uh that we should consider in all older patients who are hospitalized? Put them on melatonin or remelteon to to promote good sleep at night and reduce the risk of delirium.

SPEAKER_02 20:52

Well, I do see, you know, part of my clinical work is I do work in the inpatient hospital in the acute setting too. And uh melatonin, I commonly see melatonin used as a sleep aid in other age groups too, but also in older people. Melatonin, compared to some of the other agents that are commonly used, it is, you know, pretty benign in most situations. Uh and Remelteon, which is a prescription medication that acts at the melatonin receptors in the brain, that you know, that is uh has been demonstrated to improve sleep. And also like over-the-counter melatonin is uh in some situations, you know, can be effective for sleep. Sort of my approach to that is I I think you you hit it in something you said earlier, Arun, that the evidence for use of melatonin, for example, as a sleep aid, is mixed. You know, so the evidence is mixed. Um but my opinion of that is that if I have a patient who comes to me and they use melatonin to help them sleep and they think it helps, that's I'm not so concerned about you know the melatonin. So I I if they if they feel it helps them, uh I'm probably not gonna be a focus of my efforts and and uh deep prescribing when the when the agent is melatonin. And you asked about uh melatonin in older people in hospital to you know prevent delirium. There is some evidence for that, is my understanding. I'm not expert in that by any means, but my impression is that the evidence is a bit mixed. Um, but you know, we may learn more about that going forward.

SPEAKER_01 22:36

Thank you. Um there is so much more we could talk about. So to close, is there something that you want to add about sleep for our audience?

SPEAKER_02 22:47

You know, um people love to talk about their sleep, which is good, you know. Um so it's just it's an exciting field, it's extremely interesting. We spend a large portion of our life uh sleeping, you know.

SPEAKER_01 23:05

Should be at least.

SPEAKER_02 23:06

Yeah, really. Uh so it's just um it's just fascinating, you know, and when you have the time to chat with your patients, uh asking them about how they're sleeping, you know, please, you know, we should we should be doing that. And and um identifying when a patient mentions you know symptoms they've been having, that you know, if you you're you know, a bell goes off in your head, you know, I uh let me let me ask you a little bit more about that. You know, I think you know you follow that path and and learn a little bit more about their sleep. Because people really that my experience is that patients enjoy you uh addressing their sleep problems.

SPEAKER_01 23:45

Thank you so much. Thank you for spending the time with us. This was a lot of fun.