Sleep and cognitive decline: How PCPs can help patients concerned about dementia
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Key takeaways:
- Short sleep and poor sleep quality can both have a major impact on cognitive decline.
- When seeing patients worried about dementia, PCPs should start addressing their concerns by asking about sleep habits.
Asking about sleep habits during routine visits can help primary care physicians address cognitive decline among aging patients, according to experts.
Sleep plays an intrinsic role in one’s health, Abhinav Singh MD, MPH, FAASM, a sleep medicine physician, medical director of the Indiana Sleep Center and a member of the Sleep Foundation’s medical advisory board, told Healio.
“Sleep is health, and health is sleep,” Singh said.
Health care professionals often consider sleep to be just as important to a patient’s health as their diet and physical activity, he said — some even describe it as “the third pillar of health.” But Singh said the more appropriate analogy would be sleep as the base of health upon which pillars can be built.
“If you don't have proper sleep, do you think the best exercise regimens are going to yield the same benefit? Probably not,” he said. “Then how can you call it the third pillar, meaning you're giving it equal weight?”
A lack of quality sleep can lead to several adverse health consequences, including depression, a higher risk for high BP, heart disease, diabetes, obesity and lowered immune system function, according to Daron W. Gersch, MD, FAAFP, a family physician with CentraCare hospital in Minnesota, and the vice speaker of the American Academy of Family Physicians.
However, sleep can have a particularly profound impact on cognition, he said.
“Everybody needs sleep, and insomnia can affect you both mentally and physically,” Gersch said. “It can make you feel tired, depressed and irritable. It can make it hard for you to concentrate or perform tasks during the day.”
Current literature
In a recently published cross-sectional study, Samantha A. Keil, PhD, a postdoctoral research fellow at the University of Washington, and colleagues investigated connections between longitudinal sleep patterns and age-related cognitive function changes among 826 healthy older adults. The researchers evaluated the participants’ variability in sleep duration, change in sleep duration, sleep phenotype and median sleep duration. Cognitive impairment was defined by subthreshold performance on the Mattis Dementia Rating Scale and the Mini-Mental State Examination, and sleep duration was defined by self-reported median nightly sleep duration.
Using the Cox proportional hazard regression model analysis, Keil and colleagues found that higher sleep variability (HR = 3.06; 95% CI, 1.14-5.49) and status as a short sleeper (HR = 3.67; 95% CI, 1.59-8.5) were both significantly linked to the incidence of cognitive impairment.
This highlights the possibility that long-term instability in sleep duration could affect cognitive decline in older adults, they wrote.
“Higher variability in self-reported sleep duration over the course of decades, rather than a more consistent decline in sleep duration, was significantly associated with cognitive impairment,” Keil and colleagues wrote.
The researchers concluded that their findings indicate that “longitudinal variability in sleep duration, in addition to average sleep duration alone, may be important contributors to the development of cognitive decline in older adults.”
“They also argue that understanding the clinical relationships among age, sleep disruption, and cognitive impairment may require the assessment of sleep behavior over longer time scales than is presently common in research practice,” they wrote.
Singh said he sees patients “maybe twice a week” who are concerned about dementia and struggle with consistent sleep.
“They're worried about dementia, but they are not able to see through the fact that they are clearly sleep deprived — and ... it’s not just quantity,” he said. “When we say sleep deprivation, it's not only quantity loss. Everybody thinks, ‘Oh, I'm getting 8 hours. ... That seems pretty respectable.’ But what is the quality of those 8 hours? They don't know.”
Quality over quantity?
Nicole Danner, DO, an osteopathic physician specializing in neurology and member of the American Osteopathic Association, said the average adult needs between 7 and 9 hours of sleep.
“Sleep is the time that our body repairs itself and a time that hormones are excreted,” Danner said. “PCPs should recommend that patients get 7.5 to 8 hours of sleep and keep the same sleep schedule 7 days a week with very little variation. Proper sleep hygiene is very important.”
Although the number of hours of sleep that a patient gets is important, Singh and Gersch said the quality of one’s sleep may be even more so, especially when it comes to cognition.
“If you're getting 9 hours of sleep but it's poor quality, you'll still have the symptoms of feeling tired and making it difficult for you to concentrate and perform your tasks,” Gersch said. “As far as cognition is concerned, it is directly linked as far as how good of sleep you get and the amount of sleep you get and how you can concentrate and perform tasks.”
Many factors can affect sleep quality, including lifestyle habits, stress, medication, medical problems and hormonal changes, Gersch said. Whatever the underlying causes, “a family physician can help identify what's causing these sleep difficulties” and create an individualized treatment plan.”
“Everybody focuses on the quantity of sleep as in the number of hours, but we also have to focus on the quality of sleep,” Gersch said. “You can be getting 9 to 10 hours of sleep and still be having a lot of health issues if the sleep you're getting is not good-quality sleep.”
Gersch, Singh and Danner also noted that some populations may be at a higher risk for poor sleep quality. For example, Gersch said that those in a lower socioeconomic status, who have irregular work schedules or who do shift work can face sleep disruptions that might subsequently mean they are at a higher risk for cognitive decline.
“Equity in general can play a huge role in sleep,” he said. “If you're unhoused or if you're having to work two or three jobs in order to make ends meet, that can have severe health consequences related to your lack of sleep.”
Gersch described an encounter he had with a patient who was suffering from chronic lower back pain as a result from a motor vehicle accident he was in. When the patient came into the office to ask for more pain medication, he told Gersch he had become unhoused and was living in his car.
“Between the discomfort of having to sleep in the physical confines of his car and being unhoused — so, more exposed to the elements — meant that he wasn't sleeping as well, and that was directly relating to his back pain and how he was functioning,” he said. “We were able to get him hooked up with a social worker, we got him into a shelter, and then eventually he was able to get himself back into a home a few months later, and that played a huge role in his sleep and his ability to function.”
Recommendations for PCPs
There is only one question about sleep on the typical patient intake form at primary care practices, Singh said. So, a simple way that PCPs can help their patients, especially those concerned about their cognition, is by asking patients about their sleep habits during routine visits.
Danner said sleep disorder screening “is often overlooked” in everyday practice, “especially when patients already have multiple medical issues that need to be addressed in an office visit.”
“Patients, especially younger patients, complaining of memory loss, brain fog, headaches and fibromyalgia type symptoms should be screened for sleep disorders,” Danner said. “Patients who have obesity, snoring, narrow airway, small chin and/or large neck circumference should be screened for sleep apnea. True insomniacs can be ... very difficult to treat; they may require multiple medications to control insomnia.”
Before asking their PCPs about their issues, patients who struggle with sleep often try self-medication strategies, commonly including a melatonin supplement they take before bedtime, Singh said, and this method is only becoming more popular among patients of all ages, even children. Survey findings published in JAMA Pediatrics recently revealed that almost one in five school-aged children and preteens take melatonin for sleep.
In the short term, melatonin usually “works very well,” Gersch said, “especially for people who have changes in shifts or if you travel a lot, so you're going through different time zones.”
“Melatonin can really be very helpful in resetting your sleep-wake cycle,” he said.
However, he cautioned that melatonin is not FDA-regulated, “so the purity and safety of each brand cannot be guaranteed.”
“They should be very cautious about where they get their melatonin from and make sure that they get it from someone who they feel is a reputable source,” Gersch said.
Gersch emphasized that PCPs should work with patients whose symptoms do not improve after a few weeks with melatonin, but helping patients sleep is easier said than done.
Techniques to help patients
When deciding how to best help patients overcome their insomnia, a simple conversation with patients about their lifestyle habits is a good place to start, Gersch said.
Alongside evaluating a patient’s existing medical conditions and medications (“diabetes, prostate issues, congestive heart failure or kidney disease can all make sleep more difficult”), he suggested asking patients if they drink caffeine or alcohol, particularly around bedtime; if they use tobacco; if they watch TV before bed; if they go to bed when they feel tired or before; and their bedroom’s conditions.
Singh, Gersch and Danner said small changes like keeping one’s room quiet, cool and dark, avoiding large meals before bedtime and exercising regularly can all help improve sleep.
They also suggested:
- Minimizing screen time before bed.
- Going to bed only when one feels tired, not before. Patients can try to sleep earlier than their body wants and then they might lay awake worrying about the sleep they are not getting, Gersch said.
- Keeping a journal or a to-do list before bed to help shut down the brain for bedtime.
- Listening to ambient noise.
- Using a comfortable eye covering.
- Not obsessing about sleep (or, at least, trying not to).
“We should talk about techniques ... and I think that lends a little more seriousness because tips are easy to throw away. ‘Oh, my friend gave me this tip, it didn't work, I'm gonna throw it away,’” Singh said. “Technique almost implies that there needs to be repetition to that. They need to be disciplined in that technique [to see results].”