A Dyadic Sleep Intervention for Alzheimer's Disease Patients and Their Caregivers

Studies consistently show the negative health impact of sleep problems in both Alzheimer's disease (AD) patients and their caregivers. However, only a few sleep interventions have been conducted for AD patients or their caregivers in community settings and none have addressed both members of the dyad concurrently. To fill these gaps, this study aims to develop a sleep intervention program specifically tailored for AD patient/caregiver dyads who both experience sleep difficulties.

In 2015, Americans provided 18 billion hours of unpaid care for patients with Alzheimer's disease (AD) and other dementias, with an economic value of $221 billion. This estimate may be even higher among caregivers of AD patients when they have sleep problems. In fact, the caregivers' sleep is often disturbed by nighttime sleep disturbance of AD patients, which is one of the major reasons why those patients are admitted to institutions. Due to the bidirectional nature of sleep disturbance in AD patients and their caregivers, it is critical to develop a sleep intervention program for the dyad that addresses sleep disturbance in both individuals. Nighttime sleep disturbance in AD patients is associated with shorter survival, lower quality of life, and decreased social engagement. Poor sleep among their caregivers is associated with increased depressive symptoms, higher levels of caregiver role burden, and increased inflammation, which is known to increase risk for cardiovascular disease. Such decline in caregivers' health may then impact the quality of care for AD patients. Behavioral sleep intervention programs for AD patients or caregivers are feasible but long-term effects on improving sleep and health remain unclear. No behavioral sleep interventions have focused on the patient-caregiver dyad, and only a few behavioral sleep intervention studies have targeted community-dwelling AD patients or caregivers. Dyad-based sleep interventions may have better effects on sleep and other health outcomes because of the influence of AD patients on their caregivers and vice versa. The proposed intervention focuses on educating caregivers to improve their own and the patients' sleep, using behavioral sleep management techniques. This intervention builds upon a previous caregiver focus group study (VA HSR&D LIP 65-154, PI: Song) and the existing sleep interventional research studies, which included patients with mild cognitive impairments and AD patients. The sleep program involves 4 face-to-face meetings plus 1 telephone session. Phase 1 study aims to iteratively refine and finalize the intervention program materials with 5 AD patient/caregiver dyads. Phase 2 study aims to pilot test the effects of the intervention program (n=20 dyads) on sleep, health, and quality of life in both members of the group, compared to a non-directive education-only control program (n=20 dyads) in a small randomized controlled trial. Primary outcomes will include objective sleep efficiency and total wake time measured by actigraphy for AD patients and subjective sleep measured by the Pittsburgh Sleep Quality Index for caregivers. A unique aspect of the proposed study is that the program is tailored to address sleep problems of both patients and caregivers, and includes upstream biomarkers to evaluate a key mechanism of intervention benefits that can be further explored in future research.

manual-based sleep hygiene recommendations and a behavioral sleep intervention including sleep compression therapy

This group will receive manual-based sleep hygiene recommendations and a behavioral sleep intervention including sleep compression therapy

This group will receive information about sleep, aging, and dementia, but without specific or individualized recommendations

Sleep efficiency (mean percent time asleep while in bed) will be calculated from 3 days of wrist actigraphy

Total wake time (mean total minutes awake from sleep onset to get up time) will be calculated from 3 days of wrist actigraphy

Total score on the Alzheimer's Disease Assessment Scale-Cognitive Subscale test will be used as a measure of cognitive function

Total score on the Revised Memory and Behavior Problem Checklist will be used as a measure of problematic behaviors

Total score on the Center for Epidemiological Study-Depression will be used as a measure of depression

Total score on the Quality of Life-Alzheimer's Disease Scale will be used as a measure of quality of life

Inclusion Criteria for Alzheimer's disease (AD) patients: AD diagnosis OR probable or possible AD as documented in electronic medical record, which includes Mini Mental State Exam score >12 (indicating mild to moderate severity of AD) and neuroimaging evidence Community-dwelling >1 sleep problem >3x/week on the Neuropsychiatric Inventory Nighttime Behavior Scale Aged >60 years Able to ambulate with or without assistive device Have an eligible caregiver (see below) Inclusion Criteria for caregivers: Live with an eligible patient Aged >21 years Have regularly assisted patient with >1 of 6 basic activities of daily living (ADLs) (i.e., bathing, dressing, toileting, transfers, continence, feeding) or >1 of 8 Instrumental ADL (IADLs) (i.e., using the telephone, shopping, preparing meals, housekeeping, laundry, transportation, taking medicine, managing money) for the past 6 months Pittsburgh Sleep Quality Index (PSQI) total score >5 Montreal Cognitive Assessment (MoCA) score >= 23 Can communicate in English Exclusion Criteria: - If AD patient is bed bound