Our Mission and Goals
The Sleep & Memory Center was established in 2019 to provide excellent care to people with sleep or cognitive disorders and support to their caregivers. It is the first center in the world where Behavioral Neurology and Sleep Medicine have been organically combined, bringing together a multidisciplinary team of board-certified experts across Neurology, Psychology, and Social Work, and fulfills its mission through its, and activities.
The need for establishing the Sleep & Memory Center within the field of Cognitive Behavioral Sleep Medicine follows compelling evidence of the bidirectional causal relationship between sleep disorders on one hand and cognitive impairment and neurodegeneration on the other. People suffering from sleep problems are more likely to have or develop cognitive difficulties, whereas people with neurodegenerative diseases, such as Alzheimer’s disease, are more likely to have disrupted sleep or daytime somnolence. For those who have one or the other type of symptoms, and especially those who have both, there is an increased risk of other neurological (e.g., seizures, stroke), cardiovascular (e.g., heart attack, hypertension), metabolic-endocrine (e.g., high cholesterol, diabetes, thyroid disease), and even autonomic (e.g., orthostatic dizziness, erectile dysfunction) disorders that further interfere with people’s daily activities and quality of life.
At the same time, these recent advances in Cognitive Behavioral Sleep Medicine have helped us better understand the relationship between sleep and dementia and stimulated novel diagnostic and therapeutic protocols that can significantly improve the life of people with sleep or cognitive difficulties. Through our team of experts, we are at the forefront in developing and bringing such protocols into clinical practice, guided by medical ethics principles and by our mission to help people with sleep or cognitive-behavioral disorders.
Our Clinical Activities
Patients presenting at our clinics with sleep or cognitive-behavioral symptoms are evaluated through a personalized multidisciplinary assessment protocol tailored to their symptoms. In addition to an extensive clinical examination with a board-certified specialist, they may undergo neuropsychological, imaging, biochemical, electroencephalography, actigraphy, or sleep study testing. Our therapeutic protocols also follow a multidisciplinary approach, with pharmacological, psychotherapeutic, technological, and social interventions. In keeping with our mission to serve the needs of our community, patients have the option to establish long-term care at our center or be referred by clinician colleagues for an expert opinion and follow with their clinician after completing our evaluation protocol and receiving recommendations.
Dementia & Neurodegeneration Clinic
Adults who primarily have cognitive-behavioral concerns, or who carry a diagnosis of dementia, present with a change in their ability to think and remember as well as they did in the past. At our clinic, we examine if these symptoms relate to objective difficulties compared to other people of the same age, prior to recommending further testing or specialized therapies, thus minimizing unnecessary procedures and cost. Our initial evaluation protocol is based on international expert consensus guidelines and includes clinical examination with a specialist clinician and neuropsychological testing with a trained psychologist. During this visit, recent brain imaging and blood tests are reviewed. Importantly, considering the social impact of dementia to patients and their families in almost every aspect of life, for those in need we provide social and psychological support, and education through individual or group programs developed by our psychologists and social workers. More specialized testing, such as evaluation of sleep quality and quantity, may be recommended depending on clinical and laboratory findings during the visit.
- Remembering recent events or conversations, or relying on calendars more
- Ability to find words or recall names
- Navigate in a familiar environment
- Perceive distances or moving objects despite good eyesight
- Understand written or spoken language
- Speak fluently
- Plan or organize complex tasks
- Process information with the same speed
- Make decisions
- Pursue activities
Dementia – Major Neurocognitive Disorder (Major NCD)
The term dementia, or, more formally, major neurocognitive disorder, describes a combination of symptoms and clinical findings, collectively called a syndrome, which interferes with people’s cognition or behavior, to the extent that the person requires some additional help compared to the past in pursuing daily activities. It is a term developed to help clinicians communicate a person’s presentation before going into more details; nothing more and nothing less. This means that people with dementia have different levels of disease severity depending on specific symptoms, called a phenotype, and each dementia syndrome is associated with one or more underlying causes, with neurodegenerative brain pathologies and vascular brain disease being the most common. It is also not uncommon for certain dementia syndromes to be accompanied or, even, preceded, by other disorders, such as sleep or seizure disorders. We tend to organize dementia syndromes in the following categories, each having its own historic roots, and explaining the differences in how they are described.
Mild Cognitive Impairment (MCI) – Minor Neurocognitive Disorder (Minor NCD)
Minor NCD or MCI describes a combination of symptoms and clinical findings, collectively called a syndrome, which affect people’s cognition or behavior, but not severe enough for the person to require help compared to the past in pursuing daily activities. Much like the term dementia, it is a term developed to help clinicians communicate a person’s presentation before going into more details; nothing more and nothing less. This means that people with MCI can present with a set of symptoms, called a phenotype, and each phenotype may be associated with one or more underlying causes, which can range from neurodegenerative brain pathologies, to vascular brain diseases, to metabolic disorders, or even seizure and sleep disorders. In fact, sleep disorders can present several years before cognitive disorders show up, raising the possibility that addressing sleep problems may in fact delay the onset of cognitive symptoms. Symptoms in MCI are organized in the following domains for defining a person’s phenotype: memory, executive function, language, visuospatial-constructional skills and behavior. Depending on the underlying cause of MCI, symptoms may progress, especially in neurodegenerative brain pathologies, remain stable, such as in vascular brain disease, or even improve, if they are caused by treatable sleep problems.
Subjective Cognitive Complaints (SCC)
Much like in Minor Neurocognitive Disorders (NCD), people with SCC are concerned that their ability to perform certain cognitive tasks are not as good as they used to be and out of proportion to getting older. But in contrast to Minor NCD, cognitive performance on standardized neuropsychological tests of people with SCC fall within the normal range. It is possible that these subjective complaints are the first signs of a developing cognitive impairment that will reveal itself over time and should be thoroughly evaluated and followed over time, but in many cases do not persist or lead to any impairments.
Sleep & Alertness Clinic
Adults and children evaluated at our clinic with symptoms interfering with their sleep or wakefulness undergo an evaluation with a board-certified sleep physician and may require additional testing before deciding on the best available therapies. For those whose problems lead to poor sleep quality, a sleep study is usually required that may be performed at home or in the sleep-lab. If sleep study results indicate difficulty with breathing while asleep, then respiratory support in the form of Positive Airway Pressure (PAP – continuous PAP or auto PAP) or Non-Invasive Ventilation (NIV – e.g., bilevel PAP, servo-ventilation, volume-assured pressure support) may be recommended. Instead, symptoms of insomnia, abnormal sleep behaviors or irregular sleep-wake rhythms may require pharmacological or cognitive-behavioral therapies as appropriate. Finally, for people who are also noticing changes in their memory and ability to think in the daytime, neuropsychological testing is provided to evaluate symptom severity and direct appropriate therapies while accounting for both sleep and cognitive difficulties.
- Poor sleep quality
- Unrefreshing sleep
- Loud snoring
- Breathing pauses
- Morning headaches
- Frequent awakenings with or without a need to urinate
- Abnormal behaviors while asleep (kicking, injuring bed-partner, sleep-walking)
- Poor sleep quantity
- Sleep deprivation
- Insomnia at sleep onset or in the middle of the night, with or without short sleep duration
- Earlier than desired morning awakening
- Excessive daytime sleepiness, with or without falling dozing off or napping
- Difficulty concentrating in the daytime
- Irresistible urge to move limbs before falling asleep
- Sudden “sleep attacks” or paralysis in the daytime
- Irregular or socially limiting sleep-wake schedule
- Poor sleep quality
- Unrefreshing sleep
- Loud snoring
- Bedwetting beyond age five
- Excessive daytime sleepiness, with or without falling asleep
- Difficulty concentrating in the daytime
- Hyperactive behaviors in the daytime
- Difficulty falling asleep on school nights in teenagers, with or without delayed morning wake time
- Demanding rituals to fall asleep in young children
- Resistance to go to bed at night in young children
Patients are evaluated at the Sleep & Memory Center through a personalized multidisciplinary protocol tailored to their symptoms that includes a number of expert evaluations that our clinicians have at their disposal. Specialty diagnostic testing includes clinical evaluations with board-certified specialists in Sleep Medicine and Behavioral Neurology, neuropsychological testing with a certified psychologist, in-lab or at-home sleep studies and electroencephalography testing, actigraphy, and body fluid testing. These services are provided to patients with the option to establish long-term care at our center or be evaluated at our center and then followed by referring clinician colleagues. For people who are unable to be evaluated at the Neurological Institute of Athens or in circumstances of mandated social distancing, certain diagnostic tests can be pursued through telemedicine tools and at-home evaluations.
Specialty Therapeutic Protocols
Therapeutic protocols at the Sleep & Memory Center follow a multidisciplinary approach, with pharmacological, psychotherapeutic, technological, and social interventions, because, for most patients, there are multiple factors contributing to symptoms or placing them at risk for worse future outcomes. Such comprehensive protocols maximize benefit and minimize cost to patients by approaching the whole person and the environment they live in.
Pharmacological treatments are the backbone of most therapeutic protocols. In people with sleep or cognitive disorders, medications are effective in treating symptoms, although they may not always be effective in treating the underlying cause of symptoms. This is especially true for major neurocognitive disorders, such as, where medications help mitigate cognitive symptoms, but there are no medications to reverse existing degenerative brain damage. Similarly, for people with disabling sleep symptoms, such as where medications help awaken the brain in the daytime or insomnia where they help people fall asleep, medications cannot yet address the underlying cause of symptoms and alternative treatments are often more helpful. For this reason, there are several clinical trials underway that try to stop or delay neurodegeneration. Considering the multiple facets of neurodegeneration, pharmacological treatments will likely have to address all these facets and a combination of medications, rather than a single one, are likely to be more effective. In addition to medications benefitting people directly with their sleep or cognitive symptoms, there is good evidence that addressing comorbid risk factors, such as vascular risk factors (i.e., hypertension, hyperlipidemia, diabetes, smoking, ), and implementing non-pharmacological treatments, such as change in or using certain technological interventions, can protect the brain itself and delay disability by several years.
Lifestyle interventions can be grouped into three main categories: regular exercise, healthy diet, and consolidated sleep-wake schedule. There are several studies that support that moderate level of exercise for more than 150 minutes per week can delay cognitive decline, improve mood, and preserve brain function by several years in people with or at risk for dementia. In some cases, depending on people’s genetic make-up, a 40% delay in symptom progression has been observed in people who exercise. Even more, such a benefit has been seen in people who started to exercise in their 80s. Exercise has also a beneficial effect on sleep disorders if performed in the daytime by consolidating people’s sleep-wake schedule and allowing deeper restful sleep the following night. According to some studies, consolidated sleep allows for an additional 20% delay in cognitive decline, and even larger benefit in sleep disorders, although more controlled studies are required to validate this effect. Additional ways to consolidate sleep-wake schedules include daytime exposure to sunlight, timing of food intake to heavier meals in the daytime and lighter in the evening, and relaxing non-stimulating rituals at night, all following the principle of being active during the daytime and resting at night. The quality of the diet has also shown to be beneficial to people, with Mediterranean diet of olive oil, fish, fruits, vegetables and legumes being the main staples that seem to benefit patients. Several controlled trials are underway that will test if indeed healthy dietary habits delay cognitive decline by the suggested 10-20% rate found in observational studies.
Social education and support are critical aspects in the care of patients with neurodegenerative disorders and for some people with sleep disorders. Social workers and psychologists work with patients and their caregivers to address social daily aspects of care that prevent optimal medical benefit. These include education on patient legal rights and actions, access to healthcare and insurance coverage, rights to financial benefits, help-at-home services, and ways for optimizing communication with family and caregivers.
Proactively addressing legal issues that may arise for patients with neurocognitive disorders and their caregivers can help prevent a lot of stress down the road. This includes having a living will and assigning power of attorney for financial and medical matters. In such a way, family members know in advance and can respect a person’s desires if patients become unable to express them. Similarly, learning how to best communicate with patients that are forgetful or may become agitated near the evening can help prevent unnecessary stress to family and caregivers. In many situations, caregivers and patients with mild cognitive difficulties find it useful to be part of support groups, through which they discuss and solve problems of daily life. In many circumstances, medications can be avoided if caregivers are educated on a diagnosis and trained on how to manage behavioral symptoms of people with neurocognitive disorders. For people with sleep disorders but no cognitive impairment, social workers can prove helpful in circumstances where insurance does not cover medications or. For those people who seek further psychological support, face-to-face encounters with trained psychotherapists can prove of great help.
Psychotherapy addresses complex psychological and psychosomatic symptoms and helps the person improve their quality of life. An agreed upon contract is created between the person and their therapist as the goals of the therapeutic relationship are set. There are different techniques of psychotherapy implemented in clinical practice, and chosen depending on people’s symptoms and social environment.
Sleep psychotherapy helps people with sleep disorders, such assymptoms, difficulty tolerating a for , or difficulty in establishing a regular . The most effective psychotherapy for chronic insomnia is Cognitive Behavioral Therapy for Insomnia (CBTi), which addresses people’s maladaptive behaviors towards sleep through a combination of cognitive and behavioral techniques, and is proven to be more effective than available medications for people who are not cognitively impaired. indicate that it can also be beneficial to people who have neurocognitive disorders and their caregivers. Certain psychotherapeutic relaxation and desensitization techniques are also proven to be effective for people who struggle to tolerate their CPAP machine.
Psychotherapy is also helpful for caregivers of people with neurocognitive disorders. This can range from talk therapy to targeted Cognitive Behavioral Therapy to address caregiver dysfunctional beliefs and maladaptive behaviors.
In people withtreatment is aimed at improving people’s ventilation, during which air moves in and out of the lungs and gases are exchanged between the body (carbon dioxide) and the environment (oxygen). This requires an open airway and adequate effort in breathing in and out during sleep.
A first line treatment in maintaining an open airway in people who haveis PAP therapy, which relies on an air compressor machine that pushes air through the nose (or nose and mouth) that works as a wedge to keep the airway open and allow oxygen inhalation. PAP therapy needs to be used every time a person sleeps to achieve maximum benefit. There are different settings for PAP machines, with more recent algorithms allowing automatic variation of air pressure (AutoPAP), maintaining an open airway while improving people’s comfort. For people who also have inadequate breathing effort while asleep, such as in morbidly obese people, people with heart failure, or people with neuromuscular disorders, NIV is required, which in addition to helping maintain an open airway, helps people take a deeper less effortful breath while asleep and regulates their sleep breathing rate. This serves to not only allow oxygen in, but also let carbon dioxide out. There are different NIV machines (e.g., bilevel PAP, auto/adapt servo-ventilation, volume-assured pressure support), each being best for a different type of sleep disordered breathing syndrome. The common principle in all of them is that different pressures are applied during inhalation and exhalation, and titration of such machines requires an .
People withwhose facial anatomy leads to a narrow upper airway may be candidates for surgical interventions. Surgical interventions are divided into soft tissue surgeries, such as Tonsillectomy and Adenoidectomy that is often considered in children, and bone surgery, where expanding nasal and jaw structures allows more air to flow through the nose and throat into the lungs. Bone surgery is mostly effective for adults before their mid-40s, because bones may not heal as well after that age. For older people with sleep apnea who have trouble tolerating a PAP machine and are not candidates for bone surgery, Hypoglossal Nerve Stimulation (HNS) opens the airway through a special nerve pacemaker that pushes the tongue forward while people inhale during sleep. In children with small facial bone structures, orthodontics are often considered to expand the airways.These early interventions may prevent the need for a child to grow up and require lifelong PAP therapy.
Our Research Activities
Research is one of the core activities at the Sleep & Memory Center in line with its duty to be a force of positive change for brain health by promoting novel and innovative diagnostic and therapeutic approaches. Research projects in the field of Cognitive Behavioral Sleep Medicine focus on the bidirectional relationship between sleep disorders on one hand and neurocognitive disorders and neurodegeneration on the other. Our projects aim to develop novel protocols that provide more accurate and earlier diagnosis for complex neurological syndromes, explore novel therapeutic avenues that improve patients’ and caregivers’ quality of life through clinical trials, and advance our understanding of brain function. Our projects are conducted through independent research funding to our center and through collaborative multinational projects. Effective and quality research is best achieved by following ethical principles of patient autonomy, equity, beneficence and non-maleficence, while respecting personal information through data privacy and security. For this reason, all research projects pursued at the Sleep & Memory Center are first approved by the NIA Institutional Review Board. In the end, participation in research starts and ends according to a patient’s desire and priorities.
Active Research Projects
The purpose of the study is to answer whether Sleep Health Education (SHE) or Cognitive Behavioral Therapy for Insomnia (CBTi) can be effective in improving insomnia symptoms for people with MCI or mild dementia and secondarily delay cognitive decline and improve mood. This project will pave the way for the development of other scalable low-cost interventions that are tailored to patients with cognitive decline and their families, and has the potential to influence policy and clinical practice around the treatment of sleep disorders in neurocognitive disorders.
SHE is implemented regularly in clinical practice, where clinicians educate patients on how to best structure daily activities around healthy sleep habits. It is low cost and can be easily comprehended by the majority of people. CBTi is an established treatment for insomnia in cognitively healthy older adults that relies on multiple components (e.g., reconstructing maladaptive beliefs about sleep, behavioral modification) that are cognitively taxing to a person and require several encounters. Controlled trials are lacking in establishing whether either treatment intervention can be effective in people with neurocognitive disorders.
People with mild cognitive impairment or mild dementia with insomnia symptoms who participate in the project provide historical information on sleep and cognitive symptoms, as well as medications and past medical history, and undergo detailed neuropsychological testing, actigraphy, and polysomnography prior to being randomized in one of two treatment groups (SHE vs. CBTi). After participating in SHE or CBTi interventions, they are re-evaluated at three months through questionnaires and neuropsychological testing, and then at a year’s time through questionnaires, neuropsychological testing, actigraphy and polysomnography. If the study reveals that either of the two treatments were helpful to people, the people who did not receive the specific treatment will be given the option to receive it upon completion of the study.
The purpose of the study is to answer whether Sleep Health Education (SHE) or Cognitive Behavioral Therapy for Insomnia (CBTidt) can be effective in improving insomnia symptoms for people with MCI or mild dementia and secondarily delay cognitive decline and improve mood. This project will pave the way for the development of other scalable low-cost interventions that are tailored to patients with cognitive decline and their families, and has the potential to influence policy and clinical practice around the treatment of sleep disorders in neurocognitive disorders.
SHE is implemented regularly in clinical practice, where clinicians educate patients on how to best structure daily activities around healthy sleep habits. It is low cost and can be easily comprehended by the majority of people. CBTidt is an established treatment for insomnia in cognitively healthy older adults that relies on multiple components (e.g., reconstructing maladaptive beliefs about sleep, behavioral modification) that are cognitively taxing to a person and require several encounters. Controlled trials are lacking in establishing whether either treatment intervention can be effective in people with neurocognitive disorders.
People with mild cognitive impairment or mild dementia with insomnia symptoms who participate in the project provide historical information on sleep and cognitive symptoms, as well as medications and past medical history, and undergo detailed neuropsychological testing, actigraphy, and polysomnography prior to being randomized in one of two treatment groups (SHE vs. CBTidt). After participating in SHE or CBTidt interventions, they are re-evaluated at three months through questionnaires and neuropsychological testing, and then at a year’s time through questionnaires, neuropsychological testing, actigraphy and polysomnography. If the study reveals that either of the two treatments were helpful to people, the people who did not receive the specific treatment will be given the option to receive it upon completion of the study.
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b. Karageorgiou E, Vossel KA. Brain rhythm attractor breakdown in Alzheimer's disease: Functional and pathologic implications. Alzheimers Dement. 2017;13(9):1054-1067 PMID: 28302453
c. La AL, Walsh CM, Neylan TC, Vossel KA, Yaffe K, Krystal AD, Miller BL, Karageorgiou E. Long-Term Trazodone Use and Cognition: A Potential Therapeutic Role for Slow-Wave Sleep Enhancers. J Alzheimers Dis. 2019;67(3):911-921. PMID: 30689583
d. Sexton CE, Sykara K, Karageorgiou E, Zitser J, Rosa T, Yaffe K, Leng Y. Connections Between Insomnia and Cognitive Aging. Neurosci Bull. 2019 Jun 20. doi: 10.1007/s12264-019-00401-9. [Epub ahead of print]
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Our Educational Activities
Education is the third core activity at the Sleep & Memory Center through which we aim to inform clinicians, scientists, patients and the general public on the best clinical practices and latest research advances in the field of Cognitive Behavioral Sleep Medicine from our center and worldwide.
Education to Specialist Clinicians and Scientists
Our members regularly give educational and scientific talks at international and national conferences and fellowship training curricula targeted to the needs of colleague clinicians and scientists. Within the NIA, we organize annual workshops and conferences, quarterly grand rounds, and weekly journal club and patient review meetings
Alzheimer’s Association International Conference, Los Angeles, CA, July 15th 2019
Slow-wave sleep enhancers as a potential therapeutic approach in delaying cognitive decline in Alzheimer's disease: The Trazodone paradigm
- Stanford Sleep Medicine Center, Redwood City, CA, November 8th 2019
Sleep and Dementia
American Academy of Neurology 2020 Annual Meeting
Educational Course: Cognitive Behavioral Sleep Medicine: A Primer to a Discipline. https://issuu.com/americanacademyofneurology/docs/aan_earlylook2020_web
Cognitive Behavioral Sleep Medicine Training Program (CBSM TP)
The CBSM TP is a rigorous training program aimed to train the next generation of clinicians and clinician-scientists in Cognitive Behavioral Sleep Medicine. Established in 2020, supervised trainees learn to evaluate and manage the care of patients with neurocognitive disorders and sleep disorders working within our specialty multidisciplinary clinic teams, review polysomnography, MSLT/MWT, and actigraphy studies of their own patients, participate and present at our weekly journal clubs and patient reviews, and pursue their own research interests in CBSM through mentored guidance as well as participate in ongoing research projects at the Sleep & Memory Center towards pursuing an independent career.
Those interested to apply can email us at email@example.com, together with their CV, a personal statement, and two letters of recommendation.
Education to Patients, Caregivers, and the General Public
Our team of experts inform patients with neurocognitive or sleep disorders, their caregivers, and the public at large on the latest research and best clinical practices in the field of Cognitive Behavioral Sleep Medicine through talks and educational material.