Sleep & Memory Center

• 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
• Empathize

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.

• Major Neurocognitive Disorder of the Alzheimer’s type – Alzheimer’s Dementia
• Frontotemporal Neurocognitive Disorder Syndromes (FT-NCD)
• Progressive Supranuclear Palsy Syndromes (PSPS)
• Corticobasal Syndrome (CBS)
• Synucleinopathy-associated Major Neurocognitive Disorder Syndromes (SA-NCD)
• Vascular Major Neurocognitive Disorder Syndrome – Vascular Dementia (VaD)

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.

• 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
  • Sleep-walking
• 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

• Chronic Insomnia Disorder
• Insufficient Sleep Syndrome (ISS) – Sleep deprivation
• Sleep Apnea and Sleep Disordered Breathing (SDB) Syndromes
• Hypersomnia and Hypersomnolence
• Circadian Rhythm Sleep Disorders (CRSD)
• Parasomnias
• Restless Legs (Limbs) Syndrome (RLS) – Willis Ekbom Syndrome

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 Alzheimer’s disease, 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 hypersomnia syndromes 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, sleep apnea), and implementing non-pharmacological treatments, such as change in lifestyle habits 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 PAP machines that help with sleep apnea. 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 as insomnia symptoms, difficulty tolerating a CPAP machine for sleep apnea, or difficulty in establishing a regular sleep-wake schedule. 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. Recent findings from our and other researchers 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 with sleep disordered breathing treatment 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 have obstructive sleep apnea is 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 in-lab polysomnography study.

People with Sleep Disordered Breathing whose 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.