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Sleep Disturbance in Dementia — MRCPsych Paper B MCQ

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HardOld Age PsychiatrySleep Disturbance in DementiaMRCPsych Paper B

A 78-year-old woman with moderate Alzheimer's disease has persistent nocturnal waking and prolonged periods of wakefulness. Delirium, pain, depression, medication effects, sleep-disordered breathing and environmental triggers have been excluded. A personalised multicomponent programme involving sleep hygiene, daylight exposure, exercise and daytime activities has not produced sufficient improvement. If medication is nevertheless being considered after discussion of the limited evidence and off-label status, which option has direct placebo-controlled trial evidence of improving nocturnal sleep in moderate-to-severe Alzheimer's disease?

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Correct answer: A — Trazodone 50 mg at night

Explanation lettering: D = shown as A · A = shown as B · B = shown as C · C = shown as D

D is correct. A small placebo-controlled trial, summarised in a Cochrane review, found that trazodone 50 mg nightly increased total nocturnal sleep time by about 42 minutes and improved sleep efficiency in moderate-to-severe Alzheimer's disease. The evidence is low-certainty, and prescribing trazodone for insomnia is off-label; this is not a routine NICE recommendation. NICE prioritises personalised multicomponent sleep management and specifically advises not offering melatonin for insomnia in Alzheimer's disease. Melatonin showed little or no benefit in pooled trials. Zopiclone and diazepam lack direct trial evidence in dementia and may worsen sedation, confusion and falls. Amitriptyline has substantial anticholinergic and postural adverse effects and may exacerbate cognitive impairment.

Reference: McCleery J, Sharpley AL. Pharmacotherapies for sleep disturbances in dementia. Cochrane Database of Systematic Reviews. 2020;11:CD009178. https://www.nice.org.uk/guidance/ng97/chapter/Recommendations