Les troubles du sommeil chez les patients atteints d’un trouble neurocognitif

Les troubles du sommeil sont fréquents chez les patients avec un trouble neurocognitif. Leur diagnostic et prise en charge chez ces patients peut s’avérer complexe en pratique clinique. Cette revue narrative offre une approche systématique basée sur les données probantes afin de diagnostiquer et traiter les troubles du sommeil concomitants à un trouble neurocognitif. La maladie d’Alzheimer est fréquemment associée aux troubles des rythmes circadiens, à l’insomnie chronique ainsi qu’au syndrome d’apnées-hypopnées du sommeil. Les alpha-synucléinopathies sont quant à elles souvent associées au trouble du comportement en sommeil paradoxal, au syndrome des jambes sans repos, à l’insomnie chronique et au syndrome d’apnées-hypopnées du sommeil. Une anamnèse ciblée permettra de diagnostiquer la majorité des troubles du sommeil. Une évaluation par polysomnographie est recommandée si un syndrome d’apnées-hypopnées du sommeil ou un trouble du comportement en sommeil paradoxal sont suspectés. Les traitements de première ligne sont souvent non-pharmacologiques, notamment la thérapie cognitivo-comportementale pour l’insomnie, les modifications de l’exposition lumineuse pour les troubles circadiens et la ventilation par pression positive continue pour le syndrome d’apnées-hypopnées obstructives du sommeil. Des recommandations pharmacologiques sont discutées, en particulier pour le trouble du comportement en sommeil paradoxal et le syndrome des jambes sans repos. Les interventions non pharmacologiques multiples et soutenues sont recommandées dans le traitement des troubles du sommeil associés aux troubles neurocognitifs. Les indications pharmacologiques demeurent actuellement restreintes, et davantage d’essais cliniques randomisés intégrant une approche multimodale sont nécessaires afin d’évaluer les traitements des troubles du sommeil spécifiques aux différents troubles neurocognitifs. Sleep disorders are prevalent in patients with a neurocognitive disorder, and diagnosis and treatment in these patients remain challenging in clinical practice. This narrative review offers a systematic approach to diagnose and treat sleep disorders in neurocognitive disorders. Alzheimer's disease is often associated with circadian rhythm disorders, chronic insomnia, and sleep apnea-hypopnea syndrome. Alpha-synucleinopathies (e.g., Parkinson's disease and Lewy body dementia) are often associated with a rapid eye movement sleep behavior disorder, restless legs syndrome, chronic insomnia, and sleep apnea-hypopnea syndrome. A focused history allows to diagnose most sleep disorders. Clinicians should ensure to gather the following information in all patients with a neurocognitive disorder: (1) the presence of difficulties falling asleep or staying asleep, (2) the impact of sleep disturbances on daily functioning (fatigue, sleepiness and other daytime consequences), and (3) abnormal movements in sleep. Sleep diaries and questionnaires can assist clinicians in screening for specific sleep disorders. Polysomnography is recommended if a rapid eye movement sleep behavior disorder or a sleep apnea-hypopnea syndrome are suspected. Sleep complaints should prompt clinicians to ensure that comorbidities interfering with sleep are properly managed. The main treatment for moderate to severe obstructive sleep apnea-hypopnea syndrome remains continuous positive airway pressure, as its efficacy has been demonstrated in patients with neurocognitive disorders. Medications should also be reviewed, and time of administration should be optimized (diuretics and stimulating medications in the morning, sedating medications in the evening). Importantly, cholinesterase inhibitors (especially donepezil) may trigger insomnia. Switching to morning dosing or to an alternative drug may help. Cognitive-behavioral therapy for insomnia is indicated to treat chronic insomnia in neurocognitive disorders. False beliefs regarding sleep should be addressed with the patient and their caregiver. The sleep environment should be optimized (decrease light exposure at night, minimize noise, avoid taking vital signs, etc.). Sleep restriction can be considered as patients with a neurocognitive disorder often spend too much time in bed. The need for naps should be assessed case by case as naps may contribute to insomnia in some patients but allow others to complete their diurnal activities. Trazodone (50 mg) may also be used under certain circumstances in chronic insomnia. Recent evidence does not support a role for exogenous melatonin in patients with a neucognitive disorder and insomnia. Patients in long-term care facilities are often deprived of an adequate diurnal exposure to light. Increasing daytime exposure to light may improve sleep and mood. Patients with circadian rhythm disorders can also benefit from light therapy (morning bright light therapy in case of phase delay and evening bright light therapy in case of phase advance). Rapid eye movement sleep behavior disorder can lead to violent behaviors, and the sleeping environment should be secured (e.g., mattress on the floor, remove surrounding objects). Medication exacerbating this disorder should be stopped if possible. High dose melatonin (6 to 18 mg) or low dose clonazepam (0.125–0.25 mg) at bedtime may be used to reduce symptoms. Melatonin is preferred in first-line as it is generally well tolerated with few side effects. Patients with restless legs syndrome should be investigated for iron deficiency. Medication decreasing dopaminergic activity should be reduced or stopped if possible. Behavioral strategies such as exercise and leg massages may be beneficial. Low-dose dopamine agonists (such as pramipexole 0.125 mg two hours before bedtime) can be used to treat the condition, but a prolonged treatment may paradoxically worsen the symptoms. Alpha-2-delta calcium channel ligands can also be used while monitoring for the risk of falls. Multiple and sustained nonpharmacological approaches are recommended for the treatment of sleep disturbances in patients with neurocognitive disorder. Pharmacological indications remain limited, and further randomized clinical trials integrating a multimodal approach are warranted to evaluate the treatment of sleep disorders in specific neurocognitive disorders.