To the Editor: We present an interesting case of a patient with Alzheimer’s disease whose insomnia, restlessness, and memory impairment responded to treatment with methylphenidate.
Mr. A, a 78-year-old white man, had a 4-year history of slow-onset, progressive dementia of the Alzheimer’s type. As his dementia progressed, he would sleep no more than 1 or 2 hours per night, instead pacing or wandering around the house. When his wife could no longer manage him, she placed him in a long-term care dementia unit.
Upon hospitalization, Mr. A needed assistance with dressing, grooming, and bathing but could feed himself and walk independently. There was no history of alcohol consumption. There was a family history of Alzheimer’s disease. He had non-insulin-dependent diabetes. Results of his examination were otherwise unremarkable and did not indicate the presence of Parkinson’s disease.
In the unit, he continued to have insomnia and paced the halls at night. During the day, Mr. A would sit expressionless in a chair, not interacting with other patients or staff. After several medications were used unsuccessfully to treat his insomnia, Mr. A’s sister mentioned that her son, who had attention deficit hyperactivity disorder (ADHD), had been treated with methylphenidate, which improved his insomnia. Methylphenidate is an indirect-acting sympathomimetic agent used to treat individuals with ADHD and narcolepsy and geriatric patients who are apathetic and withdrawn. It has been shown to reduce anger and temper outbursts, to improve memory in patients who have sustained head injury (1), and to improve attention, reduce impulsivity, decrease motor activity, and improve social behavior style.
Mr. A started taking methylphenidate, 5 mg b.i.d., which was increased to 10 mg b.i.d. after 2 days. He slept all night for the first time in 4 years. More remarkably, his facial expression and interaction with other patients and staff markedly improved. He started occupational therapy, kinesitherapy, horticulture therapy, and recreational therapy. His wife noticed that he could remember her visits from the previous day and was much more animated and interactive than she had seen him in years.
To test whether the sleep improvement was caused by the methylphenidate, we tapered and discontinued the drug. Mr. A’s symptoms worsened, particularly insomnia and restlessness. His wife said that he was not as interactive as he had been before and could not remember her visits. Methylphenidate was restarted, and his symptoms once again improved. Whether Mr. A’s improved activity and participation were directly related to methylphenidate or to improved sleep is unknown.
We conclude that stimulants should be considered, particularly for patients with Alzheimer’s disease who may have a history of ADHD, for treating sleep disturbance and may be useful in reducing motor activity like pacing. We emphasize extreme caution in the use of this drug with Alzheimer’s disease patients because it may cause agitation. Controlled trials with methylphenidate may be of interest, with a low starting dose and careful observation during the clinical trial.