Sleep, Memory, and Behavior Changes Signal Deeper Neurologic Issues Case Presentation

Hector is an 82-year-old married man who has been experiencing progressive cognitive and behavioral changes over the past year.

Hector has a history of anxiety, depression, and chronic insomnia. In an attempt to self-manage his sleep difficulties, he has been taking multiple sedative and hypnotic substances—Zolpidem (Ambien) not prescribed to him, over-the-counter sleep aids, nightly alcohol, and THC gummies.

Despite these efforts, his wife reports that he remains restless and exhibits unusual nocturnal behaviors, including thrashing in bed, sleepwalking-like episodes, and periods of confusion. On one occasion, she found him awake and disoriented in the kitchen at night; on another, he was missing for several hours without a clear recollection of where he had been.

Over recent months, Hector’s daytime functioning has also declined. He has become increasingly irritable, impulsive, and forgetful, with episodes of talking to unseen people and vague explanations for his actions. His wife initially suspected poor sleep as the root cause and considered asking his primary care provider for a stronger sleeping medication.

Dr Agronin recommends a comprehensive diagnostic evaluation, including:

• Full neurological and neurocognitive assessment
• Laboratory testing and neuroimaging to rule out reversible causes
• In-lab polysomnography (sleep study) to assess for REM sleep behavior disorder
• Careful review of medication and substance use

If Lewy body dementia or another neurocognitive disorder is confirmed, pharmacologic management should proceed with caution due to heightened sensitivity to antipsychotic medications and potential for adverse reactions in this patient population.

Marc E. Agronin, MD, is a board-certified adult and geriatric psychiatrist and currently works as the Chief Medical Officer for the Frank C. and Lynn Scaduto MIND Institute and for Behavioral Health at Miami Jewish Health. He is an Affiliate Associate Professor of Psychiatry and Neurology at the University of Miami Miller School of Medicine. Dr Agronin is a graduate of Harvard University, summa cum laude, and the Yale School of Medicine. He completed his residency training in adult psychiatry at Harvard University's McLean Hospital and then a geriatric psychiatry fellowship at the Minneapolis VA Medical Center. Dr Agronin is a national expert in Alzheimer disease and geriatric mental health, and directs the memory disorder center and clinical research program at Miami Jewish Health. He is the author of the acclaimed books "How We Age: A Doctor's Journey into the Heart of Growing Old" (2011) and "The End of Old Age: Living a Longer, More Purposeful Life" (2018). Dr Agronin has written 9 other books and hundreds of articles, including "The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer's Disease and Other Neurocognitive Disorders" (2015). He has been published in The New York Times and writes regular articles on aging, health, and retirement issues for The Wall Street Journal.

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