A Geriatrician’s Advice on Sleep Problems and Dementia
Sleep problems are common in patients diagnosed with Alzheimer’s disease and other dementias. The connection between dementia and sleep is also a common source of stress for family caregivers. When your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well either.
Lack of sleep can worsen the behavior and mindset of all people, not just those with dementia. Without adequate sleep, we all become more prone to emotional instability as well as physical illnesses.
Sleep Problems in Dementia
It is equally important for both a person with dementia and his or her hard-working caregivers to get enough sleep at night. It often takes effort to evaluate and improve sleep problems. However, research has found many ways to improve sleep problems experienced by dementia patients.1 It is important to know what common causes to look for in your loved one. Being prepared and providing useful information to your doctor is incredibly helpful when assessing the root of the problem. Here’s what to know about what can cause sleep problems, how they should be evaluated, proven approaches that help, and some information about commonly used medications.
Common Causes of Sleep Changes
It’s hard to manage a problem if you don’t understand the cause of it. Several factors can cause people with dementia to have sleep problems. Here are a few to keep in mind:
Sleep changes with aging. Healthy aging adults do experience changes with their sleep as they age. Sleep becomes lighter and more fragmented, with less time spent in deep REM sleep. One study also estimated that starting in mid-life, total sleep time decreases by 28 minutes per decade. These changes are considered a normal part of aging. However, lighter sleep means it’s easier for aging adults to be awakened or disturbed by things such as arthritis pain at night or sleep-related disorders. Aging is also associated with a shift in the circadian rhythm, the body’s inner system for aligning itself with a 24-hour day. Many seniors find themselves tired earlier in the evening and tend to wake up earlier in the morning.
Chronic medical conditions and medications often affect sleep. Studies have found that older adults often experience “secondary” sleep difficulties. Secondary sleep difficulties are sleep problems that may be the result from other underlying health issues. For example, many people diagnosed with Alzheimer’s have additional chronic health problems that may be associated with sleep difficulties. Treating underlying causes can help drastically improve sleep. Common causes of secondary sleep problems include the following:
Heart and lung conditions, such as heart failure or chronic obstructive pulmonary disease
Stomach-related conditions, such as gastroesophageal reflux disease
Chronic pain from arthritis or another cause
Urinary conditions that make people prone to urinating at night, such as an enlarged prostate or an overactive bladder
Mood disorders, such as anxiety or depression
Medication side effects and substances such as alcohol (which is known to disrupt sleep)
Many sleep-related disorders become more frequent with aging. Common sleep-related disorders include sleep apnea and similar conditions known as sleep-related breathing disorders. These may affect 40-50% of seniors. Restless leg syndrome is another sleep disorder that is thought to be clinically significant in 2.5% of people.
Alzheimer’s and other neurodegenerative diseases change sleep. The brain deterioration associated with various forms of dementia affects the brain’s ability to sleep. In most cases, this causes less time spent in deep sleep and more time spent awake at night. Problems with the circadian rhythm system are also increasingly common among dementia patients. There is another disorder called REM sleep behavior disorder, which can cause violent movements during sleep and can even emerge before thinking problems become substantial. Lewy-body dementia and Parkinson’s are often associated with the REM sleep behavior disorder.
Most seniors develop lighter sleep as they age. In addition, many older adults have health problems that prompt nighttime awakenings. Sleep-related disorders, such as sleep apnea, are also common in aging. Seniors with Alzheimer’s and other dementias are likely to be affected by any of these factors that change sleep in older adults. It has also been shown that dementia brings on extra changes that make nighttime awakenings more frequent.
It’s not surprising that sleep problems are so common in people with dementia. Fortunately, there are many things that can be done to improve these circumstances for our loved ones.
How To Diagnose the Sleep Problems of Dementia
Like many problems that affect older adults, sleep problems in a person with dementia are almost always “multifactorial.” This means that there are usually several underlying issues creating the problem.
Multifactorial problems can be identified, especially if a family and the doctors are diligently keeping an eye on as many contributing factors as possible. Working with the doctors will help them understand what kinds of sleep-related symptoms and problems a loved one is experiencing. The American Geriatrics Society recommends asking your loved one these questions when evaluating their sleep problems.
(These are addressed to a patient; replace “you” with “your parent” if you are gathering information in preparation to see a health professional about a parent’s sleep issues.)
What time do you normally go to bed at night? What time do you normally wake up in the morning?
Do you often have trouble falling asleep at night?
About how many times do you wake up at night?
If you do wake up during the night, do you usually have trouble falling back asleep?
Does your bed partner say (or are you aware) that you frequently snore, gasp for air or stop breathing?
Does your bed partner say (or are you aware) you kick or thrash about while asleep?
Are you aware that you ever walk, eat, punch, kick, or scream during sleep?
Are you sleepy or tired during much of the day?
Do you usually take one or more naps during the day?
Do you usually doze off without planning to during the day?
How much sleep do you need to feel alert and function well?
Are you currently taking any type of medication or other preparation to help you sleep?
Do you have the urge to move your legs, or do you experience uncomfortable sensations in your legs during rest or at night?
Do you have to get up often to urinate during the night?
If you nap during the day, how often and for how long?
How much physical activity or exercise do you get daily?
Are you exposed to natural outdoor light on most days?
What medications do you take, and at what time of day and night?
Do you suffer any uncomfortable side effects from your medications?
How much caffeine (e.g., coffee, tea, cola) and alcohol do you consume each day/night?
Do you often feel sad or anxious?
Have you suffered any personal losses recently?
Family members may initially feel uncertain about how to answer these questions. Therefore, it is a good idea to prepare ahead of time so you can get the best help from your doctors on how to handle dementia and sleeping. It is advised that families keep a record of these questions for at least a week. Some families may also be able to use a sleep tracker or activity tracker to gather useful information.
Based on the information above, and after conducting an in-person examination to check for other medical issues, a doctor should be able to place the sleep difficulties in one (or more) of the following categories:
Difficulty falling or staying asleep
Excessive daytime sleepiness
Abnormal breathing patterns during sleep
Abnormal movements or behaviors during sleep
It may be necessary to have a sleep breathing study done to test for sleep apnea. Based on the category of the sleep problem and the underlying causes that have been identified, the doctor should then be able to propose a plan for improving sleep difficulties.
How To Improve Sleep Problems in Dementia
The exact approach to improving sleep in a person with Alzheimer’s or another dementia will depend on what underlying factors are causing sleep problems. Certain general approaches have been found to improve the sleep of many people with dementia, including those who experience sundowning symptoms. These include the following:
Outdoor light or bright light therapy during the day. Bright outdoor light helps keep the circadian signals on track. For seniors who can’t get outside for at least an hour per day, bright light therapy with a special lamp might help. A study found that bright light therapy in Alzheimer’s patients improved sleep. In addition, light therapy may aid patients who experience sundowning.
Increase daytime physical activity. Research has suggested that walking during the day can help improve nighttime sleep in people with Alzheimer’s. It may also help reduce incidences of sundowning.
Optimize environmental cues for sleep. This means keeping the sleeping environment dark and quiet at night. This is especially important in nursing homes, which often have staff active at night.
Establish a routine with a consistent wake-up time. Routines help maintain better sleep. Although it is ideal to have both a consistent bed and wake-up time, experts believe it is best to focus on wake-up time. A research study published in 2005 found that training dementia caregivers to use a combination of these techniques led to improved sleep for their patients.
Medications and Sleep Problems in Dementia
You may be wondering whether medications can help manage sleep problems in dementia.
It is important to first check current medications and make sure they are not negatively affecting a person’s sleep. For example, taking sedating medications during the day may cause an individual to sleep or nap too much, resulting in more time spent awake at night. Additionally, a diuretic offered too late in the day might be causing excessive nighttime urination.
As a caregiver, you may simply want to know, “Isn’t there a medication we can give in the evening to help my loved one sleep better at night?” Sleeping pills, sedatives, and tranquilizers are often prescribed to help keep people with dementia calmer at night. Antipsychotics prescribed may include olanzapine, risperidal, and quetiapine. Benzodiazepines include lorazepam and temazepam. There are prescription sleeping medications such as zolpidem. Your doctor may even suggest trying over-the-counter sleep aids, which usually contain some form of sedating antihistamine.
Unfortunately, all these medications might cause some concerning side effects in people with dementia. Specifically, these medications may worsen cognition and increase the risk of falling. The antipsychotics have also been associated in some cases with a risk of early death. In addition, comprehensive scientific review articles state that in clinical trials, these drugs do not conclusively improve sleep. As such, experts in geriatrics recommend that these medications should generally be avoided and only used as a last resort once behavioral approaches (e.g., setting a routine, more walking, etc.) have been tried.
However, these few medications serve as a less-risky alternative:
Melatonin: Melatonin is a hormone involved in the sleep-wake cycle. A Scottish study found that two milligrams of melatonin per night improved the sleep of people with Alzheimer’s. However, in the U.S., melatonin is a poorly regulated supplement. Studies have found that commercially sold supplements are often of questionable quality and purity. So, melatonin may work less reliably in the United States than in Europe.
Trazodone: Trazodone is an older, less-effective antidepressant that is mildly sedating. It has long been used by geriatricians as a “sleeping pill” of choice, as it seems to be less risky than the alternatives. A small 2014 study found that trazodone improved sleep in Alzheimer’s patients.
Although medications are often used to manage sleep problems in dementia, most of them are associated with high risks for serious side effects. It is advised to avoid sedatives until you’ve exhausted all other options.
Non-drug approaches, such as plenty of outdoor light, regular exercise, a stable routine, optimizing chronic conditions, and checking for pain, often help. Plus, these approaches usually improve the person’s overall quality of life.
How To Handle Dementia and Not Sleeping
No matter how effective a remedy may be, it can take some time to start working. There is also the chance that none of the remedies you try are a good fit for your loved one. When this happens, you may need to find ways to deal with, rather than resolve, sleep problems related to dementia. Here are some dos and don’ts to keep in mind.
Don’t restrain them. Many people believe it’s best to restrain their loved ones in bed at night to prevent them from wandering. This may do more harm than good. Instead, if you have a bed with guard rails, raise the rails. This may help to deter them from climbing out of bed and wandering around the house.
Do consider taking shifts. If your loved one does not sleep well at night or has developed an erratic sleep schedule, consider taking shifts with another family member. This works best if one person is a night owl and the other is a morning person.
Do reduce stimulation. Even though one family member may take the late-night and overnight shift, it is important to minimize interaction. Otherwise, the dementia patient may feel encouraged to stay up at night or maintain the erratic schedule. Keep this in mind when creating a pre-bedtime routine, as well.
Do prioritize your rest. Taking care of a loved one struggling with dementia and its side effects may take a toll on family members and their mental health. To continue to provide optimal care, you also need to practice self-care, which includes getting enough rest at night.
Is Your Loved One Spending Too Much Time Asleep?
What if a family member with dementia is having issues related to too much sleep? For instance, an 88-year-old female with dementia is sleeping more, but eating and drinking less. What could this mean? Is something wrong?
Wakefulness at Night
It is possible that your loved one may be up and about at night without your knowledge. If the desire to sleep intensifies during the day, then this may very well be the case. A person with dementia may wander around or disturb things throughout the home, but this is not always the case. It is quite possible that your loved one may lie awake in bed.
Wandering Around at Night
There is also the possibility that your loved one may move throughout the home noiselessly. If you are a heavy sleeper, you may not notice the sounds of movement at night. If you have children, you may not notice signs of wakefulness in the morning because you think the children may have moved things around. Setting up cameras in shared common spaces may help you to confirm this.
Effects of Lewy Body Dementia
If you confirm that your loved one is sleeping through the night, you may feel even more confused about their daytime tiredness. Caregivers of patients with Lewy body dementia (DLB) are very familiar with this problem. One study confirmed that the tiredness was due to changes in the sleep-wake systems of the brain for patients with DLB.
Dementia can cause sleep changes in your loved one. If you notice these changes, it is best to seek medical advice. A doctor may help to determine the cause of the problem as well as provide potential solutions.
What are some remedies that worked for you when tackling your loved ones dementia and sleeping problems? Share your suggestions with us in the comments below.