Alzheimer's and other forms of dementia often disrupt sleep patterns. Unfortunately, the lack of a good sleep routine can affect behavior, energy levels, and mood -- and wreak havoc on caregivers' sleep and the routines of the household.
Problem: Mixes up day and night (sleeps much of day, awakens at night)
Changes in the body's internal sleep timer. Sleep is partly regulated by an internal sleep timer deep in the brain, which controls the body's circadian (day-and-night) rhythm. This center seems to weaken over time in most adults, whether or not dementia is present.
The disease itself. Changes in brain cell communication cause many sleep problems for those with dementia. The sleep center is among the areas of the brain that can be affected early by cell damage.
Depression. Dementia and depression often occur together; when the depression is treated, the sleep problems sometimes improve.
Other: Non-dementia-specific causes to work through with a doctor include medication side effects, underlying disease, pain, sleep apnea, and bladder problems including urge incontinence or prostate problems. Because of these issues and other changes, humans tend to get less sleep as they age, so be sure your expectations are realistic.
What to do:
Mention the problem to a doctor to help pinpoint the cause and treat anything non-dementia-specific (such as a bladder issue or depression).
Amp up daytime activity. Try to include a daily walk, inside or out, for someone who's mobile, and activity that moves the arms for someone who isn't.
Expose your loved one to daylight. Getting morning light is especially important for regulating the body's internal clock. Take a morning walk, sit out on the porch, or position seating near a window that's open, weather permitting. Fresh air by day also seems to improve sleep at night.
Curb daytime naps as best you can; awaken your loved one when he or she dozes off.
If your loved one must nap, it should be in a recliner or chair rather than in the bed.
Limit use of the bed to nighttime sleeping. If necessary, strip it in the morning and make it up again at night right before use, to discourage daytime lounging there.
Create a strong bedtime routine, using the same "sleep cues" at the same time every night. Consider a certain type of music, a consistent snack, toothbrushing, washing up, and so on.
Make sure the room is fairly dark for sleeping; use blackout curtains or shades. For nighttime light, stick to a string of low-illumination lights leading to the bathroom or a nightlight in an en suite bathroom with the door cracked open. Some lighting reduces falls and disorientation.
Lower the thermostat at night; most people sleep best in a cool room.
Consider hiring a night aide to stay with your loved one so you can sleep at night until the situation is improved. No sense in both of you having a poor night's sleep.
Ask the doctor about low-dose trazodone, a mildly sedating antidepressant that tends to have fewer side effects than other sleep medications.
Avoid most medications often used for sleep in adults; they're generally not recommended for older adults with dementia because these drugs have been strongly linked to worsened confusion and falls. Pills to avoid include over-the-counter sleep (or "PM") medications, prescription sleep aids such as zolpidem (brand name Ambien), and sedatives such as lorazepam and diazepam (brand names Ativan and Valium). A different type of medication is melatonin, which is a natural hormone produced by the body. However, although a low dose (0.3 milligrams) of melatonin does help some adults with insomnia, research studies have found that melatonin doesn't work for adults with dementia unless bright light therapy is also used.
Antipsychotics are considered a last resort to treat sleep problems. Long-term use of antipsychotics is associated with almost twice the death risk for those with Alzheimer's.
More ways to solve dementia-related sleep problems
Problem: Agitation at night, trouble falling asleep (sundowning, sundown syndrome)
"Sundowning" -- a period of agitation that usually begins in early evening -- isn't always a sleep problem but can disrupt the ability to fall peacefully to sleep at a reasonable hour.
End-of-day (afternoon) confusion or exhaustion
Disturbance in the "biological clock" (circadian rhythm)
Decreased ability to handle stress
Poorly lit rooms and increased shadows (worsened by poor eyesight)
Difficulty differentiating dreams from reality
Restlessness due to boredom
Picking up on a caregiver's cranky mood
What to do:
Be sure your loved one's daytime routine keeps him or her engaged and as physically active as possible. There seems to be a relationship between sundowning and boredom or inactivity. Plan activities early in the day to avoid flat-out exhaustion by late afternoon.
Expose your loved one to light. Some experts advise placing a full-spectrum fluorescent lamp (2,500 to 5,000 lux) a few feet away for a couple of hours in the morning.
Make sure your loved one isn't hungry in the early evening. Offer a slow-burning snack, like oatmeal or another complex carb.
Use soothing music (of whatever type your loved one finds relaxing, whether piano solos or soft rock or big band) to calm agitation.
Discourage daytime naps.
Try closing draperies or shutters in the early evening so your loved one is less aware of the evening transition; rely on routines at set times to be your clock for the day.
Mention the problem to a doctor. Hearing and vision problems can contribute to agitation and should be checked for when any current hearing aids and vision-correction prescriptions are assessed. The doctor may also help you determine if a trial of antidepressant medication or a cholinesterase inhibitor might help. In severe cases, it may also be reasonable to try a low-dose antipsychotic. Over-the-counter sleep medications and prescription sedatives aren't recommended because they often make confusion and balance worse, which can lead to a dangerous fall.
Take care of yourself and preserve your own sleep, so that your stress levels don't inadvertently get picked up by your loved one.
Problem: Waking to use the bathroom; waking because of accidents (nocturia or functional incontinence)
Forgets to urinate before bed
Can no longer read body cues about the need to urinate
Underlying bladder or prostate issue
What to do:
Be sure to consult with the doctor to pinpoint the type of incontinence and to get specific treatment recommendations. Some prescription drugs may help, especially those for enlarged prostates; however, drugs for overactive bladder should generally be avoided as these can make thinking and balance worse.
Stop serving liquids as many as four hours before bed.
Avoid liquid meals at dinner, such as soup or stew.
Encourage bathroom use right before bed.
Remove the cup from the bathroom; it can be a visual cue to drink water during night wakings to urinate (perpetuating the cycle of needing to "go").
Consider a bedside urinal at nighttime for men with mild dementia.
Consider adult diapers, if only at night. Your loved one may not realize he or she has wet and will continue sleeping. Keep a rubberized mattress cover on the bed for further protection.