Sleep Problems in Dementia

How to Manage Sleep Problems in Dementia

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Sleep problems are common in Alzheimer’s disease and other dementias. They are also a common source of tension for family caregivers, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well.

To make matters even worse, not getting enough sleep can worsen the behavior and mindset of someone with dementia. Of course, this is true for those of us who don’t have Alzheimer’s as well: we all become more prone to emotional instability and irritation when we’re tired. Studies have also shown that even younger healthy people perform worse on cognitive tests when they are sleep-deprived.

Sleep Problems in Dementia

By Leslie Kernisan, MD (original at APlaceforMom.com/)

Getting enough sleep is important, for people diagnosed with dementia and their hard-working caregivers. Now, sleep problems do often take a little effort to evaluate and improve. But as I explain below, research has found that it is often possible to improve sleep problems in dementia.

The key is to know what common causes to look for, and come prepared to provide useful information to the doctor. 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 tried medications for this problem.

Common Causes of Sleep Changes

It’s hard to manage a problem if you don’t understand why it might be happening. There are several factors that can cause seniors with dementia to have sleep problems. These include:

1. 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 total sleep time decreases by 28 minutes per decade, starting in mid-life. Although these changes are considered a normal part of aging, lighter sleep means it’s easier for aging adults to be woken up or disturbed by any other sleep-related disorders or problems, such as arthritis pain at night. Aging is also associated with a shift in the circadian rhythm, so that many seniors find themselves sleepy earlier at night and hence wake up earlier in the morning.

2. Chronic medical conditions and medications often affect sleep. Studies have found that older adults often experience “secondary” sleep difficulties, which means that the sleep problems are being caused by an underlying health problem. Many people diagnosed with Alzheimer’s have additional chronic health problems that may be associated with sleep difficulties. Treating such problems can help improve sleep. Common causes of secondary sleep problems include:

  • 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 problems, such as anxiety or depression
  • Medication side-effects, and substances such as alcohol (which is known to disrupt sleep)

3. Many sleep-related disorders become more frequent with aging. Common sleep-related disorders include sleep apnea and related conditions (known as sleep-related breathing disorders), which may affect 40-50% of seniors, as well as restless leg syndrome, which is thought to be clinically significant in 2.5% of people.

4. Alzheimer’s and other neurodegenerative diseases change sleep. The brain deterioration associated with various forms of dementia tends to affect the way the brain sleeps. In most cases, this causes less deep-sleep time, and more awake time at night. Problems with the circadian rhythm system (the body’s inner system for aligning itself with a 24-hour day) also become more common in dementia. Furthermore, Lewy-body dementia and Parkinson’s are also associated with a sleep disorder called REM sleep behavior disorder, which can cause violent movements during sleep and can even emerge before thinking problems become substantial.

In short, most seniors develop lighter sleep as they age, and many older adults have health problems that prompt night-time 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, plus dementia brings on extra changes that make night-time awakenings more common.

Hence, it’s not surprising that sleep problems are so common in people with dementia! Now let’s talk about what can be done to improve things.

How to Diagnose the Sleep Problems of Dementia

Like many problems that affect older adults, sleep problems in dementia (and generally in aging) are almost always “multifactorial,” which means that there are usually several underlying issues creating the problem.

Multifactorial problems can be improved, especially if a family and the doctors are diligent about trying to identify as many contributing factors as possible. But you’ll need to start by helping the doctors understand what kinds of sleep-related symptoms and problems a loved one is experiencing.

Here is a list of questions that a group of geriatrics experts recommends, for evaluating 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.)

  1. What time do you normally go to bed at night? What time do you normally wake up in the morning?
  2. Do you often have trouble falling asleep at night?
  3. About how many times do you wake up at night?
  4. If you do wake up during the night, do you usually have trouble falling back asleep?
  5. Does your bed partner say (or are you aware) that you frequently snore, gasp for air or stop breathing?
  6. Does your bed partner say (or are you aware) you kick or thrash about while asleep?
  7. Are you aware that you ever walk, eat, punch, kick, or scream during sleep?
  8. Are you sleepy or tired during much of the day?
  9. Do you usually take 1 or more naps during the day?
  10. Do you usually doze off without planning to during the day?
  11. How much sleep do you need to feel alert and function well?
  12. Are you currently taking any type of medication or other preparation to help you sleep?
  13. Do you have the urge to move your legs or do you experience uncomfortable sensations in your legs during rest or at night?
  14. Do you have to get up often to urinate during the night?
  15. If you nap during the day, how often and for how long?
  16. How much physical activity or exercise do you get daily?
  17. Are you exposed to natural outdoor light most days?
  18. What medications do you take, and at what time of day and night?
  19. Do you suffer any uncomfortable side effects from your medications?
  20. How much caffeine (eg, coffee, tea, cola) and alcohol do you consume each day/night?
  21. Do you often feel sad or anxious?
  22. Have you suffered any personal losses recently?

Many families will be unsure of how to answer some of these questions initially. So to get the best help from the doctors, it’s best to prepare ahead of time. I always recommend families try to keep a journal related to 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

Sometimes additional testing is necessary, such as a sleep breathing study to evaluate sleep apnea.

Based on the category of sleep problem, and the underlying causes that have been identified, the doctor should then be able to propose a plan for improving the 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.Still, certain general approaches have been found to improve the sleep of many people with dementia. These include:

  1. Outdoor light or bright light therapy during the day. Bright outdoor light helps keep the circadian signals (the body’s inner clock) 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.
  2. Increase daytime physical activityResearch has suggested that walking during the day can help improve nighttime sleep in people with Alzheimer’s.
  3. Optimize environmental cues for sleep. This means keeping the sleeping environment dark and quiet at night. This is especially important in nursing homes, which have sometimes been found to have staff active at night.
  4. Establish a regular routine with a consistent wake-up time. A regular routine can help maintain better sleep. The ideal is to have a consistent bedtime and wake-up time, but many experts believe it’s best to start by focusing on a consistent wake-up time.

research study published in 2005 found that training dementia caregivers to use these techniques in combination did lead to improved sleep of the care recipients with Alzheimer’s.

Medications and Sleep Problems in Dementia

You may be wondering whether medications can help manage sleep problems in dementia.

To begin with, it is important to check current medications and make sure they are not negatively affecting a person’s sleep. For example, sedating medications during the day may cause a person with dementia to sleep or nap too much, resulting in more awake time at night. Or a diuretic offered too late in the day might be causing extra 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 parent sleep better at night?”

It’s true that sleeping pills, sedatives, and tranquilizers exist, and they are often prescribed to help keep people with dementia quieter at night. These include antipsychotics like olanzapine, risperidal, and quetiapine, benzodiazepines such as lorazepam and temazepam, sleeping medications like zolpidem, or even over-the-counter sleep aids (which usually contain some form of sedating anti-histamine).

Unfortunately, all these medications are likely to cause concerning side-effects in people with dementia, namely worsening cognition and increased fall risk. The antipsychotics have also been associated with a higher risk of dying. Last but not least, comprehensive scientific review articles conclude that in clinical trials, these drugs do not conclusively improve sleep.

Hence, the recommendation of experts in geriatrics is 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.

That said, there are a few medications that may be less risky, and are sometimes used:

  • Melatonin: Melatonin is a hormone involved in the sleep-wake cycle. A Scottish study found that 2mg of melatonin nightly improved the sleep of people with Alzheimer’s. However, in the U.S. melatonin is sold as a poorly-regulated supplement, and studies have found that commercially sold supplements are often of questionable quality and purity. So melatonin may work less reliably here than in Europe.
  • Trazodone: Trazodone is an older weak anti-depressant 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.

To summarize, although medications are often used to manage sleep problems in dementia, most of them are pretty risky. So it’s better to avoid sedatives until you’ve exhausted all other options.

Non-drug approaches like plenty of outdoor light, regular exercise, a stable routine, optimizing chronic conditions, and checking for pain often help. Plus, these usually improve the person’s quality of life overall.

What have you found helpful for sleep problems related to dementia? Share your suggestions with us in the comments below.

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Leslie Kernisan, MD MPHAbout the Author

Leslie Kernisan, MD, is a practicing geriatrician who believes that it shouldn’t be so hard for older adults and families to get the right kind of help with health concerns. For more practical tips – and to get her free quick guide to checking aging parents – visit her new blog at HelpingOlderParents.com.

Editor Comment

Getting good restorative sleep is important in both treating patients with dementia and helping to prevent it. The deepest stages of sleep is when the brain decides what memories to store long term, does a lot of its house cleaning, and produces important hormones. According to numerous studies in mice, neurons actually shrink in size during deep sleep so cerebral spinal fluid can circulate more rapidly and flush out beta amyloid protein and other toxins that build up from cell metabolism during the day. We just have to extrapolate the mice studies to humans, because examining their brains would kill patients.

Besides writing at Modern Health Talk, I work with Dr. Bruce Meleski at Intelligent Sleep, a sleep wellness center in Austin, and I’d like to add perspective on Melatonin, referencing Dr. Russel J. Reiter and his book on the topic. Reiter is a professor at the University of Texas Health Science Center in San Antonio and is often referred to as the father of Melatonin.

Besides being the body’s most powerful antioxidant, Melatonin regulates the circadian rhythm and promotes sleep in response to darkness and the day/night cycle. Actually, it’s the blue part of the light spectrum between 450-500 nm that the pineal gland responds to, so avoiding all blue light at night helps. In the morning, bright sunlight or full-spectrum artificial lights suppresses Melatonin production to also help regulate the circadian rhythm.

I recently learned that the amount of Melatonin we produce decreases significantly with age, so taking supplements are advised. But Melatonin also has a half-life of only about an hour, so can help you fall asleep but not necessarily stay asleep. My pharmacy buddies recommend a long-lasting, time-release version, and that’s what my wife and I take. Because supplements lack rigid FDA oversight, make sure you get Melatonin from a reputable source.