Dementia and Alzheimer's Series #6: Sleep

As often observed by the Home Care Aides of Support For Home, sleep disturbance is a major issue for many individuals with dementia, as well as their families.

Families of patients with dementia can often tolerate agitation, delusions, and wandering as long as nighttime sleep remains uninterrupted.  However, when behavioral disturbances occur day and night, families often feel compelled to resort to institutionalization.  Educating families about strategies for preventing or correcting sleep problems may help delay assisted living or skilled nursing facility placement.  Helping with such placements is what Senior Care Solutions does, but if we can help folks stay at home, that is great.

Many factors can contribute to poor sleep habits in persons with dementia, including disrupted sleep patterns, alterations in circadian rhythm, concurrent medical problems that cause frequent urination, daytime use of sedating medication, and frequent napping. In our experience, the chief causes of sleep disruption are frequent napping and excessive expectation of sleep needs.

Families often report that the patient wakes and dresses for morning activities at 3 AM. On further questioning, they may reveal that the patient naps while watching television during the day and goes to bed at 8 PM. In this common scenario, the patient's early morning awakening is not abnormal. Daily sleep requirements do not increase as a person ages, and the patient is often sleeping more than the 7 to 8 hours required for most persons to feel rested. In addition, caregivers often see the patient's nap time as an opportunity to accomplish tasks around the house. This is a shortsighted view that many come to regret.

The first step in reestablishing a normal sleep pattern is to limit daytime napping. Leaving a patient with dementia in front of a television set almost always leads to napping.  As an aside, the content of TV watched by a person with dementia must be monitored carefully, as violence or other content may be very disturbing to the patient, making sleep issues even worse.

To prevent the problem of napping in front of the TV, caregivers should engage patients in activities that are tailored to the degree of dementia, such as simple handicrafts, household tasks and, most important, regular physical exercise. Such activities can be carried out at home, but many patients and families benefit from the added structure of adult day care.

Once poor sleep hygiene has become established, it is much more difficult to eradicate. The first steps in correcting sleep problems are to set a more reasonable bedtime and prevent napping. The patient's activity level should be increased, and fluid intake should be decreased in the hours before bedtime. After a few difficult nights, the patient will begin to sleep for longer periods.

For families who cannot accept the possibility that the problem will worsen before improving, talk to the patient's doctor about the possibility of limited use of a hypnotic or sedating drug (e.g., trazodone, zolpidem tartrate, a short-acting benzodiazepine).  However, long-term reliance on sleeping medication, especially benzodiazepines, is rarely successful.  Again, a medical professional should be the decision maker concerning these approaches.

Environmental lighting may also have a role in sleep disturbance.  Light is an important modulator of circadian rhythms, which may be disrupted in dementia.  Increased lighting during afternoon and early evening hours may improve sleeping patterns.  In one sleep study on the effect of increased daytime illumination in 22 patients with dementia, improvement in the rest-activity rhythm occurred in patients with intact vision but not in visually impaired patients. A clinical trial assessing the efficacy of melatonin in the treatment of sleep disturbance in Alzheimer's disease is under way, but results are not yet available.

The most difficult part of managing sleep problems is the need for continued adherence to a rigid schedule.  Families should be taught that periodic disruption of the schedule will likely result in a return to irregular sleep patterns.  A doctor's prescription for use of a hypnotic agent for periodic administration is helpful and provides families with a sense of control.

Best wishes,

Carol Kinsel, Senior Care Solutions

 
 
 
 
 
Bert Cave, Support For Home