Sleep Disturbance in Alzheimer’s Disease and Related Disorders
People with Alzheimer’s disease and related disorders (ADRD) often have problems with sleeping or may experience changes in their sleep schedule. Scientists do not completely understand why these sleep disturbances occur, but as with changes in memory and behavior, the impact of disease on the brain can result in changes in sleep.
Common Sleep Changes
As we age, nearly everyone experiences changes in their sleep. Sleep disturbances occur more frequently and tend to be more severe in Alzheimer’s disease.
Sleep changes in Alzheimer’s disease can occur at any stage and may include:
Difficulty sleeping: Many people with dementia wake up more often and stay awake longer during the night. Those who cannot sleep may wander, be unable to lie still, or yell or call out, disrupting the sleep of their caregivers.
Shortened sleep stages: Brain wave studies show decreases in both dreaming and non-dreaming sleep stages.
Daytime napping and other shifts in the sleep-wake cycle: Individuals may feel very drowsy during the day and then be unable to sleep at night. They may become restless or agitated in the late afternoon or early evening, an experience often called “sundowning.” In extreme cases, people may have a complete reversal of the usual daytime wakefulness-nighttime sleep pattern. Experts estimate that in late stages of Alzheimer’s, individuals spend about 40 percent of their time in bed at night awake and a significant part of their daytime sleeping.
Contributing medical factors
Anyone experiencing sleep disturbances should have a thorough medical exam to identify any treatable illnesses that may be contributing to the problem. Examples of conditions that can make sleep problems worse include:
Depression
Restless leg syndrome, a disorder in which unpleasant “crawling” or “tingling” sensations in the legs cause an overwhelming urge to move them
Sleep apnea, an abnormal breathing pattern in which people briefly stop breathing many times a night, resulting in poor sleep quality
Strategies for Managing Sleep Changes
For sleep changes due primarily to Alzheimer’s disease, there are non-drug and drug approaches to treatment. Most experts and the National Institutes of Health (NIH) strongly encourage use of non-drug measures rather than medication. Studies have found that sleep medications generally do not improve overall sleep quality for older adults. Use of sleep medications is associated with a greater chance of falls and other risks that may outweigh the benefits of treatment.
Non-Drug Treatment for Sleep
Non-drug treatments are called Sleep Hygiene and aim to improve sleep environment and routine, and reduce daytime napping. Non-drug coping strategies should always be tried before medications, since some sleep medications can cause serious side effects.
Recent evidence suggests that so-called “white noise” can help people fall asleep more efficiently. Numerous electronic devices are now available for consumers, and The New York Time’s Wirecutter has a summary that will help you understand the options: The Best White Noise Machine.
Phone apps are also available for white noise generation. Wirecutter recommends myNoise, a white noise app for iPhone and Android, as well as several other apps, and the SleepFoundation.org website has a list of apps for better sleeping.
Sleep Hygiene
To create an inviting sleeping environment and promote rest for a person with ADRD, follow these recommendations:
Maintain a routine with as much regularity as possible; keep regular times for meals, going to sleep, waking up, and getting out of bed for the day.
Seek morning sunlight exposure.
Keep the daytime “active” and the nighttime “quiet”; you may need to organize activities to keep your loved one cognitively engaged and less likely to catnap during the day.
Encourage regular daily exercise, but no later than four hours before bedtime.
Avoid alcohol, caffeine and nicotine, and avoid drinking water after dinnertime (only “sips after 6”).
Treat any pain.
If the person is taking a cholinesterase inhibitor (donepezil, rivastigmine or galantamine), avoid giving the medicine immediately before going to sleep.
Make sure the bedroom temperature is comfortable.
Provide nightlights and security objects.
If the person awakens, discourage staying in bed while awake; do some relaxing activity until they feel sleepy, then return to bed; use the bed only for sleep.
Discourage watching television in bed, especially during periods of wakefulness overnight.
Medications for sleep changes
In some cases, non-drug approaches fail to work or the sleep changes are accompanied by disruptive nighttime behaviors. When that happens, seeking help from your primary care provider or memory specialist is critical. Before the appointment keep a “sleep diary” and bring it to the appointment: Write down details about your loved one’s sleep for one week, including the total time sleeping, the time they spend awake, and any known triggers that awaken them.
Avoid over-the-counter sleep medications that often contain the chemical diphenhydramine (aka “Benadryl”). This chemical is known to be risky for older adults.
The risks of sleep-inducing medications for older people who are cognitively impaired are considerable. They include increased risk for falls and fractures, confusion and a decline in the ability to care for oneself. For those individuals who do require medication, experts recommend that treatment “begin low and go slow.” Once a regular sleep pattern has been established, an attempt should be made to discontinue the medication or reduce the dose required.
Keep a Sleep Diary for Your Loved One
If your loved one has problems sleeping, try keeping a “sleep diary”: Write down details about your loved one’s sleep for two weeks, including the total time sleeping, the time they spend awake, and what woke them up in the morning. Then when you talk to a doctor about sleep issues, bring the diary to the appointment. You can download and print sleep diary worksheets from UCLA and the Sleepfoundation.org, or use the form below:
Please talk with your own/loved one’s healthcare provider before using any of this information.
