Sleep changes in Alzheimer’s
Scientists do not completely understand why sleep disturbances occur in people with dementia. Sleep disturbances associated with Alzheimer’s disease include increased frequency and duration of awakenings, decrease in both dreaming and non-dreaming stages of sleep, and daytime napping. Similar changes occur in the sleep of older people who do not have dementia, but these changes occur more frequently and tend to be more severe in people with Alzheimer’s disease.
Some people with Alzheimer’s disease sleep too much while others have difficulty getting enough sleep. When people with Alzheimer’s cannot sleep, they may wander during the night, be unable to lie still, or yell or call out, disrupting the rest of their caregivers. Some studies have shown that sleep disturbances are associated with increased impairment of memory and ability to function in people with Alzheimer’s. There is also evidence that sleep disturbances may be worse in more severely affected patients. However, a few studies have reported that sleep disruption may also occur in people with less severe impairment.
Coexisting conditions may intensify sleep problems for older adults with Alzheimer’s. Two conditions in which involuntary movements interfere with sleep are periodic limb movement and restless leg syndrome. Other common conditions that disrupt sleep include nightmares and sleep apnea, an abnormal breathing pattern in which people briefly stop breathing many times a night. In a recent study, researchers at Stanford University Medical Center found that a gene associated with OSA is also associated with a higher risk of AD and other chronic illnesses such as heart disease.
Depression in a person with dementia may further worsen sleep difficulties
Shifts in the sleep-wake cycle of people with Alzheimer’s can be severe. Experts estimate that in the later stages of the disease, affected individuals spend approximately 40 percent of their time in bed awake and a significant proportion of their daytime hours asleep. This increased daytime sleep consists almost exclusively of light sleep that compensates poorly for the loss of deep, restful nighttime sleep. In extreme cases, people with dementia may experience complete reversal of the usual daytime wakefulness/nighttime sleep pattern.
Treatment of Alzheimer’s sleep problems
Although widely used medications can temporarily improve the sleep disturbances of older adults, a number of studies have found that prescription drugs do not improve overall ratings of sleep quality in older people, whether they are living in their homes or in residential care. Thus, the treatment benefits of using sleep medications in individuals with dementia may not outweigh the potential risks. To improve sleep in these individuals, the U.S. National Institutes of Health (NIH) has encouraged use of the nondrug measures described below rather than medication therapy unless the sleep disturbance is clearly related to a treatable medical condition. It is important that the person experiencing sleep problems be professionally assessed for medical or psychiatric causes for the sleep disturbance before applying any drug or nondrug interventions.
Non-drug treatments
A variety of nondrug treatments for insomnia have been shown to be effective in older adults. These treatments, which aim at improving sleep routine and the sleeping environment and reducing daytime sleep, are widely recommended for use in people with Alzheimer’s disease. To create an inviting sleeping environment and promote rest for a person with Alzheimer’s:
- Maintain regular times for going to bed and arising.
- Establish a comfortable, secure sleeping environment. Attend to temperature and provide nightlights and/or security objects. Keep your bedroom dark, quiet and a little cool for the best results. Move out any mirrors from the bed to avoid disturbing light reflection.
- Stick to rituals that help you relax each night before bed. This can include such things as a warm bath, a light snack or a few minutes of reading.
- Avoid as much as possible emotionally disturbing activities for several hours before sleep time, like reading horror books, listening current events on radio, planning for uncomfortable phone conversation, etc.
- Don’t take your worries to bed. Bedtime is a time to relax, not to hash out the stresses of the day.
- Do not stay in bed while awake; avoid utilizing bed for activities other than sleep or intimacy.
- If you awaken at night, do not watch television.
- Overall, keep daily TV exposure to a minimum, especially within the four-hour period before bedtime.
- Establish regular meal times.
- Do not go to bed on empty stomach, if you know that hunger may wake you up at the middle of night. However, stick to light meals only not to load your digestive system to work hard at night.
- Avoid alcohol, caffeine and nicotine. Caffeine in soda, tea, coffee or other products may contribute to sleeplessness, and alcohol can contribute to confusion and anxiety.
- Avoid excessive evening fluid intake and empty the bladder before retiring.
- Avoid daytime naps if you are having trouble sleeping at night. If you must snooze, limit the time to less than one hour and no later than 3 p.m.
- Treat any pain symptoms.
- Seek morning sunlight exposure. Light therapy with a specialized light box may be helpful, too.
- Engage in regular daily exercise, but no later than four hours before bedtime.
- If you take cholinesterase inhibitors (tacrine, donepezil, rivastigmine or galantamine), avoid nighttime dosing.
- Administer drugs such as selegiline that may have a stimulating effect no later than six to eight hours before bedtime.
- If sleep-disordered breathing is suspected, consider continuous positive airway therapy. This therapy involves the use of a machine that supplies the patient with a continuous stream of air. Studies have shown this therapy to be successful among Alzheimer's disease patients.
- If you can’t fall asleep, leave your bedroom and engage in a quiet activity. Return to bed only when you are tired.
Sleep Medications for Alzheimer's Patients
Drug therapy should be considered only after a nondrug approach has failed and reversible medical or environmental causes have been ruled out. For those people who do require medication, it is imperative to “begin low and go slow.” The risks of sleep-inducing medications for older people who are cognitively impaired are considerable. These include increased risk for falls and fractures, increased confusion, and decline in the ability to care for oneself. If sleep medications are used, an attempt should be made to discontinue them after a regular sleep pattern has been established.
The list of medications that treat sleep disorders is lengthy, and includes drugs ranging from tricyclic antidepressants, such as Pamelor or Aventyl (nortiptyline), to traditional sleeping pills like Ativan (lorazepam). Aricept (donepezil), a medication already approved to temporarily limit the progression of Alzheimer's disease, has also been shown to increase oxygen saturation in patients with Alzheimer's-related sleep disordered breathing.
Each medication has possible side effects that should be discussed with a physician prior to beginning treatment.
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