Alzheimer’s disease, the most prevalent form of dementia, often leads to disruptions in sleep patterns, causing distress for both care recipients and caregivers. Sleep disturbances in dementia not only affect the quality of life of care recipients but also present significant challenges for caregivers.
Although medications seem to be the default treatment for sleep disturbances, it’s important to remember that pharmacological interventions are not the only solution to help manage sleep disturbances among those living with dementia.
For those living with dementia, it is probably even more important to take some serious time to understand the side effects of sleep medications (or any medication, for that matter) on a person’s cognitive status or impairment. Older adults tend to take other medications (i.e., polypharmacy) and these drug interactions should also be considered to ensure that the “pros” (eg., being able to sleep/uninterrupted sleep) far outweigh the “cons” (e.g., confusion, drowsiness and risk for falls).
Possible Causes of Sleep Disturbances Among People Living with Dementia
As dementia progresses, it can lead to damage in brain regions responsible for regulating sleep-wake cycles. Disrupted neuronal networks can impair the production and regulation of sleep-related hormones, including melatonin, leading to irregular sleep patterns.
Circadian Rhythm Disruption
Circadian rhythms play a pivotal role in regulating sleep-wake cycles. Dementia often disrupts the body’s internal clock, causing individuals to experience daytime drowsiness and nighttime restlessness. This circadian rhythm disruption can result in confusion about day and night, further exacerbating sleep problems. According to a study, “The Relationship Between Dementia Severity and Rest/Activity Circadian Rhythms” published in the journal Neuropsychiatric Disease Treatment, while individuals with normal brain physiology follow a normal sleep-wake cycle, those diagnosed with dementia lack these patterns. This also explains why people with dementia tend to wander at night and the possible mechanism behind sundowning.
Many medications prescribed for dementia management, such as antipsychotics and sedatives, can contribute to sleep disturbances, such as insomnia. While these medications aim to manage behavioral symptoms, they can have unintended side effects on sleep patterns. Healthcare providers must carefully consider the benefits and risks of these medications when treating individuals living with dementia. Additionally, polypharmacy without consideration of the stage of dementia, combined with the undesirable effect of insomnia, can also increase the risk for falls among older adults.
Behavioral and Psychological Symptoms
Behavioral and psychological symptoms of dementia (BPSD), including agitation, aggression, and anxiety, can manifest during nighttime hours, disrupting sleep for both care recipients and caregivers. These symptoms may be triggered by various factors, including environmental changes, stress, or pain, making it essential to identify and address their underlying causes.
Whenever possible, the use of medications should be considered as a second line treatment for managing sleep disturbances. It is important to understand the cause of the sleep pattern changes and address the cause and not merely the symptom.
What is the reason for the behaviour (ie., unable to sleep at all or have uninterrupted sleep at night)?
Did something happen recently that is causing the person some level of worry or anxiety?
For residents in long term care homes, is it because a new resident has moved in and is making noise at night that could be the cause of the sleep disruption?
Pain and Discomfort
Undiagnosed or unmanaged pain is a frequently overlooked contributor to sleep disturbances in people living with dementia. Communication difficulties often lead to pain being underreported, making it crucial for caregivers to be vigilant in monitoring for signs of discomfort. Addressing pain can significantly improve sleep quality.
The environment in which a person with dementia lives can greatly impact their sleep. Factors such as excessive noise, inadequate lighting, uncomfortable bedding, and improper room temperature can all disrupt sleep. Creating a comfortable and soothing sleeping environment can help alleviate these issues.
Individuals with dementia are not immune to common sleep disorders, such as sleep apnea and restless leg syndrome. These disorders can exacerbate existing sleep disturbances and should be evaluated and treated by healthcare professionals.
Knowing some of these possible causes can help caregivers come up with non-pharmacological approaches they can try to manage sleep disturbances in the person they are caring for.
Non-Pharmacological Approaches to Managing Sleep Disturbances
Establish a Consistent and Regular Routine
One of the most effective ways to manage sleep disturbances in people with dementia is to establish a consistent daily routine. A regular schedule can help regulate the body’s internal clock and promote better sleep patterns. Ensure that meals, physical activities, and bedtime occur at the same time each day. This routine provides a sense of security and predictability, reducing anxiety and restlessness that often accompany dementia.
Create a Comfortable Sleep Environment
A comfortable sleep environment is essential for promoting restful sleep. Pay attention to factors such as room temperature, lighting, and bedding. Maintain a comfortable room temperature and use blackout curtains to block out excessive light. Ensure that the bed is comfortable and that the room is quiet to minimize disruptions during the night.
Encourage Physical Activity
Regular physical activity during the day can help people with dementia sleep better at night. Engaging in activities like walking, gentle exercises, or gardening can promote relaxation and reduce restlessness. However, avoid vigorous exercise close to bedtime, as it may have the opposite effect and disrupt sleep.
Limit Stimulants and Caffeine
Stimulants like caffeine and nicotine can interfere with sleep patterns. It’s crucial to monitor and limit the intake of these substances, especially in the hours leading up to bedtime. Encourage decaffeinated beverages and snacks in the evening to help the person wind down.
Monitor Diet and Nutrition
Maintaining a healthy diet can contribute to better sleep in people with dementia. Avoid heavy, spicy, or large meals close to bedtime, as they can cause discomfort and disrupt sleep. Instead, opt for a light, balanced snack if necessary. Additionally, consider foods rich in sleep-promoting nutrients, such as melatonin and tryptophan, like bananas and warm milk.
Sundowning, a phenomenon where individuals with dementia become agitated or restless in the late afternoon or evening, can severely affect sleep. To manage sundowning, engage in calming activities during this time, such as reading, listening to soothing music, or practicing relaxation techniques like deep breathing exercises.
Create a Relaxing Bedtime Routine
Establishing a calming bedtime routine can signal to the person with dementia that it’s time to wind down. Activities like gentle massage, warm baths, or listening to calming music can be part of this routine. The goal is to create a relaxing atmosphere that promotes sleep.
Excessive daytime napping can disrupt nighttime sleep patterns. Encourage short, early afternoon naps if needed, but avoid late-afternoon or evening naps, as they can make it challenging to fall asleep at night.
Engage in Cognitive Stimulation
Mental stimulation is essential for individuals with dementia, but it’s crucial to strike a balance between daytime engagement and nighttime rest. Engage in stimulating activities earlier in the day and gradually transition to more calming and soothing activities as bedtime approaches.
Provide Comfort and Reassurance
People with dementia may experience confusion and anxiety, particularly at night. Offer comfort and reassurance if they wake up during the night. Gently guide them back to bed, provide a glass of water if needed, and use soft, comforting words to reassure them.
If medications are prescribed for dementia or other health conditions, consult with a healthcare professional to ensure that they are not contributing to sleep disturbances. Some medications can affect sleep patterns, and adjustments may be necessary.
Sleep Disturbance is a Behaviour and There is Always a Reason Behind the Behaviour
Pharmacological interventions are sometimes necessary in managing behaviour and may help in normalizing sleep patterns. However, for people living with symptoms of dementia, it is important to dig deeper into understanding what is/are the underlying causes of the behaviour.
Worry or anxiety about something or someone, or decorations in the building reminding them that Christmas is just around the corner, could be triggers for a person with dementia that can cause sleep disturbances. Medications may make them feel drowsy or tired, but it does not address the underlying cause of the sleep disturbances.
Instead of immediately providing drugs to help the person sleep, consider maybe assisting them in making a phone call to a family member or playing relaxing music to not only provide a calm and peaceful environment conducive for sleeping, but also mask the noise from outside that’s preventing them from sleeping.
Investigating the reason behind the behaviour takes time and patience, but it is certainly worth the investment. The person we are caring for may lack the capacity to communicate what they are thinking and feeling. However, they are often trying to tell us something… and that is through their behaviour.
Karen Tyrell CPCA, CDCP is a Dementia Consultant, Educator, Author & Advocate, and Founder of Personalized Dementia Solutions Inc. (www.DementiaSolutions.ca). Karen offers her expertise on dementia care through speaking engagements; workshops; support groups (both online and in-person) and by working one-on-one with families/caregivers to provide emotional support and practical solutions. She was also on the design team for The Village Langley (Verve Senior Living) and provides ongoing education to the Village team, families and the community. If you would like to learn more, please feel free to reach out.
The contents of this blog are provided for information purposes only. They are not intended to replace clinical diagnosis or medical advice from a health professional.