Dementia and sleep problems often go hand in hand. Scientists do not fully understand why this happens. However, they agree that it results from the changes to the brain caused by the diseases associated with dementia. When your loved one with dementia doesn’t sleep well, you probably don’t get enough sleep either. Change in sleeping patterns is, therefore, often a common source of stress for family carers.
Lack of sleep can also exacerbate the symptoms of dementia. It can affect physical health, lower immunity, and increase the risk of high blood pressure, diabetes, heart attack, and stroke.
As we all know, if someone in the house is up, usually everyone is awake, and this can end up taking a toll on relationships, well-being, and quality of life. Identifying and finding ways to treat disruption in sleep patterns is, therefore, a crucial part of living and caring well at home with dementia.
In this article, we look at some practical steps that can help your loved one sleep well at night, as well as consider some of the reasons why family members with dementia have issues surrounding sleep.
What measures can be implemented to promote a good night’s sleep?
We all need a good night’s sleep. Often, when caring for a family member with dementia, it can be a case of trial and error. However, if we have some guidelines, we can at least make some headway in combating the problems caused by lack of sleep.
Here are some tips that may help.
- Take care of any unmet needs. Often people may not sleep because they are hungry, are in pain, or even need to use the bathroom. They may be uncomfortable or too cold, or too warm. So, as a first pass, it’s important to ensure all of these needs are met. Often a person with dementia may be agitated or restless but unsure of why and unable to tell us. So a process of elimination can do wonders to seek out and resolve a problem with a simple fix.
- Address any underlying condition. Sleep disorders like restless leg syndrome (RLS) and Obstructive sleep apnea (OSA) could be causing sleep disturbances. Speaking to your doctor about this may help in exploring treatment options.
- Manage medications. Some medications like donepezil (used to help improve cognitive function) can cause insomnia. Taking this medication no later than evening mealtime can help.
- Limit daytime napping. Napping during the day is normal for older adults. However, if it becomes too much, it can reduce sleepiness at night. Limiting long periods of daytime napping can help. Doing enjoyable activities and keeping active during the day can also help reduce daytime sleepiness.
- Establish sleep routines. Establishing a set sleep and wake routine can help immensely. Rituals associated with going to bed at night can help establish daytime versus nighttime. Doing the same procedure night after night, such as getting into bed clothes and brushing teeth, can help in cementing the process of sleep time. Avoiding television and electronic devices before bed, as they can emit blue light that interferes with sleep, is also a good idea.
- Stay away from stimulants. Alcohol and caffeine are anti-sleep beverages. You should avoid drinking them a few hours before bedtime.
- Set the mood. Establishing a nightly relaxation routine for bedtime is helpful. This can include simple things like playing soothing music, taking a warm shower, dimming bright lights, or having a small, warm caffeine-free drink. All these practices will signal the body that it’s time to rest and emphasise that nighttime has come, a time separate from the daytime. In the morning, if possible, establishing a routine of going outside into natural daylight can help set the body’s biological clock for the day ahead.
- Ensure the bedroom is dementia-friendly. Steps can be taken to ensure the sleeping area is dementia-friendly. A dark, quiet, comfortable bedroom promotes sleep—some people with dementia benefit from having well-loved objects near their beds. Use blackout blinds to block out light at night when sleeping. This also helps eliminate shadows of moving trees and branches outside windows at night which can be distressing for people with dementia who may think it is someone outside. If total darkness is not calming, add night lights to create a sense of security. Night lights can also help with night-time trips to the bathroom and returning to bed quickly to resume sleep. A dementia-friendly clock can ensure the person knows what time it is if they awaken during the night. Clearing the room of daytime clothes that may prompt someone to get up and dressed can also help.
- Add light exposure: Light is a key regulator of circadian rhythm, so if possible, getting natural light during the day can help with sleep at night. If natural light is limited due to weather or other factors, indoor bright light therapy may help. Consider the use of light therapy to help reduce sleep disturbance. A pilot study by Ecumen found that light therapy improved night-time sleep and reduced agitation in people with dementia.
- Medication. Medications are considered a last resort for people with dementia. They present risks, including increased confusion, sedation, and risk of falling. However, if non-pharmacological approaches aren’t working, the doctor may recommend sleeping tablets until a regular pattern is established. The medication can then be discontinued.
- Sleep videos and apps. There are lots of great youtube videos and apps with relaxing music to help get a good sleep. This may not be suitable for everyone with dementia, but it is worth a try. Some videos with relaxing music and accompanying images for people with dementia can also be found here.
Sleep Disruption Issues that may affect People with Dementia
Sometimes when we are dealing with a particular problem, it can help to know a little bit of the background. Here are some of the problems that affect people with dementia with regard to sleeping well:
Normal Aging Process
As we age, our sleep patterns change. These changes to our regular sleeping and waking times shift to become earlier. We take longer to fall asleep. Our sleep is more disrupted, and we sleep fewer hours. In people with dementia, these changing sleep patterns are more pronounced and disruptive.
(Credit: National Sleep Foundation)
Changes in the sleep-wake cycle
Although more research is needed, scientists believe that as dementia progresses, the brain’s pathophysiological processes change the sleep-wake cycle. Fragmented sleep during the night leads to something many of you might be familiar with – lots of daytime naps! This extra daytime sleepiness is your loved one trying to compensate for lost sleep at night.
Circadian Rhythm / Cycle
The circadian rhythm is a natural, internal process that regulates the sleep-wake cycle. It repeats approximately every 24 hours. The central pacemaker of our circadian timing system is the Suprachiasmatic Nucleus (SCN), a tiny region of the brain in the hypothalamus. It is thought that people with Alzheimer’s disease may have damaged cells in their SCN. You can read more about circadian rhythm here.
(Credit: NIGMS)
Melatonin Hormone
Melatonin is a hormone primarily released by the pineal gland at night and has long been associated with controlling the sleep-wake cycle. Its main function is to convey information to different body parts about light and day so they can perform their tasks accordingly. As we age, our bodies make less melatonin. However, Melatonin production is particularly impaired in those with Alzheimer’s and other dementias.
(Credit: Brainwise: Sandhills Neurologists)
Proteins in the Brain
In Alzheimer’s disease and other forms of dementia, brain cells that process, store, and retrieve information deteriorate and die. Scientists believe that the abnormal build-up of two sets of proteins, known as Beta-Amyloid and Tau, in and around the brain plays a crucial role in this degeneration and, accordingly, the onset and progression of Alzheimer’s Disease.
In a recent study, researchers considered the question, “Is sleep disturbance a cause or a consequence of Alzheimer’s disease?”. The study concluded that it could be both. If we look at how these two proteins affect the progression of dementia, we can begin to understand why.
Beta-Amyloid: This large membrane protein usually plays an essential role in neural growth and repair. However, a corrupted form can destroy nerve cells later in life, leading to the loss of thought and memory in Alzheimer’s disease. Studies show that accumulation of the beta-amyloid protein can lump together and form amyloid plaques which then interfere with communication between brain cells.
Beta-amyloid is a byproduct secreted between brain neurons (cells) when you’re awake. If you get enough sleep, your body gets sufficient time to excrete the byproducts, and by the time you wake up, you’re refreshed, keeping your brain healthy. But if you start to get less sleep, Beta-amyloid builds up and impairs brain functions. A study into sleep found that an increase of 5% of beta-amyloid was present in the brains of healthy individuals after just one night of sleep deprivation.
Although more research is needed, scientists believe that a lack of sleep compounds the progression of Alzheimer’s disease as lack of sleep results in a decrease of the flushing out of beta-amyloid, and so the build-up continues.
Tau: Alzheimer’s also involves a brain protein called tau, which helps regulate healthy signaling between brain cells. People with Alzheimer’s disease have tangles of tau protein in their brains, indicating damage to nerve cells. As little as one night’s sleep deprivation can increase tau levels by as much as 50% in cerebrospinal fluid. As with beta-amyloid, a good night’s sleep clears excess tau.
In short, Alzheimer’s disease is linked to an excess of beta-amyloid and tau in the brain. If someone with Alzheimer’s disease is not sleeping enough, the build-up of beta-amyloid and tau is compounded, resulting in an acceleration of Alzheimer’s disease.
Sleep Cycles
During normal sleep, our bodies cycle through a series of 4 sleep stages;
(Credit: verywellhealth.com)
REM sleep (Stage 4) is believed to be essential for functions such as memory and learning. People with dementia spend less time in REM sleep and more time in the earlier stages of sleep, and this reduction in REM sleep can worsen as dementia progresses.
What are sleep disorders common in people with dementia?
People with Alzheimer’s are frequently affected by common sleep disorders. The following are some sleep disorders common in older people but with even higher rates for people with dementia:
- Restless Legs Syndrome (RLS): a sleep disorder where people have an overwhelming itchy desire to move their legs.
- Periodic limb movement disorder (PLMD): causes uncontrollable movements of the arms and/or legs at night.
- Obstructive Sleep Apnea (OSA): a condition where the throat muscle temporarily relaxes and collapses, closing the airway temporarily. When this happens, gasping for air will wake you.
- REM sleep behavior disorder: causes people to act out their dreams, sometimes in dangerous ways. It is often found in people with Lewy body dementia and can be the first symptom of this type of dementia.
Although not classified as a disorder as such, people with dementia can also experience the following:
- Sundowning: a phenomenon in which people with dementia experience increased agitation later in the day and the evening. It can lead to symptoms such as confusion, anxiety, wandering, and yelling. Sundowning can contribute to insomnia and other sleep problems when upset continues into the night. Possible causes of sundowning include the circadian rhythm changes that occur in dementia. People with dementia may also talk or cry out at night if they cannot sleep. Some people may wander around the house at night or, worse still, away from their homes, which is particularly dangerous at night.
Thank you for reading.
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Please also check out our other articles on self-care for family carers and therapeutic interventions for people with dementia.