How to Get Your Loved One With Dementia to Sleep

(This article appeared previously on APlaceforMom.com.)

Sleep problems are common in Alzheimer’s and other dementias. They also commonly drive family caregivers crazy, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well.

To make matters even worse, not getting enough sleep can worsen the thinking or behavior of someone with dementia.

But as I explain below, research has found that it is often possible to improve sleep in dementia. The key is to know what common causes to look for and come prepared to provide useful information to the doctor about dementia and sleep.

There are several factors that can cause older adults with dementia to have sleep problems:

• Heart and lung conditions, such as heart failure or chronic obstructive pulmonary disease
• Stomach-related conditions such as gastroesophageal reflux disease
• Chronic pain from arthritis or another cause
• Urinary conditions that make people prone to urinating at night, such as an enlarged prostate or an overactive bladder
• Mood problems, such as anxiety or depression
• Medication side effects, and substances such as alcohol (which is known to disrupt sleep)
• Chronic medical conditions and medications often affect sleep. Studies have found that older adults often experience “secondary” sleep difficulties, which means that the sleep problems are being caused by an underlying health problem. Many people diagnosed with Alzheimer’s have additional chronic health problems that may be associated with sleep difficulties. Common causes of secondary sleep problems include:

• Many sleep-related disorders become more frequent with aging. Examples: sleep apnea and related conditions (known as sleep-related breathing disorders), which may affect 40 to 50 percent of seniors, as well as restless leg syndrome.

• Alzheimer’s and other neurodegenerative diseases change sleep. The brain deterioration associated with various forms of dementia tends to affect the way the brain sleeps. In most cases, this causes less deep-sleep time and more awake time at night. Problems with the circadian rhythm system also become more common in dementia. Furthermore, Lewy body dementia and Parkinson’s dementia are also associated with REM sleep behavior disorder, which can cause violent movements during sleep.

To start helping doctors address your loved one's dementia-related sleep issues, you need to understand what kinds of symptoms and problems he or she is experiencing.

Check the following list of questions that a group of geriatrics experts recommends for evaluating sleep problems. An additional 10 questions are contained in the journal article here. (These are addressed to the patient.)

1. What time do you normally go to bed at night? What time do you normally wake up in the morning?
2. Do you often have trouble falling asleep at night?
3. About how many times do you wake up at night?
4. If you do wake up during the night, do you usually have trouble falling back asleep?
5. Does your bed partner say (or are you aware) that you frequently snore, gasp for air or stop breathing?
6. Does your bed partner say (or are you aware) you kick or thrash about while asleep?
7. Are you aware that you ever walk, eat, punch, kick or scream during sleep?
8. Are you sleepy or tired during much of the day?
9. Do you usually take one or more naps during the day?
10. Do you usually doze off without planning to during the day?
11. How much sleep do you need to feel alert and function well?
12. Are you currently taking any type of medication or other preparation to help you sleep?

I always recommend families try to keep a journal related to these questions for at least a week. Some families may also be able to use a sleep tracker or activity tracker to gather useful information.

Based on what the answers reveal, and after conducting an in-person examination to check for other medical issues, a doctor should be able to place the sleep difficulties in one (or more) of the following categories:

• Difficulty falling or staying asleep
• Excessive daytime sleepiness
• Abnormal breathing patterns during sleep
• Abnormal movements or behaviors during sleep

Sometimes, additional testing is necessary, such as a sleep breathing study to evaluate sleep apnea.

Based on the category of sleep problem and the underlying causes that have been identified, the doctor should be able to propose a plan.

The exact approach will depend on which underlying factors are causing the problems. Still, certain general approaches have been found to improve the sleep of many with dementia. These include:

• Outdoor light or bright light therapy during the day  Bright outdoor light helps keep the circadian signals on track. For older adults who can’t get outside for at least an hour per day, bright light therapy with a special lamp might help. A study found that bright light therapy in Alzheimer’s patients improved sleep.
• Increasing daytime physical activity  Research has suggested that walking during the day can help improve nighttime sleep in people with Alzheimer’s.
• Optimizing environmental cues for sleep  This means keeping the sleeping environment dark and quiet at night. This is especially important in nursing homes, which have sometimes been found to have staff active at night.
• Establishing a regular routine with a consistent wake-up time  The ideal is to have a consistent bedtime and wake-up time, but many experts believe it’s best to start by focusing on a consistent wake-up time.

A research study published in 2005 found that training dementia caregivers to use these techniques in combination led to improved sleep of the care recipients with Alzheimer’s.

It is also important to check medications and make sure they are not negatively affecting a person’s sleep. For example, sedating medications during the day may cause a person with dementia to sleep or nap too much, resulting in more awake time at night. Or a diuretic offered too late in the day might be causing extra nighttime urination.

As a caregiver, you may simply want to know: “Isn’t there a medication we can give in the evening to help my parent sleep better at night?”

It’s true that sleeping pills, sedatives, and tranquilizers are often prescribed to help keep people with dementia quieter at night. These include antipsychotics like olanzapine, risperdal, and quetiapine, benzodiazepines such as lorazepam (Ativan) and temazepam, sleeping medications like zolpidem (Ambien) or even over-the-counter sleep aids (which usually contain some form of sedating antihistamine).

Unfortunately, all these medications are likely to cause concerning side effects in people with dementia, namely a worsening sleep cognition and increased fall risk. The antipsychotics have also been associated with a higher risk of dying. What's more, comprehensive scientific review articles conclude that in clinical trials, these drugs do not conclusively improve sleep.

That's why experts in geriatrics recommend generally avoiding these medications, using them only as a last resort once behavioral approaches (e.g. setting a routine, more walking, etc.) have been tried.

That said, there are a few medications that may be less risky, and are sometimes used:

• Melatonin is a hormone involved in the sleep-wake cycle. A Scottish study found that 2 mg of melatonin nightly improved the sleep of people with Alzheimer’s. However, in the U.S., melatonin is sold as a poorly regulated supplement and studies have found that commercially sold supplements are often of questionable quality and purity. So melatonin may work less reliably here than in Europe.
• Trazodone is an older weak antidepressant that is mildly sedating. It has long been used by geriatricians as a “sleeping pill” of choice, since it seems to be less risky than the alternatives. A small 2014 study found that trazodone improved sleep in Alzheimer’s patients.

It’s better to avoid sedatives until you’ve exhausted all other options. Non-drug approaches like plenty of outdoor light, regular exercise, a stable routine, optimizing chronic conditions and checking for pain often help. Plus, these usually improve the person’s quality of life overall.

Leslie Kernisan, MD, is a practicing geriatrician in San Francisco who believes that it shouldn’t be so hard for older adults and families to get the right kind of help with health concerns. She's the author of When Your Aging Parent Needs Help and the founder of the website and podcast Better Health While Aging and the Helping Older Parents online programs. Read More