The night is lonely, dark, and full of unknown sounds and shadows. For someone with Alzheimer’s disease or another form of dementia, telling the difference between reality and a nightmare can be impossible. Imaging waking within an hour every time you fall asleep, confused, not knowing where you are.
Bad sleep at night means more difficult days. Anxiety and aggravation increase. And if a person naps while the sun’s up to account for a bad night, the result is sleeplessness after sunset and the terrible cycle beginning anew. Sleep is yet another complicated consideration for caregivers of loved ones with dementia. What can be done when it’s time for bed?
Studies suggest that more than half of patients with Alzheimer’s or other dementia have issues sleeping throughout the night. And it can be paradoxical, as someone who seems tired during the day will suddenly, come nightfall, be restless and even wide-awake.
An unfortunate consequence of aging, even if the brain remains relatively healthy, is that sleep becomes harder. The quality of most people’s sleep gradually deteriorates as we age. Deeper sleep is important for mental health (some studies have suggested that someone who has difficulty sleeping is more at risk to develop Alzheimer’s), and the older we get the more difficult it is to fall into a state of deep sleep. While elderly people tend to sleep more, sometimes as many as 14 hours per day, it is rarely restorative deep sleep. They are more likely to wake for reasons including discomfort and having to use the bathroom.
Insomnia is much worse for people with dementia, many of whom cannot get more than an hour or two of continuous sleep before waking, often disoriented.
In short, persons with early to mid-stage Alzheimer’s or other dementias do not require more sleep than healthy individuals of the same age. However, in practice, the quality of the sleep they experience can be very poor. To accommodate for the poor sleep, many individuals will sleep more hours.
Someone with dementia is already suffering with an inability to process the surrounding world, but imagine adding drowsiness to the equation. Not getting enough sleep, even in healthy brains, causes tension and moodiness; in someone with dementia, the effects are magnified and devastating. Feeling tired provokes aggressive outbursts, and moodiness can reach the level of full-blown depression. Mistakes become more common, even dangerous, as an elderly person is much more likely to fall or suffer an accident after a bad night’s sleep.
Days obviously become more difficult after lousy sleep, as moodiness, anxiety and aggravation are more likely. Caregivers are advised, however, not to compensate for a bad night’s sleep by allowing a person with dementia to sleep throughout the day.
Our “circadian rhythms” are the physical and mental cycle of the day, incorporating wakefulness and metabolism. Also known as the “internal biological clock,” circadian rhythms are thrown out of whack by dementia as the innate sense of day and night is lost along with the ability to think clearly. The result is, at least, confusion—people with dementia can be confused about whether it’s day or night, even if they can plainly see whether the sun is up or down. For these reasons, working to maintain a sleep routine is important, despite the difficulties. (See tips below.)
Seemingly excessive sleep may be unavoidable. As symptoms of dementia become more severe, especially in the later stages of the disease, sleeping more during both day and nighttime is common. This is because as brain function deteriorates the body loses strength, turning simple actions, like merely listening and trying to communicate, into exhausting ordeals that sap strength.
It is also possible that medications, particularly antipsychotics and antidepressants, will cause side effects that include increased sleepiness.
If someone in the earlier stages of dementia is unexpectedly sleepier than normal, it is important to speak with a doctor. Difficulty sleeping, rather than excessive sleep, is much more common in early-stage dementia, and drowsiness may indicate something else is wrong, like infection or adverse reactions to medication.
Studies have indicated that Dementia with Lewy Bodies (DLB), a form of dementia associated with how the brain processes protein, has shown higher rates of drowsiness during the day than Alzheimer’s or other dementias. Tiredness in these cases can be unrelated to how well a person slept the night before.
People with Alzheimer’s and other dementias lose their circadian rhythm, explained above as our internal sense of night and day. This means that even in the evening someone might believe it’s morning and therefore not an appropriate time to go to bed. Someone exhausted from a long day can lose the ability to understand when it’s time to sleep, and so despite a tired body sending signals craving bedtime, a dementia-racked mind will override those signals. The result of this is aggravation and anxiety. Wandering and even yelling at night is not uncommon.
There are other common reasons someone with dementia has trouble sleeping. As the sense of reality deteriorates, less lighting means more shadows can make the environment frightening. Restless leg syndrome, common for people with dementia, causes unpleasant crawling or tingling sensations and strikes typically during periods of rest, especially at night.
Another important factor for caregivers to consider is that their loved one may be sensitive to nonverbal cues indicating frustration at the end of a long day. It would be ideal to mellow as nighttime approaches, but caregiving is stressful, and if the day has been difficult it can be hard to hide its effects. This can cause an aggravated response in someone with dementia, and make it more difficult to go to sleep.
Sleep apnea is a potentially serious disorder in which breathing repeatedly stops and starts during sleep. This can be because of relaxing muscles in the throat or a problem with signals from the brain, and researchers have found that a gene associated with Alzheimer’s disease is also prevalent in cases of sleep apnea. The genetic link means sleep apnea is another potential cause of restlessness at night for people with Alzheimer’s or other dementia, as sleep apnea’s side effects include waking throughout the night and subsequent daytime fatigue.
Treatments for sleep apnea can be as simple as taking muscle relaxers, sleeping on one’s side, or losing weight, but in cases involving dementia it’s of course more complicated. Continuous positive airway pressure (CPAP) machines, a mask worn while sleeping at night, are often prescribed for sleep apnea but may not be viable for late-stage dementia sufferers because of nighttime confusion. Special dental appliances and surgery are also options, but bring their own complications. If your loved one with dementia suffers from sleep apnea, consult with a doctor about treatment options.
A study of Alzheimer’s patients and CPAP machines conducted by the University of California, San Diego found that people in the early stages of Alzheimer’s could tolerate sleeping with their masks for about five hours nightly, and also demonstrated mild cognitive improvement.
Sundowning is a term for increasing anxiety, confusion, or aggression at the end of the day, reported in roughly 20 percent of people with Alzheimer’s. The exact reason sundowning occurs is not medically established. Someone with Alzheimer’s may simply be more tired. It’s also possible that the difficulties of caregiving become less tolerable at the end of long days, so caregivers themselves are more sensitive in late evenings to anger and moodiness from a loved one in cognitive decline; sundowning has been reported as a common factor for loved ones deciding to move a person into assisted living communities like nursing homes or memory care. More on sundowning.
Sleep quality for someone with Alzheimer’s changes over time. In the disease’s late stages, sleeping more during both day and nighttime is common because day-to-day activities are more difficult and exhausting. In the first few stages, however, difficulty sleeping is common. In fact, fewer hours of deep sleep in people over 60 has been studied as a possible early sign of Alzheimer’s or other dementia. If someone in the earlier stages of dementia is unexpectedly sleepier than normal, it is important to see a doctor. Drowsiness may indicate a problem like infection or adverse reactions to medication.
Some estimates say it’s common for a person with dementia to be awake for 40 percent of their time in bed at night. There have even been reports of people with Alzheimer’s or dementia whose entire sleep cycle shifts, so they’ll sleep throughout the day and be up all night.
Experts advise avoiding sleep medications if possible, because the side effects make accidents like falling more likely, and can increase confusion. However, antidepressants, benzodiazepines, sleeping pills, and antipsychotics have been prescribed to combat dramatic changes to sleep cycles.
Another non-pharmaceutical option may be Cannabidiol (CBD) a compound derived from cannabis plants. CBD has demonstrated medicinal effects without the “high” of marijuana, and research shows it can relieve symptoms of dementia and helps maintain circadian rhythms. More on CBD, its legality and benefits.
Careful consideration of the pros and cons of medicating sleeplessness should of course be prioritized by caregivers, and non-medication methods for helping someone sleep better should almost always be tried first.