Welcome to the educational program Promoting Healthy Sleep Patterns. This program will present some principles and strategies for improving sleep patterns and for creating an environment that promotes sleep.
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This is Lesson 8 of The Alzheimer’s Caregiver. You may view the topics in order as presented, or click on any topic listed in the main menu to be taken to that section.
We hope that you enjoy this program and find it useful in helping both yourself and those you care for. There are no easy answers when it comes to the care of another, as every situation and person is different. In addition, every caregiver comes with different experiences, skills and attitudes about caregiving. Our hope is to offer you useful information and guidelines for caring for someone with dementia, but these guidelines will need to be adjusted to suit your own individual needs. Remember that your life experiences, your compassion and your inventiveness will go a long way toward enabling you to provide quality care.
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Alzheimer’s and Sleep
Sleeping through the night can be difficult for people with Alzheimer’s disease and other dementias. As dementia progresses, affected individuals spend more of their nights awake and daytime hours sleeping. Although they spend more of their time sleeping, the sleep is often light and with frequent awakenings.
Many people wake up during the night to wander. They can wake up confused, disoriented, frightened, or feeling alone. They may also suffer from delusions and/or hallucinations that disrupt sleep patterns.
Poor sleep can seriously affect those with dementia, as it can contribute to agitated behavior, delirium, decline in thinking and functioning, falls and injuries, and increased mortality.
This program will provide a general understanding of some sleep issues and offer practical tips to help improve the quality and quantity of sleep forthose with dementia and their caregivers.
Case Study 1
Let’s begin with a case study about Mary, who cares for her husband, Robert.Robert has moderate Alzheimer’s disease.
One night, Mary wakes up at 1 a.m. and finds that Robert has gotten out of bed and is wandering around in the living room muttering to himself.
What can Mary expect as she cares for her husband with Alzheimer’s disease?
A. Robert will wander off at times.
B. Mary needs to adjust to not sleeping through the night.
C. Mary needs to make adjustments to how she cares for Robert.
D. Robert will sleep during the day and stay awake during the night.
Answers:
Choice A: “Robert will wander off at times” is a good choice.
Wandering is a common behavior seen with Alzheimer’s disease, which increases in the middle stages. This behavior fluctuates so that wandering may happen more often on some days than others.
Because persons with dementia usually wander for a reason, try to meet their needs to decrease the likelihood of wandering. For example, check to see whether the person wants to eat, drink, use the bathroom, or put on more clothes.
Dedicate areas in the house that are safe for wandering. This includes rooms that are free of stairwells, clutter, dangerous objects and chemicals. Examples include unnecessary furniture, sharp or fragile objects, and obstacles on the floor.
Choice B: “Mary needs to adjust to not sleeping through the night” is a possibility.
Mary will have some nights where she will have to wake up to care for Robert and other nights where she will not. Lack of sleep is one of the main reasons caregivers place their family members with dementia in long-term care facilities.
Choice C: “Mary needs to make adjustments to how she cares for Robert” is the best answer.
There are many things Mary can do to better care for her husband. Knowing what to expect during the different stages of dementia can help the caregiver plan ahead and modify approaches to caregiving based on the circumstances.
Choice D: “Robert will sleep during the day and stay awake during the night” is a possibility.
People with dementia can experience a complete reversal of day and night sleep, especially in the late stages of the illness. An estimated 40% of those in the late stages of dementia experience this reversal.
However, practicing good sleep habits may prevent the reversal of day and night sleep patterns.
Approaches to Sleep Problems
Here are some general approaches for dealing with sleep issues.
First, learn about how dementia and aging affect sleep patterns. Aging can lead to a decrease in the amount of time the body spends in deep, restful sleep and an increase in the amount of light sleep. In addition, people also become more sensitive to the sleeping environment, including subtle things such as changes in room temperature. Dementia can cause more nighttime awakenings, less deep and restful sleep, more light sleep, and more daytime napping.
Second, keep a sleep journal to help identify any patterns of sleep disturbances. If you decide to consult a healthcare professional, keeping a diary for at least one to two weeks prior to the visit can help with the evaluation.To learn more about keeping a sleep journal, click on the link provided.
Lastly, talk to your healthcare professional for more information about other factors that can affect sleep including medical conditions, anxiety, depression, and current medications. You can also discuss medications and non-drug therapies that promote sleep.
By getting a sense of what to expect and trying to plan ahead, caregivers can help to overcome sleeping problems before they arise.
Keeping a Sleep Journal
When keeping a journal or diary, try to keep track of things like the number, length, and timing of naps during the day. Also keep note of the time that the person with dementia goes to bed at night and rises in the morning. How many times the person wakes up at night is also important, along with details such as what time these awakenings occur, and for how long.
Also mark down what the person does after awakening in the night. For example how many trips to the bathroom did the person make, and at what times. Also make note of any unusual nighttime activity such as wandering and rummaging.
Be sure to keep records of anything you give or do before bed to help the person sleep or reduce agitation.
You can use this general guide to rate the person’s sleep at night:
A difficult night means very little or no sleep. Figure anything less than 2 hours. A poor night which means little sleep, generally 2-4 hours.
A fair night which means multiple, brief awakenings lasting less than 30 minutes and a total night’s sleep of more than 4 hours.
Finally, a good night, with only a brief awakening of less than 30 minutes and a total night’s rest of more than 4 hours.
Talking to a Healthcare Professional
Some topics that you may want to talk to a healthcare professional about include specific health problems that may be affecting sleep. These include medical conditions, such as prostate problems, that can cause physical discomfort and frequent urination, which can disrupt sleep.
Also tell the healthcare professional about any feelings of depression, sadness or anxiousness that the person may be having.
Discuss the person’s current medications, their side effects, and the possibility of changing medications that may be interfering with sleep.
Ask about any recommendations for non-drug approaches to promoting sleep.
If non-drug approaches have not been effective, ask about medications that can help promote sleep.
Promoting Healthy Sleep Patterns
Here are some tips for promoting healthy sleep patterns. First, keep regular routines by establishing a relaxing bedtime or sleep routine, which helps to reinforce sleep cues. Also, try to keep the same bedtime and rising time and try not to wake the person during the night unless truly necessary. Remember, if there is a new caregiver, have the previous caregiver accompany the new one during the first one or two days/nights in order to introduce the new person and help establish a connection.
Second, limit daytime napping to 20-30 minutes and avoid naps in the late afternoon and evening. Third, the bed should be used primarily for sleeping, so discourage the person from staying in bed while awake, watching television, or reading.
Fourth, discourage the person from watching television while trying to fall asleep, as it can keep the body stimulated. Additionally, watching programs such as the news before going to sleep can cause nightmares for someone with dementia.
Fifth, minimize pain and fatigue, which are frequent causes of insomnia or poor sleep. Sometimes it is difficult for someone with dementia to tell others about pain or fatigue, so caregivers should learn to read body language and investigate the possibility of pain or discomfort. Look for signs such as increased agitation, the holding, guarding, or favoring of certain body parts, decreased mobility, wincing, feeling cold or feverish to the touch, or rapid breathing. It is important to treat pain as much as safely possible, especially prior to bedtime. Talk to a healthcare professional about pain management.
Lastly, look for and attend to other causes of discomfort, such as a full bladder, constipation and incontinence. You should encourage the person to use the toilet before going to bed.
Creating an Environment That Promotes Sleep
Here are some strategies for creating an environment that promotes sleep.
First, establish a comfortable, familiar, and secure sleeping environment by making sure that the room is quiet and at a comfortable temperature for the person. Keep in mind that the elderly are more sensitive to cold and can chill easily even when others feel warm, so always have a couple of blankets on hand. Make sure that the person’s clothing and bed linens are comfortable, clean and dry, by always changing after spills or soiling. Place security objects, such as a favorite blanket or stuffed animal, within easy reach. Place nightlights or dim lights to softly light the room for sleeping, but avoid too much light as that can interfere with sleeping.
Second, try to provide a pleasant atmosphere in the bedroom by surrounding the person with familiar people in happy, relaxed moods. You can also place favorite objects and photos in view and try playing calming music. Pleasant, relaxing fragrances in the room, such as vanilla, roses, and peppermint can also act as soothing agents. Research has shown that the fragrances of Melissa oil (or lemon balm) and lavender oil can help relax individuals with dementia and reduce agitation, especially if combined with massage.So try rubbing Melissa or lavender oil onto the person’s arms and face before bedtime. When creating a pleasant, comfortable environment for someone, always take into consideration the person’s personal preferences.
Activities That Promote Healthy Sleep Patterns
There are also some activities that the individual with dementia can do to help promote healthy sleep patterns.
One activity is to get bright light exposure. This can be done through natural sunlight or artificial light therapy. Bright light can help regulate the body’s biological clock to stay awake during the day and sleep at night and can even slow down the progression of dementia. It also can improve moods and difficult behaviors. So provide opportunities to get sunlight exposure and keep living areas as brightly lit as possible during the day. Consider using bright light therapy with a light box for at least 1 hour a day when natural sunlight is not a possibility.
Another activity that people can do to promote sleep is to exercise regularly. Exercise induces physical fatigue and helps to maintain mobility, physical strength, balance, and bone mass. Consider discussing exercise options with a healthcare professional if you have concerns about safety and health risks.
Select exercises that the person can perform safely.For example, if the person has limited mobility, consider chair exercises or water aerobics. Schedule regular exercise during the day but not less than 4 hours before bedtime, as exercise may be too stimulating for someone with dementia before trying to sleep.
Physical activity should be interspersed with quiet activities so that the person does not become over-fatigued. Caregivers should not only encourage their care recipients to exercise, but should also try to exercise with them when possible, as this will benefit the caregivers’ health and stress level as well.
Foods That Interfere with Sleep
It is important to keep in mind that what people eat and drink can affect how well they sleep. Therefore caregivers should control the person’s diet and fluid intake.
First, don’t let the person drink too much fluid in the evening. This can lead to frequent trips to the bathroom at night.
Second, restrict the intake of alcohol. Alcohol may help a person to fall asleep, but it has a rebound effect, which causes awakening later on.
Third, avoid caffeinated products in the late afternoon and evening, Remember that caffeine can be found in drinks as well as foods such as chocolate.
Fourth, avoid tobacco, which can be stimulating.
Fifth, avoid heavy or rich food late in the evening, as that can cause stomach upset. Instead, try giving the person a light snack before bedtime.
Foods That Promote Sleep
Some foods can actually help promote sleep. Try serving sleep-promoting foods for dinner or an evening snack.
Examples include dairy products such as cheese and milk; soy products like tofu or soy milk, other beans and lentils; whole grains, rice and oats; and a variety of nuts and seeds, including peanuts, almonds and sunflower seeds. Proteins such as eggs, fish and poultry also help to promote sleep, as do some fruits and vegetables, including avocados, peaches, asparagus and bananas.
Keep in mind that giving the person a light snack before bedtime can prevent awakenings caused by nighttime hunger.
Guidelines for Drug Therapies to Promote Sleep
If non-drug treatments do not work, the caregiver should consider contacting a physician to discuss possible medications that can help promote healthy sleep patterns. Here are some guidelines to discuss with the physician about using medications that promote sleep.
Use the lowest possible effective dose of the medication. This will help minimize the side effects. You may have to work with a physician to adjust the amount of medication you give before you find a dose that works best for the individual.
Sleep medications should only be given when necessary, or as needed,rather than on a scheduled basis. This means giving the medication only on the nights that the individual is having difficulty sleeping.
Never give more than the maximum dose within a 24 hour period as prescribed by the physician.
Once a regular sleep pattern has been established, talk to the physician about trying to slowly decrease and discontinue the sleep medication.
Remember that any change to medication regimens should be done under the supervision of a physician
Summary
In summary, dementia can cause more nighttime awakenings, less deep and restful sleep, more light sleep, and more daytime napping, especially in the later stages of the illness. Before talking to a healthcare professional about health problems and medications that can affect sleep, keep a sleep journal to identify any patterns of sleep disturbances for at least two weeks.
To promote healthy sleep patterns, it is best to keep regular routines, limit daytime napping, minimize pain and fatigue and discourage staying in bed while awake, watching television, or reading. Also discourage the person from falling asleep while watching television. You should regulate diet and fluid intake, especially before bed, however giving a snack of sleep-promoting foods before bedtime can be beneficial.
Establish a comfortable, familiar, and secure sleeping environment. Try to provide a pleasant atmosphere in the bedroom by surrounding the person with familiar people and objects. Try playing calming music and provide relaxing fragrances, such as lavender or Melissa oil. Always take into consideration the person’s preferences for comfort.
Other things that can help improve sleep patterns include bright light therapy, regular exercise, and sleep-promoting medications.
Written by: Jennifer Kretzschmar, PhD (University of Texas Health Science Center San Antonio), and Sharon Lewis, PhD, RN, FAAN (University of Texas Health Science Center San Antonio)
Edited by: Mindy J. Kim-Miller, MD, PhD (University of Chicago School of Medicine)
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Sleeping through the night can be difficult for people with Alzheimer’s disease and other dementias. As dementia progresses, affected individuals spend more of their nights awake and daytime hours sleeping. Although they spend more of their time sleeping, the sleep is often light and with frequent awakenings. 
spends in deep, restful sleep and an increase in the amount of light sleep. In addition, people also become more sensitive to the sleeping environment, including subtle things such as changes in room temperature. Dementia can cause more nighttime awakenings, less deep and restful sleep, more light sleep, and more daytime napping.
When keeping a journal or diary, try to keep track of things like the number, length, and timing of naps during the day. Also keep note of the time that the person with dementia goes to bed at night and rises in the morning. How many times the person wakes up at night is also important, along with details such as what time these awakenings occur, and for how long. 
Second, limit daytime napping to 20-30 minutes and avoid naps in the late afternoon and evening. Third, the bed should be used primarily for sleeping, so discourage the person from staying in bed while awake, watching television, or reading. 
First, establish a comfortable, familiar, and secure sleeping environment by making sure that the room is quiet and at a comfortable temperature for the person. Keep in mind that the elderly are more sensitive to cold and can chill easily even when others feel warm, so always have a couple of blankets on hand. Make sure that the person’s clothing and bed linens are comfortable, clean and dry, by always changing after spills or soiling. Place security objects, such as a favorite blanket or stuffed animal, within easy reach. Place nightlights or dim lights to softly light the room for sleeping, but avoid too much light as that can interfere with sleeping.
One activity is to get bright light exposure. This can be done through natural sunlight or artificial light therapy. Bright light can help regulate the body’s biological clock to stay awake during the day and sleep at night and can even slow down the progression of dementia. It also can improve moods and difficult behaviors. So provide opportunities to get sunlight exposure and keep living areas as brightly lit as possible during the day. Consider using bright light therapy with a light box for at least 1 hour a day when natural sunlight is not a possibility. 
First, don’t let the person drink too much fluid in the evening. This can lead to frequent trips to the bathroom at night.
Examples include dairy products such as cheese and milk; soy products like tofu or soy milk, other beans and lentils; whole grains, rice and oats; and a variety of nuts and seeds, including peanuts, almonds and sunflower seeds. Proteins such as eggs, fish and poultry also help to promote sleep, as do some fruits and vegetables, including avocados, peaches, asparagus and bananas. 
Use the lowest possible effective dose of the medication. This will help minimize the side effects. You may have to work with a physician to adjust the amount of medication you give before you find a dose that works best for the individual. 