10: Sleep: Managing Hallucinations, Illusions, Delusions, Nightmares, Sundowning, Anxiety and Depression

This program will:

• Discuss how these issues can affect sleep
• Present some strategies for managing them

• There are no easy answer when its comes to the care of another
• Our hope is to offer you useful information and guidelines for caring for someone with dementia
• These guidelines will need to be adjusted to suit your own individual needs

Sleep Issues associated with Alzheimer’s Disease

• Spend more time awake at night and sleeping during the day
• Wake up during the night to wander
• Wake up confused, disoriented, frightened, or feeling alone
• Delusions and hallucinations disrupt sleep patterns

• HALLUCINATIONS: false sensory perceptions of objects or events
• ILLUSIONS: misinterpretations or incorrect perceptions
• DELUSIONS: firmly held incorrect or inaccurate beliefs

How did Mary try to calm and reassure Robert?

• A. Mary offered to look around the room to see if anyone was there.
• B. Mary used a calm voice and reassuring touch.
• C. Mary tried to distract Robert from the topic of his misperception.
• D. Mary did not try to convince Robert that what he saw was not real.
• E. All of the above.

Choice E: All of the above, is the best answer. Choice A: Mary offered to look around the room to see if anyone was there, is a good choice.

• Acknowledge the person’s concern and provide reassurance

Choice B: Mary used a calm voice and reassuring touch, is also a good answer.

• Stay calm and show empathy
• Avoid pointing out errors, arguing, scolding, or embarrassing the person
• Be careful about touching someone

Choice C: Mary tried to distract Robert from the topic of his misperception, is another good answer.

• Use distraction to redirect the person’s attention onto something pleasant

Choice D: Mary did not try to convince Robert that what he saw was not real, is a good answer.

• Trying to convince people that hallucinations are not real will make them more upset and make it harder to get them back to sleep

• Do not argue or try to reason with the person
• Ignore the hallucination, illusion, or delusion if there is no harm caused
• Use reassuring words with a calm voice and comforting touch
• Find a solution to reassure the person
• Try distraction
• Consider asking about the false perception
• Investigate for things that may have caused the hallucination or illusion

• Listen
• Offer reassure
• Remove triggers or sources of stress

Sundowning refers to a worsening of behavioral symptoms that occurs near sunset or nightfall Factors that can increase the risk of sundowning:

• Being in a dimly lit room
• Disturbances in the person’s biological clock
• Fatigue at the end of the day
• Pain
• Over-stimulation
• Restlessness

• Keep regular waking and sleeping times as much as possible
• Follow a bedtime routine
• Limit daytime idleness with activities
• Encourage regular exercise
• Make afternoon and evening hours calming
• Control the diet
• Address any stressful environmental factors
• Provide good lighting
• Check for and treat pain
• Consult a healthcare professional

Anxiety is a state of worry, nervousness, uncertainty, or fear resulting from the anticipation of an event or situation that is real or imaginary Anxiety may appear in the following ways:

• Fear
• Excessive worry or nervousness
• Restlessness
• Heart palpitations
• Sleep disturbances

• Acknowledge concerns and offer reassurance and comfort
• Distract or redirect
• Use relaxation techniques and spiritual activities
• Anxiety can be a sign that activities are becoming difficult
• Simplify activities and instructions
• Be flexible and adaptive
• Seek support groups
• Consider a combination of drug and non-drug therapies

Depression is an illness that involves the body, mood and thoughts, and affects the way a person acts, feels about oneself, and thinks about things Common symptoms of depression:

• Poor sleep patterns
• Loss of energy, initiative and interest
• Increased confusion or forgetfulness
• Change in appetite
• Feelings of hopelessness, sadness and guilt
• Crying spells, irritability and moodiness
• Increase in pain symptoms, shortness of breath, or stomach problems

• Talk to a healthcare professional
• Involve a therapist or counselor
• Join a support group
• Sunlight and bright light therapy

• Hallucinations, delusions, illusions, sundowning, anxiety, and depression can disrupt sleep

HALLUCINATIONS, DELUSIONS, ILLUSIONS

• Offer reassurance, empathy and comfort
• Use distraction
• Find out its meaning or cause
• Remove any environmental triggers

SUNDOWNING

• Keep regular schedules and routines
• Provide activities and encourage regular exercise
• Make afternoon and evening hours calming
• Treat pain
• Control the diet
• Address any stressful environmental factors

ANXIETY AND DEPRESSION

• Offer reassurance, empathy and comfort
• Redirect
• Simplify activities and instructions
• Relaxation techniques and spirituality
• Exercise, sunlight and bright light therapy
• Support group, therapist, or counselor
• Consult a healthcare professional if non-drug therapies are not successful

Written by:
Catherine M. Harris, PhD, RNCS.
Mindy J. Kim-Miller, MD, PhD

Edited by:
Sasha Asdourian

www.LightBridgeHealthcare.com

• Aggarwal, N., et al., People with dementia and their relatives: personal experiences of Alzheimer’s and of the provision of care. Journal of Psychiatric and Mental Health Nursing, 2003. 10: p. 187-197.
• Allen, R., Should we aggressively evaluate and treat sleepiness in the elderly? Sleep Medicine, 2003. 4: p. 477-478.
• Asada, T., et al., Associations between retrospectively recalled napping behavior and later development of Alzheimer’s disa. Sleep, 2000. 23(5): p. 1-6.
• Coste Koenig, J., Learning to speak Alzheimer’s: a groundbreaking approach for everyone dealing with the disease. 2003, Boston, New York: Houghton Mifflin Company. 240.
• Ellgring, J., Depression, psychosis, and dementia: Impact on the family. Neurology, 1999. 52(7): p. S17-S20.
• Farlow, M., Pharmacokinetic profiles of current therapies for Alzheimer’s disease: Implications for Switching to Galantamine. Clinical Therapeutics, 2001.23(Suppl A): p. A13-A24.
• Fatigue: When to rest, when to worry. (2006 August 16). Mayoclinic.Com. Retrieved on March 30, 2008 from http://premium.europe.cnn.com/HEALTH/library/HQ/00673.html.
• Ficca, G. and P. Salzarulo, What in sleep is for memory? Sleep Medicine, 2004. 5: p. 225-230.
• Gais, S. and J. Born, Low acetylcholine during slow-wave sleep is critical for declarative memory consolidation. PNAS, 2004. 101(7): p. 2140-2144.
• Gordon, A., Insight into auditory hallucinations and psychosis. International Journal of Geriatric Psychiatry, 1997. 12: p. 410-411.
• Gruetzner, H., Alzheimer’s: A Caregiver’s Guide and Sourcebook. Vol. Updated and Revised. 1992, New York, Chichester, Brisbane, Toronto, Singapore:John Wiley and Sons, Inc. 308.
• Hallucinations. 2004, Alzheimer’s Association. Retrieved on March 30, 2009 from http://www.alz.org/national/documents/topicsheet_hallucinations.pdf.
• Harding, A., G. Broe, and G. Halliday, Visual hallucinations in lewy body disease relate to lewy bodies in the temporal lobe. Brain, 2002. 125: p. 391-403.
• Haythornthwaite, J., M. Hegel, and R. Kerns, Development of a sleep diary for chronic pain patients. Journal of Pain and Symptom Management, 1991. 6(2):p. 65-72.
• Hyyppa, M. and E. Kronholm, Quality of sleep and chronic illnesses. Journal of Clinical Epidemiology, 1989. 42(7): p. 633-638.
• Lamberg, L., Illness, not age itself, most often the trigger of sleep problems in older adults. JAMA, 2003. 290(3): p. 319-323.
• Lewis, S., Stress Relief for Caregivers. 2003, University of Texas Health Science Center at San Antonio.
• Luboshitzky, R., et al., Actigraphic sleep-wake patterns and urinary 6-sulfatoxymelatonin excertion in patients with Alzheimer’s disease. Chronobiology International, 2001. 18(3): p. 513-524.
• Luxenberg, J., Clinical Issues in the Behavioural and Psychological Symptoms of Dementia. International Journal of Geriatric Psychiatry, 2000. 15: p. S5-S8.
• Martin, J., et al., Circadian rhythms of agitation in institutionalized patients with alzheimer’s disease. Chronobiology International, 2000. 17(3): p. 405-418.
• Mayo, W., et al., Individual differences in cognitive aging: implication of pregnenolone sulfate. Progress in Neurobiology, 2003. 71: p. 43-48.
• McCurry, S., et al., Training Caregivers to Change the Sleep Hygiene Practices of Patients with Dementia: The NITE-AD Project. JAGS, 2003. 51(10): p.1455-1460.
• McCurry, S., et al., Treatment of sleep and nighttime disturbances in Alzheimer’s disease: a behavior management approach. Sleep Medicine, 2004. 5: p.373-377.
• Menefee, L., et al., Self-reported sleep quality and quality of life for individuals with chronic pain conditions. Clinical Journal of Pain,
• Mittelman, M.S., C. Epstein, and A. Pierzchala, Counseling the Alzheimer’s Caregiver: A Resource for Health Care Professionals. 2003: American Medical Association – AMA Press. 346.
• Morin, C., D. Gibson, and J. Wade, Self-Reported Sleep and Mood Disturbances in Chronic Pain Patients. Clinical Journal of Pain, 1998. 14(4): p. 311-314.
• Murgatroyd, C. and R. Prettyman, An Investigation of visual hallucinosis and visual sensory status in dementia. International Journal of Geriatric Psychiatry,2001. 16: p. 709-713.
• Neubauer DN. Sleep problems in the elderly. Amer Acad Family Phys. 1999. 59(9): 2551.
• Philips, B. and S. Ancoli-Israel, Sleep disorders in the elderly. Sleep Medicine, 2001. 2: p. 99-114.
• Rabow, M.W., J.M. Hauser, and J. Adams, Supporting family caregivers at the end of life. JAMA, 2004. 294(4): p. 483-491.
• Roth, T., J. Costa e Silva, and M. Chase, Sleep and cognitive (memory) function: research and clinical prespectives. Sleep Medicine, 2001. 2: p. 379-387.
• Roth, T., et al., The Art of Good Sleep. Sleep Medicine, 2004. 5(Suppl 1): p. S1.
• Sleep and seniors: Insomnia isn’t inevitable. 2004 July 6, Mayo Clinic Staff.
• Sleep Changes in Alzheimer’s Disease Fact Sheet. 2004, Alzheimer’s Association. p. 1-3.
• Sleep: Your body’s means of rejuvenation. 2004, Mayo Clinic.
• Soeda, S., et al., Aging and visual halluncinations in elderly psychiartic outpatients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2004.28: p. 401-404.
• Strine, T. and D. Chapman, Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Medicine, 2005. 6: p.23-27.
• Stroke, O.O.C.A.P.L.N.I.O.N.D.A., Brain Basics: Understanding Sleep. October 8, 2004, National Institutes of Health: Bethesda, MD.
• Tappen, R.M., Interventions for Alzheimer’s Disease: A Caregiver’s Complete Reference. 1997, Baltimore: Health Professions Press, Inc. 239.
• Tariot, P., Medical management of advanced dementia. JAGS, 2003. 51(5, Supplement): p. S305-S313.
• Teri, L., R. Logsdon, and S. McCurry, Nonpharmacologic treatment of behavioral disturbances in dementia. Med Clin N AM, 2002. 86: p. 641-656.
• Tractenberg, R., et al., The sleep disorders inventory: an instrument for studies of sleep disturbances in persons with Alzheimer’s disease. Journal of Sleep Research, 2003. 12: p. 331-337.
• Tsuno, N., et al., Fluctuations of source locations of eeg activity during transition from alertness to sleep in Alzheimer’s disease and vascular dementia.Neuropsychobiology, 2004. 50: p. 267-272.
• Van Someren, E., Circadian rhythms and sleep in human aging. Chronobiology International, 2000. 17(3): p. 233-243.
• Vgontzas, A. and A. Kales, Sleep and its disorders. Annu Rev Med, 1999. 50: p. 387-400.
• Volicer, L., et al., Sundowning and circadian rhythms in Alzheimer’s disease. Am J Psychiatry, 2001. 158(5): p. 704-711.
• Yehuda, S., S. Rabinovitz, and D. Mostofsky, Essential fatty acids and sleep: mini-review and hypothesis. Medical Hypotheses, 1998. 50: p. 139-145.