26: Late Stages: Behavior & Sleep

This program will:

  • Discuss common behavior and sleep issues that develop in the late stages of Alzheimer’s disease
  • Present some principles and strategies for addressing behavior and sleep problems
  • 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
  • Wandering and pacing
  • Rummaging
  • Catastrophic reactions
  • Verbal aggression
  • Combativeness
  • Agitation and aggression

Associated with brain changes

  • False perceptions (perceptual distortions)
  • Hallucinations
  • Illusions
  • Delusions
  • Paranoia and suspiciousness
  • Negativity
  • Refusal of care
  • Apathy
  • Brain changes due to Alzheimer’s
  • Normal changes of aging
  • Medical conditions
  • Environmental stress
  • Task expectations
  • Loss of impulse control
  • Judgment impairment
  • Motivational decline (apathy)
  • Delusions, illusions & hallucinations
  • Loss of functional abilities
  • Executive function
  • Impulse control
  • Judgment
  • Motivation
  • Attention and concentration
  • Apathy
  • No facial expression
  • Indifference
  • Diminished initiative
  • Poor persistence
  • Flat emotional response
  • Lack of insight
  • No emotion
  • Low social engagement
  • Depression
  • Sad face & posture
  • Worry
  • Low attention & concentration
  • Appetite & sleep disturbance
  • Suicidal thoughts or attempts
  • A healthcare professional needs to evaluate the symptoms to determine the condition and the best approach for treatment
  • Apathy and depression can occur together in the same person
  • Robert shows some resistance when taken to the dining room for meals
  • Doesn’t acknowledge others at the table
  • Doesn’t ask to be taken to the bathroom when he needs to go
  • Disinterested in the people around him
  • Shows little or no emotion on his face
  • If not directed to do so, he doesn’t eat, bathe, brush his teeth, or talk to anyone
  • Indifferent to his surroundings and events

What can we do to help Robert?

  • A. Encourage exercise.
  • B. Engage in communication.
  • C. Start him on medication.
  • D. All of the above.

Choice A: Encourage exercise, is an excellent choice.

  • Exercise improves respiration and circulation
  • Increases delivery of oxygen and nutrients
  • Exercise options in the late stages
  • Chair exercises, ball toss
  • Walking with assistance
  • Music, dancing
  • Increase activity over time
  • Select exercises that are within the person’s abilities
  • Consult a healthcare professional about health risks

Choice B: Engage in communication, is another good choice.

  • Engage
  • Spend quality time
  • Sit together at mealtime
  • Get in close
  • Make eye contact and smile
  • Show interest
  • Speak clearly
  • Use simple terms with the important words last
  • Use body language to help convey the meaning
  • Use gentle but firm direction in activities

Choice C: Start him on medication, is another good possibility. Choice D: all of the above, is the best answer. Robert will need close personal attention from an engaged caregiver who will use simple, direct communication to provide direction and encourage exercise.

  • Caused by fear
  • Often from delusions and hallucinations
  • Caregivers should be calm and reassuring
  • Use simple, clear communication
  • HALLUCINATION: false perception
  • VISUAL HALLUCINATION: seeing something that is not there
  • AUDITORY HALLUCINATION: hearing something or someone that is not there
  • ILLUSION: misperception or misinterpretation of a real object
  • DELUSION: false idea or belief that is strongly held
  • Primarily due to brain damage
  • Functional losses can lower a person’s sense of mastery and self-worth, further leading to suspicion and fear of people
  • Physical Illness
  • Loss of self worth
  • Unwarranted or exaggerated mistrust
  • Caregivers should be careful so as not to give any reason to be suspicious
  • Consider consulting a healthcare professional about medications that reduce their occurrence

Responding to Hallucinations, Illusions, and Delusions

  • Do not be argumentative or dismissive

What would be a better way for a caregiver to respond?

  • A. Investigate the surroundings.
  • B. Check for fever or other signs of illness.
  • C. Look for environmental causes.
  • D. Offer reassurance.
  • E. All of the above.

Choice A: Investigate the surroundings, is a very good response.

  • Acknowledge and respect the person’s assertion and dignity
  • Look around to reassure the person

Choice B: Check for fever or other signs of illness, is also a great answer.

  • Physical illness, fever, medication, and severe constipation are common causes of delirium, which can cause impaired perceptions

Choice C: Look for environmental causes, is another great response.

  • Cover mirrors and windows
  • Provide adequate lighting
  • Arrange room to prevent shadows
  • Remove clutter and hazardous objects
  • Eliminate sources of noise if possible
  • Offer reassurance
  • Stay with them
  • Divert their attention
  • Consult a healthcare professional

Choice D: Offer reassurance, is another great answer.

  • Do not argue or try to correct the person
  • Offer reassurance that everyone is safe and everything is okay
  • Watch the person to make sure there is no danger of harm to self or others.

Choice E: All of the above, is the best answer.

  • Diversion or redirecting is a useful strategy for managing false perceptions and beliefs
  • Shift a person’s attention to a pleasant topic or activity
  • Do not argue—instead, reassure the person
  • Compliment and “build up” the person’s self-esteem
  • These strategies can promote self worth and allow people to reminisce
  • Sometimes hallucinations and delusions can be pleasant
  • Not harmful
  • Pleasant to those experiencing them
  • Can be allowed and even used as topics of discussion
  • Hallucinations, illusions, delusions, apathy, and negativity are often symptoms of late stage alzheimer’s disease
  • Many factors contribute to these behavior changes
  • Normal changes of aging, vision and hearing loss, medical conditions, and the environment
  • Apathy is characterized by diminished initiative, poor persistence in activities, indifference, and lack of interest, emotions and insight
  • Engage the person
  • Use gentle but firm directions
  • Encourage exercise
  • Consider medications
  • Hallucinations, illusions, and delusions are perceptual distortions
  • Do not argue or dismiss the fear
  • Investigate potential causes
  • Provide reassurance
  • Use redirection
  • Modify the environment, lighting, noises
  • Treat each person with dignity and respect
  • Nighttime awakenings, wandering at night, illusions, hallucinations and nightmares
  • Reversal of the usual daytime wakefulness/ nighttime sleepiness pattern
  • Loss of deep, restful sleep
  • Low level of wakefulness and alertness
  • Near comatose condition

Nonpharmacological Sleep-Wake Cycle Interventions

  • Increase daytime activities and physical exercise
  • Increase exposure to daylight
  • Use a light therapy box
  • Let sunlight into the room or light up a room as much as possible during the day
  • Nighttime darkness
  • Quiet room

Nonpharmacological Sleep-Wake Cycle Interventions (cont’d)

  • Sleep Hygiene
  • Consistent schedule
  • Nighttime rituals and routines
  • Comfortable in bed
  • Limit naps
  • Use bed primarily for sleeping
  • Minimize pain and fatigue
  • Learn to read body language and look for signs of pain or fatigue
  • Look for and attend to any discomfort
  • Talk to a healthcare professional

Nonpharmacological Sleep-Wake Cycle Interventions (cont’d)

  • Sleep Hygiene (cont’d)
    • Avoid excessive drinking in the evening
    • Restrict the use of alcohol
    • Prevent caffeine intake in the late afternoon and evening
    • Avoid tobacco
    • Avoid heavy or rich food late in the evening
    • Try a light snack before bedtime
    • Serve sleep-promoting foods for dinner or evening snack
      • Dairy products; soy products, beans and lentils; whole grains, rice and oats; some nuts and seeds; eggs, fish and poultry; and certain fruits and vegetables.
  • Orient and reassure
  • Remind them it is sleep time
  • Offer a quiet activity
  • Warm milk or calming herbal tea
  • Sit with person

For more information about managing nighttime awakenings and other sleep issues, click here.

  • Provide reassurance
  • Use reassuring words, a calm voice, and comforting touch if appropriate
  • Do not argue or try to convince the person
  • Investigate their concern
  • Find a reassuring solution
  • Use distraction to redirect attention onto something positive or pleasant
  • Consider asking about whatever frightened them
  • Look for environmental causes
  • Listen
  • Offer reassure
  • Remove triggers or sources of stress
  • Late stage sleep issues
    • Changes in sleep-wake patterns
    • Nighttime awakenings
    • Hallucinations
    • Illusions
    • Nightmares
  • Practice good sleep hygiene
    • Consistent routines
    • Supportive environment
  • Get exercise
  • Use bright light therapy
  • Regulate diet
  • Offer reassurance and comfort
  • Investigate for possible causes
  • Try to find reassuring solutions
  • Use distraction
  • Modify the environment to remove any potential triggers or sources of stress

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

Edited by:
Sasha Asdourian


27: Late Stages: Personal Care

Select the best answers from the list of choices following each question.

Click here to open Certificate of Completion

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