Understanding Sleep Disturbances in Dementia

Welcome, everyone, who are tuning in to another new

episode of The Truth, Lies, and Alzheimer's Show. And I am Lisa

Skinner, your host. Today's topic, we are going to talk

about understanding sleep disturbances with dementia, its

causes, its impact, and I'm going to share with you some

caregiver strategies that hopefully will be very helpful

for you. So, sleeps to services are actually very common and

often profoundly troubling for people who are living with

dementia, and for those who care for them, I don't think any of

us would disagree with that. Disrupted sleep can manifest as

insomnia, excessive daytime sleepiness, nighttime wandering,

REM sleep behavior disorder, restless leg syndrome, and or

fragmented sleep with frequent awakenings. The consequences

extend beyond fatigue. Cognitive function can worsen, mood can

deteriorate, safety concerns can rise, and the overall quality of

life for both the person living with dementia and their care

partners can decline. So today I want to delve into the

multifactorial causes of sleep problems with dementia. What

sleep disturbance looks like across different dementia

syndromes, and a broad practical toolkit for care partners to

improve sleep quality and safety. First thing I'm going to

talk about, why sleep becomes disturbed in dementia. It's

because neurodegenerative changes disrupt normal

sleep-wake regulation, dementia alters the brain networks that

govern circadian rhythms, wakefulness, and sleep stages.

Also, degenerative changes in areas such as the suprachematic

schematic nucleus, which is the brain's internal clock, the

posterior hypothalamus, brainstem arousal systems, and

thalamic circuits can blunt the ability to consolidate sleep at

night and to stay awake during the day. Hopefully, that didn't

all go over your heads. Neurotransmitter imbalances, for

example, the acetylcholine, the serotonin, the dopamine, and the

melatonin pathways that are in our brains, implicated in both

sleep and cognitive function become dysregulated as the

dementia progresses, contributing to fragmented sleep

and altered sleep architecture. Then, in addition to that,

coexisting medical conditions and symptoms play a role,

including pain, arthritis, urinary or bowel symptoms, sleep

apnea, nocturia, reflux, and respiratory issues can disrupt

sleep in dementia. Communication barriers can make it hard for

individuals to report their discomfort, which care partners

may need to identify through observation and patterns that

emerge. Additionally, depression and anxiety, which, as we all

know, are very common in dementia, can contribute to

insomnia or disruptive sleep patterns, medications and

medication interactions. Some drugs used to treat dementia

symptoms, for example, agitation, anxiety, depression,

and or nocturnal behaviors can also disturb sleep. Sedatives

might initially help, but can and do worsen cognitive

impairment at times and increase daytime lethargy. Conversely,

stimulants or certain antidepressants may interfere

with nighttime sleep, another cause polypharmacy, which is the

regular use of five or more medications at the same time in

older adults, can increase the risk of adverse interaction. Ins

that do fragment sleep or reduce sleep efficiency. Then we have

sensory and environmental factors. There are sensory

changes, which include hearing, vision loss, altered taste, and

reduced sensitivity to temperature. These can all

affect comfort and sleep, the sleep environment, the noise,

the light, the room temperature, and an unfamiliar routine. The

all these things matter a great deal for someone living with

dementia. Our circadian rhythm misalignment and activity

patterns play a role. People with dementia often experience

reduced exposure to natural light during the day, leading to

weaker circadian synchronization. So without

strong day night cues, they become confused at night or feel

sleepy at odd times. Irregular daytime napping or excessive

daytime sleepiness can perpetuate a vicious cycle of

nighttime wakefulness and progression of dementia and

sleep, there are different dementias that show distinct

sleep patterns. So I'm going to go over a few. For example, Lewy

body dementia commonly features pronounced REM sleep behavior

disorder and fluctuating cognition that can worsen sleep

disruption. Alzheimer's disease often includes increased

nocturnal awakenings and decreased deep sleep.

Frontotemporal dementia can affect routines and behavior,

impacting sleep-wake stability differently, so here are some

common sleep disturbances by dementia type. We're going to

start with Alzheimer's disease. They can experience fragmented

sleep with frequent awakenings, reduced slow wave sleep and REM

sleep, daytime naps, and potential sundowning, which, as

we know, is increased confusion and agitation in the late

afternoon evening, but I also want to mention that it can

occur at any time, Lewy body dementia, or LBD. Those folks

can experience REM sleep behavior disorder.

In other words, acting out dreams, having vivid dreams,

daytime sleepiness, and variability in alertness, also

sensitivity to antipsychotics can complicate management.

Frontotemporal dementia, also known as FTD, they can

experience disrupted routines and social behavior, which can

alter their sleep patterns. Some individuals may have delayed

sleep phases or irregular sleep wake cycles, and vascular

dementia. Sleep apnea and vascular risk factors can

contribute to sleep fragmentation, and as a result,

increased daytime fatigue, Parkinson's disease with

dementia, also known as PDD, can they can experience sleep

fragmentation, REM sleep behavior disorder, daytime

sleepiness, and restless leg syndrome are more common due to

overlapping motor and non motor symptoms, so I find that really

interesting. The variation between the brain diseases and

the disrupted sleep patterns. So, a practical assessment and

observation for our care partners, it's recommended that

we track the patterns that we see in our individuals by

maintaining a simple sleep diary for two to four weeks, noting

their bedtime, the time that they fall asleep, the number and

duration of their awakenings, how many naps they take, the

medications they're on, and mood or agitation levels. Monitor

their daytime activity and note daytime activities, light

exposure, and opportunities for movement. Also, increase daytime

activity and outdoor light do help consolidate nighttime

sleep. So, there's a few suggestions for any of you who

are caring for those with sleep disruptions. You can identify

the triggers by looking for patterns around meals, caffeine

or alcohol intake, medications with sedative or stimulant

effects, pain episodes, urinary symptoms, and or environmental

triggers, such as noise, temperature of the room, and the

lighting, those may need to be adjusted. Safety checks assess

for nocturnal wandering, their fall risk, misperceptions, or

disorientation at night. Consider an assessment of sleep

apnea risk. If you notice loud snoring, that's a sure sign that

somebody may actually be suffering from sleep apnea, but

it's treatable. Witnessed pauses in breathing or morning

headaches that may be present, and if they can't articulate

that to you, they will figure out a way to let you know that

they're in pain. Make sure that you have a clinician review all

of their medications for sleep disrupting potential and assess

for treatable conditions like pain management, urinary

symptoms, infection, thyroid issues, depression,

hypothyroidism, and anemia. Here are some evidence-based

non-pharmacological strategies. The non-pharmacological

approaches are preferred as first line strategies due to

lower risk of adverse effects and better long term outcomes,

try to stick with a daily structured routine, establish

consistent wake times, consistent meal times,

activities, and bedtime rituals predictability we know can

reduce anxiety and help regulate the internal clock. Bright light

exposure during the day aim for 30 to 60 minutes of natural

daylight exposure, especially in the morning, now light boxes can

be helpful for individuals who do have limited outdoor time. In

terms of physical activity, encourage regular daytime

movement appropriate to their ability. Gentle exercises like

walking, chair exercises or tai chi is shown to improve sleep

and mood. Evening wind down routine, dim lighting, quiet

activities, soothing music, warm beverages, but not caffeinated,

all can signal the body that night is approaching and avoid

stimulating activities later in the day. You want to do those

earlier in the day, and one of the memory neighborhoods that I

oversaw, we routinely gave gentle hand massages with a

soothing lotion, and that proved to be very calming and relaxing

at the end of the day, and helped our residents sleep

better. So you might try that, like maybe right before they go

to bed, nutrition and hydration timing. Try to avoid large meals

late in the evening, limit their caffeine afternoon, monitor

alcohol intake. Hydration should be balanced to minimize

nocturnal trips to the bathroom. Nap management, if naps are

necessary, keep them short, 20 to 30 minutes, and earlier in

the day again to reduce nighttime wakefulness. Here's

some suggestions for sleep environment optimization: ensure

a comfortable room temperature roughly 60 to 67 degrees

Fahrenheit, or 15 to 19 degrees Celsius, low noise, minimized

glare, and a secure familiar sleeping space. You can.

Consider white noise machines or soft air protection if noise is

unavoidable. Here are some comfort measures for nocturnal

awakenings. If your person is wakeful, engage in calming

activities rather than stimulating stimuli.

Use soothing lighting and ensure safety measures like locks,

alarms, bed rails, if appropriate, pain and symptom

control regularly assess and treat pain, bathroom discomfort,

reflux, or respiratory symptoms that may awaken the person at

night. You can perform skin and comfort checks, and ensure

comfortable clothing, appropriate bedding, and foot

warmth if they're cold. A lot of elderly people, they experience

cold hands and cold feet much more than we do, so be mindful

of that, please. Medications, and when they might be

considered, again review with the clinician. Medication

management should always be personalized. A clinician can

determine whether sleep issues are primarily due to dementia,

another underlying medical condition that we call

comorbidities, or due to a medication side effect. Some

physicians will prescribe sleep-promoting medications, but

we all know that we want to use those with caution, like

hypnotics, antidepressants with sedating effects, or

antipsychotics may be used short term under medical supervision,

but they do carry risks, such as confusion, falls, and increased

delirium dependence, and paradoxical agitation. Another

thing is melatonin and melatonin receptor agonists. Melatonin can

actually help some people with dementia fall asleep earlier or

improve their sleep consolidation through effects,

but they vary, and melatonin generally has a favorable safety

profile, but should be used with caution and always, always,

always under the supervision of a physician, and then treating

underlying medical conditions, sleep apnea again can be treated

with CPAP therapy. Restless leg syndrome may respond to iron

supplementation if iron deficiency is present. Need to

be tested for that. Urinary symptoms can be managed with

bladder training, medications, or catheter continent strategies

if necessary. Avoid polypharmacy where possible, in other words,

being on at least five medications at a time. Regular

medication reconciliation to minimize unnecessary drugs can

also reduce sleep disturbances and adverse interactions. Now,

caregiver-targeted techniques that can reduce nighttime

disruptions. Here are some suggestions for that plan, and

communicate. You can do this by creating and sharing a simple

daily plan with the person you're caring for, using

familiar cues and consistent language to reduce confusion at

night, a safety first approach. So, let's say if wandering or

bolting is a concern for you, implement safety devices like

door alarms, motion sensors, and consider a safer sleep

arrangement always balance safety with dignity and

independence. You can use assistive devices such as night

lights, absorbent protective underwear, as appropriate. Easy

to use bathroom strategies and accessible mobility aids can all

reduce fear and nighttime trips. Here's some calming techniques

that you can use during these awakenings. Gentle reassurance

is so critical, a familiar object. Soft background music or

a familiar scent can soothe agitation without escalating it.

Partner and caregiver support, nighttime caregiving can be

exhausting, which I'm sure many of you who are listening today

already know, so consider respite care, daytime help, or

sharing night duties with a partner or family member to

reduce burnout. It can happen so fast. And now I'm going to share

with you some communication strategies: keep language

simple, avoid arguing or correcting misperceptions, and

acknowledge feelings. Nonverbal reassurance often matters as

much as words. Use non-intrusive monitoring like a bed alarm, and

I actually have one right here to show you. This is the signal

safe fall monitor. It clips on to things in the back. You can

hook it up to their bed to a chair, so let's say you're a

caregiver and you're in the kitchen preparing lunch for the

person you're caring for. You can put this monitor on the

chair that they're sitting in, and if they get up off that

chair, you will hear the alarm, so you will know to go make sure

that they're going to be safe, and that they are not getting up

from their chair, and then becoming a fall risk. Hip

fractures are way too common in the elderly, and these - this is

a, an example of a situation where somebody could fall and

break. So, these are wonderful, and these products are a

blessing for helping manage these type of situations.

They are available on Amazon, so yeah, check them out if that's

something that you think can help with nighttime wandering or

getting out of a chair when maybe you're not directly in the

room and you're worried about falls, and if you have a chance,

please visit mindingdementia.com We have a newly updated website,

and we actually have a free offer on there, you can get it's

a document that I created, so all you have to do is fill out

your email address, and we will send you that downloadable

document with every medical and legal document that you might

need to know about to make sure your loved ones' affairs are in

order. I'm going to wrap this up with when to seek professional

help, so if sleep disturbances persist despite

non-pharmacological measures, if there's a new pattern of rapid

cognitive decline that coincides with sleep changes, if daytime

functioning deteriorates or safety concerns increase due to

nighttime behavior. These are all signals that you might need

to consult a physician. Also, if there are signs of severe sleep

apnea, you're noticing significant fatigue, depression,

or psychotic-like symptoms that suggest delirium or other

conditions requiring evaluation time to check in with the

physician. Also, if there is a concern about medication side

effects or interactions, so a multidisciplinary approach is

often beneficial, including the primary care physician, a

neurologist, a geriatric psychiatrist, sleep medicine

specialists, occupational therapists, physical therapists,

and or social workers, a dementia-friendly sleep

assessment can definitely guide tailored interventions. So I

hope you enjoyed what I shared with you today. This is a topic

that many, many people are challenged with, so hopefully

this information will be helpful moving forward. You can

implement a lot of the suggestions that I've given you,

and as always, I will be back next week with another new

episode of The Truth, Lies, and Alzheimer's Show, and I'm Lisa

Skinner, your. Host, have a great rest of your week,

everybody. Try to stay happy, try to stay healthy, and I'll be

back next week. Thanks.