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DISCLAIMER ...
There is no hard and fast answer to addressing a problem behaviour.
The following information is provided as a tool to help the Caregiver find the solution that works for situation they are faced with.

Problem Behaviours - Sleeping

| Possible Causes | Coping Strategies | Other Considerations | Additional Information

Being a Caregiver at home is a difficult task and can become overwhelming at times. Each day brings new challenges as the caregiver copes with changing levels of ability and new patterns of behavior. For the exhausted caregiver, sleep can’t come too soon. Many caregivers cite sleep disturbances, including night wandering and confusion, as the reason for institutionalizing the elderly.

JMB_SleepThe problem with Alzheimer's disease, as well as other forms of dementia, is that the disease has negative effects on the sleep/wake cycle. The greater the degree of dementia, the sleepier the patient is. With more severe forms of dementia, patients are often sleepier during the day, and their sleep at night tends to be fragmented and disrupted. Over a 24-hour period, for example, patients are rarely awake and rarely asleep for a full hour at a time. They are constantly waking up at night and falling asleep during the day.

This pattern is fairly common in Alzheimer's patients.

Scientists don't completely understand why sleep disturbances occur with Alzheimer's disease and dementia. As with changes in memory and behavior, sleep changes somehow result from the impact of Alzheimer's on the brain. Some studies indicate as many as 20 percent of persons with Alzheimer's will experience increased confusion, anxiety and agitation beginning late in the day. Others may experience changes in their sleep schedule and restlessness during the night. This disruption in the body's sleep-wake cycle can lead to more behavioral problems.

Possible Causes

Physiological or Medical Causes

  • Illness such as angina, congestive heart failure, ulcers, arthritis, urinary tract infections, twitching and leg cramps, sleep apnea (breathing difficulties)
  • Urinary tract infections which cause constant pressure to urinate
  • "Restless legs" (twitching) or leg cramps, often caused by metabolic problems
  • Depression
  • Side effects of medications, such as diuretics
  • Sleep apnea (breathing difficulties)
  • Need for less sleep with increased age
  • Disrupted sleep patterns due to progressive dementia.
    • The ability to sleep appears to deteriorate as cognitive abilities decline.

Environmental Causes

  • Too hot or cold
  • Lighting  - darkness disorientated
  • Can't find bathroom
  • Change in environment (hospitalization often causes a change in sleep patterns)

Other Causes

  • Too much time in bed
  • Too much daytime napping
  • To fatigued to calm down and sleep
  • Not enough exercise
  • Hunger
  • Agitation from upsetting situation, such as a bath or an argument with caregiver
  • Hallucinations or bad dreams

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Coping Strategies

  • Have a good medical work-up to identify and treat medical problems.
    • Treat pain with an analgesic (Aspirin, Motrin®, Tylenol®, Nuprin® or Advil®) at bedtime, if approved by doctor.
    • Try Vitamin E for "restless legs".
    • Also discuss with doctor stopping or changing diuretic medications that may be contributing to this problem.
    • For sleep apnea (breathing difficulties characterized by heavy snoring) help person lose weight if obese.
    • See doctor and discuss eliminating sedatives that may be contributing to this problem.
  • Have an evaluation for depression done, if early morning awakening (e.g., waking regularly at 4:00a.m.) is a problem.
  • Antidepressants given at bedtime may help sleep.
  • Have all medications carefully evaluated for side-effects.
  • Check whether person appears to be too hot or cold on awakening ... Internal thermostat may change with dementia.
  • Provide adequate lighting during evening hours ... Shadows, glares, or poor lighting may contribute to agitation and hallucinations.
  • Provide nightlights or soft lighting while sleeping to cut down on confusion during night and to aid in finding bathroom.
  • Make sure there is a clear, well lit pathway to the bathroom.
  • Practice the route during the day.
  • Place a commode or hand held urinal next to bed if finding the bathroom is a problem ... Make sure person goes to bathroom before going to bed.
  • Try to change environment as little as possible.
  • Have the person spend less time in bed.
  • Try getting person up at an earlier ... and up later until tired. Many people require only 6-8 hours of sleep.
  • Make sure the bed and bedroom are comfortable and familiar to the person ... A favourite blanket or pillow or bedclothes may be helpful.
  • Maintain a set bedtime and waking routine, once a good routine is established.
    • Continue bedtime rituals from the past (e.g., a glass of milk before bed, or music on radio at bedtime).
  • Try bedrails - They may help to remind some people that they are in bed.
    • For others, however, they may be confusing and may lead to falls if person tries to climb out of bed.
  • Try to prevent daytime napping, unless person seems very fatigued in evening hours. Then try a short rest or nap after lunch.
  • Make sure the person is getting adequate exercise ... Try to take one or two vigorous walks a day.
  • Cut down on caffeine (coffee, tea, soft drinks, chocolate) during day (eliminate completely after 5:00p.m.)
  • Cut down on alcohol intake ... Discuss the effects of alcohol and medications being taken with physician.
  • Make sure person is not hungry at night ... Try a light snack before bed or during night.
  • Some herbal teas may have a calming effect.
  • Warm milk often helps promote sleep.
  • Avoid bathing (or other upsetting activities) in late afternoon or evening, unless warm baths relax person.
  • Avoid laying clothes out for the next day or talking about the next day's activities ... This may be confusing and give a "wake-up" signal.
  • Allow person to sleep on couch or in armchair, if refusing to get into bed

Make the house, or an area of the house, safe for the person to wander in alone at night.

  • Safety proofing a house for safe night wandering might include:
    • Gating off stairs;
    • Special locks or alarms on doors to outside;
    • Locking off kitchen or locking up dangerous items;
    • Making sure windows are locked.
  • Give a backrub or massage legs at bedtime or during night wakefulness.
  • Try a softly playing radio beside the bed.
  • Hire a nighttime companion or work out shifts so that primary caregiver can get sleep.
  • Gently remind person that it is dark out and time for sleeping.
  • Consider allowing the person to be up at night, if this can be accomplished safely and without destroying caregiver's routine.

For sundowning (agitation and wandering in late afternoon/evening):

The term "sundowning" refers to a state of confusion at the end of the day and into the night. Sundowning isn't a disease, but a symptom that often occurs in people with dementia.

Factors that may aggravate late-day confusion include:

  • Fatigue
  • Low lighting
  • Increased shadows
  • Disruption of the body's "internal clock"

Coping Strategies may include:

  • Try to distract - put on music;
  • give person something to hold, feel, or fiddle with;
  • go for a walk;
  • try a craft activity;
  • turn on the television.
  • Try closing blinds or curtains to shut out darkness.
  • Turn lots of lights on to brighten atmosphere and combat shadows.
  • Try to be rested for better coping at the most agitated time of day.
  • Try to minimize noise, confusion, and numbers of people around during the most agitated time of day.
  • Try a rocking chair.

Research suggests that a low dose of melatonin — a naturally occurring hormone that induces sleepiness — in combination with exposure to bright light during the day may help minimize the disorientation associated with sundowning. When sundowning occurs in a care facility, it may be related to the flurry of activity during staff shift changes. Staff arriving and leaving may cue some people with Alzheimer's to want to go home or to check on their children — or other behaviors that were appropriate in the late afternoon in their past. It may help to occupy their time during that period.

In nursing homes or adult foster care homes:

  • Increase staffing, volunteers, or family visits at that time of day to permit more one- to-one attention.
  • Be aware that use of restraints usually makes the agitation worse.
  • Try a beanbag or more advanced Gel chair - they are soft, comfortable, hard to get out of, easily cleaned ... However, people may need assistance getting up.
  • Be aware that shift changes are often noisy, confusing times of day which can contribute to agitation

General:

  • Use psychotropic medications, such as Haldol® or Mellaril®, to take the edge off agitation ... Use only with very careful medical supervision. In some people with dementia, these medications have the opposite effect, making people more agitated.
  • Use sleeping medications only as A LAST RESORT.
    • Be aware that their effectiveness is only short term, but may be helpful in establishing a more regular sleep cycle.
  • However, sleeping medications may add to confusion on waking.

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Other Considerations

  • Be very cautious with the use of any kinds of medications for inducing sleep ... Sometimes they may make symptoms of confusion and disorientation worse ... A physician familiar with dementia must very carefully monitor psychotropic or sleeping medications.
  • Problems with sleeping or late evening agitation are often a stage in dementia that eventually passes... Many Alzheimer's patients begin sleeping more during the later stages of the illness.
  • It is important to try to recognize elements in the environment, the medical situation, or problems of communication that might be contributing to sleep problems, before deciding on particular strategies to try ... Sometimes keeping a log or diary which tells what happened when, and what else was going on at the time, can help pinpoint a possible cause of problems.
  • Sleep problems are one of the symptoms that are least tolerated by family caregivers.

Additional Information

Alzheimer's Association (ADRDA) chapter newsletters

Davignon, Denise and Pauline Bruno. Insomnia: Causes and Treatment, Particularly in the Elderly. Journal of Gerontological Nursing, 8(6), 1982.

Lerner, Roslyn. Sleep Loss in the Aged: Implications for Nursing Practice. Journal of Geronrological Nursing, 8(6), 1982.

Mace, Nancy and Peter Rabins. The 36-Hour Day. Baltimore: The Johns Hopkins University Press, 1981.

Reynolds, Charles, David Kupfer, and Deborah Sewitch. Diagnosis and Management of Sleep Disorders in the Elderly. Hospital and Community Psychiatry, 35 (8), 1984

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