Understanding Sleep Disturbances in Dementia

Are you caring for a loved one with dementia? You don't have to figure this out all on your own. Welcome to Truth, Lies Alzheimer's, the show that helps you reimagine a new relationship with your loved one, a relationship a little more free of stress and anxiety. Join host Lisa Skinner and her 30+ years of experience as she guides you on a new path to a better relationship with those you care for. Here's Lisa.

Welcome everyone who are tuning in to another new episode of The Truth, Lies 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 gonna share with you some caregiver strategies that hopefully will be very helpful for you. So sleep disturbances 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 suprachiasmatic 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, 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 5 or more medications at the same time in older adults, can increase the risk of adverse interactions 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. Ideal 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 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 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, increase 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 2 to 4 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 a sure sign that somebody may actually be suffering from sleep apnea, but it's treatable. Uh, 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.

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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 even consider white noise machines or soft ear 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, um, 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 risk. 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 continence strategies if necessary. Avoid polypharmacy where possible. In other words, being on at least 5 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 nightlights, 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 avid— 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 gonna 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, monitoring like a bed alarm, and I actually have one right here to show you. This is the SignalSafe 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, um, 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 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 one's affairs are in order. I'm gonna 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 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. Thank you for listening to Truth, Lies Alzheimer's. We hope you found something in today's episode that helps. We understand that caring for a loved one with dementia can be the challenge of a lifetime, but you don't have to do it alone. If you're ready for exclusive access to even more great content and resources. Head on over to Facebook and join Lisa Skinner's Minding Dementia support group. We're a community of like-minded caregivers, and we're here to help.