Sleep and Alzheimer's Disease
I have a loved one who is suffering from Alzheimer's disease. She tends to sleep a great deal during the day, and she has trouble staying asleep at night. She also tends to wander around the house at night. Is that related to her Alzheimer's disease?
The problem with Alzheimer's disease, as well as other forms of dementia, is that it 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.
Many Alzheimer's patients experience what is called "sundowning": agitated behavior that is thought to occur primarily after the sun goes down; for example, pacing, yelling out, or getting violent. This behavior is usually repetitive. Sundowning can include wandering around at night. Wandering and incontinence are the top two causes of institutionalization, because the family member has great difficultly taking care of a patient who displays one characteristic or the other.
It's important to realize that sundowning doesn't always occur after sundown; it can take place all day long and frequently peaks around 12:30 – 1:00 p.m. It is just easier for the family member to cope with a behavior like wandering during the day than at night, when it is more disruptive.
What can I do as her caregiver?
Unfortunately, there is no silver bullet. There are medications that are used to try to bring agitated behavior and sleep under control. Sometimes these medications make the patient better, sometimes worse. It is important to talk with the patient's physician about the advantages and disadvantages of medication in treating forms of dementia.
Fortunately, there are some things you can do at home to help improve the patient's behavior:
- Keep the patient on as regular a schedule as possible. Get her out of bed at the same time each morning, and put her to bed at the same time each night. Try to discourage her from taking multiple naps during the day—one nap in the afternoon is all right, as long as it lasts no more than an hour. During the day, keep the patient as active as possible.
- It's also important to get the patient to eat her meals at a regular time each day. In fact, the more routine there is in the schedule, the better the patient is able to cope with the effects of Alzheimer's.
- It is important to expose the patient to as much bright light as possible. In a nursing home, most patients are exposed to bright light for only 10 minutes a day. Generally in the community, patients are exposed to about 30 minutes a day. Even this is not enough. It would be better if the patient were exposed to bright light for several hours a day. Take her outside whenever possible, especially in the morning. Morning light offers the best exposure, because in a patient with dementia, their circadian rhythm is out of sync with the rhythm of the environment. Bright light improves their functioning and makes them more alert.
- It is also important that the environment be dark at night. If the patient tends to wander at night and you are worried about her falling or bumping into furniture, you can keep a nightlight on. But understand that bright light interferes with circadian rhythms. Otherwise, keep the patient's bedroom as dark as possible. You should also keep the environment as quiet as possible during the night.
- Avoid caffeine. Products such as coffee, tea, chocolate or soda can interfere with the circadian rhythm.
- Exercise is very important. Have her do whatever she is capable of doing: for example, take the patient on a short walk every day on a regular basis, and engage her in throwing a beach ball. Even if she has to use a wheelchair, encourage her to do arm exercises.
Are there other health problems I should look for?
One of the characteristics of dementia is sleep disordered breathing. More than 80 percent of dementia patients have sleep apnea. If we can treat them successfully for sleep apnea, we might be able to improve their sleep at night and their alertness during the day. Speak to the patient's physician about this possibility.
Improving sleep at night and functioning during the day helps to postpone institutionalization, which would be better for the patient and the family and would save tens of millions of dollars.
--Sonia Ancoli-Israel, PhD, is Professor of Psychiatry at the University of California, San Diego. She is also Director of the Sleep Disorders Clinic at the Veterans Affairs San Diego Healthcare System. Dr. Ancoli-Israel is author of All I Want Is a Good Night's Sleep.
This article originally appeared in the Winter 2001 issue of sleepmatters.