Why don’t people with dementia sleep well?

It’s partly because most people with dementia are older, and older people have different sleep patterns - almost half of older people have a nap every day, for at least half an hour, so they don’t have all their sleep at night.  Over 80, people are likely to nap for more than an hour. 

“Anxiety and depression is often experienced by people with dementia in addition to the specific sleep problems that dementia may present.  The person may wake at night, and get up to explore their environment, which may no longer feel familiar or safe.”

When you are older it can take longer to get to sleep and you tend to wake up more and have less deep, refreshing sleep.  This is partly due to changes in the sleep hormone melatonin. Painful medical problems that come with old age can keep you awake, for example arthritis. Other diseases such as Parkinson's disease cause specific sleep disturbances.  In any case, anyone may have a disturbed night because of continence issues, indigestion, heart disease or lung diseases that cause shortness of breath.  Unfortunately, some of the medicines for these conditions may also interfere with sleep.  A quarter of all older people have sleep apnea which is where your sleep is interrupted because of pausing in breathing.   

Anxiety and depression is often experienced by people with dementia in addition to the specific sleep problems that dementia may present.  The person may wake at night, and get up to explore their environment, which may no longer feel familiar or safe.  The urge to sleep is reduced in people who don’t have enough exercise and many people with dementia don’t merely lose motivation to exercise but are actively discouraged from taking exercise by risk averse families or other care givers.  The hormone melatonin is influential in the sleep wake cycle, and it is metabolized by access to day light or blue spectrum light, so exercise in day light in the early part of the day is valuable.

What can be done to support a good night’s sleep at home?

What works is usually based on knowledge of the person and what they like – the sort of thing that only a family member could know or suggest.

Carer anxiety

Carer anxiety can unsettle the person with dementia causing a spiral of agitation in the household.  The carer may be “hyper-alert” at night, concerned about the danger of “wandering”. The use of movement sensors can allow them to relax and sleep deeply safe in the understanding that if the person with dementia gets up and about, they will be alerted.  Information about movement sensors and other assistive technology can be found at Ask Sara.

The bed

Sometimes a frail older person is given a different “hospital” style bed to sleep in at home or the bed has been moved to a different room. There is not a lot of research on what makes the best bedding.  Familiarity is best in dementia so changing both things can give rise to problems, and the risk should be considered.

Management of continence

Good quality, long-lasting, continence products can allow an uninterrupted night.  Drinking any fluid close to bedtime may increase the need to get up.  Limiting fluids to some extent in the late evening makes sense, but only if the person is well hydrated throughout the rest of the day, which is not always the case in dementia care. Particular attention should be paid to daytime hydration if you are going to rely on nighttime dehydration to promote continuous sleep.  It is common sense advice to avoid eating and drinking close to bedtime but be aware of the risk of a 12 hour fast from supper to breakfast, which is known to assist with intended weight loss. Many frail older people with dementia have unintended weight loss so something like a little milk and a biscuit at bedtime might be advisable, as well as having food available for nighttime snacking.  Carers who understand the ‘wake-up” effect of caffeine in coffee may not be aware of other sources, such as tea or cocoa.

Medication

The use of sedative medication is always a concern because of hangovers it can lead the following day to napping, falls and continued sleep pattern disruption.  There is also mortality and morbidity risks presented by some psychotropic medication.  If every other method has been tried, it may be necessary and prescribers are advised to start at the lowest dose, to support a natural sleep pattern and avoid daytime drowsiness.

Rules of the bedroom

Some useful rules include;

• Keep the room as dark as possible, as this affects the basic human sleep pattern.  Increase the light when you want the person to wake, even if it is still dark outside, and vice versa. 

• People will sleep better in a warm bed in a cooler room.  It is important to be able to control the temperature in the bedroom.

• Good air quality is vital, and so open a window to allow this within safety parameters

• For use of the toilet, use movement sensors for appropriate lighting.  An ensuite toilet is ideal, where the toilet seat can be seen from the head of the bed, but without that, lighting and familiarity with the layout can help.

• There is a danger of falls at night, so it is important to have a smooth, matt surface to walk on.  Avoid hazardous slippers.

Sleep hygiene

It is important to slow down in the time leading up to bedtime.  Television or using computer screens is known to stimulate wakefulness.  This is not just because of the excitement of any content, but also because the spectrum of light from the screen affects melatonin metabolism.

Keep daytime “signals” to the minimum, by keeping outdoor clothes and shoes in a different place.  Keep the bedroom for sleeping only.  In some care homes, night staff wear pajamas and dressing gowns so that if seen by residents, a visual clue is offered that it is nighttime.  This strategy may work at home if everyone gets dressed for bed, even if they are not planning to go there at the same time as the person with dementia.   

Every house has nighttime rituals, such as switching off electrical sockets and lamps and putting things away, and letting the dog out for the last trip to the end of the garden.  Make the most of those signals to create a rhythm that the person will instinctively follow.  If the person has a faith, prayer or meditation at this time may bring a natural and familiar end to the day.

Agitated and aggressive behaviour at night

Aggression and agitation can be expressed by shouting, or moving about, which are particularly difficult to cope with at night.  All difficult behaviour in dementia can be thought of as an expression of distress, and the aim of the carer should be to reduce stress.  This is a tall order, but the person living alongside the patient is probably best equipped to say what would help them to be calm.  There are no hard and fast rules, but some basics.  For example, don’t argue, even if the person is wrong.  You will not persuade them and may upset them more.  Try to be relaxed yourself, as your own tension will increase the stress in the situation. 

More help can be found on websites of national Alzheimer’s organisations such as www.alzheimers.org.uk   and other useful publications such as Dementia: the One-Stop Guide and Carers and Caring the One-Stop Guide.