Daytime Sleep And Dementia: What Caregivers Need To Know

Sleep disturbances are common in people with dementia, with up to 50% of patients experiencing them. While it is normal for people with dementia to sleep a lot during the day, it is not advisable to let them sleep whenever they want. Maintaining a healthy sleep schedule is optimal for rest. Long naps, especially later in the afternoon, can disrupt their sleep-wake cycle, doing more harm than good.

Excessive daytime sleepiness is more common in people with Parkinson's disease dementia or Lewy body dementia than in those with Alzheimer's disease. Insufficient sleep at night, sedating medications, damage to brain cells caused by dementia, changes in sleep patterns caused by dementia, mental health conditions, and other sleep disorders such as sleep apnea are some factors that contribute to daytime sleepiness.

To help a person with dementia sleep better at night, caregivers can encourage physical activity, create a calming bedtime routine, and talk to a doctor about potential causes.

Excessive daytime sleepiness in people with dementia

Excessive daytime sleepiness is a common feature among individuals with dementia, especially in the later stages of the disease. This can be distressing for family and friends, who may worry that something is wrong. However, sleeping more during the day is often a normal part of the progression of dementia and is not usually a cause for concern unless it occurs suddenly or is accompanied by other symptoms.

There are several factors that can contribute to excessive daytime sleepiness in people with dementia:

• Changes in the brain: Disruption to the body's circadian rhythm, or internal "biological clock," can make it harder for people with dementia to distinguish between night and day, leading to reversed sleep patterns.
• Specific types of dementia: Sleep disturbances are particularly common in Lewy body dementia and Parkinson's disease dementia due to physical changes in the brain and the association with REM sleep behaviour disorder.
• Napping during the day: Frequent naps, especially in bed, can disrupt night-time sleep.
• Medical conditions: Sleep apnea and restless leg syndrome can disrupt sleep and are more common in older adults.
• Medication: Some medications, such as antipsychotics, antidepressants, antihistamines, and sleeping pills, can contribute to sleepiness.
• Pain and discomfort: Older patients with dementia may experience joint pain and other sources of discomfort that can disrupt sleep.

To help manage excessive daytime sleepiness in people with dementia:

• Establish a healthy sleep routine: Encourage regular bedtime and wake-up times, daily activities, and exposure to natural daylight.
• Adjust the environment: Use blackout curtains at night and consider light therapy during the day to regulate the body clock.
• Review medication: Discuss medication side effects with a doctor and consider adjusting dosages or timing.
• Limit daytime napping: Encourage shorter naps in a chair rather than in bed to promote lighter sleeping.
• Promote relaxation: Create a restful environment, avoid caffeine and alcohol, and establish calming bedtime routines.

The impact of dementia on the brain

Dementia is a general term for diseases that cause changes in memory and/or thinking skills, severely impairing a person's daily functioning. While dementia primarily affects memory, it can also cause mood changes and difficulties with walking, speaking, or finding one's way. The cause of dementia is often unknown, but research suggests that it is related to a build-up of proteins in the brain that interferes with its functioning. Different types of dementia are associated with different proteins, such as beta-amyloid and tau in Alzheimer's disease and alpha-synuclein in Lewy body dementia.

Vascular dementia, the second most common form of dementia after Alzheimer's, is caused by decreased blood flow damaging brain tissue. This can occur due to blood clots, ruptured blood vessels, or narrowing/hardening of blood vessels supplying the brain. The impact of vascular dementia depends on the size and location of the affected area. If a small area in the memory-controlling part of the brain is affected, the person may experience forgetfulness, but their ability to perform normal activities may remain intact. However, if a larger area is affected, they may have trouble thinking clearly or solving problems, impacting their daily functioning.

Alzheimer's disease, the most common form of dementia, disrupts communication between neurons, resulting in widespread loss of brain function. Neurons stop working properly, lose connections with other neurons, and eventually die. This damage typically begins in parts of the brain involved in memory, such as the entorhinal cortex and hippocampus, before affecting areas responsible for language, reasoning, and social behaviour. Over time, Alzheimer's leads to a gradual loss of independence, and the disease is ultimately fatal.

Dementia can impact the brain in various ways, depending on the type and stage. While the specific changes vary, they generally lead to a decline in cognitive abilities and independence, affecting an individual's daily life and well-being.

Non-drug treatments for sleep changes

• Maintaining regular times for meals, bedtime, and waking up.
• Encouraging exposure to morning sunlight and daily exercise, but no later than four hours before bedtime.
• Avoiding alcohol, caffeine, and nicotine.
• Ensuring the bedroom is a comfortable temperature and has nightlights for safety.
• Discouraging television watching during periods of wakefulness.
• Keeping the patient active during the day with outdoor strolls, socialising, and engaging in stimulating activities.
• Adjusting eating patterns, limiting food intake in the evening, and having dessert after lunch instead of dinner.
• Making daytime napping a part of the routine, preferably at the same time and place each day, and for the same short length of time.
• Keeping clocks visible and clear to help the person with dementia distinguish between night and day.

Medications for sleep changes

Medications are sometimes used to treat sleep disturbances in people with dementia. However, non-drug treatments are recommended as the first-line approach to managing these problems. This is because studies have found that sleep medications generally do not improve overall sleep quality for older adults. The use of sleep medications is associated with a greater chance of falls and other risks that may outweigh the benefits of treatment.

If non-drug treatments are unsuccessful, medications may be required. However, the risks of sleep-inducing medications for older people who are cognitively impaired are considerable. They include an increased risk of falls and fractures, confusion and a decline in the ability to care for oneself. If sleep medications are used, an attempt should be made to discontinue them after a regular sleep pattern has been established.

The type of medication prescribed by a doctor is often influenced by behaviours that may accompany the sleep changes. The decision to use an antipsychotic drug should be considered with extreme caution. Research has shown that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The U.S. Food and Drug Administration (FDA) has ordered manufacturers to label such drugs with a "black box" warning about their risks and a reminder that they are not approved to treat dementia symptoms.

• Tricyclic antidepressants, such as nortriptyline.
• Benzodiazepines, such as lorazepam, oxazepam and temazepam.
• "Sleeping pills" such as zolpidem, zaleplon and chloral hydrate.
• "Atypical" antipsychotics such as risperidone, olanzapine and quetiapine.
• Older "classical" antipsychotics such as haloperidol.
• Melatonin.
• Orexin antagonists, such as suvorexant and lemborexant.

Caring for a loved one with dementia

Understanding Dementia

Dementia is a progressive disease that affects the brain, and as it advances, it's not unusual for the sleep pattern of the affected individual to change. They may sleep too little or too much, and their internal body clock, which regulates the sleep-wake cycle, may become disrupted. This can make it difficult for them to distinguish between night and day.

Self-Care for the Caregiver

It's essential to prioritise your own well-being while caring for a loved one with dementia. Remember, you cannot pour from an empty cup. Here are some self-care tips:

• Accept help: When people offer assistance, say yes! Have a list of tasks that others can help with, such as bringing meals, running errands, or simply providing companionship while you take a break.
• Forgive yourself: Caregiving is demanding, and it's normal to feel a range of emotions, including frustration and impatience. Forgive yourself for not being a "perfect caregiver" because no such thing exists.
• Practise mindfulness: Consider reading books or attending programmes that teach mindfulness techniques to help you stay calm, centred, and compassionate during this challenging time.

Communication Strategies

Communication with a loved one with dementia can be difficult, but here are some tips to improve your interactions:

• Use straightforward language: Speak in simple, straightforward sentences about what is going to happen. Avoid complex explanations or arguments as they may no longer respond to logical reasoning.
• Redirect and distract: Instead of correcting their memory lapses, redirect the conversation or distract them by asking about the person they've mentioned or their home. This can help calm them down.
• Therapeutic lying: While honesty is usually the best policy, consider if it's truly necessary to correct every misconception. For example, if your loved one believes they are a volunteer at the daycare centre, does it cause any harm to let them hold on to that belief?

Daily Routine and Sleep

Establishing a daily routine can help your loved one with dementia and improve their sleep patterns:

• Daily activities: Plan a daily schedule that includes outdoor walks, social interactions, and engaging in stimulating activities like dementia cafes or support groups. Exposure to natural daylight is crucial for regulating their body clock.
• Bedtime and wake-up routine: Try to maintain consistent bedtime and wake-up times. Establish calming bedtime and morning routines, such as playing soft music, reading, or using scented pillow sprays to signal that it's time for sleep.
• Limit daytime napping: While complete prevention of daytime napping may not be necessary, try to regulate it. Encourage napping at the same time and place each day, preferably in a chair instead of a bed, to promote lighter sleeping.
• Adjust eating patterns: Limit food intake in the evenings and opt for a healthy snack or light meal. You can also try having dessert after lunch instead of dinner.
• Hydration: Encourage your loved one to drink fluids throughout the day, especially earlier in the day, to avoid frequent bathroom trips at night.

Medical Considerations

• Review medication: Some medications can contribute to sleepiness or confusion. Consult with their doctor about the optimal time of day to take their medication and whether any adjustments are needed.
• Rule out other conditions: Sleep disturbances may be caused by other medical issues such as sleep apnea or restless leg syndrome. Consult a doctor to rule out or treat any underlying conditions.
• Pain management: Older patients with dementia often experience joint pain, which can disrupt their sleep. Ensure proper pain management to improve their comfort and sleep quality.

Remember, every person with dementia is unique, and you may need to adapt these strategies to find what works best for your loved one. It's important to stay patient, flexible, and compassionate throughout this journey.

Frequently asked questions