Sleep disturbances in Alzheimer's patients

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Alzheimer's patients sleeping problems and caregiver exhaustion are two of the most common reasons Alzheimer's patients are eventually placed in nursing homes. Some studies indicate that as many as 20 percent of Alzheimer's patients will, at some point, experience periods of increased confusion, anxiety, agitation and disorientation beginning at dusk and continuing throughout the night.

There are many "interventions" that can help minimize sleep disruptions. Many medicines used as sleeping aids can be harmful, and often are not particularly effective in Alzheimer's patients anyway, so it is best to try other approaches first.


>> POSSIBLE CAUSES OF SLEEP DISTURBANCES

Sleep disturbance may be caused by Alzheimer's itself, but there are other possible causes that should be ruled out.

* Check the side effects of the medicines and supplements your loved one is taking. Some can cause agitation, vivid dreams, or insomnia.

* If your loved one is taking a cholinesterase inhibitor (aricept, exelon, razadyne/galantamine), avoid giving it to your loved one before bed. Available data suggest that the type of cholinesterase inhibitor that is given, and the time at which it is given, may be critical in avoiding the development of sleep disturbances and minimizing them once they have been triggered. Higher levels of the inhibitors in the blood during the day and lower levels at night are better.

* Your loved one may have some sort of pain (arthritis, muscle aches, dental problems, untreated ear or sinus infections, or a urinary tract infection) that is causing too much discomfort for him to sleep. Have his doctor examine your loved one for such problems. Talk with his doctor about using a mild analgesic at night for restlessness due to aches and pains.

* Physical discomfort from ailments such as bladder or incontinence problem, an enlarged prostate, etc, could be making it difficult to sleep. Again, seek medical advice.

* Your loved one may have a sleep disorder such as restless leg syndrome, REM sleep behavior disorder, nocturnal myoclonus, or sleep apnea, which are relatively common in elderly individuals. For example, more than 80 percent of dementia patients have sleep apnea. If the patient can be treated successfully for sleep apnea, it may improve his sleep at night and his alertness during the day. Speak to your loved one's doctor about this possibility.

* Your loved one may be suffering from depression, which is relatively common in Alzheimer's patients and can cause problems with sleep. In addition to poor sleep, symptoms of depression may include poor appetite, facial expressions of suffering or sadness, and possibly verbal expressions of feelings of hopelessness, helplessness and guilt. Talk with the doctor about evaluating your loved one for possible depression, and perhaps trying an antidepressant.


>> NON-DRUG INTERVENTIONS

There are many things that you can try to help your loved one sleep better at night ... so you can, too!

* Keep your loved one on as regular a schedule as possible. Get him out of bed at the same time each morning, and put him to bed at the same time each night. Try to give your loved one's day a regular rhythm, with meals, outings, and bathing happening at about the same times each day. Try to schedule more physically and mentally demanding activities earlier in the day, so your loved one will not be overly-tired and cranky by evening. Schedule all doctors' appointments at roughly the same time if you can, such as first thing in the morning or right after lunch. It's not unlike the way a new parent organizes the day around a baby's sleep-wake cycle.

* Try to discourage your loved one from taking multiple naps during the day. If he seems very fatigued during the day, let him have a short rest (an hour or so) in the afternoon.

* It is important to expose your loved one to as much bright light during the day as possible, especially outdoors. The circadian (biological) rhythm of dementia patients can be out of sync with the rhythm of the environment; daytime bright light improves their functioning and helps them be more alert. In general, studies on bright light therapy have shown that ≥ 2,000 lux for two to four hours per day, at the same time each day, can improve the sleep-wakefulness cycle, and reduce behavior problems, in many, but not all, Alzheimer's patients. Interestingly, several studies have shown that evening bright light is more effective than morning bright light or increased daytime activity, although the time of day that is best can vary for individual patients, and for different types of dementias. One study found that those with Alzheimer's disease were more responsive to an increase in whole-day indirect light, for example, while patients with multi-infarct dementia were most responsive to the traditional light box (e.g., the Day-Light Box 10000, providing 10,000 lux).

* Exercise will help your loved one feel more tired at bedtime (as well as being good for your loved one's overall health and cognitive function!) Encourage him do whatever he is capable of doing. For example, take your loved one on walks every day, preferably outdoors where your loved one will get some fresh air and a chance to get reacquainted with the surroundings. (This is just as important for you, since caregivers often have trouble finding the time to get the exercise they need!) Engage him in throwing a beach ball. Even if he has to use a wheelchair, encourage him to do arm exercises.

* Daily social activity at regular times during the day may also improve both sleep and neuropsychological function.

* Avoid caffeinated products such as coffee, tea, chocolate or soda, because they interfere with the circadian rhythm. Restrict the consumption of sweets to the morning hours. Cut out alcohol and nicotine.

* Serve dinner early, and offer only a light meal.

* Set a quiet, peaceful tone in the evening. Do not allow your loved one to watch TV shows that are distressing (violent, scary, or sad.) Play soothing music if your loved one enjoys it.

* Have a regular time for going to bed, and a routine for getting ready for bed. Taking a bath, brushing teeth, and getting into pajamas is a routine our loved ones have had from early childhood, and can trigger the memories of how to behave at night ... staying in bed, and going to sleep.

* Have your loved one use the toilet right before bedtime.

* Give your loved one a bath, warm milk or herbal tea (but not too much, or he'll need to use the toilet during the night!), and a back rub at bedtime. Some caregivers believe that Therapeutic Touch can relax a dementia patient and help him sleep.

* Fear, seeing or hearing things that are not real, and confusion may get worse in the dark, so sitting with your loved one for a while, as he drifts off to sleep, may help.

* Make sure the pajamas your loved one wears are comfortable -- soft, loose, no scratchy lace or appliques, and not too warm or too cool. Cut labels from the neck -- they scratch, itch and can rub sensitive skin. Avoid synthetics such as polyester, which induce sweating, and can be rough on the skin and make it itch. Many older people develop allergies to synthetics. Cotton stands up to repeated washing. Read the labels to be sure pajamas (or other clothing) are 100% cotton before buying. Look for cotton knits, because knits stretch and are softer on the skin. Rayon is the only man made fiber with natural breathability, and is washable. Spin dry long enough to remove wrinkles then take out and hang dry. Rayon /cotton blends are fine. Silk knits are warming and light on the skin, but they often feel sticky in a hot humid climate. Stay away from highly perfumed softeners and strong bleaching when washing clothes. Look to more nature friendly products and rinse thoroughly after washing. The less chemicals on the skin, the better.

* Make sure that the bed, the pillows and blankets, and the bedroom, are comfortable. Your loved one may be restless because his body is getting stiff from an old mattress or the wrong pillow, the blanket is scratchy, or the room is too warm or too cold. All-cotton sheets, percale or especially flannel, may be the most comfortable. Again, stay away from highly perfumed softeners and strong bleaching when washing sheets and pillow cases.

* If your loved one is incontinent, cover the bed mattress with breathable water-resistant covers instead of plastic covers and rubber sheets. Neither plastic nor rubber allows the skin to breathe. Plastic induces sweating, which is uncomfortable and increases the potential for skin breakdown. It isn't necessary to protect the entire mattress unless your loved one isn't being changed regularly. Water-resistant covers used along with the baby crib pads (and towels) which protect the torso area should be enough. Clean them regularly and do not wait until everything is dirtied.

* Create a calm atmosphere for sleeping. Close the curtains and leave night lights on all night in the bedroom, hall, and bathroom. Some dementia patients become disoriented or imagine things in the dark and become upset. Shadows may look scary, so check the placement of night lights to make sure there are no shadows in corners or on walls. Try to eliminate loud noises during the night. Use "white noise", like the hum of a fan or soft music, to block out the little night-time noises that may confuse or frighten.

* Stuffed animals, a baby doll, or a pet may soothe your loved one and allow him to sleep. Some caregivers have reported success with body pillows to cocoon their loved ones, making them feel more secure.

* Place a commode next to the bed for nighttime urination. Walking to the bathroom in the middle of the night may wake your loved one up too much, and then he can't get back to sleep.

* Consider changing the sleeping arrangements. Your loved one may prefer to sleep in a different bedroom, or in a recliner or on the couch rather than in bed. Be sure that the furniture is designed so that your loved one won't fall out while sleeping.

Once your loved one is awake and upset, approach him in a calm manner. Find out if there is something he needs. Gently remind him of the time and lead him back to bed. (Don't pull on him ... offer him your hand and let him take it.) Avoid arguing or asking for explanations. Offer reassurance that everything is all right and everyone is safe.


>> MEDICINES

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 your loved one's doctors about the advantages and disadvantages of medication in treating dementia patients.

According to the Alzheimer's Association, most doctors tend to avoid prescribing traditional sleeping pills for older adults with dementia, as the drugs can have serious side effects, including incontinence, problems with balance, falls or increased agitation. Sedatives such as Ambien, Sonata, and Lunesta can induce delirium. Many of these drugs can have dangerous, complicated interactions with the other medicines commonly prescribed for dementia patients.

One widely used alternative is the antidepressant trazodone (Desyrel), which tends to make people sleepy. Sedating antidepressants such as mirtazepine may be considered. Anti-anxiety medications are also sometimes helpful; but some of these can affect cognition, so be sure to look up potential side effects. See the Johns Hopkins Memory Special Report:

http://www.johnshopkinshealthalerts.com/reports/memory/671-1.html

Doctors also recommend that dementia patients avoid over-the-counter sleep aids. The active ingredient in many of these is diphenhydramine (Benadryl), an antihistamine that makes people feel drowsy. Diphenhydramine further suppresses the activity of one of the main brain cell messenger chemicals whose activity is already reduced by Alzheimer's. It can cause delirium and hallucinations, and worsen cognitive dysfunction.

(Note that diphenhydramine is also an ingredient in many "nighttime" or "PM" versions of popular pain relievers and cold and sinus remedies. Be careful to watch out for these!)

"Natural" sleep aids such as melatonin and tryptophan are often suggested by caregivers. However, as far as I could determine, there have been few studies to determine whether either one would be effective in Alzheimer's patients. Patients taking prescription antidepressants should not take tryptophan or melatonin, as either of these may interact with antidepressants and produce harmful results.

Some caregivers have had good results giving melatonin to their Alzheimer's loved ones. Others have not. A recent clinical trial indicated that melatonin does not appear to be useful for most Alzheimer's patients. See:

http://www.alzforum.org/new/detail.asp?id=932

If you decide to try it, use melatonin only under the supervision of a doctor. Very little is actually known about this over-the-counter supplement, including its safety / toxicity or its interactions with other drugs, especially in fragile people such as Alzheimer's patients. Melatonin has been reported to cause side effects in healthy people, such as fatigue, nightmares, hypotension, sleep disorders, and abdominal pain. Melatonin should be avoided for people with a history of seizures, as it lowers the seizure threshold. Although melatonin is not regulated by the FDA in the U.S., it is classified as a neurohormone and cannot be sold over the counter in Europe. The purported 'pharmacologic dose' is 3 mg, but some studies indicate lower doses (0.3 mg) are effective, and that repeated administration of 3 mg may disrupt, rather than improve, sleep in some people. Some authorities say melatonin use on consecutive nights should be avoided, and only the lowest effective dose should be taken. See:

http://www.alzforum.org/dis/tre/drc/detail.asp?id=52

Tryptophan has been studied for treating Alzheimer's in clinical trials, but for improving cognitive functioning, not for relieving insomnia. As far as I can tell, it was not found to be effective for that particular application. However, tryptophan *has* been studied for treatment of chronic insomnia in otherwise healthy people, and found to be effective, so it might be an option to consider. Animal studies (rats) found that an analogue of tryptophan, 5-hydroxytryptophan, is significantly more effective than tryptophan for improving sleep. I haven't been able to find any reports on 5-HTP being tested for treating insomnia in humans, although it has been studied for treating certain symptoms of other neurodegenerative disorders such as Parkinson's. Again, try this supplement only under the supervision of a doctor.

The following link is to an excellent article on the use of melatonin and/or tryptophan while taking antidepressants. It explains how they work, some possible drug interactions, etc.

http://www.medscape.com/viewarticle/563447


>> WHEN NOTHING WORKS...

Nighttime restlessness doesn't last forever. It typically peaks in the middle stages, then diminishes as the disease progresses.

In the meantime, make sure that you, yourself, can still sleep. This requires either a very safe room for your loved one to pace in, or else another caregiver who takes over at night. If you opt for the former, use a baby monitor so you can hear your loved one if he becomes upset or needs help. Safety-proof your loved one's room by taking out throw rugs, knickknacks, wall pictures, etc., leaving only the bed and dresser. Remove lamps and in their place, install overhead track lighting with dimmer switches. Make sure the windows are Plexiglas, in case your loved one bangs into them by accident. Install a peep hole in the door that gives you a 180-degree view of the room so that you can observe him without opening the door (thus awakening him). Pipe soft music into the room to blot out extraneous noise. Paint the woodwork the same color as the walls, to cut down on your loved one finding and rattling the door.

If you opt for another caregiver watching your loved one, make sure your home is safe and secure. Be aware that wandering can start up without warning, and plan ahead. Restrict access to certain rooms or levels by closing and locking doors, and install tall safety gates between rooms. Door sensors and motion detectors can be used to alert family members when a loved one is wandering.