Sleep problems in dementia

About half of people over the age of 65 experience changes in sleep. In dementia, sleep disturbances occur in about 80% of patients. Most often, sleep changes will appear in the middle stages of dementia/Alzheimer's. It is not clear what specific changes in the brain lead to changes in sleep patterns, and the changes vary as the disease progresses.

Common sleep disorders are:

• Oversleeping (hypersomnolence)
• Difficulty falling asleep or staying asleep (insomnia)
• Changes in breathing during sleep to the point of sleep apnea syndrome Sleep Apnea (OSA, Obstructive Sleep Apnea)
• Physical disorders, such as restless legs disorder
• Disturbances in the sleep-wake cycle, so that day and night become alternating

These will manifest themselves, among other things, in behavioral phenomena such as:

• Waking up early and "starting a new day" while it's still dark
• Waking up several times at night and walking around the house
• Sleep more during the day
• Having trouble getting up in the morning
• Falling asleep early in the evening and more…

The impact of sleep disorders on people with dementia/Alzheimer's

Although the person with dementia/Alzheimer's may appear to sleep a lot, the quality of sleep is often poor. Everyone, with or without dementia/Alzheimer's, suffers from physical and cognitive difficulties when they don't get enough sleep. People with dementia/Alzheimer's often experience less slow-wave sleep and rapid eye movement (REM) sleep, which are the types of deep sleep that are important for feeling refreshed and energized from sleep.

Sleep disorders can cause:

• Increased irritability
• Impaired attention and concentration
• Limited cognitive ability
• Amplification of emotional distress
• Increased risk of falls

In recent years, there has been increasing awareness of the impact of sleep deprivation and/or sleep disorders throughout life as a risk factor for the development of dementia . For example, obstructive sleep apnea (OSA) significantly increases the risk of Alzheimer's or vascular dementia, and the effect of this background factor should be ruled out as part of the diagnostic process for dementia.

Effects of types of dementia on sleep disorders:

• Vascular dementia: This dementia occurs due to changes in the blood supply to the brain and patients with it are 2.5 times more likely to experience insomnia (difficulty falling asleep or staying asleep). As mentioned above, patients with this dementia often have sleep apnea syndrome, in which the airway is partially or completely blocked, which may manifest as loud snoring or coughing. In each case, the brain "wakes" the person up to allow air to enter properly, often by stimulating a change in position or something similar. This syndrome also increases the risk of heart attack and stroke.
  
  
• Dementia with Lewy bodies and dementia due to Parkinson's disease: Sleep disturbances are reported in the majority of people diagnosed with Parkinson's disease and dementia with Lewy bodies (approximately 90% of patients). Sleep disturbances in these types of dementia include excessive daytime sleepiness (EDS), insomnia, hallucinations, sleep apnea, and REM sleep behavior disorder.
  • REM sleep behavior disorder: Usually during REM sleep, which is dream sleep, there is a disconnect between the activity of the brain and the activity of the muscles, so that we can dream that we are running/climbing/jumping, etc., while our body remains limp and without significant movement. In this disorder, this disconnect between body and brain does not exist, and the person moves their limbs during the dream to perform the movements they are dreaming. The person themselves are not aware of this at all, and the one who is harmed is the person sleeping next to them. There are sometimes cases of actual harm and injury to the partner. As mentioned, the person dreaming is not aware of this. It is not recommended to wake them up to stop the movements, and there is no point in talking about it while they are awake. The appropriate solution is to sleep in separate beds, and perhaps even separate rooms if possible (sometimes the movements are also accompanied by shouting and noises that disturb the other person's sleep).

Coping with sleep disturbances in dementia/Alzheimer's

Addressing sleep disorders should be personalized to the person with dementia/Alzheimer's and their functioning. First, it is recommended to work to create good sleep hygiene:

• Sun exposure during the day: Sunlight is a very important factor in the secretion of melatonin, a hormone essential for inducing the feeling of needing sleep. Just sitting on a balcony in the sun for half an hour is enough to get the necessary effect.
  
  
• Bedroom with appropriate lighting: Closed blinds and windows, no bright lights, lighting to direct you to the bathroom (preferably red/orange lighting)
  
  
• Room temperature The recommended temperature for sleeping is about 18 degrees - remove electrical devices from the bedroom (including TV, mobile phone, computer, digital clock, etc.)
  
  
• Reducing drinks With caffeine and "heavy" food in the afternoon and evening – moderate physical activity in the afternoon-evening
  
  
• Creating a bedtime routine – Using a device that produces "white noise": Popular devices abroad that mask environmental noises that may interfere with falling asleep or during sleep, such as barking dogs, moving cars, etc. In the context of dementia/Alzheimer's, sometimes the noise of an air conditioner or fan (especially if they are not new and the quiet type) may also be a noise factor that negatively affects sleep. 
  
  
• Light therapy: A treatment in which the person is exposed to certain light frequencies (special lamps) for defined periods of time with the aim of normalizing the sleep-wake cycle. Reports on the effect in dementia/Alzheimer's are varied and there is no clear indication for using this treatment method.

What else can you do?

• Gravity blanket:  A weighted blanket (filled with small silicone balls) that affects the nervous system in a way similar to a deep massage. The weight of the blanket calms the nervous system and may help maintain sleep continuity. There are reports of a beneficial effect of this intervention, but as with any treatment for dementia/Alzheimer's, the response is individual and it is not possible to know in advance who will benefit from it and who will not. It is important to adjust the weight of the blanket individually, and the accepted formula is that the weight of the blanket is about 10% of the user's weight.
  
  
• Painkillers: A common reason for waking up at night is pain, especially joint pain. Sometimes the person with dementia/Alzheimer's will not report this, nor will they respond positively to a direct question about it. It is recommended to consider Together with the attending physician Possibility of administering appropriate painkillers before bedtime or during the night.
  
  
• People with dementia/Alzheimer's who are also diagnosed with sleep apnea: The standard treatment for sleep apnea is the use of a device that compresses air into the lungs, also called BPAP or CPAP. These devices are effective in treating this syndrome, but they are not comfortable or easy to use, even for a person with a normal brain, let alone a person with dementia. However, it is always recommended to try if this is the recommended treatment, even if the use is for part of the sleep time only.
  
  
• sleeping pills: Sometimes there is no escape from using medication for sleep disorders in dementia/Alzheimer's. It is important to do this in consultation with a specialist and not to give all kinds of over-the-counter/natural medications, etc. Similar to other changes in dementia/Alzheimer's, it will often be necessary to combine medication for sleep with adjusting the environment and daily routine in accordance with the suggestions above and in previous posts. Sleeping medication always has a "price" of impairing alertness, not only at night, and may also have an adverse effect on mobility. As mentioned, lack of sleep also has a similar impact on the person with dementia/Alzheimer's and their caregiver.
  
  
• Medical cannabis: There are reports of a beneficial effect of Medical cannabis On sleep in dementia. However, there is currently no clear scientific evidence regarding the benefit of using medical cannabis in dementia compared to using sleeping pills/sedatives/antipsychotics, etc. All preparations may improve or worsen symptoms.
  
  
• Aromatherapy: Some family members report success using appropriate oils, especially lavender. Only with the advice of a professional.