How Sleep and Dementia Intertwine

Dementia often alters sleep patterns. Family members often complain that their loved one with dementia does not sleep well. As the disease progresses, sleep-related symptoms may get worse. But what causes these symptoms? Here we discuss risk factors of sleep disturbances and the effects associated with them.

According to the National Sleep Foundation guidelines, older adults need seven hours of sleep each night. However, as we age, our sleep-wake patterns alter which affects other bodily functions such as hunger. These changes happen due to changes in the brain, hormones such as cortisol, and other illnesses. About 50% of people with dementia show disturbed sleep patterns. As the disease progresses, sleep-related symptoms usually get worse. Research studies have observed that in long-term care facilities, up to 80% of people with dementia show sleep-related symptoms.

Risk factors of sleep disturbances

The sleep cycle is controlled by the hypothalamus, a part of the human brain. It releases chemical signals (neurotransmitters) that help in transitioning to sleep or arousal. As the neural pathways in the brain get affected, hypothalamic dysfunction results in altered sleep patterns. To slow down the decline in the function of the brain, it is crucial to know the risk factors associated with sleep disturbances.

• Obesity and sleep apnea. Persons with obesity may experience sleep apnea. In sleep apnea, breathing temporarily stops during sleep and then starts again. Due to sleep apnea, the brain does not get enough oxygen, which worsens dementia.
• Other chronic illnesses. Chronic diseases such as gastroesophageal reflux disease (GERD) may cause bouts of coughing at night, which disturbs sleep. Congestive heart disease may increase the frequency of urination at night. Depression may cause excessive sleepiness.
• Medications. Medicines prescribed for other illnesses may affect sleep patterns. For instance, some medicines that lower elevated blood pressure e.g., beta-blockers. may cause insomnia, nightmares, and daytime fatigue; decongestants given for cough/cold may delay sleep onset; some steroids can increase awakenings during the nighttime.

When persons with dementia (or their family members) report sleep-related symptoms, the doctor may examine chronic illnesses and adjust medication dosage accordingly.

Sleep disturbances in dementia

People with dementia show altered sleep patterns and poor sleep quality. Some commonly observed symptoms are the following:

For some people with dementia, “sundowning” starts late afternoon and continues through the night. They may feel confused, anxious, and start ignoring directions. Common symptoms of sundowning include pacing, yelling, wandering, or following family members wherever they go.

Restless leg syndrome (RLS), a movement disorder, is commonly observed in persons with Lewy body dementia. When experiencing RLS, people with dementia have an uncontrollable urge to move their legs. Since movement relieves their symptoms, your loved one may wake up and walk at night. Periodic limb movement disorder (PLMD) is like RLS but involves the movement of both legs and arms.

Rapid eye movement (REM) sleep is considered stage 4 of sleep and during this deep sleep stage, people experience dreams. REM sleep behavior disorder is characterized by people acting according to their dream e.g., punching someone or kicking them. In such situations, patients may potentially harm themselves due to an injurious action or fall.

The relationship between sleep and dementia can be best described as bidirectional i.e., sleep disorders increase the risk of dementia and vice-versa. Sleep apnea and insomnia are common sleep disorders that increase the risk of dementia.

Remedies for sleep disturbances

There are several ways how you can help your loved one with dementia to cope with sleep disturbances:

• Sleep diary. A sleep diary may be a simple but effective tool to understand the sleep patterns of your loved one. Typically sleep diary notes the time to bed, time to rise, number of times awakened at night, and any other associated symptoms such as sleep talking.
• Safe environment. Ensure that your loved one is safe as they wake up at night (e.g., railings for the bed).
• Healthy lifestyle. Although these symptoms can cause distress to the person with dementia and their family member, some simple lifestyle changes may prove to be beneficial. For instance, regular and adequate exposure to sunlight reduces daytime sleepiness and increases sleep at night. Following sleep hygiene by keeping a regular schedule and limiting caffeine helps immensely.
• Exercise. Physical activity can also improve the quality of sleep for persons with dementia. Depending on their physical abilities, light exercises such as walking, jogging, or dancing can prove beneficial. As the disease advances, engaging in household chores, such as gardening and laundry, provides the necessary physical activity.
• Alternative medicine. Some individuals like to try alternative medicines such as massage therapy and aromatherapy. In aromatherapy, various essential oils are used to apply on the skin, for baths, or for massage. These oils are diluted using another carrier oil such as jojoba oil or coconut oil. Research studies have shown that lemon balm and lavender oil have beneficial effects on persons with dementia. For other alternative therapies, limited scientific evidence is available.

Before using any alternative therapies, gather information about their safety and effectiveness. Also, discuss with your care team what options may work well for you. When a non-pharmacological approach does not prove to be effective, your doctor may prescribe medication to your loved one. Talk to your nurse (or professionals on the care team) to discuss the sleep symptoms of your loved one.