Sleep problems are common in Alzheimer’s and other dementias. They also commonly drive family caregivers crazy, because when your spouse or parent with Alzheimer’s doesn’t sleep well, this often means that you don’t sleep well.
To make matters even worse, not getting enough sleep can worsen the thinking or behavior of someone with dementia. Of course, this is true for those of us who don’t have Alzheimer’s as well: we all become more prone to irritation and emotional instability when we’re tired. Studies have also shown that even younger healthy people perform worse on cognitive tests when they are sleep-deprived.
Hence getting enough sleep is important, for people diagnosed with dementia, and for their hard-working caregivers. Now, sleep problems do often take a little effort to evaluate and improve. But as I explain below, research has found that it is often possible to improve sleep problems in dementia.
The key is to know what common causes to look for, and then come prepared to provide useful information to the doctor. In this article, I’ll cover:
- Common causes of sleep problems in Alzheimer’s and other dementias,
- How sleep issues should be evaluated
- Proven approaches that help improve sleep in dementia
- What to know about commonly tried medications for this problem
Common Causes of Sleep Changes and Problems in People with Dementia
It’s hard to manage a problem if you don’t understand why it might be happening. There are several factors that can cause older adults with dementia to have sleep problems. These include:
- Sleep changes with aging. Healthy aging adults do experience changes with their sleep as they age. Sleep becomes lighter and more fragmented, with less time spent in deep REM sleep. One study also estimated that total sleep time decreases by 28 minutes per decade, starting in mid-life. Although these changes are considered a normal part of aging, lighter sleep means it’s easier for aging adults to be woken up or disturbed by any other sleep-related disorders or problems, such as arthritis pain at night. Aging is also associated with a shift in the circadian rhythm, so that many older adults find themselves sleepy earlier at night and hence wake up earlier in the morning. For more, see here: How Sleep Affects Health, & Changes With Aging
- Chronic medical conditions and/or medications. Studies have found that older adults often experience “secondary” sleep difficulties, which means that the sleep problems are being caused by an underlying health problem. Many people diagnosed with Alzheimer’s have additional chronic health problems that may be associated with sleep difficulties. Treating such problems can help improve sleep. Common causes of secondary sleep problems include:
- Heart and lung conditions, such as heart failure or chronic obstructive pulmonary disease
- Stomach-related conditions such as gastroesophageal reflux disease
- Chronic pain from arthritis or another cause
- Urinary conditions that make people prone to urinating at night, such as an enlarged prostate or an overactive bladder
- Mood problems, such as anxiety or depression
- Medication side-effects, and substances such as alcohol (which is known to disrupt sleep).
- Many sleep-related disorders become more frequent with aging. Common sleep-related disorders include sleep apnea and related conditions (known as sleep-related breathing disorders), which may affect 40-50% of older adults, as well as restless leg syndrome, which is thought to be clinically significant in 2.5% of people.
- Alzheimer’s and other neurodegenerative diseases change sleep. The brain deterioration associated with various forms of dementia tends to affect the way the brain sleeps. In most cases, this causes less deep-sleep time, and more awake time at night. Problems with the circadian rhythm system (the body’s inner system for aligning itself with a 24-hour day) also become more common in dementia. Furthermore, Lewy-body dementia and Parkinson’s dementia are also associated with a sleep disorder called REM sleep behavior disorder, which can cause violent movements during sleep and can even emerge before thinking problems become substantial.
In short, most aging adults develop lighter sleep as they age, and many older adults have health problems that prompt nighttime awakenings. Sleep-related disorders such as sleep apnea are also common in aging. Older adults with Alzheimer’s and other dementias are likely to be affected by any of these factors that change sleep as people age, plus dementia brings on extra changes that make night-time awakenings more common.
Hence, it’s not surprising that sleep problems are so common in people with dementia! Now let’s talk about what can be done to improve things.
How to Diagnose the Sleep Problems of a Person with Dementia
Like many problems that affect older adults, sleep problems in dementia (and generally in aging) are almost always “multifactorial,” which means that there are usually several underlying issues creating the problem.
Multifactorial problems can be improved, especially if a family and the doctors are diligent about trying to identify as many contributing factors as possible. But you’ll need to start by helping the doctors understand what kinds of sleep-related symptoms and problems a loved one is experiencing.
Here is a list of questions that a group of geriatrics experts recommends, for evaluating sleep problems. (These are addressed to a patient; replace “you” with “your parent” if you are gathering information in preparation to see a health professional about a parent’s sleep issues.)
- What time do you normally go to bed at night? What time do you normally wake up in the morning?
- Do you often have trouble falling asleep at night?
- About how many times do you wake up at night?
- If you do wake up during the night, do you usually have trouble falling back asleep?
- Does your bed partner say (or are you aware) that you frequently snore, gasp for air or stop breathing?
- Does your bed partner say (or are you aware) you kick or thrash about while asleep?
- Are you aware that you ever walk, eat, punch, kick, or scream during sleep?
- Are you sleepy or tired during much of the day?
- Do you usually take 1 or more naps during the day?
- Do you usually doze off without planning to during the day?
- How much sleep do you need to feel alert and function well?
- Are you currently taking any type of medication or other preparation to help you sleep?
- Do you have the urge to move your legs or do you experience uncomfortable sensations in your legs during rest or at night?
- Do you have to get up often to urinate during the night?
- If you nap during the day, how often and for how long?
- How much physical activity or exercise do you get daily?
- Are you exposed to natural outdoor light most days?
- What medications do you take, and at what time of day and night?
- Do you suffer any uncomfortable side effects from your medications?
- How much caffeine (eg, coffee, tea, cola) and alcohol do you consume each day/night?
- Do you often feel sad or anxious?
- Have you suffered any personal losses recently?
Many families will be unsure of how to answer some of these questions initially. So to get the best help from the doctors, it’s best to prepare ahead of time. I always recommend families try to keep a journal related to these questions for at least a week. Some families may also be able to use a sleep tracker or activity tracker, to gather useful information.
Based on the information above, and after conducting an in-person examination to check for other medical issues, a doctor should be able to place the sleep difficulties in one (or more) of the following categories:
- Difficulty falling or staying asleep
- Excessive daytime sleepiness
- Abnormal breathing patterns during sleep
- Abnormal movements or behaviors during sleep
Sometimes additional testing is necessary, such as a sleep breathing study to evaluate sleep apnea.
Based on the category of sleep problem, and the underlying causes that have been identified, the doctor should then be able to propose a plan for improving the sleep difficulties.
How to Improve Sleep Problems in Dementia
The exact approach to improving sleep in a person with Alzheimer’s or another dementia will depend on what underlying factors are causing sleep problems. Still, certain general approaches have been found to improve the sleep of many people with dementia. These include:
- Outdoor light or bright light therapy during the day. Bright outdoor light helps keep the circadian signals (the body’s inner clock) on track. For older adults who can’t get outside for at least an hour per day, bright light therapy with a special lamp might help. A study found that bright light therapy in Alzheimer’s patients improved sleep.
- Increase daytime physical activity. Research has suggested that walking during the day can help improve nighttime sleep in people with Alzheimer’s.
- Optimize environmental cues for sleep. This means keeping the sleeping environment dark and quiet at night. This is especially important in nursing homes, which have sometimes been found to have staff active at night.
- Establish a regular routine with a consistent wake-up time. A regular routine can help maintain better sleep. The ideal is to have a consistent bedtime and wake-up time, but many experts believe it’s best to start by focusing on a consistent wake-up time.
A research study published in 2005 found that training dementia caregivers to use these techniques in combination did lead to improved sleep of the care recipients with Alzheimer’s.
Medications to Manage Sleep Problems in Dementia
You may be wondering whether medications can help manage sleep problems in dementia.
To begin with, it is important to check current medications and make sure they are not negatively affecting a person’s sleep. For example, sedating medications during the day may cause a person with dementia to sleep or nap too much, resulting in more awake time at night. Or a diuretic offered too late in the day might be causing extra nighttime urination.
As a caregiver, you may simply want to know: “Isn’t there a medication we can give in the evening, to help my parent sleep better at night?”
It’s true that sleeping pills, sedatives, and tranquilizers exist, and they are often prescribed to help keep people with dementia quieter at night. These include antipsychotics like olanzapine, risperidal, and quetiapine, benzodiazepines such as lorazepam and temazepam, sleeping medications like zolpidem, or even over-the-counter sleep aids (which usually contain some form of sedating anti-histamine).
Unfortunately, all these medications are likely to cause concerning side-effects in people with dementia, namely worse cognition and increased fall risk. The antipsychotics have also been associated with a higher risk of dying. Last but not least, comprehensive scientific review articles conclude that in clinical trials, these drugs do not conclusively improve sleep.
Hence, the recommendation of experts in geriatrics is that these medications should generally be avoided, and only used as a last resort once behavioral approaches (e.g. setting a routine, more walking, etc.) have been tried.
That said, there are a few medications that may be less risky, and are sometimes used:
- Melatonin. Melatonin is a hormone involved in the sleep-wake cycle. A Scottish study found that 2mg of melatonin nightly improved the sleep of people with Alzheimer’s. However, a more recent randomized trial of melatonin in people with dementia was negative. Also, in the U.S. melatonin is sold as a poorly-regulated supplement, and studies have found that commercially sold supplements are often of questionable quality and purity.
- Trazodone is an older weak anti-depressant that is mildly sedating. It has long been used by geriatricians as a “sleeping pill” of choice, as it seems to be less risky than the alternatives. A small 2014 study found that trazodone improved sleep in Alzheimer’s patients.
To summarize, although medications are often used to manage sleep problems in dementia, most of them are pretty risky. So it’s better to avoid sedatives until you’ve exhausted all other options.
Non-drug approaches like plenty of outdoor light, regular exercise, a stable routine, optimizing chronic conditions, and checking for pain often help. Plus, these usually improve the person’s quality of life overall.
Remember, sleep is important for health, and it’s especially important for family caregivers.
For more on sleep in older adults (whether or not they have Alzheimer’s), see these posts:
- How Sleep Affects Health, & Changes With Aging
- 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia
This article was last updated by Dr. K in August 2022.
My 88 year old husband has Alzheimer’s and Vascular Dementia. He is often awake at night and wandering around the house, confusing nights with days. Our doctor has recommended lorazepam but I’ve read your post and am reluctant to use this drug. Do you have much experience of using 2mg melatonin at night? Any advise gratefully received. Thank you.
Nicole Didyk, MD says
Yes, in geriatrics we would be very cautious about using lorazepam in someone like your husband.
Melatonin seems to help some people, and is probably not very risky. It’s reasonable to try it, and see if it helps. Good luck!
I am 74 and lost my husband 6 years ago. I’ve suffered depression since. Most recently I took a trip in Europe. I kept waking up at night panicking over where my dog was (in-fact he was staying with family in the States) and where articles of clothing were, etc. It scared me and now back home with my dog, I’m still waking during the night worrying over things I may have left in Europe or in the plane. I recently tapered myself off Fluoxetine, too, for fear of losing my memory, so now I’m worried I need something else to improve my mood and brain. I know I’m not as alert as I used to be but now I’m worried I may have Lewy Body as my sister has.
Nicole Didyk, MD says
I’m sorry to hear about your loss and your mood challenges. I can understand worrying about dementia with Lewy bodies, especially if your sister has that diagnosis.
There can be many causes of sleep disturbance in older adults, and dementia is not the most common cause on that list. Anxiety and depression are very common causes of insomnia, and in a person who has stopped an antidepressant recently, I wonder if that’s a factor. Often, those with anxiety are woken up or have trouble falling asleep because of worries, even irrational ones.
Dr. K has an excellent article about insomnia, which you can read here: https://betterhealthwhileaging.net/top-5-causes-sleep-problems-in-aging-and-proven-insomnia-treatments/
My father is 75 lived with me for 8 years. He was diagnosed with Lewy bodied dementia with white cell matters and severe aniexty and depression. We went through so much with hallucinations, anxiety, sleeping with him taken turns watching him etc. He has a triple by pass and he tortures my husband and I to live back home – we did! He spent 32,000.00, took over every neighbors yard parking random cars and boats he bought! He would wash his truck 4 am, eat at 3:00am and never slept!
So I went to check on him and he passed out on me he lived right behind fire department! He came back to live with me for 4 more years until now he went crazy on us went took off and tortured our neighbors and laid in a neighbors lawn they called the cops and emt. Well, he refused to come home with my husband and I went to hospital and I refused to bring him home because he had scared us to point where we slept with our door locked cause he would be awake all night long! For months!
So the hospital placed him in a facility after the hospital told him he could drive and live on his own! This quack doctor that just wanted him gone had no idea what he was dealing with!!! My father in is assisted living calling me everyday and threatening me cause he wants to live at his house again but he is a danger to himself and others!!! Calls the cops ran away from the faculty! We pay for him to be there cause he has to have 24 hour care!! What to do it’s so hurtful the things he says to me! My sister died my mother has passed and there’s him and I only!! What do you do??
Nicole Didyk, MD says
It sounds like you’ve really been through the wringer with your dad, and I could understand that it would put strain on you and your family. Your frustration with the medical system is a common situation as well.
Many children of aging parents in your situation learn how to enforce boundaries about frequency and type of contact with their parent. Even the most caring child needs to set limits to maintain as healthy a relationship as possible.
You’ve been caring for your dad for a while, but I think you would really benefit from Dr. K’s new book, “When Your Aging Parent Starts Needing Help – a geriatrician’s step-by-step guide to Memory Loss, Resistance, Safety Worries, & More”. There are tips in there about how to communicate with your dad’s medical team to get the information you need and share what they need to hear.
No matter what, make sure that you look after yourself and your family. This is a lot for one person to manage.
robert lee moore says
I am part of the internet community that Dr. Kernisan helps with Helping Older Parents. I am discouraged because I had a geriatric pharmacist look at the meds my mom was taking for Lewy Body dementia(LBD). She suggested discontinuing the hydroxyzine(?? because it is on DeBeers list and suggested mom get back on Aricept avoid vistaril cream and use melatonin before before trazadone at night to help her sleep. All of the sudden,,,the facility wants to use a gene sight test,,,which is not in the contract and they did not mention it to me or my sister. What is going on? the thing about clinical studies for this test are small and non blinded and one study admits it only included causcasians
Nicole Didyk, MD says
I’m glad you’re part of the Helping Older Parents membership – it’s a great community!
As a geriatrician, I often work with pharmacists to review medications in my older patients and then collaborate to decide which of the suggested changes we should make. I’m not in favour of changing several meds at once because this makes it more difficult to determine if the changes are making a difference to the person’s symptoms.
I wasn’t familiar with the “gene sight” test, and when I looked it up, it appears to be a test that develops a profile of a person’s drug metabolism genes. This data is used to try to predict which psychiatric medications will work best for them. Looking at a couple of the scientific studies of this test, the studies were small and included few people over 65. It’s not the standard of practice to use these tests currently, and I don’t have any experience using the gene sight in my own practice.
It seems to me that any medical testing would need a person’s consent, and that is definitely something to ensure in the situation you describe.
It sounds like communication with the facility could be better, and I think the Helping Older Parents Membership is a great place to get guidance and support. This would be a good question for the next coaching call!