One of the most common forms of dementia, Alzheimer’s disease is an irreversible brain disorder that slowly destroys a person’s memory and cognitive functioning. Onset typically appears around age 65 or later. Every 5 years after that, a person’s risk of getting Alzheimer’s doubles.
Alzheimer’s disease affects as many as 5 million Americans. Scientists still don’t know how to prevent, slow, or cure the disease. Meanwhile, the death rate has increased 55% over the past decade and a half, and with the silver tsunami on the horizon, the number of patients is expected to explode
Sleep problems and Alzheimer’s are interconnected. People living with Alzheimer’s experience difficulty sleeping, while people who have sleep issues earlier in life are at greater risk for developing the disease.
With the consequences of Alzheimer’s as high as it is, it’s common to get nervous at any early sign of the disease. However, some aspects of the normal aging process, such as occasional memory loss, can look like Alzheimer’s symptoms, even if they’re not. But if the senior themselves is unaware of the memory loss, it could be a sign of something more serious like Alzheimer’s or dementia. SeniorAdvisor.com offers a helpful article that breaks down the distinction between normal memory loss versus Alzheimer’s and dementia.
Alzheimer’s comes on slowly, and as the disease progresses, the individual goes through three distinct stages, all with their own set of symptoms. Symptoms typically first appear in the mid-60s.
Mild or early-stage Alzheimer’s lasts 2 to 4 years and includes the following symptoms:
- Lower energy and/or motivation to engage in work activities or hobbies
- Forgetfulness of things that just happened
- Language difficulties, such as problems expressing themselves or finding the right word
- Difficulty completing common tasks, such as following a recipe
- Getting lost often
Individually, many of these symptoms could be indicative of another disorder, so it’s important to speak to a doctor once you start to notice them. They will ask additional questions so they can provide you and your loved ones with a proper diagnosis, whether it’s Alzheimer’s or something else.
Moderate or middle-stage Alzheimer’s lasts 2 to 10 years and starts to interfere with a person’s daily life. Symptoms include:
- Significant memory loss, including difficulty recognizing family and friends, losing things and trouble finding them again, and forgetting important life events and memories
- More communication problems, such as using the wrong words or rambling
- Difficulty working out problems
- Confusion about time, place, or weather
- Wandering and getting lost
- Quickness to get upset or lash out
- Difficulty sleeping
- Delusions and paranoia
- Increased depression due to awareness of their symptoms
Severe or late-stage Alzheimer’s lasts 1 to 3 years. At this point, symptoms worsen across the board and begin to include more physical problems in addition to the emotional and cognitive ones, such as:
- Extreme memory loss, resulting in confusion about time and place
- Difficulty speaking, expressing themselves, or understanding others
- Extreme mood swings
- Difficulty swallowing or moving around
- Loss of bladder and bowel control
- Noticeable weight loss
All stages of Alzheimer’s present sleep problems, although the manifestation is different and increases in severity as the disease progresses. The disease attacks the person’s brain, including the parts responsible for regulating their sleep-wake cycle. As a result, their circadian rhythm becomes desynchronized, and a sudden tendency to oversleep and sleep at irregular hours serve as a common early warning sign of Alzheimer’s. Lack of quality sleep worsens their other symptoms, which makes things harder on their caregiver, who may start getting less sleep themselves.
The sleep issues and nighttime disturbances associated with Alzheimer’s are often what leads families to seeking out professional help, whether through an in-home caregiver or an Alzheimer’s care facility.
At-Risk; Poor Sleep and Alzheimer’s
Much research has focused on the correlation of chronic sleep deprivation and consequent predisposition for developing Alzheimer’s.
A 2017 study by Washington University in St. Louis found that depriving healthy, middle-aged adults of slow-wave sleep increased two separate brain proteins associated with Alzheimer’s. Just a single night of sleep deprivation increased amyloid beta levels, the brain protein associated with Alzheimer’s. Then, when researchers interrupted their slow-wave sleep for a week in the same participants, their tau brain protein levels increased.
Both of these brain proteins work together to attack brain tissue, and their presence overwhelms PET scans of patients with Alzheimer’s.
The Washington University researchers specifically interrupted slow-wave deep sleep because that is the restorative stage of sleep where your brain flushes your system, enabling you to wake up feeling refreshed. It’s the same stage of sleep that gets interrupted by disorders like sleep apnea, which are also associated with Alzheimer’s (more on this below). So even if an individual is asleep the entire time, they’re spending more time in lighter stages of sleep and are thus unable to reap the benefits of deep sleep. When this interruption becomes chronic, it can lead to the sort of mild cognitive impairment that’s an early sign of Alzheimer’s.
The study was small, with only 17 participants, but the results were convincing enough to lead researchers to conclude that chronic sleep deprivation during middle age could increase your risk of Alzheimer’s later on.
Others have confirmed or found similar findings linking Alzheimer’s risk with changes in sleep architecture. For example, in a larger study of over 300 adults aged 60 or older, participants were assessed over a long period, lasting 12 years on average. The researchers found that less time spent in REM sleep (the stage of sleep where you dream), as well as a lower REM sleep percentage, increased the participants’ dementia risk. In fact, for each 1% reduction in REM sleep, their dementia risk increased by 9%.
These sleep-wake cycle disturbances are a prevalent problem among Alzheimer’s patients and have the ability to hasten onset of the disease as well as its progression.
Common Sleep Problems in Alzheimer’s Patients
Alzheimer’s disease is associated with a long list of sleep issues. Changes to the body’s internal clock, as well as the disorienting mental and emotional symptoms of the disorder, contribute to sleep problems, including:
- Irregular sleep patterns: Early-stage Alzheimer’s patients suddenly start sleeping significantly more than usual, whether they’re sleeping in or taking more naps. Likewise, they have difficulty falling asleep at night and staying asleep throughout the night.
- Insomnia: Because of their changing circadian rhythms, older adults are already prone to sleep less, but it’s worse for those with Alzheimer’s. As the disease progresses, their circadian clock will continue shifting later, making them want to stay up at night more and sleep during the daytime.
- Hypersomnia: Hypersomnia refers to excessive daytime sleepiness that’s not caused by insomnia or sleep deprivation. It goes hand in hand with Alzheimer’s, causing patients to have difficulty staying awake during the day.
- Daytime dozing: Because they have so much trouble falling asleep at night, many people with late-stage Alzheimer’s spend most of their night awake in bed. As a result, they’re very tired the next day, tend to nap a lot. However, giving in to these feelings will only keep them up later the following night, creating a vicious cycle.
- Sundowning: It’s common for seniors with Alzheimer’s and dementia to develop Sundowner’s syndrome. They start to feel restless, agitated, and anxious in the early evening (when the sun is going down), and symptoms continue through the night. They’ll pace anxiously, or follow their caregiver around. They may also wander off, which is especially dangerous since they are already predispositioned to become lost and confused. Lower light and shadows can contribute to sundowning hallucinations and increase feelings of fear or confusion.
Diagnosing Sleep Problems in Alzheimer’s Patients
Sleep problems in Alzheimer’s patients are generally categorized into four main types. Below we review each of these:
1. Trouble falling/staying asleep (insomnia)
The changing circadian clock caused by Alzheimer’s result in insomnia, where individuals have difficulty falling asleep at night and staying asleep. An insomnia diagnosis requires that these symptoms be present for a month or longer.
Other Alzheimer’s symptoms contribute to insomnia. For example, depression is a comorbid condition of both insomnia and Alzheimer’s, and antidepressant medications can worsen insomnia. Also, the loss of bladder control associated with later stages of Alzheimer’s wakes individuals during the night due to a frequent need to urinate.
2. Excessive daytime sleepiness (hypersomnia)
Alzheimer’s patient experience circadian dysrhythmia, the scientific term for a disrupted sleep-wake cycle and body clock. Due to this, many Alzheimer’s patients find themselves lying awake at night, unable to sleep, and then feel exhausted the following day as a result, resulting in hypersomnia. By the time they reach the later stages of the disease, they may not ever spend a full hour either awake or asleep.
Light therapy and melatonin supplements are the recommended treatment for helping reset the circadian clock (more on these in the Treatment section below).
To help the doctor diagnose hypersomnia, caregivers may consider keeping a sleep diary to track how much the Alzheimer’s patient sleeps during the day or at night.
3. Excessive nighttime activity (restless leg syndrome) or breathing issues (apnea)
Since it is often associated with insomnia, researchers expect that restless leg syndrome (RLS) occurs with some frequency among Alzheimer’s and dementia patients. Restless leg syndrome (RLS) is characterized by an uncontrollable and uncomfortable tingling sensation in the legs, often while in a supine position, and a correspondingly irresistible urge to move the legs to find relief.
A person without Alzheimer’s who is suffering from RLS is typically able to self-describe their symptoms. However, the confusion, delusions, and communication issues associated with AD can make Alzheimer’s patients unreliable at self-diagnosis. So, their best bet is for spouses or caregivers to notice the symptoms and report them to a doctor. Another contributing factor for RLS is iron deficiency. In those cases, iron replacement therapy can minimize or eliminate symptoms of RLS, although a doctor should always sign off on it first, in case the iron supplement has adverse affects due to other medications the person is taking.
In addition to RLS, sleep apnea can cause or exacerbate Alzheimer’s-related hypersomnia or insomnia. Sleep apnea has also been correlated with dementia, although researchers don’t know if a causal relationship exists between the two. Fortunately, studies have shown that CPAP therapy is not only an extremely effective treatment for sleep apnea, but it also improves cognitive functioning and memory and reduces daytime sleepiness in Alzheimer’s patients.
4. Nocturnal hallucinations and/or behavioral problems
Individuals with dementia may also show signs of REM sleep behavior disorder (RBD). People with RBD act out their dreams, thrashing or moving about in bed, harming themselves or a sleep partner. It should be noted that RBD is different from the wandering at night common in Alzheimer’s patients. Unlike nocturnal wandering associated with Sundowner’s, RBD episodes are short, occur during REM sleep in the second half of the night, and are characterized by a violent movement of the limbs while asleep.
People in the later stages of Alzheimer’s tend to have nocturnal hallucinations, which are worsened by Sundowner’s symptoms, low lighting conditions, or the presence of shadows. Individuals will begin to pace repetitively, become incontinent, get violent, or wander.
Questions for Caregivers
If you’re caring for a loved one with AD, ask yourself the following questions. These reveal warning signs that they are experiencing one or more of the Alzheimer’s-related sleep problems described above.
- When do they go to sleep and when do they wake up?
- Do they have difficulty falling or staying asleep? How often do they wake up during the night?
- Are they tired during the day, and prone to taking one or more naps?
- Do you hear loud snoring or audible gasps while they sleep?
- Do they kick their legs around while asleep? Do they appear to physically act out their dreams? Do they appear uncomfortable when lying down?
- Do they wake up often to use the restroom?
- Are they depressed, moody, or reactionary?
- Are they taking any medication or have another condition that could be causing any of these symptoms?
If you answered yes to any of these, talk to your doctor. They will ask you additional questions, such as the nature of the movements, how the person acts when they are awake, and any additional medications they are taking or illnesses they have been diagnosed with.
Treating Sleep Problems in Alzheimer’s Patients
When it comes to Alzheimer’s-related sleep issues, it’s best to avoid pharmacotherapy entirely for Alzheimer’s-related sleep issues.
Little research has been done into the side effects of sleep medications with Alzheimer’s patients, or how they can interact with other medications the senior may be taking. In fact, some prescription sleep aids like Ambien have been shown to increase senior’s fall risks by 4 times. Similarly, while some over-the-counter sleep aids can improve some elements of the patient’s sleep, they’ll do so at the risk of increasing their tendency to fall, be confused, or experience rebound insomnia.
All new medication, whether sleep-related or not, should be introduced using a “begin low and go slow” approach, as the Alzheimer’s Association recommends. Some nighttime doses should be avoided at night altogether, such as cholinesterase inhibitors or other stimulating drugs.
Fortunately, there are several behavioral treatments that can help manage sleep problems for Alzheimer’s patients. Improving their sleep may in turn reduce the severity of their symptoms, enabling their caregiver to get more sleep themselves and keep providing the best care possible.
1. Establish a regular sleep schedule.
Encourage your loved one to go to bed and wake up at the same time every day, to create a sense of routine and give them back some sense of control over their life.
If they’re suffering from excessive daytime sleepiness, limit their naps to a few power naps, 30 minutes or shorter, to avoid them entering deep sleep and waking up even drowsier than before.
If your loved one does wake up at night, don’t get frustrated or force them to stay in bed, which in turn may make them frustrated as well. Instead, give them a simple task to work on or a book to read so they at least rest, and hopefully the mind will naturally fall back asleep.
2. Follow good sleep hygiene.
Simple behavioral modifications can be especially helpful for inducing a good night’s sleep.
- Eat a healthy diet free of overly fatty, sugary, or spicy foods.
- Avoid caffeine and alcohol – these interfere with quality sleep and may pose dangerous side effects depending on the medication the patient is taking.
- Limit screen time in the hour before bed so the blue light doesn’t increase their feelings of alertness. Those caring for patients w
ith moderate to severe Alzheimer’s should especially avoid dramatic TV shows, as they can provide fodder for hallucinations or delusions.
3. Manage liquid intake.
To avoid nighttime urination, limit liquids in the early evening and use the restroom before bedtime. If bladder control continues to be a problem, purchase waterproof bedding and sheets. These are made of easily cleanable materials designed to not develop an odor, even with frequent urination.
4. Create a bedroom environment conducive to sleep.
Remove electronics from the bedroom, and keep it otherwise cool and dark. Invest in blackout curtains to block out additional light. Use a white noise machine to block out noise from other rooms in the house or outdoors.
For those with hallucinations, remove any objects that cast a shadow and keep the lighting bright enough during the day to prevent shadows. Cover up or remove mirrors.
Purchase a comfortable supportive mattress and consider additional sleep products to keep them safe asleep. Do not restrain late-stage patients in bed, or anyone who has become accustomed to wander. Instead, use guard rails to help keep them in bed and floor pads to protect them in case of a fall.
5. Try light therapy.
Light therapy is a common treatment for individuals with shifted or delayed circadian clocks. It employs specialized light boxes which are designed to deliver 10,000-lux of natural sunlight, without the harmful UV rays. They are widely available online and come in lamps, visors, and even alarm clock varieties.
Alzheimer’s patients with advanced-phase circadian clocks, who are falling asleep too early, should use the box at night, while those with delayed clocks should use it upon waking up.
6. Stay busy during the day.
Light exercise helps tire the body so sleep comes easier by nighttime. If possible, try to do the exercise outside, and early in the morning. The natural sunlight will help reset the body’s internal clock. Also keep your loved one busy during the day with hobbies and calming activities.
7. Treat any underlying sleep problems.
If your loved one has sleep apnea, get them fitted for a continuous positive airway pressure (CPAP) machine. Alternately, there are several anti-snoring devices, chinstraps, and mouthpieces that help keep the airways open during sleep, but are less effective than CPAP therapy.
Weighted blankets can soothe symptoms of RLS. For sizing, choose one that’s 10% of your loved one’s body weight, and add 1 pound.
8. Educate all caregivers on the treatment plan.
These behavioral treatments do work, but only if you keep up with them regularly, which is why everyone involved in caring for your loved one should be educated on the plan for managing their sleep issues.
A randomized, controlled trial of Alzheimer’s patients with their family caregivers demonstrated that when caregivers are educated on specific recommendations (like the ones we’ve listed here), and then implement them, it significantly reduces the frequency of nighttime awakenings, amount of time spent awake at night, and feelings of depression.
- AgingCare.com offers a comprehensive database of articles on Alzheimer’s and dementia, written by senior health experts, as well as a forum for caregivers.
- The Alzheimer’s Association is the premier nonprofit organization dedicated to fighting Alzheimer’s. Their website offers a wealth of resources for families and caregivers, including this sleep changes fact sheet, and an overview of treatments for sleep changes and sundowning. The organization also runs a 24/7 helpline (1-800-272-3900), hosts several fundraising events and awareness walks, and provides online message boards.
- The National Institute on Aging is the government’s portal for the latest information, studies, and more on Alzheimer’s and dementia.
Recommended Alzheimer’s Sleep Products
- Regalo’s bed rails come padded so your loved one won’t damage themselves should they come in contact with it while sleeping. Their swing down design makes it easy to get in and out of bed.
- These waterproof sheets and mattress covers by Priva are designed to last 300 wash cycles.
- YnM’s weighted blankets are available in different sizes and colors to help soothe symptoms of RLS.
- White noise machines like this one from Pictek can block out noise and distractions from other rooms in the house.
- Aura’s light therapy lamp delivers 10,000 lux of bright light and can be positioned on a desk or table for use in the early morning or late afternoon.
All product images from Amazon.