Practical Solutions for Dealing with Sleeping Problems

SUMMARY: This article addresses the sleeping problems Alzheimer’s patients commonly have and gives practical suggestions for caregiver coping.

POSSIBLE CAUSES

Physiological or Medical Causes:

-Illnesses, such as angina, congestive heart failure, diabetes, ulcers, alcoholism.

-Pain caused by illnesses such as arthritis.

-Urinary tract infections which cause constant pressure to urinate.

-“Restless legs” (twitching) or leg cramps, often caused by metabolic problems.

-Depression.

-Side effect of medications, such as diuretics.

-Sleep apnea (breathing difficulties).

-Need for less sleep with increased age.

-Disrupted sleep patterns due to progressive dementia. The ability to sleep appears to deteriorate as cognitive abilities decline.

Environmental Causes:

-Too hot or too cold.

-Lighting poor – darkness disorienting.

-Can’t find bathroom.

-Change in environment (Hospitalizations often result in changes in sleep patterns.)

Other Causes:

-Too much time spent in bed at night

-Too much daytime napping.

-Too fatigued to calm down and sleep.

-Not enough exercise.

-Too much caffeine or alcohol.

-Hunger.

-Agitated from upsetting situation, such as a bath or an argument with caregiver.

-Disturbing dreams.

COPING STRATEGIES

* Have a good medical work-up to identify and treat medical problems.

* Treat pain with an analgesic (Aspirin, Motrin(r), Tylenol(r), Nuprin(r) or Advil(r)) at bedtime, if approved by doctor.

* Try Vitamin E for “restless legs”. Also discuss with doctor stopping or changing diuretic medications that may be contributing to this problem.

* For sleep apnea (breathing difficulties characterized by heavy snoring) help person lose weight if obese. See doctor and discuss eliminating sedatives that may be contributing to this problem.

* Have an evaluation for depression done, if early morning awakening (e.g., waking regularly at 4:00 a.m.) is a problem. Antidepressants given at bedtime may help sleep.

* Have all medications carefully evaluated for side-effects.

* Check whether person appears to be too hot or cold on awakening. Internal thermostat may change with dementia.

* Provide adequate lighting during evening hours. Shadows, glares, or poor lighting may contribute to agitation and hallucinations.

* Provide nightlights or soft lighting while sleeping to cut down on confusion during night and to aid in finding bathroom.

* Make sure there is a clear, well lit pathway to the bathroom. Practice the route during the day.

* Place a commode or hand held urinal next to bed if finding the bathroom is a problem.

* Make sure person goes to bathroom before going to bed.

* Try to change environment as little as possible.

* Have the person spend less time in bed. Try getting person up at an earlier hour or keeping up later until tired. Many people require only 6-8 hours of sleep.

* Make sure the bed and bedroom are comfortable and familiar to the person. A favorite blanket or pillow or bed clothes may be helpful.

* Maintain a set bedtime and waking routine, once a good routine is established. Continue bedtime rituals from the past (e.g., a glass of milk before bed, or music on radio at bedtime).

* Try bedrails. They may help to remind some people that they are in bed. For others, however, they may be confusing and may lead to falls if person tries to climb out of bed.

* Try to prevent daytime napping, unless person seems very fatigued in evening hours. Then try a short rest or nap after lunch.

* Make sure the person is getting adequate exercise. Try to take one or two vigorous walks a day.

* Cut down on caffeine (coffee, tea, soft drinks, chocolate) during day; eliminate completely after 5:00 p.m.

* Cut down on alcohol intake. Discuss the effects of alcohol and medications being taken with physician.

* Make sure person is not hungry at night. Try a light snack before bed or during night. Some herbal teas may have a calming effect. Warm milk often helps promote sleep.

* Avoid bathing (or other upsetting activities) in late afternoon or evening, unless warm baths relax person.

* Avoid laying clothes out for the next day or talking about the next day’s activities. This may be confusing and give a “wake-up” signal.

* Allow person to sleep on couch or in armchair, if refusing to get into bed.

* Make the house, or an area of the house, safe for the person to wander in alone at night.

* Safety proofing a house for safe night wandering might include:

-gating off stairs;

-special locks or alarms on doors to outside;

-blocking off kitchen or locking up dangerous items;

-making sure windows are locked.

* Give a backrub or massage legs at bedtime or during night wakefulness.

* Try a softly playing radio beside the bed.

* Hire a nighttime companion or work out shifts so that primary caregiver can get sleep.

* Gently remind person that it is dark out and time for sleeping.

* Consider allowing the person to be up at night, if this can be accomplished safely and without destroying caregiver’s routine.

* For sundowning (agitation and wandering in late afternoon/evening):

-Try to distract -put on music; give person something to hold, feel,

or fiddle with; go for a walk; try a craft activity; turn on the

television.

-Try closing blinds or curtains to shut out darkness.

-Turn lots of lights on to brighten atmosphere and combat shadows.

-Try to be rested for better coping at the most agitated time of day.

-Try to minimize noise, confusion, and numbers of people around

during the most agitated time of day.

-Try a rocking chair.

* In nursing homes or adult foster care homes:

-Increase staffing, volunteers, or family visits at that time of day

to permit more one-to-one attention.

-Be aware that use of restraints usually makes the agitation worse.

-Try a beanbag chair -they are soft, comfortable, hard to get out of,

easily cleaned. However, people may need assistance getting up.

-Be aware that shift changes are often noisy, confusing times of day

which can contribute to agitation.

* Use psychotropic medications, such as Haldol(r) or Mellaril(r), to take the edge off agitation. Use only with very careful medical supervision. (In some people with dementia,these medications have the opposite effect, making people more agitated.)

* Use sleeping medications only as A LAST RESORT. Be aware that their effectiveness is only short term, but may be helpful in establishing a more regular sleep cycle. However, sleeping medications may add to confusion on waking.

OTHER CONSIDERATIONS

* Be very cautious with the use of any kinds of medications for inducing sleep. Sometimes they may make symptoms of confusion and disorientation worse. Psychotropic or sleeping medications must be very carefully monitored by a physician familiar with dementia.

* Problems with sleeping or late evening agitation are often a stage in dementia that eventually passes. Many Alzheimer’s patients begin sleeping more during the later stages of the illness.

* It is important to try to recognize elements in the environment, the medical situation, or problems of communication that might be contributing to sleep problems, before deciding on particular strategies to try. Sometimes keeping a log or diary which tells what happened when, and what else was going on at the time, can help pinpoint a possible cause of problems.

* Sleep problems are one of the symptoms that are least tolerated by family caregivers. When the caregivers are unable to get adequate sleep themselves, night after night, they become high risk candidates for accidents or illness, and their relatives become likely candidates for nursing homes.

* It may be helpful for the caregiver to try meditation-or relaxation techniques to help him/herself fall back asleep quickly.

REFERENCES:

Alzheimer’s Association (ADRDA) Chapter Newsletters.

Davignon, Denise and Pauline Bruno. “Insomnia: Causes and Treatment, Particularly in the

Elderly”. Journal of Gerontological Nursing, 8 (6), 1982.

Lerner, Roslyn. “Sleep Loss in the Aged: Implications for Nursing Practice”. Journal of

Gerontological Nursing, 8 (6), 1982.

Mace, Nancy and Peter Rabins. The 36-Hour Day. Baltimore: The Johns Hopkins

University Press, 1981.

Reynolds, Charles, David Kupfer, and Deborah Sewitch. “Diagnosis and Management of Sleep

Disorders in the Elderly”. Hospital and Community Psychiatry, 35 (8), 1984.

Source: Understanding Difficult Behaviors.

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