Sleep Issues and Sundowning

People with Alzheimer’s and dementia may have problems sleeping or increases in behavioral problems that begin at dusk and last into the night (known as sundowning).

Causes

Nighttime restlessness doesn’t last forever. It typically peaks in the middle stages of Alzheimer’s, and then diminishes as the disease progresses.

Scientists don’t completely understand why sleep disturbances occur with Alzheimer’s disease and dementia. As with changes in memory and behavior, sleep changes somehow result from the impact of Alzheimer’s on the brain. Some studies indicate as many as 20 percent of persons with Alzheimer’s will experience increased confusion, anxiety and agitation beginning late in the day. Others may experience changes in their sleep schedule and restlessness during the night. This disruption in the body’s sleep-wake cycle can lead to more behavioral problems.

Factors that may contribute to sundowning and sleep disturbances include:

• End-of-day exhaustion (both mental and physical)
• An upset in the “internal body clock,” causing a biological mix-up between day and night
• Reduced lighting and increased shadows causing people with Alzheimer’s to misinterpret what they see, and become confused and afraid
• Reactions to nonverbal cues of frustration from caregivers who are exhausted from their day
• Disorientation due to the inability to separate dreams from reality when sleeping
• Less need for sleep, which is common among older adults

Talk to a doctor about sleep issues

Discuss sleep disturbances with the doctor to help identify causes and possible solutions. Physical ailments, such as urinary tract infections or incontinence problems, restless leg syndrome or sleep apnea (an abnormal breathing pattern in which people briefly stop breathing many times a night) can cause or worsen sleep problems. For sleep issues due primarily to Alzheimer’s disease, most experts encourage the use of non-drug measures, rather than medication. In some cases when non-drug approaches fail, medication may be prescribed for agitation during the late afternoon and evening hours. Work with the doctor to learn both the risks and benefits of medication before making a decision.

Coping strategies for sleep issues and sundowning

• Keep the home well-lit in the evening.Adequate lighting may reduce the agitation that occurs when surroundings are dark or unfamiliar.

• Make a comfortable and safe sleep environment. The person’s sleeping area should be at a comfortable temperature. Provide nightlights and other ways to keep the person safe, such as appropriate door and window locks. Door sensors and motion detectors can be used to alert family members when a person is wandering.
• Maintain a schedule. As much as possible, encourage the person with dementia to adhere to a regular routine of meals, waking up and going to bed. This will allow for more restful sleep at night.
• Avoid stimulants. Reduce or avoid alcohol, caffeine and nicotine, which can all affect ability to sleep. Discourage watching television during periods of wakefulness at night, as it can be stimulating.
• Plan more active days. A person who rests most of the day is likely to be awake at night. Discourage afternoon napping and plan more challenging activities such as doctor appointments, trips and bathing in the morning or early afternoon. Encourage regular daily exercise, but no later than four hours before bedtime.
• Talk to a doctor. Discuss sleep disturbances with a doctor to help identify causes and possible solutions. Most experts encourage the use of non-drug measures rather than medication.
• Be mindful of your own mental and physical exhaustion. If you are feeling stressed by the late afternoon, the person may pick up on it and become agitated or confused. Try to get plenty of rest at night so you have more energy during the day.
• Share your experience with others. Join a support group or an online support community, and share what response strategies have worked for you and get more ideas from other caregivers.

If the person is awake and upset:

• Approach him or her in a calm manner.
• Find out if there is something he or she needs.
• Gently remind him or her of the time.
• Avoid arguing.
• Offer reassurance that everything is all right.
• Don’t use physical restraint. If the person needs to pace, allow this to continue under your supervision.