Sundowning, Sleep Disturbances and Alzheimer's Disease

Aging and Sleep Disorders

As more emphasis is put on treating the person with Alzheimer's as well as searching for a cure, we find more professional attention focused on managing and alleviating the symptoms of the disease, thereby improving quality of life. One symptom that is only recently receiving such attention is the sleep disturbances that often accompany many forms of dementia. Abnormal sleep can be the result of a wide variety of causes, and is not thoroughly understood in cases involving people with dementia. It is known that people who suffer from dementia spend less time in deep sleep, awaken more often during the night, are more likely to wander at night, and nap more often during the day.

There does seem to be a connection between the neurological effects of dementia and various sleep disorders. On the other hand, not all sleep problems that a person with dementia might experience are due to the effects of the disease.

The process of aging plays a significant role in sleep problems. As we get older we just naturally accumulate body aches and pains. For those pains and for other conditions that often accompany aging, many people take more and more medications as they age. The incidence of sleep apnea and periodic limb movement also increase with age, and circadian rhythms change. All of these factors, and a host of others, can disrupt sleep.

The Nature of Sleep Disorders

Sleep disorders and disturbances come with a variety of characteristics and have many causes. Some of the sleep disorders that are common in people with Alzheimer's disease include:

• Increased frequency and duration of nighttime awakening
• Daytime napping
• Decrease in the time spent in deep sleep. This can lead to increase in awakenings
• Difficulty falling asleep and insomnia
• Sundowning - disorientation and confusion that often occurs in people with dementia late in the day
• Shifts in sleep/wake cycle - more time awake during the night and asleep in the day
• Sleep apnea
• Periodic limb movement disorder

Causes of Sleep Disorders

It is not always easy, or even possible, to determine the factor or factors responsible for sleep disorders. Before undertaking a sleep therapy plan, determine and eliminate as many of these factors as possible.

Environmental Factors
Light and noise in the sleeping environment can be responsible for nighttime awakening. A sleeping environment that is too warm or too cold can also make sleeping difficult. An early morning garbage truck, a streetlight outside the bedroom window, street noises and similar disturbances can make it hard to fall asleep and stay asleep. These external elements can be the easiest to identify, and the simplest to remedy. Begin here when designing a sleep plan.

Physical Factors
Body pains from arthritis and a host of other maladies that accompany the process of aging can make it difficult to fall asleep and stay asleep. Dehydration, infections, over stimulation from television, caffeine from coffee or tea drunk late in the day: these are some typical culprits in sleep disturbances. Medications and drug interactions can also interfere with natural sleep cycles. Consult your medical professional if you suspect that medications might be contributing to a sleep problem.

Physiological and Medical Factors
Because Alzheimer's and other dementias effect the brain, it is likely that the disease is at least partly responsible for sleep disorders that are common in people with these conditions. Alzheimer's affects the part of the brain that is the seat of our biological clock, the suprachiasmatic nucleus. Disruption of the sleep cycle often results from the body's circadian rhythms being out of phase with the natural daylight/darkness pattern, kind of like jet-lag. Bright-light therapy has been shown in numerous studies to regulate circadian rhythms in people with Alzheimer's and dementia.
      Periodic limb movement disorder (PLMD) is a rhythmic or periodic movement of the legs during sleep. This can cause awakening and otherwise disrupt sleep. Little is known about the causes of PLMD, and there is no cure. Incidence does increase with age. Caffeine can make the condition worse, as can certain antidepressant drugs. There are medications that seem to help, so consult your doctor if you think this condition is causing sleep problems.
      Sleep apnea, characterized by disruptions in breathing during sleep, is one of the better known sleep disorders. It can affect anyone, but is more common in people over forty years old. It is estimated that as many as 70 to 80 percent of people with dementia suffer from sleep apnea. A study done at the University of California showed that treatment for obstructive sleep apnea improved cognitive functioning in people with Alzheimer's disease. Talk to your doctor or medical professional if you suspect sleep apnea.

Tips to Improve Sleep

There are things that we can all do to improve our sleep. Not only is it important for a person with dementia to get the best rest possible; the caregiver needs to sleep well too. You may eventually have to talk to medical professionals to develop a sleep treatment program, but these tips can provide a good starting point.

• Keep a bedtime routine. Go to bed and wake up at the same time every day.
• As much as possible, use the bedroom for sleeping only.
• Make the bedroom and bed comfortable. It should be as quiet and dark as possible, with the temperature not too hot or too cold.
• Avoid daytime naps.
• Television, visitors (especially children), new and unfamiliar activities, all can unduly excite a person with dementia. Limit these and similar activities to early in the day.
• Avoid caffeine, especially in the afternoon and evening. Remember that tea, many soft drinks, and chocolate contain caffeine.
• Alcohol can be responsible for frequent nighttime awakenings.
• Spicy and rich foods, or too much food in the evening can make falling asleep and staying asleep difficult. On the other hand, a light snack before bedtime can actually improve sleep. Bedtime snacks should be light on protein, but contain carbohydrates and the amino acid tryptophan.
• Drinking too much liquid, especially before bed, can result in waking up for trips to the bathroom.
• Exercise regularly, but not too late in the day, as that can stimulate and raise body temperature making falling asleep more difficult.
• Get some light every day. This is especially important in the winter when natural light levels are lower, and we're inside more. A walk in the sun or sitting in front of a sunny window can help regulate our natural biorhythms. If it is difficult get enough sun, several light sources are available to supplement natural light.
• Engage in a quiet, relaxing activity before bedtime, like listening to music, or practice relaxation techniques.
• Most herbal teas contain no caffeine, and some are natural sleep aids. Most health food stores, and many grocery stores will stock a wide variety of herbal teas, many blended specifically for sleep. These will help promote healthy nighttime sleep whenever they are consumed during the day; they don't have to be (and probably shouldn't be) consumed right before bedtime. Chamomile is one of the herbs known for promoting sleep: others include Balm, St. Johns Wort, Passionflower, and Valerian.
• Aromatherapy is another natural treatment that has proven helpful to many who suffer from difficulty sleeping. Chamomile, jasmine, lavender, lemon balm (Melissa), rose, sandalwood, and ylang ylang are among the essential oils that help sleep.

Aromatherapy and Sleep

The effect of Roman Chamomile oil on sleep in elderly people was reported in the Journal of the Canadian Geriatric Society in 2001. This study involved 43 patients in an elderly care facility in London, 18 of whom suffered from Alzheimer's or another dementia. The study concluded that chamomile aromatherapy "causes modest but statistically significant increase in sleep in the sleep deprived."