Expert: Mary Gordon - 1/31/2010

Question
Hi- My mother-in-law is currently dealing with caretaking for her husband who is in the medium-advanced stages of the disease. She had hoped to get him in the routine of sleeping at night and staying awake during the day. This has proven impossible to do- he refuses to go back to bed in the middle of the night and ends of sleeping randomly throughout the day. This is a two-fold problem- one, my mother-in-law cannot count on consistent sleep for herself, thus exasperating her efforts to assist him and two sometimes they have a required Dr. Appt. in the morning which makes it very difficult to et him up if he finally goes to sleep in the early morning hours. What to do?! Any suggestions?

Answer
Hi Amy,

Your poor mother in law ! As you probably know, sleep disturbances are fairly common in people with progressive dementias. They do go with brain damage, and disturbances to circadian rhythms. Dementias can reverse a person's sleep-wake cycle, causing daytime drowsiness and nighttime restlessness - and the problem can get worse as the illness progresses. Eventually, endless tiny naps can replace deep, restorative nighttime sleep. As I know you fear, this not only impacts the health of the person with Alzheimer's, but the health and ability to cope of the caregiver. It's a serious issue, since if she is getting sick or at the end of her rope from exhaustion, she won't be able to keep him at home.
Things your mother in law can consider:

Make sure he isn't suffering from any other health problems that can interfere with sleep - such as sleep apnea, restless legs syndrome, depression, or even aches and pains that make it hard to sleep.

Check over his medications, and make sure they are being taken at a time of the day where side effects won't interfere with sleep. For example, take drugs that might have a stimulating effect in the morning, and medications that might make him sleepy at bedtime. I'd also ask the doctor to review everything that he is on. Sometimes sleeplessness can be an unexpected side effect for an individual taking a medication - for example, some antidepressants can actually cause sleep problems in some people.

Avoid letting him have caffeine, alcohol or tobacco. Caffeine in soda, tea, coffee etc. can  contribute to sleep problems, as can alcohol can contribute to confusion and anxiety. If he is in the habit of either, give him decaffeinated substitutes, a substitute drink in a familiar cocktail glass, or nonalcoholic beer or wine. Both caffeine and alcohol can also contribute to anxiety and agitation, and confusion - none of it good for a person with dementia.

Routine, routine, routine - just the same as you establish for a small child you want to get onto a "schedule". Do the same things in the same way every night at the same times - so the associations are made with going to bed. The routine might include a snack of warm milk, pajamas, bathroom, soft music or a story, a back rub - whatever is predictable and soothing to him. If bathing makes him upset, do it earlier in the day. I'd also avoid TV in the evening if he tends to get agitated by it, or if it causes him to fall asleep in front of it earlier than bedtime.

It's also important that the bedroom is associated with sleep.  TVs, radios and other sources of entertainment should be kept out of the room.  Make sure the room is comfortable and slightly cool. Leave a night light on so he isn't disoriented and confused if he wakes in the middle of the night. Place security objects, such as a favorite blanket, within easy reach.

If he does get up at night, be as low key, soothing, and BORING as possible. No point to get him even more wound up by confronting, arguing etc. He will pick up on tension and upset and mirror that himself.  

Encourage physical activity during the day. Plan his days to include walks and other physical activities- keep him busy and moving around if possible. Taper his activities as the day winds down so that he doesn't get wound up by physical activity close to bedtime.

Try to get him up at the same time every day.  Exposing him to a few hours of bright sunlight in the morning may improve his sleep at night - for example, take him for a morning walk. Light therapy with a specialized light box can also help to reset internal rhythms. Here is some information on light therapy. It might not be for him, but it is worth asking the doctor about.
http://www.sleepeducation.com/Treatment.aspx?id=4

Try to limit daytime sleep. If he needs a nap, make sure it's short (i.e 20-30 minutes) and not too late in the day (i.e. no later than early afternoon). Try having him nap on the couch or a recliner than in bed. If he is in the habit of drowsing in front of the TV - it might be time to ration TV watching. My mother in law was in a special Alzheimer's ward for two years, and they actually banned TV on the ward entirely because of the sleep issues it contributed to. They would wheel one in for special events like a movie night, but other than that - no TV.

I know that keeping him awake and active during the day can be draining - your mother in law might want to consider hiring a sitter for a few hours every day to keep him moving while she has a nap or gets some time to herself. If she has friends, neighbors, a faith community, she might want to try to tap into volunteers who might be able to take some turns with him. Day programs such as "adult daycares" can also be a godsend. They can provide stimulation, exercise, socializing and activities that are next to impossible to accomplish in a home environment - and they also will give her a break.  

If nothing else is working, she might want to consider getting someone to sit with him at night - whether a family member who can take turns spelling her off or a hired person. She needs some rest! If she is reluctant to hire anyone, consider how much it would cost to put him in a home because her health has broken down from lack of good sleep!

When she is talking to the doctor, she can also discuss sleep aids. Generally, prescription sleep aids are not recommended because they can  increase confusion, risk of falls, and even be habit forming. However, they might be good for occasional use. There are also over the counter medications like gravol and benedryl or even melatonin that might help him. However, nothing should be given to him without clearing it with the doctor to make sure nothing will interact with other meds he may be on, or affect other medical conditions.

Hope this helps. I know this is a very difficult problem to tackle.  

Mary G.