Expert: Mary Gordon - 8/28/2011

Question
Background: My wife was diagnosed with Alzheimers (AZ) two years ago by a local neurologist (and her diagnosis was confirmed at Johns Hopkins) about 10 months after she had a major fall that fractured her jaw. Some four months later (18 months ago) she fell again and suffered several back fractures.

Her back problems have now healed and she can walk (sometimes with a walker) but haltingly. Her weight is good and her demeanor is good -- she is not at all agitated or "difficult" -- and she often is quite lucid, especially  in front of company. Her memory of past events, however, is almost nil.

Current Issue: My wife sleeps 14 hours at night and then naps for all but 3 or 4 hours during the day. Her doctor has not suggested any treatment to keep her more alert and, rather, considers this sleep pattern as unremarkable and just an inevitable manifestation of the AZ disease.

My Questions: Can you confirm that this pattern is to be expected? Might it be caused by something other than her AZ condition? Is there any medication (or other treatment) I should be considering?

Answer
Hi Sid,

A couple of things come to mind. Many people with progressive neurological damage will experience excessive sleepiness and lethargy - and as Alzheimer's progresses, most people will sleep more and more, and be less and less alert and active. It's a function of the brain injury.  However, despite her falls, it doesn't sound like she is late stage. People with AD are very variable in sleep patterns and needs, but this does sound excessive for her stage of the illness.

A lot of people with Alzheimer's will also have disturbed sleep patterns - their circadian rhythms are disturbed so they are often not sleeping well at night, but can be very drowsy  during the day. A significant portion have breathing problems - the estimate is 30-70% having some sort of sleep disordered breathing patterns such as sleep apnea. This can mean the person doesn't get good quality of sleep at any time, leading them to sleep more and more. Does she snore? Does she have restless legs? Does she get up a lot ?

Apathy (the person doesn’t feel like doing anything) is common in Alzheimer’s disease and may be contributing to her sleeping, especially if there are not stimulating activities during the day to keep her occupied and moving around. If she is at home all day, you might want to try enrolling her in adult daycare to keep her busy and engaged. It can be difficult to provide the kind of stimulation she might get from that type of program at home. If she is drowsing in front of the TV, you might want to ban TV watching during the day. My mother in law was on an Alzheimer's ward by mid AD and they had removed all the TVs because they found the residents would sit napping in front of them all day instead of participating in activities, and then not necessarily sleep very well at night.

If you don't want to try daycare, you might want to hire someone to keep her moving - to come up with simple activities that might keep her interested and active. Being awake more during the day and getting more exercise might improve the quality of her sleep at night. It's also a dangerous spiral for her to be sleeping so much in terms of muscular strength. As you know, her muscular coordination and balance is impacted by the illness. However, if she is spiraling down from lack of movement, she will get more and more wobbly and weak, which will contribute to loss of ability to walk earlier than necessary, and could lead to falls (i.e. you might be out of the room and she will try to get up and fall before you get there).

Depression is also common in Alzheimer’s disease and can certainly show up in some people as excessive sleeping, especially if it represents a change from previous sleep habits, and should be treated.

Sedating medications can be a cause of excessive sleeping. Common sedatives include allergy medications like diphenhydramine (Benadryl), sleeping pills, and some antidepressants, such as amtriptyline (Elavil), mirtazapine (Remeron), and trazodone, to name a few. Sleepiness can also be a side effect of other medications. You don't mention what she might be taking. A doctor should be reviewing all her medications to make sure they are all necessary and if any can be causing this. Sometimes there are alternatives that cause less sleepiness, or even changing the time of day she takes them can often help.

In general, people with Alzheimer's Disease feel better and think more clearly if they are on a regular sleep schedule.  You can see, it may be she has some medical problem, a psychiatric problem or is on a medication that is playing a role in this. It may also be she will need a medication to better regulate her sleeping. In most cases, this is a fixable problem, and such a fix will likely improve her energy, mood and concentration. Even if you can't change it in the end, it is completely worth it to try.

If you are not getting help from her current doctor (you don't mention if this is the dementia specialist or her family doctor), I'd try another doctor to get an assessment done. If this is her GP, you probably know many of them don't know much about dementia and can be maddeningly passive when it comes to behavioral issues that cause real caregiver grief. Are there any dementia clinics near where you live, where you could get expert advice and support? I do think this should not be accepted without investigation by someone who takes your concern more seriously.

Thinking of you.

Mary