CAROLINE BARTLE discusses why sleep can be a problematic area for people with dementia, and what we can do about it.
Many individuals may struggle with sleep at various points in their lives and impaired sleep may impact upon quality of life. Less understood, is the long-term impact of prolonged sleep deprivation. Sleep serves a restorative function in the brain, and has a critical role in our ability to process information and think clearly. However could there be more potentially harmful and longer term impacts of sleep deprivation?
Alzheimer’s Disease International (ADI) published a report last year on potential modifiable risk factors relating to the onset of dementia and within the report suggested decreased sleep may be a potential risk factor for cognitive decline, however indicated in the summary that these studies were limited and had a short follow time. Lack of sleep generally has also been associated with poorer cognitive performance, and increased rates of mortality.
Evidence suggests that there may be a number of complex neural processes at play which impact on the long term function of the brain. One theory suggests that lack of sleep may increase the risk of amyloid plaque formation, which is part of the pathology of Alzheimer’s disease. Another study found that day-time sleepiness may be correlated with the onset of vascular dementia.
Research in this area suggests that where causal relationships can be determined, interventions may be possible to aid and encourage sleep in order to delay the possible onset of dementia. Despite these individual research papers, the jury is still out on a definitive correlation between lack of sleep and the onset of dementia.
While the research on the long-term impact of poor quality sleep is interesting, the priority of services is the daily management of sleep difficulties, particularly for people with a level of cognitive decline, or dementia, where sleep difficulties exasperate their difficulties. Where there are cognitive demands, lack of sleep only adds to the disorientation. Therefore, sleep can impact significantly on quality of life, can increase emotional distress and in some cases lead to transition to residential care.
For many services working with people with dementia, who experience sleep difficulties, it has become an expensive problem. Higher levels of staffing during the night are often required, or more staff to review increasing incidences of emotionally distressing and challenging behaviour during the day.
A common challenge for services is ‘sundowning’, when a person finds themselves in a state between sleep and wakefulness, possibly caused by sleep deprivation. The person may become agitated and disorientated. Presenting changes in behaviour may also be as a consequence of changing light levels, which triggers a reaction to the environmental clues. For example, a change in light levels may indicate to a person that it is time to finish work, and return home. The person may then become agitated, particularly when they find it difficult to return home. When considering interventions to minimise agitation this should always be done in the context of the person’s reality.
If the environment is too hot, or too cold, or too light or too dark, or any way unfamiliar (potentially as a consequence of transitions in care, or as a consequence of memory problems) this can be distressing, and cause significant anxiety impacting on a person’s ability to fall asleep. Night time may also be a lonely experience for many people with dementia.
Some of the main interventions to treat sleep disorders are pharmacological. However, side effects of medications can exasperate cognitive difficulties, and increase the risk of adverse outcomes, such as an increased risk of falls. There has been some research linking the use of benzodiazepine to an increased risk of Alzheimer’s disease. Commonly used medications, like Donezepil can stimulate the cholinergic nervous system increasing the risk of disturbed dreams. Medication prescribed for a number of co-morbid conditions can also interfere with sleep.
There are a number of other factors which may impact on the quality of sleep: pain, depression, anxiety, diabetes, depression, arthritis, and renal failure. Just under three quarters of people living with dementia, also live with another condition.
Research carried out in a community setting in New Zealand found that there were three main areas for developing coping strategies: 1) strategies related to the sleeping environment 2) safety issues surrounding sleep and night time waking 3) techniques to relax at night and stay awake during the day. Services could benefit from distinguishing these categories, as a useful framework for possible interventions.
Another area of interest in the treatment and support of sleep disorders is the use of bright light therapy. The mechanism that controls the wake-night cycle is called the circadian rhythm. The daily light-dark cycle is the primary synchronizer responsible for supporting the circadian rhythms to the 24-hour day. Light helps to maintain the circadian rhythm, and can be introduced artificially to help reset those rhythms. Bright light therapy has been well researched in the area of dementia care and sleep. One study found favourable results when combined with the use of melatonin. Melatonin decreases when a person develops Alzheimer’s disease. Simple environmental changes can also be made to ensure that an individual has more access to light during the day; ensuring that there is adequate outdoor space, ensuring that curtains are pulled back during the day and the light fittings are the appropriate strength.
Other simple mechanisms include relaxation therapy, or having a quiet time before bed. Exercise has also been found to improve sleep, and could be potentially used as an effective treatment. A vast range of assistive technologies which enhance safety at night are now widely available.
Support services need to have in place a holistic management plan to respond to sleep disorders. A strategy should not only ensure improvements in quality of life, but also reduce the costs of responding to behavioural disturbances.
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Things that you can do
- Environmental adaptations, such as noise and light levels
- Assistive technologies which help with safety at night
- Bright light therapy
- Melatonin supplements
- Increased activity in the day
- Sleep hygiene
- Avoiding caffeine and alcohol
- Pain management
- Review of life history
- Environmental adaptations to support orientation
- Provide night time activities programme