Sleep Disturbances in Dementia What They Are and What to Do Karen M

Sleep Disturbances in Dementia What They Are and What To Do Karen M. Rose, PhD, RN; and Rebecca Lorenz, PhD, RN

Abstract Approximately one quarter of adults with dementia experience sleep disturbances. The purpose of this article is to (a) describe and define sleep disturbances in individuals with dementia, (b) describe techniques to assess for sleep disturbances in individuals with dementia, and (c) provide nursing interventions to improve sleep in this patient population. Typical presenta- tions of sleep disturbances in individuals with dementia are described, along with medications that may interfere with sleep. Suggestions for nursing measures that can be implemented © 2010/iStockphoto.com/Soyhan Erim to enhance sleep are also presented. Nurses have numerous nonpharma- tudies estimate that between sleep disruption. The etiologies cological options to assist with the Sone quarter and one half of of sleep disruptions in AD are older adults with Alzheimer’s multifaceted. Degradation of regulation of sleep-wake rhythms in disease (AD) and other demen- neuronal pathways that initiate individuals with dementia. tias experience some form of and maintain sleep, changes in the hypothalamic suprachiasmatic nu- cleus (the circadian “pacemaker” About the Authors of the body), and other modifica- Dr. Rose is Assistant Professor of Nursing and Claire M. Fagin Postdoctoral Fellow, tions in brain stem regions and University of Virginia, Charlottesville, Virginia; and Dr. Lorenz is Assistant Professor pathways that regulate sleep-wake of Nursing, St. Louis University, St. Louis, Missouri. cycles have been implicated in The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity. Dr. Rose acknowl- the sleep disturbances observed edges support from the John A. Hartford Foundation’s Building Academic Geriat- in AD patients (Bliwise, 2004). ric Nursing Capacity Award Program. Dr. Lorenz acknowledges support from the Frequent manifestations of sleep Individualized Care for At-Risk Older Adults training program at the University of disturbances in individuals with Pennsylvania, National Institute of Nursing Research (T32NR009356). AD include reversal of day-night Address correspondence to Karen M. Rose, PhD, RN, Assistant Professor of Nursing and Claire M. Fagin Postdoctoral Fellow, University of Virginia, PO Box 800782, 202 sleep pattern, frequent nighttime Jeanette Lancaster Way, Charlottesville, VA 22908; e-mail: [email protected]. awakenings, increases in daytime Posted: April 22, 2010 sleep, and decreases in slow-wave doi:10.3928/00989134-20100330-05 sleep and rapid eye movement

Journal of Gerontological Nursing • Vol. 36, No. 5, 2010 age. Continuous positive airway Table 1 pressure therapy has been shown Signs and Symptoms of Sleep Disorders to be well tolerated and effective for sleep apnea in those with AD Nighttime (Ancoli-Israel et al., 2008). Periodic Apneic episodes limb movements of sleep and Falls restless legs syndrome diagnosed Frequent awakenings by polysomnography or formal sleep studies have been found to Frequent leg movement during sleep or when lying awake in bed occur in individuals with cognitive Noticeable snoring impairment and are predictive of Talking while asleep reduced total sleep time (Richards Wandering et al., 2008). In older adults with cognitive Daytime impairment who reside in nursing Agitation, hostility, or combativeness home facilities, the presence of Complaints by roommate or caregiver pain has been linked to sleep Excessive daytime sleepiness and/or napping disturbances, as well as depressive symptoms and decrements in Falling asleep early in the evening quality of life (Swafford, Miller, Falls Tsai, Herr, & Ersek, 2009). Loss of physical function Environmental factors, such as the Reduced cognitive function (i.e., problems in concentration, attention, memory) presence of loud noises and limited exposure to bright light or natural Reduced participation in activities sunlight, have been implicated as precursors for sleep disturbances in Sources. American Medical Directors Association (2006); Bloom et al. (2009); Martin, Shochat, older adults with dementia. and Ancoli-Israel (2000). Assessment of Sleep Disturbances in sleep (Bliwise, 2004). Studies us- result, such individuals often take individuals with Dementia ing global measures of cognition frequent, short-duration naps Nursing assessment is the have reported that fragmented sleep throughout the day to make up for foundation for the creation of increases in concert with severity their lost sleep at night. In addition, any nursing care plan because of dementia. Further, lifestyle other medically diagnosed sleep it provides the evidence for the changes that often accompany pro- disturbances occur frequently in development of interventions. gression of dementia, the presence individuals with dementia. Assessment typically begins of pain, and frequently prescribed In individuals with dementia with an interview and a physical medications for those with demen- who reside in long-term care examination. If the patient is tia may worsen sleep disturbances. facilities, the prevalence of unable to provide a reliable sleep The purpose of this article is to (a) obstructive sleep apnea has been history, the nurse should talk with describe and define sleep distur- estimated to be as high as 70% the patient’s family member or bances in individuals with dementia, to 80% (Ancoli-Israel, 2006), yet caregiver. Sleep habits, history (b) describe techniques to assess for estimates among the community- of sleep problems, and any sleep disturbances in individuals dwelling portion of this population medications or other substances with dementia, and (c) provide nurs- are unknown. Sleep apnea is (e.g., alcohol) used to promote ing interventions to improve sleep in defined as irregular breathing at sleep should be discussed. It is this patient population. night due to complete or partial important to assess environmental, closure of the upper airways, behavioral, and psychosocial Sleep Disturbances in accompanied by apneas (cessation factors that may be contributing to Dementia of breathing) and hypoxemia disturbed sleep. Table 1 provides Individuals with dementia (Panossian & Avidan, 2009). Risk a list of signs and symptoms that experience excessive daytime factors for sleep apnea include indicate a sleep disorder. sleepiness associated with elevated body mass index, supine The patient’s medical history fragmented sleep at night. As a sleep position, and increased also holds clues to potential sleep

10 Copyright © SLACK Incorporated problems. Nurses should look for risk factors and other chronic Table 2 conditions, such as depression, Common chronic conditions that Affect Sleep that are commonly associated with nocturnal disturbances in sleep Chronic Condition Effects on Sleep (Table 2). Certain medications Acute or chronic pain Sleep onset difficulties, frequent awakenings and polypharmacy also create Congestive heart failure Orthopnea, nocturia sleep disturbances, so the Delirium Fragmentation of sleep-wake cycle assessment should include careful consideration of all medications Depression Difficulty maintaining sleep, excessive sleepiness being taken (Table 3). In addition, the times of day medications are Gastroesophageal reflux disease Frequent awakenings due to coughing and heartburn/discomfort given can contribute to sleep problems. For example, a diuretic Obesity Snoring, apnea agent taken just before bedtime Pulmonary disease Awakenings due to coughing or shortness increases the probability of of breath nocturia, and sedating medications taken in the morning can cause Sources. American Medical Directors Association (2006); Bloom et al. (2009). daytime napping. A variety of survey instruments have been used to assess sleep in older adults and may be completed by a family member or previous 2 weeks. Symptoms available in the clinical setting. caregiver. Simple sleep diaries can described include difficulty falling The gold standard of sleep be used for caregivers to record asleep, getting up during the night, assessment is polysomnography. bedtimes, describe nighttime and sleeping excessively during the This technology is the only awakenings, and document day (Tractenberg et al., 2003). way to obtain information on risetime. Identifying whether the Daytime sleepiness can be specific sleep stages, the presence person has more difficulty going quickly assessed using the of obstructive sleep apnea, and to sleep or staying asleep may Epworth Sleepiness Scale (Johns, restless legs syndrome. A referral help determine the most effective 1991). Using a scale of 0 (would to a sleep specialist may be interventions. For example, sleep never fall asleep) to 3 (high indicated if these disorders are onset difficulties are often related chance of falling asleep), this suspected after assessment. to anxiety, poor sleep hygiene, and questionnaire asks the patient or restless legs syndrome (Susman, caregiver to rate the likelihood Nursing Interventions 2001). Sleep maintenance problems the patient would fall asleep for Promoting Sleep in are often associated with chronic during eight common situations. individuals with Dementia alcohol use, medication side Questions can be omitted if they Sustained inadequate sleep effects, depression, or sleep apnea are not applicable (i.e., a question hygiene may also be a risk factor (Susman, 2001). about being stopped in traffic can for the development of sleep Validated rating scales of sleep be omitted if the person no longer disturbance in older adults. Sleep symptoms can be helpful during drives). A score of 10 or higher hygiene refers to a number of sleep the initial assessment as well as indicates the need to further assess habits that can be performed to during follow up to determine for common sleep disorders. enhance sleep (Table 4). Although the effectiveness of treatment Objective measures of sleep sleep hygiene is recommended for interventions. The Sleep Disorders include wrist actigraphy and all older adults, no studies have Inventory was developed and polysomnography. Actigraphy specifically focused on the efficacy validated for patients with provides nonintrusive technology of sleep hygiene measures alone dementia and has great utility in to assess sleep-wake cycles on improving sleep in individuals both home and long-term care in individuals with dementia with dementia. Regardless, sleep settings (Tractenberg, Singer, (Ancoli-Israel et al., 2003). Wrist hygiene measures remain the Cummings, & Thal, 2003). It actigraphs, similar to watches, firstline treatment for impaired describes the frequency, severity, are worn for several consecutive sleep. and caregiver burden of sleep- days. However, actigraphs Increasing daytime activity and disturbed behaviors within the are expensive and not readily physical exercise are known to

Journal of Gerontological Nursing • Vol. 36, No. 5, 2010 11 Table 3 Medications associated with disrupted sleep Drug Class Examples Effects Analgesic drugs Nonsteroidal anti-inflammatory drugs Decreased sleep efficiency Opioid drugs Sedation, decreased REM and SWS Antihistamine drugs (older Diphenhydramine (Benadryl® and others) Daytime sleepiness varieties) Antihypertensive drugs Beta blockers, alpha blockers Insomnia, nightmares, vivid dreams, daytime fatigue Antiparkinsonian drugs Levodopa/carbidopa (Atamet®, Sinemet®) (high dosages), Insomnia, daytime sleepiness dopamine agonist drugs Antipsychotic drugs Clozapine (Clozaril®), olanzapine (Zyprexa®), quetiapine Sedation (Seroquel®) Bronchodilator drugs Theophylline (Slo-phyllin® and others), albuterol (AccuNeb® Sleep onset difficulties, increase and others) in awakenings during night Central nervous system Modafinil (Provigil®), caffeine Sleep onset difficulties stimulant drugs Corticosteroid drugs Prednisone (Deltasone®), dexamethasone (Decadron®) Daytime fatigue, sleep onset difficulties, increase in awakenings during night Decongestant drugs Pseudoephedrine (Sudafed® and others), phenylephrine Sleep onset difficulties (Neo-Synephrine® and others) Histamine type-2 receptor Cimetidine (Tagamet®), ranitidine (Zantac®), famotidine Insomnia, somnolence antagonist drugs (Pepcid®), nizatidine (Axid®) Lithium Lithium Daytime sleepiness Stimulating antidepressant Protriptyline (Vivactil®), bupropion (Wellbutrin®, Zyban®), REM sleep, short total sleep time drugs selective serotonin reuptake inhibitors, venlafaxine (Effexor®), monoamine oxidase inhibitors

Sources. Ancoli-Israel & Ayalon (2009); Ancoli-Israel, Ayalon, and Salzman (2008); Mintzer & Burns (2000); Neubauer (2008); Salzman (2008). Note. REM = rapid eye movement; SWS = slow wave sleep. enhance sleep in individuals with regulation of melatonin rhythm effects can include vivid dreaming dementia, as they may correct the and for circadian sleep-wake or nightmares (Neubauer, 2008). circadian rhythm disturbances cycles. Because light is a zeitgeber, Medication schedules should be these individuals experience (King or “cue” for wakefulness, more adjusted appropriately to prevent et al., 2008). Simple interventions, exposure to light may be helpful in creation or exacerbation of sleep including increasing social decreasing daytime sleepiness and problems. activities (e.g., participation in an thus promotion of nighttime sleep. hour of simple games, engagement Exposure to bright-light therapy Conclusion in other meaningful activities), in the morning or throughout the Sleep disturbances occur have shown improvements in day has been shown to improve frequently in individuals with nighttime sleep in individuals total nighttime sleep in individuals dementia, oftentimes increasing as with dementia (Richards, Beck, with dementia who reside in the severity of dementia increases. O’Sullivan, & Shue, 2005). nursing facilities (Sloane et al., Changes in the brain region, in Exposure to bright light 2007). addition to normal changes in sleep or more natural sunlight is As described above, a variety as a result of aging, add to the sleep recommended for individuals with of medications, both prescription disturbances experienced by older dementia as well as older adults in and over the counter, can interfere adults with dementia. Numerous general. Light plays a role in the with sleep (Table 3). Medication nonpharmacological measures

12 Copyright © SLACK Incorporated Table 4 Nonpharmacological Nursing Interventions to Promote Sleep Category Intervention Rationale Sleep hygiene Limit caffeine (e.g., coffee, tea, soft drinks, chocolate), Stimulant products promote wakefulness measures cigarettes, stimulant agents, and alcohol If medically able, increase activity in the afternoon or early Promotes daytime arousal, reduces daytime nap- evening, but not close to bedtime ping, and reduces depression Increase exposure to bright light or sunlight during the Helps maintain circadian rhythms, which are day and early evening hours established by patterns of light and dark Avoid napping, if possible, or limit to one nap of less than Weakens the homeostatic drive to sleep 30 minutes Check the effect of medications on sleep See Table 3 Maintain comfortable temperature, darkness, and proper A comfortable sleep environment promotes ventilation in bedroom sleep Minimize light and noise exposure as much as possible Light and noise disrupt sleep Eat a light snack if hungry Hunger can keep a person awake Avoid heavy meals at bedtime Reduces nighttime awakenings caused by gastroesophageal reflux disease Limit liquids in the evening Reduces nighttime awakenings caused by nocturia Keep a regular schedule (i.e., rest and retire at the same Maintaining temporal patterns of rest and activ- time every day, eat and exercise on a regular schedule) ity enhances synchrony with circadian rhythm Practice stress-management techniques (i.e., discuss Reducing stress and promoting relaxation at worries and stressful events enough time before bedtime, bedtime will augment a person’s readiness for practice progressive muscle relaxation or other tech- sleep niques to promote relaxation) Environment Use a noise machine to provide “white noise” Has been shown to promote sleep maintenance in some populations Massage Provide slow-stroke back massage during bedtime routine Has been shown to promote sleep in nursing home residents with dementia Delirium Assess for signs of delirium; to prevent delirium, frequent- These measures reduce anxiety and help main- ly reorient the person by keeping clocks and calendars in tain circadian rhythms living and sleeping areas, maintain a regular schedule, and keep day and night associated with environmental light and dark

Sources. Ancoli-Israel and Ayalon (2009); Cole and Richards (2007); Floyd (1999); Harris (2009); Smith (2002).

other sleep disturbances associated with can be undertaken by nurses prescription and over the counter, chronic illness. American Journal of to assist with the regulation of is warranted, as many medications Managed Care, 12(8 Suppl.), S221-S229. sleep-wake rhythms in individuals interfere with sleep. Further, if Ancoli-Israel, S., & Ayalon, L. (2009). Diag- with dementia. Increasing obstructive sleep apnea is diagnosed nosis and treatment of sleep disorders in older adults. Focus, 7, 98-105. adherence to basic sleep hygiene in individuals with dementia, a trial Ancoli-Israel, S., Ayalon, L., & Salzman, C. measures, promoting increased use of a continuous positive airway (2008). Sleep in the elderly: Normal varia- levels of activity and exercise, pressure machine is warranted. tions and common sleep disorders. Har- vard Review of Psychiatry, 16, 279-286. and augmenting the amount of Ancoli-Israel, S., Cole, R., Alessi, C., exposure to sunlight and bright References Chambers, M., Moorcroft, W., & Pollak, light are firstline treatments for American Medical Directors Association. C.P. (2003). The role of actigraphy in the sleep disturbances in individuals (2006). Clinical practice guideline: Sleep study of sleep and circadian rhythms. disorders. Columbia, MD: Author. Sleep, 26, 342-392. with dementia. A thorough Ancoli-Israel, S. (2006). The impact and Ancoli-Israel, S., Palmer, B.W., Cooke, J.R., evaluation of all medications, both prevalence of chronic insomnia and Corey-Bloom, J., Fiorentino, L., Nata-

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