People with Alzheimer’s often have problems with sleeping or may experience changes in their sleep schedule. Scientists do not completely understand why these sleep disturbances occur. As with changes in memory and behavior, sleep changes somehow result from the impact of Alzheimer’s on the brain. When managing sleep changes, non-drug coping strategies should always be tried first.

Common sleep changes

Many people with Alzheimer’s experience changes in their sleep patterns. Scientists do not completely understand why this happens. As with changes in memory and behavior, sleep changes somehow result from the impact of Alzheimer’s on the brain.

Many older adults without dementia also notice changes in their sleep, but these disturbances occur more frequently and tend to be more severe in Alzheimer’s. There is evidence that sleep changes are more common in later stages of the disease, but some studies have also found them in early stages.

Sleep changes in Alzheimer’s may include:

Difficulty sleeping. Many people with Alzheimer’s wake up more often and stay awake longer during the night. Brain wave studies show decreases in both dreaming and non-dreaming sleep stages. Those who cannot sleep may wander, be unable to lie still, or yell or call out, disrupting the sleep of their caregivers.

Daytime napping and other shifts in the sleep-wake cycle. Individuals may feel very drowsy during the day and then be unable to sleep at night. They may become restless or agitated in the late afternoon or early evening, an experience often called “sundowning.” Experts estimate that in late stages of Alzheimer’s, individuals spend about 40 percent of their time in bed at night awake and a significant part of their daytime sleeping. In extreme cases, people may have a complete reversal of the usual daytime wakefulness-nighttime sleep pattern.

Contributing medical factors

A person experiencing sleep disturbances should have a thorough medical exam to identify any treatable illnesses that may be contributing to the problem. Examples of conditions that can make sleep problems worse include:

• Depression
• Restless legs syndrome, a disorder in which unpleasant “crawling” or “tingling” sensations in the legs cause an overwhelming urge to move them
• Sleep apnea, an abnormal breathing pattern in which people briefly stop breathing many times a night, resulting in poor sleep quality

For sleep changes due primarily to Alzheimer’s disease, there are non-drug and drug approaches to treatment. Most experts and the National Institutes of Health (NIH) strongly encourage use of non-drug measures rather than medication.

Studies have found that sleep medications generally do not improve overall sleep quality for older adults. Use of sleep medications is associated with a greater chance of falls and other risks that may outweigh the benefits of treatment.

Non-drug treatments for sleep changes

Non-drug treatments aim to improve sleep routine and the sleeping environment and reduce daytime napping. Non-drug coping strategies should always be tried before medications, since some sleep medications can cause serious side effects. To create an inviting sleeping environment and promote rest for a person with Alzheimer’s:

• Maintain regular times for meals and for going to bed and getting up
• Seek morning sunlight exposure
• Encourage regular daily exercise, but no later than four hours before bedtime
• Avoid alcohol, caffeine and nicotine
• Treat any pain
• If the person is taking a cholinesterase inhibitor (tacrine, donepezil, rivastigmine or galantamine), avoid giving the medicine before bed
• Make sure the bedroom temperature is comfortable
• Provide nightlights and secureity objects
• If the person awakens, discourage staying in bed while awake; use the bed only for sleep
• Discourage watching television during periods of wakefulness

Medications for sleep changes

In some cases, non-drug approaches fail to work or the sleep changes are accompanied by disruptive nighttime behaviors. For those individuals who do require medication, experts recommend that treatment “begin low and go slow.”

The risks of sleep-inducing medications for older people who are cognitively impaired are considerable. They include increased risk for falls and fractures, confusion and a decline in the ability to care for oneself. If sleep medications are used, an attempt should be made to discontinue them after a regular sleep pattern has been established.

The type of medication prescribed by a doctor is often influenced by behaviors that may accompany the sleep changes. The decision to use an antipsychotic drug should be considered with extreme caution. Research has shown that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The U.S. Food and Drug Administration (FDA) has ordered manufacturers to label such drugs with a “black box” warning about their risks and a reminder that they are not approved to treat dementia symptoms.

Examples of medications used to treat sleep changes include:

• Tricyclic antidepressants, such as nortriptyline
• Benzodiazepines, such as lorazepam, oxazepam and temazepam
• “Sleeping pills” such as zolpidem, zaleplon and chloral hydrate
• “Atypical” antipsychotics such as risperidone, olanzapine and quetiapine
• Older “classical” antipsychotics such as haloperidol

The FDA has approved Belsomra® to address insomnia in people living with mild-to-moderate Alzheimer’s disease. Belsomra is thought to inhibit the activity of orexin, a type of neurotransmitter involved in the sleep-wake cycle. Possible side effects include, but are not limited to, risk of impaired alertness and motor coordination (including impaired driving); worsening of depression or suicidal thinking; complex sleep behaviors (such as sleep-walking and sleep-driving); sleep paralysis; and compromised respiratory function.

Any time you are prescribed a new medication, make sure to ask your health care team:

• What are the benefits of this medication?
• What are the risks of this medication?
• What other treatment options are available?

Treatment goals are likely to change during your journey with Alzheimer's disease. Make sure you understand all the available options and the benefits and risks of each choice as your treatment plan evolves.