Sleep and Alzheimer's

Our minds are a powerful thing. But for some, particularly older adults, memory and thinking can begin to fade, leading to a devastating and debilitating diagnosis of Alzheimer’s disease. In time, Alzheimer’s patients become disoriented and confused. Even sleep becomes challenging. It’s not fully understood why, but it is believed that sleep problems are somehow related to Alzheimer’s effects on the brain. Often as the disease progresses, so does the severity of sleep disturbances. Let’s take a closer look at how Alzheimer’s affects sleep for patients and their caregivers.

Common Sleep Disorders for Alzheimer’s Patients

Sundowning

As many as one in five people with Alzheimer’s experiences feelings of restlessness and agitation in the late afternoon or early evening. This is often referred to as “sundowning.” The exact cause of sundowning is not known but it is likely aggravated by fatigue, reduced light at the end of the day, increased shadows, or the patient confusing reality with their dreams. Sundowning may also indicate the presence of an infection, such as a urinary tract infection. For individuals in nursing home facilities, sundowning may be triggered by an increase in activity caused by workers changing shifts or visitors clamoring in the hallways.

Insomnia

Insomnia is a sleep disorder characterized by difficulty falling asleep or staying asleep. Approximately one-fourth to one-third of people with dementia have insomnia. They often wake during the night and stay awake longer. When Alzheimer’s patients wake at night, they may become agitated, wander, or call out, which also disrupts the sleep of their caregiver.

Sleep-wake rhythm disorders

Alzheimer’s patients may become drowsy during the day and take naps, which make it difficult for them to fall asleep at night. This can create a shift in the sleep-wake cycle and disrupt the body’s natural circadian rhythm. Experts have found that people in the later stages of the disease often experience a complete reversal of their sleep-wake patterns, spending a significant amount of the day asleep, and lying awake in bed most of the night.

Restless leg syndrome

Restless leg syndrome (RLS) is one of the most common sleep disorders occurring in people with Alzheimer’s disease. It is characterized by an unpleasant sensation that causes an irresistible urge to move the legs. RLS typically occurs in the evening hours and is more severe at night when trying to go to sleep. The symptoms are usually described as an itching, crawling, pulling, aching, throbbing, or a pins-and-needles sensation. Some studies suggest RLS may be due to a dysfunction of the dopaminergic system caused by the progression of Alzheimer’s disease. Dopaminergic pathways are sets of neurons in the brain that trigger the release of dopamine, a neurotransmitter involved in various bodily functions.

Sleep apnea

Obstructive sleep apnea occurs when breathing during sleep repeatedly stops because the soft tissues of the mouth have fallen back and blocked the airway. This causes fragmented sleep because during an episode of apnea, the sleeper is aroused to gasp for air. Some studies suggest that breathing disorders during sleep occur most often in people with Alzheimer’s disease than those without dementia. Breathing disorders during sleep may also contribute to the progression of Alzheimer’s-related vascular changes in the brain. There is also evidence that suggests that the risk of cognitive decline increases with the number of apneas (complete blockage of air) and hypopneas (partial blockage of air).

Depression

As many as 40% of people living with Alzheimer’s disease suffer from depression, particularly during the early and middle stages of the disease. But sometimes it’s hard to determine if someone is suffering from depression or from early signs of Alzheimer’s disease because the symptoms are similar. For example, both Alzheimer’s and dementia can cause someone to lose interest in once-enjoyable activities, socially withdraw, experience memory problems, have difficulty concentrating, and sleep too much or too little. Scientists are not sure what the relationship is between the two conditions, but biological changes in the brain caused by Alzheimer’s may strengthen a person’s predisposition to depression.

How Caretakers’ Sleep is Affected

More than 16 million people in the United States are caretakers to someone with Alzheimer’s disease or dementia. It is a true labor of love, and one that can become all-consuming. Alzheimer’s is a progressive disease for which there is no cure. As the needs of the patient increase, the burden to the caregiver increases. Caregiving can cause sleep disruptions in a number of ways:

• Nighttime interruptions: Good sleep helps restore the body and the mind — for both the patient and the caretaker. But people with Alzheimer’s often awaken during the night. When they do, they might become restless or call out, and often you will be awakened to tend to their needs.
• Emotional stress: Caretakers also struggle with the emotional pressures of caring for their loved one. This can increase the risk for significant health problems and depression. In fact, nearly all Alzheimer’s or dementia caretakers report feeling sad, anxious, lonely, or exhausted — all of which can make falling asleep and staying asleep challenging.
• Multitasking: It’s challenging enough to care for someone with Alzheimer’s, but if you’re also caring for your children or working a regular job, it can be downright overwhelming. Sometimes there’s just not enough hours in a day to do everything, and you are forced to cut back on your sleep, or have to change the hours during which you sleep. This can throw your sleep-wake cycle out of sync, making it difficult for you to fall asleep at night and leave you exhausted during the day.

One of the most restorative things you can do is get a good night’s sleep. But that can be difficult when you have the weight of the world on your shoulders. Here are some solutions to help you lighten your load:

• Ask for help: Caring for someone dear to you is a true act of love. You shouldn’t feel guilty to ask for help from others when you are feeling overwhelmed. Taking time away from the stress of caregiving can make you a better caregiver. If other family members are unavailable, call on friends or contact volunteer organizations. Don’t feel guilty to accept help for grocery shopping or cleaning so you can direct your focus more to your loved one.
• Tap into resources: Alzheimer’s organizations provide a wealth of practical support, advice, and training for caretakers. They can also connect you with support groups or online communities where you can lean on others who are going through similar experiences.
• Talk to someone: Sharing your struggles with a trusted friend, family member, clergy member, or therapist can help you unwind. You’ll sleep better having lightened your emotional load.
• Get moving: Getting at least 30 minutes of exercise each day can improve your health, your mood, and your sleep. If you can’t commit to a full 30 minutes, then take several 10-minute breaks during the day to stretch your legs. But don’t do any hard workouts too close to bedtime. Strenuous exercise releases endorphins, the “feel good” chemical, and can make it difficult for you to unwind at bedtime.
• Relax: Take some time to practice relaxation techniques such as deep breathing exercises, meditation, or yoga. If time permits, get a massage to help loosen tense muscles.

According to Carol Amos, author of H.O.P.E. for the Alzheimer’s Journey, “If the caretaker is not sleeping because of their overwhelming caregiving responsibilities, they can use the H.O.P.E. acronym to become a more productive caregiver:

• Help – Caregivers can reach out to others (family, friends, professional caregivers) for help. Develop a circle of support. Also reach out to the medical community for an accurate diagnosis.
• Organization – Caregivers can organize the caregiving responsibilities. Establish a daily routine and organize the calendar (appointments), paperwork (medical, financial, insurance, legal, etc.), and outside support.
• Preparation – Caregivers can prepare in advance for when their loved one declines and requires more care.
• Education – Caregivers can educate themselves on the disease to know what to expect. They can join a support group (available on social media or virtually) to learn from the knowledge and experience of the group leader and other caregivers.”

Sleep Tips and Treatment

Non-drug treatments should be the first line of defense for treating sleep problems in people with Alzheimer’s. One reason is that older people who take sedating medications may be at greater risk for falls and fractures. If your loved one is having difficulty sleeping, talk to their doctor about options. Depending on the sleep issue, their doctor may decide that medication is necessary. Let’s take a look at some treatment options:

Over-the-counter medications

• Melatonin is a dietary supplement that is generally considered safe for Alzheimer’s patients and may offer modest improvement in sleep.
• OTC sleep aids like Unisom or Zzzquill*

 * WARNING: OTC sleep aids, like the antihistamine diphenhydramine (the active ingredient in brands like Benadryl, Unisom, Zzzquill) are not recommended as a first-line insomnia treatment for older adults in general because they have high rates of side effects including sedation, cognitive impairment, and excessive daytime sleepiness. Talk to your loved one’s doctor before giving any OTC medication.

Prescription medications

• Tricyclic antidepressants (nortriptyline)
• Benzodiazepines (lorazepam, oxazepam, temazepam)
• Zolpidem (includes brand names Ambien, Intermezzo) and Zaleplon (includes brand name Sonata)
• Atypical antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa) and quetiapine (Seroquel)*
• Classical antipsychotics such as haloperidol (Haldol)*

* WARNING: Antipsychotics can cause an increased risk of stroke or death in older adults with Alzheimer’s or dementia, and should not be used in older patients with cognitive problems. If your loved one has early onset Alzheimer’s disease, you can discuss with your loved one’s doctor about whether an antipsychotic medication is a good option for improving sleep.

Non-drug treatments 

• Establish a routine: Maintaining regular times for meals as well as for going to bed and waking can help you keep your loved one’s sleep-wake cycle in sync. Dr. Waqas Ahmad, a physician at Insurecast, suggests having “dinner at least 3 hours before sleep time … the patient should not eat a big meal at night.”
• Exercise: Exercise can do wonders for the body and soul. Encourage daily walks or other light activities, but not too close to bedtime as it could disrupt sleep.
• Avoid stimulants: Caffeine and nicotine are stimulants and can keep you from falling asleep if you take them too close to bedtime.
• Limit alcohol: A small amount of alcohol is OK for people in earlier stages of Alzheimer’s if it doesn’t interfere with their medication. Too much alcohol before bedtime can make falling asleep easier but can awaken you at night and prevent you from falling back to sleep.
• Treat pain: If your loved one is in pain, treat it before bedtime. Pain is uncomfortable and makes sleep difficult.
• Time medications: Some medications to treat Alzheimer’s, such as drugs known as cholinesterase inhibitors, can make people more alert. If possible, time the medication so that it is not administered right before bedtime.

Improve sleep hygiene

• Nightlights: Provide nightlights in bathrooms, hallways, and other pathways to prevent bumps and falls and to reduce agitation if your loved one wakes confused during the night.
• Bedroom temperature: A room that is too cold or too hot can interfere with sleep. The best nighttime thermometer setting is usually between 65 and 72 degrees.
• Avoid blue light too close to bedtime: Not all light is the same. Blue light is the kind that is emitted from electronics with screens. These blue wavelengths are great when we’re awake because they increase attention, reaction times, and mood. But at night, they can prevent you from falling asleep and should be avoided before bedtime.
• New mattress: If your mattress is old and sagging, it isn’t giving you or your loved one the kind of support you both need to sleep well and wake up refreshed. Newer memory foam and hybrid mattresses not only provide comfort, they also help keep your spine in alignment to reduce lower back pain and allow for extra give at pressure points such as the shoulders and hips. Some even come with cooling gel technology or copper infusions to help reduce joint pain and inflammation.

Alzheimer’s Symptoms and Diagnosis

So, what is Alzheimer’s disease?

According to Dr. Vikram Tarugu, M.D., CEO of Detox of Florida, “Alzheimer’s disorder is an early type of dementia. Dementia is a general word for brain disorders or illness disorders that negatively influence learning, perception, and behavior.” This means that Alzheimer’s disease is the most common type of dementia. Dementia is not classified as a disease but is a general term for a decline in mental ability that interferes with daily activity. Alzheimer’s, on the other hand, is a specific degenerative brain disease caused by cell damage that impairs the complex brain.

The most common early symptoms of Alzheimer’s include:

• Difficulty remembering new information
• Trouble planning or solving problems
• Difficulty completing familiar tasks
• Disorientation
• Difficulty judging distance or determining color or contrast
• New problems recalling words while speaking or writing
• Losing things
• Poor judgment
• Withdrawal from social activities
• Mood or personality changes
• Sleep problems

As Alzheimer’s progresses, symptoms get more severe and include: 

• Difficulty speaking
• Trouble swallowing
• Mobility issues

The disease progresses in five stages:

1. Preclinical Alzheimer’s disease — Identified only in research settings before symptoms occur.
2. Mild cognitive impairment due to Alzheimer’s disease — Marked by small changes not noticeable enough to affect work or relationships, such as memory lapses when it comes to recent conversations or events. 
3. Mild dementia due to Alzheimer’s disease — This is the stage when Alzheimer’s is often diagnosed. People with mild dementia may forget recent events, have a change in personality or have difficulty expressing thoughts.
4. Moderate dementia due to Alzheimer’s disease — Occurs when people grow more confused and begin to need help with some daily activities such as bathing, grooming, or going to the bathroom.
5. Severe dementia due to Alzheimer’s disease — This late-stage may involve the loss of the ability to communicate coherently, the need for assistance with personal care, and the inability to walk or sit up without assistance.

The progression of Alzheimer’s disease varies from person to person. On average, people live between three to 11 years after diagnosis, and in some cases, up to 20 years. Death in these patients is usually caused by pneumonia, dehydration, malnutrition, falls, or infections.

Diagnosing Alzheimer’s

One reason why Alzheimer’s disease is not diagnosed until the mild dementia stage may be because your loved one is trying to hide symptoms from you. Family members may also be hesitant to report symptoms they observe. But getting an early diagnosis is important because it means treatment can be started sooner when it’s most effective. 

Alzheimer’s is not diagnosed with simply a blood test, brain scan, or physical exam. Instead, doctors generally conduct a complete evaluation to rule out any other causes for the symptoms. If Alzheimer’s is suspected, your doctor will likely refer you to a neurologist, geriatrician, or other specialist. It can take as much as six months to a year to get a formal Alzheimer’s diagnosis.

Who’s at risk?

More than 5 million people in the United States are living with Alzheimer’s disease, most of whom are 65 years of age or older. But as many as 200,000 people in the U.S. under the age of 65 are diagnosed with early-onset Alzheimer’s. 

Alzheimer’s risk factors include:

• Being 65 years old or older
• Family history and genetics
• Down syndrome
• Mild cognitive impairment 
• Previous head trauma
• Poor sleep
• Lifestyle factors, including:
  • Sedentary lifestyle
  • Obesity
  • Smoking
  • High blood pressure
  • High cholesterol
  • Poorly controlled type 2 diabetes

What causes Alzheimer’s?

Researchers still don’t fully understand the exact causes of Alzheimer’s. And while genetics may be a risk factor, only about 1% of Alzheimer’s cases are genetic in nature. What we do know is that a buildup of brain proteins is likely to blame. This damages and disrupts brain cells called neurons, and causes them to lose connections with each other and eventually die. 

This toxic effect usually starts in the region of the brain that controls memory long before symptoms arise. This explains why early symptoms of Alzheimer’s often involve short-term memory loss. As the disease progresses, it spreads to other regions of the brain. More neurons die and the brain begins to shrink. Symptoms become more severe, and patients may experience difficulty speaking, swallowing, and walking, eventually succumbing to dehydration, malnutrition, falls, or infections.

In the search for a cause, researchers have begun to narrow their focus on two proteins that appear to have a toxic effect on the brain — plaques and tangles. Plaques are made up of clusters of beta-amyloid proteins, which form larger deposits in the brain called amyloid plaques. Tangles are tau proteins that transform into neurofibrillary tangles that wreak havoc on the neuron’s ability to transport nutrients and other essential materials.

What’s the connection to sleep?

According to Kate Kunkel, author of “Don’t Let the Memories Fade: A Holistic Approach to Preventing Dementia and Creating a Healthier and More Vibrant Future,” it is important to understand that “sleep difficulties run both ways – meaning that a lack of quality sleep can be a serious risk factor to developing cognitive issues, and cognitive decline including Alzheimer’s often results in sleep issues. It is a vicious circle, because the less sleep you get, the more damage can be done to the brain itself.” This means that sleep and Alzheimer’s can act as a two-way street. Similarly, Kimberly Truong, MD MPH, the Founder & Lead Physician at Earlybird Health, added that “sleep plays a vital role in making memory and executive functioning, and with recent knowledge advancements we know there’s a bidirectional relationship with sleep and Alzheimer’s. What that means is, poor sleep can lead to dementia, while at the same time, Alzheimer’s dementia also leads to poor sleep.”

Plaques and tangles may play a role in disrupting sleep in Alzheimer’s patients. Previous studies have shown that sleep clears the brain of beta-amyloid, and that lack of sleep elevates the level of beta-amyloid. One study, published in the journal Proceedings of the National Academy of Sciences, found that people who were sleep deprived and reported having worse moods also had larger increases of beta-amyloid. Dr. Amylee Amos of the Amos Institute said that “when we fail to get good quality sleep, we miss out on this highly favorable metabolic process and allow these plaques to accumulate, which can contribute to Alzheimer’s disease.”

In another study, researchers at Washington University School of Medicine in St. Louis found that older people who get less slow-wave sleep — the deep sleep credited for processing memories and helping you wake feeling refreshed — have higher levels of tau. This suggests that sleep difficulties may be an early sign of Alzheimer’s disease.

According to Dr. Tracey, Scientific Writer for Fitness Savvy and Medical Researcher with a PhD in Neuroscience, MSc in Molecular Neuroscience and BSc in Biomedical Sciences, “Sleep is complex from a neurological perspective and involves multiple pathways. The disease pathology associated with Alzheimer’s may mean that specific neurons required to manage sleep patterns are damaged. Interruption in signaling pathways can underlie sleep disorders.”

The Progression of Alzheimer’s Research

There is no magic pill that can prevent, cure, or even slow the progression of Alzheimer’s disease. But there are several medications that can temporarily improve symptoms such as memory loss, problem solving, and reasoning in early stages. The challenge is that these medications can help brain cells communicate with each other. But they don’t stop the cell death and progression of the disease. 

There are several drugs in development that seek to do this and there are several clinical trials underway. Researchers believe that the key to effectively treating the disease may lie in combining several drugs, similar to how AIDS and some cancers are treated. 

Some of the strategies being investigated target the protein plaques and tangles that appear to damage brain cells of Alzheimer’s patients. Other options include reducing chronic low-level brain cell inflammation caused by the disease and exploring the effects of insulin on the brain.

Unfortunately, developing and testing the safety and effectiveness of medications takes time, a precious commodity for people with Alzheimer’s disease and their family members and caretakers. But efforts are underway to speed up the process. An alliance of pharmaceutical companies, nonprofit organizations, and government agencies have formed the Coalition Against Major Diseases (CAMD), a partnership that aims to share clinical trial data in order to accelerate the development and review of more effective Alzheimer’s treatments.

Final Thoughts

Alzheimer’s disease is a devastating and debilitating disease that can adversely affect the sleep quality of patients as well as their caregivers. But don’t lose hope. There are ways to improve sleep quality which, in turn, benefit you and your loved one’s overall health and wellbeing.