Sleep

The importance of sleep

Sleep is an essential function necessary for our physical and mental well-being. Since we spend around 30% of our time asleep it is important that we ensure it is time well spent on achieving good quality sleep.  A good night sleep enables both body and mind to recharge and enable the brain to maintain cognitive function. Lack of sleep may result in difficulties in processing thoughts, emotions and memories and sustaining focus and attention required to manage activities of daily living. In contrast a good night’s sleep can improve our cognitive function as well as promote cardiac health, regulate blood sugars, boost the immune system and restore energy levels and so improve mood and mental well-being.

Both for the person with dementia and the carer, lack of sleep can be exhausting and can make managing during the day even more challenging and lead to poor mental health and well-being. Adults should aim for 7-9 hours of sleep per night; however the quality of sleep is more important than the quantity.

About the sleep-wake cycle

Our sleep-wake cycle is one of our internal processes, following a 24-hour cycle known as circadian rhythms. These circadian rhythms respond primarily to light and darkness and regulate our sleep patterns by controlling when a person is tired and needing sleep and when they are alert and awake. The brain contains our “internal biological clock” keeping everything in time. It is a cluster of nerve cells forming the suprachiasmatic nucleus – the SCN. The SCN is in the hypothalamus region of the brain and receives direct input from the eyes, light received resets the clock to correspond to the day-night cycle. The SCN, our biological clock, produces alerting signals to promote wakefulness and to switch off the sleep drive or it will promote sleep by turning off alerting signals. It communicates with areas of the brain throughout the day to manage metabolism, body temperature, movement and hormone production. The changing light levels initiate signals which are sent to the pineal gland triggering the release of hormones associated with sleep or alertness. In the evening the sleep-inducing hormone is melatonin and in the morning cortisol is released which increases energy and alertness. People who have difficulty with their natural wake-sleep cycles may sometimes be prescribed small amounts of melatonin to improve sleep. Stimulants such as caffeine can block out some of the signals which create the feeling or pressure of sleepiness especially if they are consumed later in the day.

Sleep is initiated by both our internal body clock, which controls the circadian rhythm described above and also our sleep-wake homeostasis or “sleep pressure” which tracks the need to sleep after being awake for a period of time. The pressure for sleep increases the longer a person is awake. External factors can sometimes influence our sleep needs, as well as exposure to light, this could include our environment, medications, medical conditions, stress, or simply what we eat and drink.

How might a dementia diagnosis impact sleep patterns?

The specific symptoms experienced by a person with dementia will depend on which disease they are diagnosed with and which area of the brain has been damaged. A diagnosis of any form of dementia is unique to that person and everyone will have a different experience. Other factors such as additional illnesses, and the environment can affect how a person may respond to their symptoms.

With age it is expected that our sleeping patterns may change. People living with dementia may also develop new or altered sleep patterns. Damaged cells in the SCN caused by some types of dementia mean that people living with dementia may experience fundamental changes to their circadian rhythms preventing regular and adequate deep sleep. These changes may include difficulty falling asleep or staying asleep, sleeping more during the day or getting tired earlier in the evening, waking more frequently throughout the night or experiencing light sleep. If sleep changes start to interfere with the ability to function day-to-day then it is important to seek medical advice to ensure that it is not a medical condition or medication that is causing the problems. Sleep changes can be related to any of the following:

• Changes to the area of the brain which controls sleep pressure

• Physical conditions such as urine infections

• Pain from other conditions such as arthritis

• Environmental factors including lighting, noise, or temperature

• Medication

• Anxiety or depression

Some of the main sleep disorder that can be experienced by a person living with dementia are these:

• Restless leg syndrome. This is most common in people with Lewy Body dementia, it is where a person has an overwhelming urge to move their legs during sleep. Some people may also experience ‘Periodic limb disorder’ which can cause either legs or arms to move uncontrollably at night.

• Obstructive sleep apnea (OSA) is common in Alzheimer’s disease and is the most common form of sleep disordered breathing. It occurs when a person experiences a brief lapse in breathing caused by partial or complete closure of the upper airway whilst asleep. OSA is also a risk factor for development of Dementia.

• REM sleep behaviour disorder is also common in Lewy body dementia. It can cause an individual to physically act out dreams whilst asleep, they can be unpleasant and may involve violent body movements.

If an individual experiences ongoing problems with sleep it is important to speak to the GP or a community mental health nurse. They will try to identify the cause and understand how best to deal with the situation. This could be treating pain or infection, making medication changes or introducing new medication such as melatonin (the hormone which tells your brain that it is dark and to go to sleep).

Sleep medication is not always recommended in people with dementia so non-drug treatments and strategies are likely to be the first go to. Keeping a sleep diary to note how frequently the issues occur and if there are any triggers or patterns can be really helpful for sharing with a GP who might also refer onto a specialist if this is required.

Good Sleep Strategies for People living dementia:

• Daily routine: Set the morning alarm for the same time each day. A clock showing whether it is morning or night-time can be very beneficial. Try to wake the person at the same time each morning and keep to a routine throughout the day around washing, dressing and mealtimes.

• Natural light: This will encourage the body’s natural wake-sleep cycle through increasing melatonin levels. Ensure particularly in the morning that the person gets adequate natural light outside or sitting by a window especially in the winter.

• Lighting: Ensure there is adequate lighting inside either artificial or natural during the day. In the evening at dusk draw the curtains but keep lighting on inside and then towards evening / bedtime dim the lights.

• Activity: Encourage daily activity preferably outdoors either walking or gardening for at least 20-30 minutes.

• Naps: If the person needs to nap in the day try to restrict this to a short nap in the morning or straight after lunch so it does not interfere with night-time sleep.

• Early Evening: Encourage the person to do light exercise or a calm activity to wind down. Avoid stimulants in the evening such as caffeine or alcohol). Have a light snack for supper

• Bedroom: Where possible try to keep the bedroom for night-time use only. The room should be uncluttered, dark, quiet and a good temperature. For safety an amber nightlight or low-level light can be used, but ideally use sensor lights which turn on when movement is detected.

• Bedtime: Use a bedtime cue, e.g., the 10’oclock news, turning off light and familiar routines. Keep a regular routine with same time bedtime, nightwear on & hygiene routine. Discourage TV or reading at bedtime - keep this activity for the living room and try soft music in the bedroom to assist sleep. If the person does not live alone, it is useful for others in the property to all get ready for bed at the same time as it can act as a cue.

Tackling difficulties with a sleep routine

If the person is not ready to sleep, make sure the environment is safe for them to walk around until they have completed whatever it is they feel they need to do before going to bed.

If the person does not live alone, it is useful for others in the property to all get ready for bed at the same time as it can act as a cue for them to also get ready.

It may take a few weeks to establish a good sleep routine, but it is worth persevering with the tips above to achieve this.

If the person is still having difficulty with sleep patterns it is also worth a discussion with the GP especially if they have not had a medication review in a little while.

Further support & Take-away Tasks

• Our free Wayfinding service are available to chat through any of the above and can share examples of some strategies that may work for you just get in touch to find out more.

• Family and friends can all access support from Sage House to improve their understanding of dementia and enabling you to have a better quality of life.

There are lots of strategies and tips to support with different aspects of dementia and they can be found in some of our other information sheets.

Contact Sage House and book an appointment with a Wayfinder to discuss any concerns you might have around dementia.