Alzheimer's disease is characterized by frequent sleep disturbances that profoundly affect patients as well as caregivers. While older people in general sleep more fitfully, many of those with Alzheimer's are that much more restless at night. It's as if their internal biological clocks have been "reset" by the neurological disease. They may stay up all night, or they may wake to go to the bathroom, become confused and disoriented, and then wander through the house or try going out.

When people with dementia can't sleep, promptly analyze whether they are in pain and whether their medication has a side effect causing sleeplessness. Schedule a physical examination to check for signs of depression, for medical conditions causing discomfort and for bladder infections or prostate problems leading to frequent urination or incontinence — any of which could disturb sleep. Consult the physician about perhaps managing the patient's existing medications to avoid daytime drowsiness and nighttime restlessness.

If only it were as straightforward to handle "sundown syndrome. "Starting at dusk and continuing throughout the night, many people with dementia become more confused, disoriented, anxious, agitated, insecure, restless. The causes of "sundowning" behavior are not known, but you can take measures to help keep the combination of sleep problems and wandering from overwhelming patients and caregivers alike. This is so critical because patient sleeplessness and caregiver exhaustion are two of the most common reasons why people with Alzheimer's are eventually placed in nursing homes.

The following sections offer caregiver tips for helping them and for getting sleep yourself. These strategies are designed to help improve the sleep patterns of loved ones with Alzheimer's and keep them at home longer.

What you do during the day will affect how people with dementia sleep at night. Structure their day around meaningful social activities and sufficient physical exercise. Following are guidelines for establishing a daytime routine aimed at reducing nighttime sleeplessness.

Provide appropriate physical activity and exercise during the day

Plan more active days. A person who rests during the day is likely to be awake at night, whereas exercise will improve sleep quality and quantity. Just be careful to avoid evening exercise, which can be too stimulating near bedtime. If the person is prone to wandering, encourage at least one long walk a day. Many people with Alzheimer's have an extraordinary need to pace for hours; if possible, pacing should not be restricted.

Keep the person occupied, active and awake during the day

Plan activities throughout the day for people with dementia. Instead of simply watching TV, try dancing to familiar music or talking walks together outdoors. Ask the person to help with simple household activities like folding clothes or sweeping the floor. Don't hesitate to enlist family, friends, companions and professionals to help keep the cognitively impaired individual busy with social, mental and physical activities.

Consider sending the person to an adult day-care center

Adult day-care services are among the best ways to keep people with Alzheimer's active during the day. An adult day-care center would not only ensure that the person will be well occupied during the day, but would also relieve you of caregiving responsibilities long enough to get some much-needed respite. So could in-home respite care such as companion services that help supervise recreational activities and visiting.

Establish a regular sleep schedule and routine

Try to maintain a regular sleep schedule — same bedtime, same wake-up time, same naptime each day. While valuing routine, be flexible to any sudden "resetting" of the body's internal clock. Alteration in the sleep-wake cycle is often not permanent, with nighttime restlessness typically peaking in the middle stages and diminishing as the disease progresses. People with Alzheimer's may revert to earlier patterns or sleep for increasing periods of time.

Expose the person to bright light to help set the body's internal clock

Exposing people with Alzheimer's to either natural or artificial light, ideally between 6 A.M. and 9 A.M., can help restore the circadian rhythms disrupted by the disease and reset their internal clock. Weather permitting, encourage them to get an hour of bright sunlight and fresh air each day. During seasons when it's too cold or too hot outside, consider looking for an adult day-care center with a solarium.

Discourage daytime napping

If people with dementia are napping during the day, they will be less tired at night. When they must sleep during the day, limit the naps to 30 minutes and try not to allow them after 2 P.M. Napping after 2 P.M. will disrupt nighttime sleep. What's more, if they must nap during the day, take advantage of the opportunity to get some rest yourself. (On a cautionary note, it's better for them to nap during the day than become sleep-deprived.)

Control the person's diet

Avoid foods and beverages with caffeine — chocolate, coffee, tea and soda — and restrict them to the morning hours. Similarly restrict the consumption of sweets, and avoid alcohol. Serve dinner early, and offer only a light meal or snack before bedtime. Limit fluids after dinner. The last drink of the day should be two hours before bedtime unless there is some medical reason for continuous fluids. Just be sure the person has been drinking plenty of liquids throughout the rest of the day to prevent dehydration.

Manage existing medications to avoid daytime drowsiness

Because some drugs cause drowsiness during the day, consult the patient's physician about perhaps changing the schedule of current medications to dispense those with sedative side effects at night. Sometimes, the physician may find it necessary to discontinue nonessential medications or switch to an alternative drug that does not affect sleep through daytime drowsiness and nighttime restlessness.

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Tips for Getting the Patient Ready for Bed

Remind the person to use the bathroom before bedtime

Encourage people with dementia to empty their bladders as close to their bedtime as possible. Toileting should be standard procedure at bedtime as well as first thing in the morning and after meals. Because people with Alzheimer's may forget to use the bathroom, keep in mind that you may need to remind them by encouraging them and asking them if they have to go.

Try soft music to reduce anxiety and promote relaxation at bedtime

In addition to playing mellow musical favorites, you could try relaxing your loved one with a back rub or even a warm bath. If the person likes watching TV in the evening, make sure the subject matter is light so as not to be frightening or upsetting. Be aware that nighttime confusion makes it increasingly difficult to distinguish between real life and fictional violence or televised news events.

Do not insist that the person wear pajamas

Following the maxim about never going to bed mad, it's even more important not to upset or anger people with dementia right before bedtime. If forcing the issue by insisting that they wear pajamas or nightgowns could start an argument or cause agitation, let them sleep in their clothes. After all, it is far more important that they get sleep, no matter what they're wearing to bed.

Let the person sleep where it's most comfortable

Sometimes people with Alzheimer's disease will not sleep in their beds, but will readily fall asleep in a favorite chair or on a couch. If necessary, allow them to sleep there, as it's better than having them not sleep at all. Moreover, consider how waking someone with dementia at night just to get into bed is likely to confuse and agitate the person. However, be sure to wake them for toileting or changing as necessary.

Tips for Preparing the Patient's Bedroom for Sleep

Eliminate or reduce any noise that might disrupt sleep

Be sensitive to environmental conditions that could make it difficult for the person to fall asleep or stay asleep. Limit noise that might disturb the person with dementia. For example, you might want to disconnect the ringer on the bedroom telephone at night.

Leave a light on in the bedroom to help orient the person upon awakening

Place a nightlight in the bedroom so that people confused by dementia can more readily identify their surroundings if they wake up in the middle of the night. Keeping the bedroom partially lit will reduce agitation that occurs when surroundings are dark and unfamiliar, and help diminish the chance of confused patients misinterpreting what they see as hallucinations in a darkened room. Moreover, this will lessen the chance of a fall on the way to the bathroom.

Leave the bathroom light on and maintain a clear, visible pathway

Make sure the bathroom is easily accessible. Clear the pathway of any obstacles, such as furniture, walkers, shoes, throw rugs. Light the pathway as well as the bathroom. To help locate the bathroom, consider using reflective tape on the floor leading to it and around the bathroom door or painting the door a bright color. To help identify it in the early stages of the disease, consider hanging a large sign on the door with a picture of a toilet or block letters saying "BATHROOM." Avoid having items nearby that could be mistaken for a toilet, such as a trashcan.

Place a commode beside the bed if the person often wakes up to urinate

Older people may awaken many times at night to urinate and find themselves unable to get back to sleep. Placing a portable commode or urinal bottle by the bed is less dangerous and sometimes less upsetting than a nighttime walk to the bathroom. With less emotional upset, the person with dementia may fall back asleep more easily. As Alzheimer's disease erodes short-term memory, be sure to point out the commode, urinal or bedpan to the person every night as many times as necessary. Avoid having items nearby that could be mistaken for a commode, such as a wastebasket.

Be sure the room and the bed are comfortable

Make sure the climate in the bedroom is neither too cool nor too warm. Also make sure that the mattress and the bedding are comfortable. For example, quilts are less likely to tangle than blankets and sheets.  

Draw shades to limit shadows in the room

Make sure to limit shadows or other environmental distractions that could be misinterpreted and frighten the person. Be sensitive to how "sundowning" can cause confused patients to misinterpret what they see and hallucinate at night.  

Tips for Managing Sleep Interruptions

Assume that the person with dementia is disoriented upon awakening

Everyone has experienced the jarring sensation of awakening and momentarily not knowing where you are or what time it is. People with Alzheimer's are often that much more disoriented when they awake, especially at night, and thus need to be reoriented and reassured after sleep is disrupted. Keep this tip in mind when they doze off on a couch or in a chair: consider how disoriented or agitated they might become when they are awakened at night.

Remind the person that it's time for sleeping

Upon awakening in the middle of the night, some confused persons forget that they were even sleeping. Try gently reminding them to turn over and go back to sleep.

Once the person is awake and upset, experts suggest that caregivers:

• Approach the person in a calm manner.
• Find out if there is something the person needs.
• Gently remind the person that it's nighttime.
• Avoid arguing or asking for explanations.
• Offer reassurance that everything is all right and everyone is safe.
• Try soothing music if needed to allay anxiety and restlessness.
• Speak softly and quietly, using a relaxed tone of tone.
• Never betray your own exasperation over being awakened.

Make sure that incontinent patients are comfortable

If incontinence is a problem, check to see whether the person needs help toileting or changing. Never let the person remain in wet or soiled diapers. Change the person's diapers as many times as necessary. Get the person up once at night if toileting is necessary. If there is a problem with confused Alzheimer's patients trying to remove diapers at night, consider getting them in a one-piece outfit for sleeping or cutting the legs off a pair of pantyhose and place the panty portion over the diaper. Click here to see our caregiving tips on Incontinence and Toileting.

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Often the major problem in a family is not that the person with Alzheimer's isn't sleeping at night, but that the caregiver is exhausted. The following tips may help caregivers get the rest needed to keep their loved ones with dementia at home longer.

Make sure the house is safe for the person with Alzheimer's

Make a part of the house so safe that the person with Alzheimer's can be up and pacing while the caregiver is sleeping in another room. Caregivers must make sure their home is safe and secure, especially if the person with dementia wanders. The combination of sleeplessness and wandering can be deadly if the person is at risk for falling down stairs. Restrict access to certain rooms or floors by closing and locking doors, and install safety gates and window locks. Door sensors and motion detectors can be used to alert family members when someone is wandering.  For more ideas on keeping your loved one safe, read about our Safe Return Program for wandering Alzheimer's patients and consult our Home Safety caregiving tips.

Consider hiring a nighttime companion to supervise the patient

A nighttime companion would enable the caregiver to enjoy uninterrupted sleep with peace of mind that the loved one is safely supervised. If hiring a companion is not practical for financial or other reasons, another family member could be designated to relieve the primary caregiver of some overnight caregiving responsibilities.

Consult the patient's physician about prescribing a sedative or tranquilizer

Sometimes, a tranquilizer may "take the edge off" difficult behavior enough to stabilize volatile home situations. However, when considering medication, there are many things to watch out for:

• Older people are more subject to side effects from drugs than younger people. Their metabolisms also require smaller dosages to reach a therapeutic level.
• People with dementia are that much more sensitive to drugs than the well elderly.
• Elderly people are more likely to be taking medication for other illnesses that can be aggravated by a sedative or tranquilizer. Be sure to ask all the patient's doctors as well as your pharmacist about possible drug interactions.
• A sleeping pill or tranquilizer can sometimes cause excessive daytime drowsiness. Such a hangover effect can worsen the cognitive function during the day, making the person more confused, more vulnerable to falls and incontinent.
• If tranquilizers are prescribed to control behavior, they are likely making the person drowsy during the day.
• Sometimes a sedative or tranquilizer can have the opposite effect of what is expected and paradoxically even make sleeping worse.
• Sedatives may be justifiably necessary to enable a caregiver to keep a loved one at home, but the same chemical restraints would not be justified upon the patient's admission to a nursing home with adequate staff trained to handle difficult nighttime behavior through other interventions.
• If pain is suspected as a source of sleeplessness in Alzheimer's patients who have difficulty communicating their discomfort, a trial of over-the-counter pain medication (such as Tylenol) may be justified. Provide adequate pain relief for arthritic conditions or other sources of chronic pain.

Consider using bedrails

Although bedrails may help some Alzheimer's patients stay in bed, they may agitate others or lead to falls from greater heights. You must assess whether bedrails would promote safety (by reminding people with dementia that they're in bed) or increase the danger of falling (by upsetting confused patients enough to try climbing over them). When using a hospital bed at home (with or without rails), lower the mattress for sleep. In considering bedrails and other restraints, be sure that patient safety outweighs all other factors. Restraints, be they physical or chemical, should be used only when justified as absolutely necessary.

Sources: the Alzheimer's Disease and Related Disorders Association website (www.alz.org); the National Capital Area Chapter of the Alzheimer's Association website (www.alz-nca.org); Nancy L. Mace and Peter V. Rabins's book The 36-Hour Day: A Family Guide to Caring for Persons with Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life (1999, Third Edition, Johns Hopkins University Press).

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