Sleep problems and treatments for people with dementia

Insomnia includes a wide range of sleep problems, such as taking a long time to fall asleep, waking up often during the night, having nightmares and waking up early in the morning. These result in the person not getting enough good-quality sleep.

Insomnia is a common problem for people with dementia, and different causes include the following:

• The person may be struggling with pain or discomfort.
• They may have other health conditions that make sleep more difficult, such as heart or breathing problems, heartburn, constipation, urinary tract infections or incontinence.
• They may be feeling anxious, stressed or depressed.
• They may be taking medications that cause insomnia as a side effect. This is common with drugs prescribed to improve dementia symptoms, such as donepezil, rivastigmine, or galantamine.

These drugs can also lead to very vivid dreams or nightmares. If this happens, they may find taking their medication in the morning rather than at bedtime helps.

There are drugs that can help a person get to sleep more easily. However, most have unpleasant or potentially dangerous side effects, such as dizziness and an increased risk of falls. This makes them less safe for a person with dementia to take. They tend to only be prescribed for very short-term use when the person has severe sleep problems.

Dementia can disrupt the body’s normal cycle of day and night and their body clock. This means that many people with dementia feel tired and sleepy during the day. They may take many naps that then make it harder for them  to sleep properly at night.

The condition is common in people with dementia with Lewy bodies (DLB), Parkinson’s disease dementia and the more advanced stages of Alzheimer’s disease. It also increases the chances of the person having hallucinations and delusions.

For more information on hallucinations and delusions see Changes in perception.

The best way to manage excessive daytime sleepiness is through a healthy sleep routine (see Tips for healthy sleep). These tips can be very challenging for you to follow, if the person with dementia is exhausted from disturbed (or lack of) sleep.

If this happens, it is better that they take one or two short naps for less than an hour each, ideally around the middle of the day. This should mean their daytime sleeping will not make it harder to go to sleep at bedtime.

Sleep-disordered breathing is a group of disorders that affect the ability of a person to breathe normally during sleep. The most common is obstructive sleep apnoea (pronounced ap-nee-a).

The person’s airway collapses or narrows while they’re asleep, which causes loud snoring and prevents them from breathing properly. It is more common in people with Alzheimer’s disease and vascular dementia.

Sometimes a person with sleep apnoea may stop breathing for more than a minute. When this happens, the levels of oxygen in their blood and brain can fall to dangerously low levels, causing them to wake up suddenly and gasp for air.

The condition can cause drowsiness, low mood and headaches when the person is awake. It can also contribute to dementia symptoms becoming worse over time.

A person with sleep apnoea should be seen by their GP as this can be a serious medical condition. They may also find that making some simple adjustments to their sleeping behaviour helps them to sleep better. These include:

• sleeping on one side of the body
• not smoking or drinking alcohol before going to sleep
• not taking sleeping pills (unless prescribed by the doctor) as these can make the condition worse.

Another treatment for sleep apnoea is continuous positive airway pressure (CPAP). A machine gently pumps air through a mask worn over the mouth or nose, when the person is asleep. It prevents the airway from becoming too narrow, which means the person gets the oxygen they need to sleep soundly and wake up less often during the night.

Wearing the CPAP mask can feel very strange and a person with dementia may not be able to tolerate it. A person with more advanced dementia symptoms is likely to try to remove it.

Restless legs syndrome is a condition where the person has a strong urge to move their limbs while they are awake and at rest. It is much more common at night. It can make falling asleep at night more difficult, because the person cannot relax properly.

They may have unpleasant sensations, such as aching or tingling, which only feel better if they keep moving. If they have difficulty communicating verbally, they may rub, tap or hit their legs to try to show you their discomfort. A person with restless legs syndrome may often feel the need to get out of bed and walk around at night.

The cause of restless legs syndrome is still not well understood but the condition is common in people with dementia with Lewy bodies (DLB) or Parkinson’s disease dementia. Other health conditions may increase the risk of having it, such as arthritis, diabetes, thyroid disorders, kidney problems and iron deficiency. It may also be worse for people who take drugs for anxiety and depression.

Treatments include being more physically active during the day and a better sleep routine. Some people also try massage, acupuncture, or wearing an inflatable compression device around the legs. While there isn’t enough evidence to show that they help, they might be worth trying if other treatments haven’t worked.

The most common drugs for treating this condition are pramipexole, ropinirole or rotigotine. These need to be used carefully. They may make hallucinations or delusions worse in people who have pre-existing psychotic symptoms – particularly those with DLB or Parkinson’s disease dementia.

Taking a daily iron supplement may help to improve symptoms if the person has iron deficiency (which can be diagnosed by their GP).

Periodic limb movement disorder causes the person to unconsciously move their limbs – most often their legs and feet – while they are asleep. This movement causes the person to wake up often. Their sleep is interrupted, and they may not get enough deep sleep. The condition can occur more often in people with DLB or Parkinson’s disease dementia.

Some drugs may cause periodic limb movement disorder, such as antidepressants, allergy medications, anti-sickness drugs, and antipsychotics. If any of these are being taken by the person with dementia, then switching to another drug may help to improve their sleep problems.

Most doctors prefer to not treat this condition with drugs unless it is seriously disrupting a person’s sleep. When drugs are used, they tend to be similar to those for restless legs syndrome.

REM (rapid eye movement) behavioural sleep disorder (RBD) causes the person to physically act out their dreams when they go through phases of REM sleep. Usually, muscles are paralysed during this type of sleep. However, for a person with RBD this doesn’t happen.

They may physically act out their dreams, which can be violent in nature and their arms and legs may flail around. They may wake up suddenly and fall out of bed. If they are sleeping next to a partner, these involuntary movements can cause injury.

As a result, many couples affected by RBD sleep separately. To help, mattresses can be placed around the bed to cushion the person if they fall out. Some people find sleeping on a mattress on the floor works best for them. Some people find that they sleep better in a sleeping bag. Sharp objects should be removed from the bedroom.

When dreams are vividly unpleasant or violent, it can leave the person feeling drained and exhausted the next day. Usually, the person does not remember that these dreams happened.

RBD is very common in people with DLB and Parkinson’s disease, and is more common in men than women. It often develops several years before the person is diagnosed with dementia.

The main drugs used to treat RBD are melatonin and clonazepam. Melatonin tends to be prescribed more for people with dementia, as clonazepam may worsen other symptoms of dementia and leave the person feeling drowsy during the day. It may also increase the risk of falling or developing sleep apnoea.

Other drugs are sometimes used when neither of these drugs improve the symptoms. However, there is not much evidence that they work.