Sundowning (changes in behaviour at dusk)

As the clocks go back this weekend, and with evenings becoming darker earlier, Helen Green who works on Dementia UK’s Admiral Nurse Dementia Helpline talks about how she united one family troubled by sundowning 

Sundowning is a term used for the changes in behaviour that occur in the evening, around dusk. Some people who have been diagnosed with dementia experience a growing sense of agitation or anxiety at this time.

Sundowning symptoms might include a compelling sense that they are in the wrong place. The person with dementia might say they need to go home, even if they are home; or that they need to pick the children up, even if that is not the case. Other symptoms might include shouting or arguing, pacing, or becoming confused about who people are or what’s going on.

This article at Dementia UK explains how the Dementia Helpline supported one family troubled by sundowning

See also Dementia UK’s leaflet on Good habits for bedtime

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Practical tips on preventing sundowning

  • Follow a routine during the day that contains activities the person enjoys
  • Going outside for a walk or visiting some shops is good exercise
  • Limit the person’s intake of caffeinated drinks. Consider stopping the person from drinking alcohol altogether. Caffeine-free tea, coffee and cola are available, as is alcohol-free beer and wine
  • Try and limit the person’s naps during the day to encourage them to sleep well at night instead
  • Close the curtains and turn the lights on before dusk begins, to ease the transition into nighttime
  • If possible, cover mirrors or glass doors. Reflections can be confusing for someone with dementia
  • Once you are in for the evening, speak in short sentences and give simple instructions to the person, to try and limit their confusion
  • Avoid large meals in the evening as this can disrupt sleep patterns
  • Introduce an evening routine with activities the person enjoys, such as: watching a favourite programme, listening to music, stroking a pet etc. However, try to keep television or radio stations set to something calming and relatively quiet—sudden loud noises or people shouting can be distressing for a person with dementia.

Disrupted sleep – a cause or consequence of Alzheimer’s?

In this blog, Honor Pollard explores if sleep problems could have a long-term effect on the brain| Alzheimers Research UK 

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Growing evidence points to a link between poor quality of sleep and an increased risk of Alzheimer’s disease. We know that disturbed sleep can be one of the earliest signs of Alzheimer’s and it often occurs years before changes to memory and thinking skills start to show. But this is not the full story when it comes to sleep and dementia.

A number of studies have shown that interrupted sleep may speed up the progression of Alzheimer’s in the brain. But it’s difficult for researchers to tease apart cause and effect. They need to work out whether poor quality sleep might contribute to the development of the disease or vice-versa.

Full article at Alzheimers Research UK 

 

A treatment for sleep disorders in dementia?

This paper investigates the feasibility and acceptability of a six-session non-pharmacological therapy for people with dementia who have disturbed sleep.  The authors conclude that the ‘DREAMS-START’ intervention for sleep disorders in dementia is both feasible and acceptable | International Psychogeriatrics | via The Mental Elf

In people with dementia, symptoms such as agitation and inappropriate behaviour are fairly well known for being difficult to cope with. What is less well known is that people with dementia often sleep badly. They may wander, putting themselves at risk, and being awake at night then tends to make them sleepy during the day. This sleep disruption can cause a lot of stress for their carers.

Available treatments for this problem do not appear to be very effective. The current study tests a new intervention called DREAMS-START (Dementia RElAted Manual for Sleep; STrAtegies for RelaTives), which is delivered to carers over six sessions to help them cope with and improve sleep problems.

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Abstract

Background:40% of people with dementia have disturbed sleep but there are currently no known effective treatments. Studies of sleep hygiene and light therapy have not been powered to indicate feasibility and acceptability and have shown 40–50% retention. We tested the feasibility and acceptability of a six-session manualized evidence-based non-pharmacological therapy; Dementia RElAted Manual for Sleep; STrAtegies for RelaTives (DREAMS-START) for sleep disturbance in people with dementia.

Methods:

We conducted a parallel, two-armed, single-blind randomized trial and randomized 2:1 to intervention: Treatment as Usual. Eligible participants had dementia and sleep disturbances and a family carer and were recruited from two London memory services and Join Dementia Research. Participants wore an actiwatch for two weeks pre-randomization. Trained, clinically supervised psychology graduates delivered DREAMS-START to carers randomized to intervention; covering Understanding sleep and dementia; Making a plan (incorporating actiwatch information, light exposure using a light box); Daytime activity and routine; Difficult night-time behaviors; Taking care of your own (carer’s) sleep; and What works? Strategies for the future. Carers kept their manual, light box, and relaxation recordings post-intervention. Outcome assessment was masked to allocation. The co-primary outcomes were feasibility and acceptability.

Results:

In total, 63 out of 95 eligible referrals consented  62 were randomized, and 37 out of 42  adhered to the intervention.

Conclusions:

Psychosocial risk factors and Alzheimer’s disease

New study predicts that sleep disturbance, depression, and anxiety increase the hazard of Alzheimer’s disease | Aging & Mental Health

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Objectives: Alzheimer’s disease (AD) dementia is a neurodegenerative condition, which leads to impairments in memory. This study predicted that sleep disturbance, depression, and anxiety increase the hazard of AD, independently and as comorbid conditions.

Methods: Data from the National Alzheimer’s Coordinating Center was used to analyze evaluations of 12,083 cognitively asymptomatic participants. Survival analysis was used to explore the longitudinal effect of depression, sleep disturbance, and anxiety as predictors of AD. The comorbid risk posed by depression in the last two years coupled with sleep disturbance, lifetime depression and sleep disturbance, clinician-verified depression and sleep disturbance, sleep disturbance and anxiety, depression in the last two years and anxiety, lifetime depression and anxiety, and clinician-verified depression and anxiety were also analyzed as predictors of AD through main effects and additive models.

Results: Main effects models demonstrated a strong hazard of AD development for those reporting depression, sleep disturbance, and anxiety as independent symptoms. The additive effect remained significant among comorbid presentations.

Conclusion: Findings suggest that sleep disturbance, depression, and anxiety are associated with AD development among cognitively asymptomatic participants. Decreasing the threat posed by psychological symptoms may be one avenue for possibly delaying onset of AD.

Full reference: Burke, S. L. et al. |  Psychosocial risk factors and Alzheimer’s disease: the associative effect of depression, sleep disturbance, and anxiety | Aging & Mental Health | 2018 Vol. 22, issue 12 | p 1577-1584 |  DOI: 10.1080/13607863.2017.1387760

Decreased deep sleep linked to early signs of Alzheimer’s disease

Researchers have uncovered part of the explanation for why poor sleep is linked to Alzheimer’s disease. | via ScienceDaily

Poor sleep is a hallmark of Alzheimer’s disease. People with the disease tend to wake up tired, and their nights become even less refreshing as memory loss and other symptoms worsen. But how and why restless nights are linked to Alzheimer’s disease is not fully understood.

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Now, researchers at Washington University School of Medicine in St. Louis may have uncovered part of the explanation. They found that older people who have less slow-wave sleep — the deep sleep needed to consolidate memories and wake up feeling refreshed — have higher levels of the brain protein tau. Elevated tau is a sign of Alzheimer’s disease and has been linked to brain damage and cognitive decline.

The findings, published in Science Translational Medicine, suggest that poor-quality sleep in later life could be a red flag for deteriorating brain health.

Full story at ScienceDaily

Link to research: Lucey BP, et al. | Reduced non-rapid eye movement sleep is associated with tau pathology in early Alzheimer’s disease | Science Translational Medicine | Jan. 9, 2019

See also: Lack of deep sleep and more day time naps could be early sign of Alzheimer’s, study suggests | The Independent

Sleep Disturbances in Alzheimer’s Disease

Sleep requirements change throughout life. As part of normal aging, sleep generally becomes briefer and fragmented, with older people often having multiple naps throughout the day. In this article, Osman Shabir explains that this may not be the pattern of sleep seen in patients with Alzheimer’s disease and other neurodegenerative conditions, however. | via News Medical

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Most patients with Alzheimer’s develop sleep problems which worsen as the disease progresses. Some common sleep disturbances seen in patients with Alzheimer’s are:

  • Loss of the ability to stay asleep, despite being able to get to sleep
  • Increased sleep latency (duration required to get to sleep is longer)
  • Increased agitation before bedtime and throughout the night
  • Disorientation upon waking up (in the night, or in the morning)
  • Sleepy during the day, whilst being alert during the night (circadian abnormalities)
  • Periodic limb movement (PLM) is worsened in around 50% of Alzheimer’s patients
  • Shorter duration of both slow-wave-sleep (SWS) and rapid-eye movement sleep (REM) despite the total number of sleep cycles remaining unchanged

The article notes however that not all studies have shown a significant correlation between sleep disruption and Alzheimer’s disease, either in the pre-clinical stage or after symptoms develop. Therefore, not all Alzheimer’s patients suffer from sleep problems, and likewise, not all people suffering from sleep issues in older age necessarily have Alzheimer’s. However, it is now increasingly accepted that sleep loss may indeed be an important risk factor and symptom of Alzheimer’s disease. Whether sleep loss contributes to Alzheimer’s progression, or whether Alzheimer’s causes sleep problems, is yet to be determined.

Full article: Alzheimer’s Disease and sleep disruption | News Medical

Lighting intervention improves sleep and mood for Alzheimer’s patients

A tailored lighting intervention in nursing homes can positively impact sleep, mood and behavior for patients with Alzheimer’s disease, according to preliminary findings from a new study | American Academy of Sleep Medicine | via ScienceDaily

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People with Alzheimer’s disease and related dementias may experience sleep problems, wandering, and associated daytime irritability. This study tested whether a tailored daytime lighting intervention could improve sleep and behavior in Alzheimer’s patients living in long-term care facilities.

The study involved 43 subjects diagnosed with Alzheimer’s disease and related dementias who were exposed to an active and inactive tailored lighting intervention for successive 4-week periods. Compared to baseline and to the inactive lighting condition, the lighting intervention significantly decreased sleep disturbances, depression and agitation. While all measures improved, the most significant improvement was seen in sleep quality.

Full story at ScienceDaily

Further detail: American Academy of Sleep Medicine