Late Stage Symptom: Sleep Issues

Reviewed by: HU Medical Review Board | Last reviewed: June 2019 | Last updated: March 2023

As Alzheimer’s disease progresses, the symptoms can change and become more pronounced at each stage, particularly the behavioral symptoms. While the physical and cognitive changes can be challenging, behavioral symptoms can be distressing to a person with Alzheimer’s disease and their partner, family, or caregivers. While there are treatments for various behavioral symptoms, there is no cure, and no treatment will fully stop the symptoms or slow down the progression of the disease. These treatments help to mitigate symptoms, and various lifestyle modifications can help minimize disruption, ease symptoms, and improve quality of life.

Sleep disruption in Alzheimer’s typically changes depending on the stage of disease. Those in the early stages of Alzheimer’s disease may sleep more than expected, waking up disoriented; in the later stages, sleep cycles may be flipped and the person might wake up more often at night and sleep during the day.1 In advanced Alzheimer’s, sleep cycles are very disrupted and individuals typically don’t sleep for long periods of time, but rather doze on and off throughout the day.1 Learning more about sleep issues and Alzheimer’s disease can provide the information an individual needs to make adaptations to their schedule and hopefully get better sleep.

Causes of sleep disruptions

It’s not known exactly what causes sleep disturbances in Alzheimer’s disease, but there are some factors that might contribute to these difficulties, including:2,3

  • Mental and physical exhaustion by the end of the day
  • Disorientation
  • Changes in the internal body clock, which mix up wake/sleep and night/day schedules
  • Changes in lighting (less light, more shadows) may scare those with Alzheimer’s as the night goes on
  • Need for less sleep, common among older adults
  • Nonverbal cues from caregivers who are exhausted at the day’s end
  • Restless legs syndrome in some people
  • Depression
  • Sleep apnea

Non-drug treatments for sleep issues

While there are drug therapies for sleep disturbances, they aren’t generally first-line treatments. Non-drug treatments are tried first, since medications can have serious side effects and increase the risk of falls and cognitive disturbances. Treatment aims to reduce daytime sleeping and napping to help reset the internal clock and improve your sleep routine. This includes1,3,4:

  • Keep a regular meal schedule and wake/sleep schedule
  • Avoid (or minimize as much as possible) alcohol, caffeine, and nicotine
  • Make sure the thermostat is set at a comfortable temperature
  • After waking, try to stay in bright light
  • Create simple everyday routines
  • Try to get some form of physical activity each day, but no later than 4 hours before bed
  • Modify your home environment to minimize danger (ie, falls)
  • If taking a cholinesterase inhibitor, don’t take before bedtime
  • At night, turn on nightlights and keep security objects nearby
  • Treat any pain or discomfort
  • Light therapy
  • Progressive muscle relaxation
  • Cognitive-behavioral therapy

Medications for sleep issues

If non-drug strategies aren’t working, talk with a doctor about medications for the sleep issues. There are risks with these medications since they can increase falls, stroke, and hasten cognitive decline. They should be used at low doses and discontinued once a sleep routine is in place. Various types of medications can be used to treat sleep issues and their associated behaviors, including antidepressants, benzodiazepines, sleep medications, and antipsychotics.3 The kind of medication used will likely depend on any other behaviors being exhibited and how well a person tolerates various kinds of medications, as well as taking into account other medications the person might be on, and the possible interactions.

Sleep disturbances are a common symptom in Alzheimer’s disease, but there are ways to address them and their impact. Talk with a doctor about how it affects behavior and life, and work with loved ones to figure out ways to minimize its impact and hopefully create better sleep patterns.

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