Sleep: Managing Nighttime Awakenings and Wandering

Welcome to the educational program Managing Nighttime Awakenings and Wandering. This program will present discuss some reasons for nighttime awakenings and present some strategies for managing them. It will also provide strategies for preventing and managing wandering and for improving home safety for wandering.

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You may view the topics in order as presented, or click on any topic listed in the main menu to be taken to that section. We hope that you enjoy this program and find it useful in helping both yourself and those you care for.

There are no easy answers when it comes to the care of another, as every situation and person is different. In addition, every caregiver comes with different experiences, skills, and attitudes about caregiving. Our hope is to offer you useful information and guidelines for caring for someone with dementia, but these guidelines will need to be adjusted to suit your own individual needs.

Remember that your life experiences, your compassion, and your inventiveness will go a long way toward enabling you to provide quality care.

Let’s get started.

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Sleep Issues and Alzheimer’s Disease

Sleeping through the night can be difficult for people with Alzheimer’s disease and other dementias. As dementia progresses, affected individuals spend more of their nights awake and daytime hours sleeping. Although they spend more of their time sleeping, the sleep is often light and with frequent awakenings.

Many people wake up during the night to wander. They can wake up confused, disoriented, frightened, or feeling alone. They may also suffer from delusions and/or hallucinations that disrupt sleep patterns.

Poor sleep can seriously affect those with dementia, as it can contribute to agitated behavior, delirium, decline in thinking and functioning, falls and injuries, and increased mortality.

This program will provide a general understanding of some sleep issues and offer practical tips to help improve the quality and quantity of sleep for those with dementia and their caregivers.  

Case Study 1

Here is a scenario with Mary and her husband, Robert, who has moderate Alzheimer’s disease.
Why was Robert unable to get to the bathroom?
  • A. He forgot where the bathroom was.
  • B. He got hungry and wanted to go to the store to buy some food.
  • C. He couldn’t remember why he got up.
  • D. He wasn’t sleepy and got bored.
  • E. He was distracted by the shoes.

Answers:

Choice A (“He forgot where the bathroom was”) is a good answer.

It is possible for people with dementia to forgot where the bathroom is even as they get up to use it. To address this issue, leave a clear, well-lit path from the bed to the toilet by removing clutter and objects that might confuse or impede the person. Practice walking the path from the bed to the bathroom with the person before going to bed and consider putting up bathroom signs with arrows that point the way to the bathroom.

Choice B: “He got hungry and wanted to go to the store to buy some food” is a possibility.

Though Robert may have initially woke up to use the bathroom, he may have then realized that he was hungry and got distracted by his desire to find food. To address this issue, try giving the person a light snack before bedtime of sleep-promoting food. Examples include dairy products such as cheese and milk; soy products like tofu or soy milk, other beans and lentils; whole grains, rice and oats; and a variety of nuts and seeds, including peanuts, almonds and sunflower seeds. Proteins such as eggs, fish and poultry also help to promote sleep, as do some fruits and vegetables, including avocados, peaches, asparagus and bananas.

Choice C: “He couldn’t remember why he got up” is a possibility.

People with dementia can forget why they started doing something or what they were told to do. Try to reorient them to the time of day and remind them that it is time for sleeping.

Check to see if they need to use the toilet, or have some discomfort or pain, and if so, help them to address the issue. Also, try posting bathroom signs with arrows that point the way to the toilet. Seeing the signs may help people to remember that they need to use the bathroom.

Choice D: “He wasn’t sleepy and got bored” is a possibility.

It is not unusual for a person with dementia to get up during the night and not feel sleepy. If you cannot get someone to go back to sleep, try redirecting the person’s thoughts onto something relaxing. For example, try going into another room to enjoy a relaxing activity, or turn on some soothing music.

Consider allowing the person to wander in a dedicated, safe area for wandering. Safe wandering can actually provide some exercise and help relieve restlessness and boredom.

Choice E: “He hurt himself when he bumped into the furniture and got distracted” is a good answer.

The discomfort from bumping into the furniture may have refocused his attention to sitting down and attending to his pain. When Robert sat down and saw his shoes and jacket, he may have thought that it was time to get dressed and ready for the day.

To prevent injuries during the night, try to create a safe environment for the person by removing clutter and objects that might pose danger. Remove area rugs and other tripping hazards if possible. Try to keep hallways and pathways from room to room as clear as possible. If individuals wake up at night or wander, leave enough light on for them to see what they are doing.

Mary’s Approach to Managing Robert’s Wandering

The next day, Mary decides to make some changes in the house. To decrease any stress Robert might feel due to the changes, Mary makes sure that his favorite comfort items are in view in his new surroundings. This includes Robert’s favorite blanket, pillows, and pajamas.

Mary also installs some nightlights to help light the path to the bathroom. She moves the bed to the corner, away from the windows so that headlights from passing cars and outside noises do not disturb Robert. She removes unnecessary furniture from the bedroom, including the television and its stand, so that it is easier and safer to move about the room. By removing the television, Mary and Robert are not tempted to watch TV in bed.

The bedroom is now a dedicated place for sleeping and napping. Mary followed the caregiver tips to create a better sleeping environment for Robert and to decrease the risk of wandering.

Case Study 2

Many people with Alzheimer’s disease wake up during the night feeling confused, disoriented, or frightened. They may suffer from delusions and/or hallucinations that disrupt sleep patterns.   

Here is a scenario with Mary and her husband, Robert, who wakes up distressed.

This case study demonstrates a few ways to approach distressed individuals when they wake up at night. Here is a list of tips that includes some of the approaches we observed as well as other tips for managing nighttime awakenings.

First, assess whether the person is confused or experiencing discomfort of any kind.

If the individual wakes up frightened or confused, use a soft, calming tone of voice and body language to orient and reassure them of the safe and familiar surroundings. Reassure the person that everyone and everything is okay.

Try to address any need or source of discomfort before the person goes to bed or falls back to sleep after awakening. See if the person is in pain and in need of some pain medication? Maybe the person is hungry and in need of a snack or drink of water? Maybe the person needs to use the bathroom, or has soiled the bed? You can ask if the temperature is okay, or if their clothing is uncomfortable.

Managing Nighttime Awakenings

If the individual becomes combative, remain calm and try to figure out from the person’s verbal and non-verbal message the reason for the behavior. It is important to not argue. Do not persist in trying to reason with the person as it will likely fail. Instead, offer reassurance.

If the person is frightened, offer to look around to make sure that everything is okay. Once the person has relaxed and taken care of any needs, approach the topic of going back to bed.

If you cannot get someone to go back to sleep, consider taking a break from the subject. Divert the conversation elsewhere or use a distraction such as taking a walk, singing or listening to music, reading, or eating a snack. For example, try taking the person to another room to enjoy a relaxing activity or get a snack.

Lastly, consider consulting a physician if sleep patterns do not improve. A physician can prescribe medication to promote sleep. At the same time, a physician can check for medical issues that can disrupt sleep. For example, prostate problems can cause frequent urination and physical discomfort during the night.

Managing Nighttime Incontinence and Toileting

Incontinence and frequent trips to the toilet can result in sleep loss for both the caregiver and care recipient, as people in the middle and later stages of Alzheimer’s disease have increasing difficulty controlling their bodily functions, including urinating and bowel movements. They are less aware of the urge to relieve themselves or may not associate the urge with getting to the bathroom.

Incontinence and frequent trips to the toilet can be particularly problematic at night when the person is sleeping or trying to fall asleep, resulting in sleep loss for both the caregiver and care recipient.

Here are some tips for managing nighttime toileting and incontinence.

These include planning scheduled trips to the bathroom during the day and limiting fluid intake before bed. Before going to bed, you should encourage the person to use the bathroom. This is also a good time to practice walking the path from the bed to the bathroom with the person and to make sure that the path to the bathroom is well lit and unobstructed. A nightlight should be left on in the bathroom at all times, along with a “bathroom” sign on the door. You may also need to consider a bedside urinal or commode if the person has difficulty getting to the bathroom.

Make sure clothing is easy to take off without too many buttons, zippers, or belts.

And never let someone remain in wet or soiled clothing or diaper.

Increasing Nighttime Home Safety

The caregiver may not always be awakened when the person with dementia wakes up. So the caregiver should take precautions to make sure that the home is as safe as possible for those who wander alone at night.

Here are some strategies for improving nighttime home safety for wandering.

First, keep areas all areas free of clutter, especially around the bed. Make sure that there is enough light in the room for the person to see what they are doing and that the path to the toilet is clear. To safeguard against falls, put up hand railings on walls, and remove area rugs.

Second, dedicate a space that is safe for wandering. This means keeping hazardous chemicals and cleaners locked away. One option in the later stages of Alzheimer’s is to use childproof locks on cabinets.

To discourage someone from exiting the home during nighttime wandering, use door locks, latches, or bolts that require keys, and put soft safety covers over doorknobs. Use these devices only when a caregiver is at home in case of a fire or other emergency. Install window locks so windows open only slightly. Place door alarms, motion sensors, or bells on doors to alert the caregiver when a door is opened.

People with dementia are also prone to heeding visual cues that signal leaving, so do not leave shoes, keys, briefcases, or umbrellas by the door. You can also post door signs that say stop, do not enter, do not open, or closed. Such signs can be enough to remind the person that those doors are off limits.

Strategies for Preventing Wandering

There are several strategies caregivers can try to reduce the risk of wandering.

First, try to determine the reason for wandering. Wandering may be an attempt to get something such as food, drink, security, physical activity, or something familiar or lost. The person may need to use the toilet or may feel restless.

Ask the person often what they want to find or do because those with dementia usually wander for a reason. Make frequent checks during the day to see if they have any unmet needs and try to address them before they start wandering. Offer drinks and snacks throughout the day and ask about toileting needs. The elderly often become cold even in warm environments, so see if the person wants a sweater or blanket.

Try to identify possible sources of stress that may be triggering the wandering. For example, the room may be too noisy, too cold, or too hot. The person may be upset about something that happened during the day or something that was on the TV or news. The person may be seeking safety from a hallucination, delusion, or nightmare.

Try changing daily routines that may be triggering the wandering. Sometimes people with dementia establish a ritual that triggers wandering. Changing the preceding ritual may prevent the wandering. For example, if a person wanders after eating dinner, try changing the dinner ritual. Have the person sit in a different chair during dinner. Change the person’s shoes after dinner. Get the person started on a relaxing activity immediately after dinner.

Lastly, if the individual is taking medications, consult a physician about the possibility that a medication may be causing restlessness. Discuss the possibility of changing the medication regimen to decrease the risk of wandering.

Tips for Managing Wandering

There are several steps caregivers can take in order to manage wandering, including making the home safer.

First, dedicate areas that are safe for wandering and exercise. Make sure the areas are clear of stairwells, clutter, sharp or fragile objects, chemicals, obstacles on the floor, and other hazards.

If the person likes to rummage, provide a drawer or chest for rummaging in this safe area.

Make sure that the person has comfortable, secure shoes and regularly check their feet for any blisters, sores, or toenail problems.

Watch closely to ensure the person’s safety as well as the safety of others and to monitor where they wander. If the person tries to wander into an area that you want to remain off-limits, cue them away from that area.

Place childproof doorknob covers, locks that require keys on both sides, or door alarms on doors that you do not want the person to open easily or without being detected.

Provide individuals with a medical bracelet or necklace and place their name, medical conditions and important phone numbers in a wallet or purse. You can also have the same information sewn into or written on their clothing.

If the person is missing, first check the immediate surroundings. Look in closets, the basement, and the garage. Check unusual places as well, such as crawl spaces, mechanical rooms, and the attic if accessible.

If the person wanders away from home, notify the police and let them know that the missing person has dementia and will likely be confused and disoriented. Have pictures of the person along with an accurate description of physical features and clothing.

Another option to consider is placing a locator on the person, such as a GPS (Global Positioning System), RFID (Radio Frequency Identification) or Cellular locator. These come in many forms, such as wristbands, ankle bracelets, and hand-held devices. Some of these devices require monthly fees. There are also wanderer alert systems, which set off an alarm if a person wearing the transmitter wanders more than a set distance from the base unit.

Lastly, consider enrolling the individual in the Alzheimer’s Associations Safe Return Program or a similar program that helps find people with dementia who have wandered.

Click here to learn about the Safe Return® program.

Summary

In summary, dementia can cause more nighttime awakenings, less deep and restful sleep, more light sleep, and more daytime napping, especially in the later stages of the illness.

Strategies for managing nighttime awakenings include reminding the individuals about where they are and what time it is, and reassuring rather than correcting or arguing with them. Trying to find out the reason for the awakening and addressing any issues. Trying to prevent the triggers before the wandering occurs. Distracting the person with a new topic, taking a walk, playing music, reading, or providing a snack. Finally, consulting a physician if the sleep pattern does not improve.

Strategies for managing wandering include addressing any possible reasons or triggers before wandering occurs. This includes removing any sources of stress and changing any routines that may be leading to wandering. It is important to dedicate safe areas for wandering that are free of clutter and hazards, and have good lighting. Modifications should be made in the home to increase safety, such as removing hazardous objects and chemicals, and placing childproof doorknob covers, locks, and door alarms. If the person tends to wander, place a medical bracelet or necklace along with important information and numbers on the person. Consider using a wanderer alert system or locator system.

Finally, if the person is missing, check the surroundings first, then notify the police and any programs that help search for wandering persons, such as the Alzheimer’s Association’s Safe Return program.

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→ Next Lesson (Sleep: Managing Hallucinations, Illusions, Delusions, Nightmares, Sundowning, Anxiety, and Depression)

 

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Written by: Jennifer Kretzschmar, PhD (University of Texas Health Science Center San Antonio), and Sharon Lewis, PhD, RN, FAAN (University of Texas Health Science Center San Antonio)

Edited by: Mindy J. Kim-Miller, MD, PhD (University of Chicago School of Medicine)

 

References:

  • Aggarwal, N., et al., People with dementia and their relatives: personal experiences of Alzheimer’s and of the provision of care. Journal of Psychiatric andMental Health Nursing, 2003. 10: p. 187-197.
  • Allen, R., Should we aggressively evaluate and treat sleepiness in the elderly? Sleep Medicine, 2003. 4: p. 477-478.
  • Asada, T., et al., Associations between retrospectively recalled napping behavior and later development of Alzheimer’s disa. Sleep, 2000. 23(5): p. 1-6.
  • Coste Koenig, J., Learning to speak Alzheimer’s: a groundbreaking approach for everyone dealing with the disease. 2003, Boston, New York: HoughtonMifflin Company. 240.
  • Ellgring, J., Depression, psychosis, and dementia: Impact on the family. Neurology, 1999. 52(7): p. S17-S20.
  • Farlow, M., Pharmacokinetic profiles of current therapies for Alzheimer’s disease: Implications for Switching to Galantamine. Clinical Therapeutics, 2001.23(Suppl A): p. A13-A24.
  • Fatigue: When to rest, when to worry. (2006 August 16). Mayoclinic.Com. Retrieved on March 30, 2008 from http://premium.europe.cnn.com/HEALTH/library/HQ/00673.html.
  • Ficca, G. and P. Salzarulo, What in sleep is for memory? Sleep Medicine, 2004. 5: p. 225-230.
  • Gais, S. and J. Born, Low acetylcholine during slow-wave sleep is critical for declarative memory consolidation. PNAS, 2004. 101(7): p. 2140-2144.
  • Gordon, A., Insight into auditory hallucinations and psychosis. International Journal of Geriatric Psychiatry, 1997. 12: p. 410-411.
  • Gruetzner, H., Alzheimer’s: A Caregiver’s Guide and Sourcebook. Vol. Updated and Revised. 1992, New York, Chichester, Brisbane, Toronto, Singapore:John Wiley and Sons, Inc. 308.
  • Hallucinations. 2004, Alzheimer’s Association. Retrieved on March 30, 2009 from http://www.alz.org/national/documents/topicsheet_hallucinations.pdf.
  • Harding, A., G. Broe, and G. Halliday, Visual hallucinations in lewy body disease relate to lewy bodies in the temporal lobe. Brain, 2002. 125: p. 391-403.
  • Haythornthwaite, J., M. Hegel, and R. Kerns, Development of a sleep diary for chronic pain patients. Journal of Pain and Symptom Management, 1991. 6(2):p. 65-72.
  • Hyyppa, M. and E. Kronholm, Quality of sleep and chronic illnesses. Journal of Clinical Epidemiology, 1989. 42(7): p. 633-638.
  • Lamberg, L., Illness, not age itself, most often the trigger of sleep problems in older adults. JAMA, 2003. 290(3): p. 319-323.
  • Lewis, S., Stress Relief for Caregivers. 2003, University of Texas Health Science Center at San Antonio.
  • Luboshitzky, R., et al., Actigraphic sleep-wake patterns and urinary 6-sulfatoxymelatonin excertion in patients with Alzheimer’s disease. ChronobiologyInternational, 2001. 18(3): p. 513-524.
  • Luxenberg, J., Clinical Issues in the Behavioural and Psychological Symptoms of Dementia. International Journal of Geriatric Psychiatry, 2000. 15: p. S5-S8.
  • Martin, J., et al., Circadian rhythms of agitation in institutionalized patients with alzheimer’s disease. Chronobiology International, 2000. 17(3): p. 405-418.
  • Mayo, W., et al., Individual differences in cognitive aging: implication of pregnenolone sulfate. Progress in Neurobiology, 2003. 71: p. 43-48.
  • McCurry, S., et al., Training Caregivers to Change the Sleep Hygiene Practices of Patients with Dementia: The NITE-AD Project. JAGS, 2003. 51(10): p.1455-1460.
  • McCurry, S., et al., Treatment of sleep and nighttime disturbances in Alzheimer’s disease: a behavior management approach. Sleep Medicine, 2004. 5: p.373-377.
  • Menefee, L., et al., Self-reported sleep quality and quality of life for individuals with chronic pain conditions. Clinical Journal of Pain, 2000. 16(4): p. 290-297.
  • Mittelman, M.S., C. Epstein, and A. Pierzchala, Counseling the Alzheimer’s Caregiver: A Resource for Health Care Professionals. 2003: American Medical Association – AMA Press. 346.
  • Morin, C., D. Gibson, and J. Wade, Self-Reported Sleep and Mood Disturbances in Chronic Pain Patients. Clinical Journal of Pain, 1998. 14(4): p. 311-314.
  • Murgatroyd, C. and R. Prettyman, An Investigation of visual hallucinosis and visual sensory status in dementia. International Journal of Geriatric Psychiatry,2001. 16: p. 709-713.
  • Neubauer DN. Sleep problems in the elderly. Amer Acad Family Phys. 1999. 59(9): 2551.
  • Philips, B. and S. Ancoli-Israel, Sleep disorders in the elderly. Sleep Medicine, 2001. 2: p. 99-114.
  • Rabow, M.W., J.M. Hauser, and J. Adams, Supporting family caregivers at the end of life. JAMA, 2004. 294(4): p. 483-491.
  • Roth, T., J. Costa e Silva, and M. Chase, Sleep and cognitive (memory) function: research and clinical prespectives. Sleep Medicine, 2001. 2: p. 379-387.
  • Roth, T., et al., The Art of Good Sleep. Sleep Medicine, 2004. 5(Suppl 1): p. S1.
  • Sleep and seniors: Insomnia isn’t inevitable. 2004 July 6, Mayo Clinic Staff.
  • Sleep Changes in Alzheimer’s Disease Fact Sheet. 2004, Alzheimer’s Association. p. 1-3.
  • Sleep: Your body’s means of rejuvenation. 2004, Mayo Clinic.
  • Soeda, S., et al., Aging and visual halluncinations in elderly psychiartic outpatients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2004.28: p. 401-404.
  • Strine, T. and D. Chapman, Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Medicine, 2005. 6: p.23-27.
  • Stroke, O.O.C.A.P.L.N.I.O.N.D.A., Brain Basics: Understanding Sleep. October 8, 2004, National Institutes of Health: Bethesda, MD.
  • Tappen, R.M., Interventions for Alzheimer’s Disease: A Caregiver’s Complete Reference. 1997, Baltimore: Health Professions Press, Inc. 239.
  • Tariot, P., Medical management of advanced dementia. JAGS, 2003. 51(5, Supplement): p. S305-S313.
  • Teri, L., R. Logsdon, and S. McCurry, Nonpharmacologic treatment of behavioral disturbances in dementia. Med Clin N AM, 2002. 86: p. 641-656.
  • Tractenberg, R., et al., The sleep disorders inventory: an instrument for studies of sleep disturbances in persons with Alzheimer’s disease. Journal of Sleep Research, 2003. 12: p. 331-337.
  • Tsuno, N., et al., Fluctuations of source locations of eeg activity during transition from alertness to sleep in Alzheimer’s disease and vascular dementia.Neuropsychobiology, 2004. 50: p. 267-272.
  • Van Someren, E., Circadian rhythms and sleep in human aging. Chronobiology International, 2000. 17(3): p. 233-243.
  • Vgontzas, A. and A. Kales, Sleep and its disorders. Annu Rev Med, 1999. 50: p. 387-400.
  • Volicer, L., et al., Sundowning and circadian rhythms in Alzheimer’s disease. Am J Psychiatry, 2001. 158(5): p. 704-711.
  • Yehuda, S., S. Rabinovitz, and D. Mostofsky, Essential fatty acids and sleep: mini-review and hypothesis. Medical Hypotheses, 1998. 50: p. 139-145.
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