Sleep Disturbance

Preventing and managing sleep disturbance

The following scenario describes the recommended approach and responses to preventing and managing sleep disturbance. Below the flow chart you will find specific strategies to manage sleep disturbance.


 

Sleep Distrubance flow chart

Sleep disturbance is a common complaint in older people. The major factors contributing to sleep disorders in both normal ageing and dementia may be one or a combination of:

  • ‘Normal’ physiological changes associated with ageing;
  • Physical or mental health disorders;
  • Unhealthy sleep hygiene

Attempt to follow the person’s previously established preparing to sleep routine, e.g. did they always have a glass of warm milk before bed?

Identify the A (activating) factor by assessing whether the sleep disturbance is related to the following:

C = Consequence B = Behaviour A = Activating Event

Environment

Changes to the environment

Staff changes, altering furniture/decor, changing rooms/usual environment, altering of routine etc. may adversely effect the sleep routine of the person with dementia.

Climate

Check whether the environment & bedding provide appropriate warmth & comfort.

Stimulation

The person with dementia does not sleep as deeply and may have disrupted sleep due to excessive noise/stimulation both internal & external to the building.

Restraint

Is restraint being applied? If yes, see Alternatives to Restraint before proceeding.

Aesthetic

Are there enough cues and light to orientate the resident or do they wander into someone’s room through disorientation/confusion. Are they able to find the toilet?

Physical health, trauma or primary sleep disorder

Primary sleep disorder

Sleep apnoea, periodic limb movement disorder, or restless leg syndrome may be contributing factors in disturbed sleep.

Metabolic

Are they hungry? Be aware of the nutritional needs of people with physical illness such as diabetes.

Infection

Has the behaviour had recent sudden onset? Eg urinary tract infection causes constant pressure to urinate? Delirium is a common cause of restlessness. (please refer to the Confusion Assessment Method [CAM]).

Pain

May be caused through acute or chronic illnesses. Pain may be caused through trauma that has not been identified due to the person's inability to communicate. Is there a history of falls? If the person has chronic pain, are they receiving adequate analgesia? Consider such conditions as shingles, neuralgia etc.

Medication

Consider whether insomnia is due to medication. e.g. may be causing ‘restless’ legs or cramps. The person may awake as diuretics result in need to urinate.

Impaction &/or dehydration

Constipation and /or dehydration can seriously impact on the behaviour of elderly people and on their ability to sleep.

Cognitive impairment

A person with dementia has a reduced need for sleep. Although not everyone with dementia will suffer from sleep disturbance a significant number will experience disruption to the normal day/night sleep cycle.

Psychological and mental health

Mental illness

Does the client have a previous history of psychiatric illness? Insomnia or early morning wakening may be symptoms of illness such as depression, anxiety or psychosis.

Recent loss

Grief/bereavement, loss of independence, may all add to a persons anxiety, depression etc.

Past life events

Sleep disturbance may be related to a memory of a significant life event being triggered. e.g. an item on the TV, or significant anniversary may trigger the memory and emotions of a traumatic event such as bereavement, bushfire or war experiences or abuse (physical/financial/sexual). Refer to a GP if sleep disturbance is associated with any of the above.

Specific management strategies to develop a healthy sleep regime

Whose problem is it? Why is it a problem? Rule out staff culture and regimented routine as a causative factor. Remember that older people and especially people with dementia have a reduced need for sleep and may not be upset by their fragmented sleep.

Interventions to encourage sleep must aim to have a positive effect for the person with dementia, rather than aim to make caring for the person less difficult.

Promoting sleep
  • Review whether the person’s previous bedtime rituals are being followed.
  • Avoid over-stimulation prior to bed-time eg high caffeine intake, situations that provoke anxiety and /or catastrophic reactions.
  • Encourage the person to participate in light physical activity throughout the day.
  • Ensure comfortable positioning and adequate pain relief (especially if the person is unable to communicate pain or discomfort).
  • Assess for psychiatric disorders eg depression, anxiety, agitation or psychosis and refer for appropriate treatment.
  • Ensure the bedroom is quiet, reassuring and relaxing.
  • Close your eyes and identify the sounds (creaking doors, wheelie frames or buzzers can all add up to an overstimulated environment).
  • How ‘busy’ is the environment? e.g. bright colours, patterns, too much clutter.
  • Provide adequate lighting to reduce confusion & disorientation:
  • Ensure the doorway to the toilet is well lit and easy to access or provide a commode /hand held urinal next to the bed.
  • Toilet before the person goes to bed.
  • Continue the bedtime rituals from the past e.g.: If the person is used to having a midnight snack, provide them with a snack before they go to bed. A person who has spent most of their life working night shift may have a reversed sleep pattern.
  • Avoid laying out clothes the day before. Having tomorrow's clothing laid out the evening before, may send a message to wake up and get dressed.
  • Dress in appropriate attire - Dressing someone in the pyjamas sends a non verbal message to go to bed or sleep.

Note: Do not use cot rails or restraint to try and confine the person to bed.

Managing disrupted sleep
  • Check for signs of infection. Does the client/ resident have a history of infection eg urinary tract infection, chest infection. Check temperature, pulse & blood pressure .
  • If symptoms have a sudden onset, assess for delirium.
  • Identify what woke them. Check above causes and strategies. Attempt to remedy cause eg turn down the radio, offer pain relief, add an extra blanket for warmth, is the bed comfortable?
  • Most people only need six-eight hours sleep with the amount of sleep needed normally decreasing with age. People with dementia need even less. Allow the person to sit up later to avoid early morning wakening. Avoid day time napping by increasing activity or stimulation. Light activity through the day will help stimulate healthy sleep.
  • If emotionally upset (crying, anxious, fearful), assess for depression. Communicate with them in an uncomplicated way to validate their feelings and gently reassure. Use touch and massage if appropriate and allow settling with a warm drink and some company. Encourage returning to their room after they have settled or stay in their room with them until they feel comfortable. Ask whether they would like the door open/shut or the light on. Medication should only be used as a last resort!
  • Check how much sleep the person has actually had. Attempting to persuade the person to remain in bed if they have already had enough sleep may trigger resistance, frustration and even a catastrophic reaction. Are they restless and agitated due to fatigue? Consider short rest periods through the day.
  • Allow the person to sit or wander quietly in the lounge room or other safe area (including their own room). Offer them a warm drink such as Milo and a light snack. If they show signs of drowsiness, encourage them to return to bed, but do not try to force them to do so. If they do not wish to return to their room allow them to sit in a comfortable armchair or lay on the couch.
  • Review medication especially side effects and timing of medication.
  • Is medication appropriate? eg Are diuretics causing sleep disruption due to need to pass urine?
  • Giving of antipsychotics may induce feeling of restlessness.
  • Most night time sedatives are only effective in the short term. Reduce the possibility of sleep apnoea by reviewing night time sedation and encouraging weight loss to reduce obesity.
Managing sleep disturbance in the community

Sleep disruption is one of the behaviours that leads to carer stress and burnout and is likely to lead to the person with dementia being placed in residential care. Follow the strategies above to minimise the risk of sleep disruption. The following strategies may also be of use.

Make the house or an area of the house safe for the person to wander in at night by:

  • Providing a gate at the top and bottom of stairs.
  • Installing alarms for external doors.
  • Locking away dangerous implements.
  • Turning off the gas at night.
  • Locking windows.
  • Provide regular daytime /night time carer respite so the carer can catch up on sleep.

References and recommended reading

Alzheimer's Association Australia (2000). Help Sheets for people with dementia and their families and carers. Alzheimer's Association Australia. [available online] http://www.alzheimers.org.au.

Lees, C. Hecht, H. & Hall, K. (1998). Behaviour & Dementia: A practical guide for health workers & families who care for people with behavioural disturbances in the setting of dementia. The Caulfield Behaviour Support Team. An Initiative of the Australian Commonwealth Psychogeriatric Unit Project.

Lovestone, S. & Gauthier, S. (2001). Management of Dementia. Martin Dunitz Ltd, London.

McCurry S.M. Logsdon, R.G. Teri, L. Gibbons, L.E. Kukall, W.A. Bowen, M.D. McCormick, W.C. & Larson, E.B. (1999). Characteristics of sleep disturbance in community-dwelling Alzheimer's disease patients. Journal of Geriatric Psychiatry & Neurology. Vol. 12:No.2., pp.53-59.

Vitiello, M.V. & Borson, S. (2001). Sleep disturbances in patients with Alzheimer's disease: epidemiology, pathophysiology and treatment. CNS Drugs. Vol.15:No.10., pp.777-796.

Satlin, A. (1994). Sleep disorders in dementia. Psychiatric Annals, Vol.24:No.4., pp.186-191.