any advice for sleeplessness with ALZ patient

[heynow1313]

My friend's mom is in the moderate phase of ALZ, progressing slowly but steadily. For the past few months, she has been exhibiting clear signs of sleep disturbances. Not so much in the way of hallucinations, wandering, sleep talking, or night terrors, but rather sleeplessness, restlessness, and general lack of sleep. She's averaging probably3-4 hours of rest a night. She lives at home and there are night vision cameras in her room so that her daughters can see exactly what her night is like. Eyes wide open half the night. Lots of movement of limbs.

She knows this stage is here. They've entered into new territory and have asked my advice as to non-pharm ways to manage.

Any and all recommendations, advice, thoughts are so appreciated. Thanks in advance.

[tpnurse95]

Limit caffiene several hours before bed, including coffee, chocolate, tea, and medications containing caffiene. Provide a snack that has had cheese or milk before bed time, they contain L-tryptophan which helps to induce and maintain sleep. Ensure the environment is dark and quiet. Sometimes to much silence can cause restlessness, a fan or soft music can sometimes break this silence without adding to much extra stimulation. This is called "white noise." Allow downtime in the evening before bedtime to allow time to wind down. Activities like sowing, knitting, or reading can relax the mind. Some studies show stimulation from a tv or computer can cause difficulty falling asleep, however if this is part of her regular sleep routine it may not be the cause of her insomnia. Administer medications that can interrupt sleep in the early day rather then at night such as steroids and diuretics.

[CrunchRN, ADN, RN]

Sounds like sundowning. There are some good meds for that.

[heynow1313]

thanks for the responses so far. Of course the family is trying to avoid medication at all costs. While sundowning is likely occurring- my friend said they are pretty good at redirecting her and the main issue is her inability to sleep.

tpnurse95- thank you for all your suggestions. almost everything you've discussed they've already tried or is a non-issue in the first place. The patient lives at home so they are really able to cater the sleep environment to her. She has had so many poor night's sleep in a row; yet, she remains awake the majority of the night.

I'm trying to do research on the issue and want to know how I can best explain to the family why this is happening. Of course, I know some of the differences between the normal population and those with dementia in terms of sleep/wake cycle, circadian rhythm disturbances, etc... and was wondering you you all- who work closely in the geri population- can offer me any more in the way of explanation or research on the matter. Do you think medication is inevitable if the sleep continues to be so compromised?

Thank you.

[CoffeeRTC, BSN, RN]

We've been using melatonin a lot more and it seems to help. You might have to up the dosage on it though. We really try to stay away from the other sleep meds and find that they don't always work but cause a lot of other issues. How about aroma therapy like Lavendar? Sounds silly, but what about a warm bath or shower? Has he been assessed for pain? Even minor aches can keep someone up. Tylenol has been effective for some.

Realizing that what works today or this week, might not work next week.

[heynow1313]

Yes- the doctor did recommend melatonin. He also recommended seroquel. What I did not mention in the post was that in addition to the insomnia, she is masturbating almost all night. Aggressive, agitated and threatening with the caregivers. Her daughter is now weighing the risks and benefits. it also is not silly about hte baths, lavender. I believe in the power of holistic and natural remedies. For this individual and the intensity of what she's experiencing- I doubt they will be enough. Have you guys had experience with Seroquel?

[ktwlpn, LPN]

While I understand the holistic approach I know a geri-psych consult is invaluable at this stage.I see two issues here.First is her sleep pattern.What is the impact on her and the family from this? Is their rest interrupted as well? This and incontinence seem to be the common triggers that lead to LTC.The body's clock is disrupted by the damage the disease causes the brain.We just go with it-we make sure the resident gets meals and plenty of liquids while they are awake. awake.The masturbating and aggressive behaviors need to be addressed and can be treated.There are no risks,the disease is terminal and the goal should be comfort right now....It is also important for the family to accept they can not control this,they need to consult with experts.

[jdub6]

Yes- the doctor did recommend melatonin. He also recommended seroquel. What I did not mention in the post was that in addition to the insomnia, she is masturbating almost all night. Aggressive, agitated and threatening with the caregivers. Her daughter is now weighing the risks and benefits. it also is not silly about hte baths, lavender. I believe in the power of holistic and natural remedies. For this individual and the intensity of what she's experiencing- I doubt they will be enough. Have you guys had experience with Seroquel?

Just a note, these behaviors can be signs of frontal lobe dementia rather than alzheimers. As someone else said geriatric psych or even just a good geriatric internist can help both diagnose accurately and give treatment specific to this condition.

I think you are absolutely on the right track with trying sleep hygiene first, then something like melatonin. (And kudos to the family for their dedication to keeping her home and comfortable). There does come a point where dementia is terminal and in the end stage they may need to use whatever they can to keep her safe and calm, but before that it can be very tricky as things like seroquel can help some but cause horrible side effects in others. (I would try this as a last resort only...if she is just awake but safe and comfortable I would personally stay away from seroquel and the like, but if the aggression is causing major issues they may need to use it. )

In my experience there is no one answer for all pts. I think you are on the right track with starting mild and escalating if need be. If they do start meds this population needs to "start low and go slow" to monitor for side effects. If this is not a safe option and her behaviors rapidly escalate to totally unsafe and redirection stops working you may want to look into geriatric inpatient psych units for aggressive med titration and monitoring.

[heynow1313]

jdub6- yes! I was already thinking along the lines of frontal lobe and was wondering the family is using the term "alzheimers" as sort of a catch-all because it's more familiar. And I am recommending a geri-psych consult. Do you all have experience using melatonin for this population? And if so, dosage recs?

Thank you so much for your encouragement that we are on the right track. This is a miserable, unfair disease. I appreciate all of the responses I've received. Truly.