LOUISVILLE, KY – Sleep disturbance is common among individuals with dementia – particularly in the institutional setting. But not everything that looks like sleep disturbance is a clinical problem requiring pharmacologic therapy, according to Elizabeth Hames, DO, and Juliet Holt Klinger. During a session entitled “Sleep Disturbance in Dementia: Strategies for Patient Improvement and Reduction of Caregiver Burden” presented at the AMDA Annual Conference, Dr. Hames provided a stepwise approach to sleep disorders. She recommended first assessing for a primary sleep disorder, then assessing for contributing medical co-morbidities, reviewing medications to identify those that might disturb sleep, assessing the environment and psychosocial factors, considering short-term pharmacological treatment if necessary, and incorporating long-term non-pharmacological strategies. The latter, which can include sleep hygiene, light therapy, sleep/wake scheduling, physical and social activity, and environmental modifications, is sometimes sufficient for addressing sleep-related issues, said Dr. Hames, assistant professor at Nova Southeastern University College of Osteopathic Medicine in Ft. Lauderdale, FL. First, however, it should be determined whether the issues truly represent a clinical problem. “I think the first thing we can do is rule out the ‘non-problems,’” according to Juliet Holt-Klinger, senior director of dementia care at Brookdale Senior Living Solutions, Chicago. A common “non-problem” has more to do with staffing issues than with sleep issues; residents are often directed to bed too early. “If you put somebody to bed at 7 p.m. and they wake up 8 hours later at 3 a.m., is that a disorder that requires medication, or is that our issue as providers?” she asked. A key question is whether the sleep-wake cycle is affecting the person negatively. “We need to be clear about what is a true problem and what is an unmet preference or historic habit,” she said, noting that some residents may simply be “night owls,” or may have formerly worked night shifts. “Sleep is a very intimate thing … we shouldn't be the ones to determine when people go to sleep,” she said. Rather, take a person-centered approach, focusing on the individual and working to understand the person and the personality behind the dementia. Gathering the details necessary to get to know the person may require interviews with family and former care partners of those who no longer may be able to recall or communicate details. Ask about more than just hours slept per night, Ms. Holt-Klinger advised. Ask about sleep history and habits, sleep difficulties over time, normal routines and rituals, and preferences regarding bedding, room temperature, and lighting, she said. Other factors that may contribute to sleep-related issues include walking or wandering, which could be associated with a perceived or unrealistic task or worry that the person feels they should attend to; roommate issues, such as snoring; and waking to urinate, which can be particularly problematic if assistance is required. An especially common cause of sleep-related issues is untreated pain, Ms. Holt-Klinger added. As for addressing the issues, start early in the day, she said, explaining that unresolved tensions of the day can create stress that interferes with sleep. Late-day agitation, or sundowning, may result from a lack of person-centered activities throughout the day, lack of a good structured routine, lack of adequate prompting and cueing throughout the day, and lack of a sense of belonging or a maintenance of relationships. Things that can help alleviate the stress and frustration include herbal tea, massage or soothing touch, a hot bath, warm milk, being read to, body pillows, time with pets, hot water bottles, lavender and essential oils for promoting relaxation, and ambient sound. Also, address the environment, and ensure that the cues point toward sleep: lower the lighting – and consider using amber spotlights above toilets to allow for safe toileting at night while reducing the intrusiveness of bright lights, and reduce activity and noise levels in hallways. “This is a time when staff should be very, very slowed down and very calm, using soft voices and touch,” she added. Non-pharmacological interventions should be integrated into the plan of care. Pharmacologic treatment should be evaluated regularly; when non-pharmacologic methods are successful, consider reducing or eliminating drugs, she said.
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Feb 1, 2018
Gian Carlo Parico + 2
Open Access
