By Alyssa Parks
NYU Steinhardt
Department of Occupational Therapy
Professional MS, Class of 2022

Research has demonstrated that sleep quality tends to decline as we age. In fact, somewhere between 40-70% of older adults suffer from insomnia. This is especially problematic as insufficient sleep has been correlated with a decrease in quality of life. Furthermore, older adults with dementia are at an increased risk of chronic insufficient sleep due to a combination of typical age-related changes as well as disease-specific issues like nighttime wandering, daytime sleepiness, incontinence, and hallucinations. 

Caregivers for these patients are negatively impacted in tandem, becoming sleep deprived themselves, thus increasing caregiver burden. The consequences of this cycle of insomnia often include increased physical and psychological distress for the caregiver and institutionalization for the patient. 

While there are pharmacological methods to treat sleep disturbance, like benzodiazepines and supplements like melatonin, these options pose their own issues such as sedation, increased risk for falls, and exacerbations in cognitive impairment. However, non-pharmacological interventions which involve altering the habits, behaviors, and environments of the patient with dementia can be an effective alternative. 

These types of interventions are also known as sleep hygiene. As experts in implementing environmental and task-based modifications, there is no better or more relevant health professional to address these issues than occupational therapists. 

Detecting Sleep Disturbances in Patients with Dementia

Before diving into sleep hygiene-based solutions, it is important to be able to recognize the signs of sleep disturbances in dementia patients. Since the nature of the disease impacts memory, the patient’s report on their quality of sleep may or may not be reliable depending on what stage of dementia they are in. 

If they are in the mid-late stages, there are a few indicators that can be observed within a therapy session. These indicators might include: 

• Excessive sleepiness 
• Disorientation
• Increased agitation 
• Aggression 

You may also observe a low level of arousal and have considerable difficulty engaging the patient in any kind of activity. Although these behaviors may suggest that the patient is experiencing sleep disturbances at night, it is not enough to come to a definitive conclusion. Therefore, the next best step is consulting with the caregiver. 

The patient’s caregiver is an invaluable source of information because they spend the most time with the patient. Moreover, we can expect their sleep-wake cycles to be closely intertwined as any nightly disturbances will fall upon the caregiver to manage. They will be able to provide the most accurate information about the patient’s typical bedtime and an approximation of how much time is spent asleep. Most pertinently, the caregiver can report exactly what sleep disturbances the patient experiences and the strategies that are being employed to manage them. 

6 Sleep Hygiene Principles for Patients with Dementia

To assist caregivers and improve sleep for your patients, consider these tips for improving sleep hygiene. 

1. Create a Bedtime Routine or Ritual

Patients with dementia benefit from repetition because it helps to orient them to person, time, and place. This can in turn help decrease agitation and aggression. Accordingly, one of the first lines of defense against sleep disturbances is creating and implementing a consistent bedtime routine. 

The patient should ideally go to sleep and wake up around the same time every day. Additionally, engaging the patient in a nightly ritual may help to signal that bedtime is near. This may look like brushing their teeth, taking nightly medications, or even listening to a relaxing song.

2. Modify the Sleep Environment

There are certain environmental factors that are not conducive to sleep such as excessive overhead lighting, loud noises (e.g. television), and room temperature. The sleep environment should be calming to the patient. Consider dimming or turning off the lights entirely, limiting noise, and adjusting the room temperature to a comfortable level (e.g. utilizing a fan/AC or heater).

3. Limit Daytime Napping

While naps are not inherently good or bad, their impact can differ based on the time of day, duration, and frequency. Generally speaking, daytime naps should be no longer than 30 minutes and they should not be taken past 1 pm. In addition, the patient should not nap more than 2-3 times daily. 

4. Daily Exercise

As we age, exercise is increasingly important in order to maintain good physical and mental health. In addition, daily physical activity has been associated with improved ability to fall asleep and overall sleep quality. By contrast, an excessively sedentary lifestyle can be harmful to the patient and potentially exacerbate sleep disruptions. For ambulatory older adults, something as simple as daily walks lasting at least thirty minutes can help induce sleepiness at night time. 

5. Lighting

Daytime light exposure has a greater impact on sleep than some may think. Exposure to blue light waves in particular, which we can get from the sun, helps to develop a healthy circadian rhythm. 

During the day when the sun is out, our level of melatonin (the hormone that induces sleepiness) is at its lowest and our arousal is high. However, at nighttime when the sun is down, our levels of melatonin increase which helps us to fall asleep. As such, it is beneficial to expose patients with dementia to natural light by spending time outdoors when possible in order to maintain a circadian rhythm that aligns well with the natural cycle of the sun.

6. Track Progress

Keep a daily/nightly sleep log or diary to track your patient’s progress. Record details such as bedtime and wake time, and take note of what works well for the patient and what does not. Over time, a pattern of behavioral responses to each intervention will become apparent. This can help to create a sleep profile containing all the strategies that have been successfully implemented and which can be readily used moving forward.

Caregiver’s Role vs. an OT’s Role in Sleep Hygiene

Occupational therapists work to maximize our patient’s independence and functional performance when doing the activities that are important to them throughout the day. Sleep is a fundamental factor that underlies our ability to do anything. That’s why it is viewed as an instrumental activity of daily living (IADL) within the OT practice framework. Since so many patients with dementia experience sleep disturbances, it is our responsibility to assess and develop interventions that can assist in mitigating it to increase our patients’ quality of life. 

Thus, the OT’s role is to work closely with the patient’s caregiver in a collaborative effort to develop feasible solutions to facilitate improvements in sleep quality. While caregivers are capable of implementing any of the aforementioned sleep hygiene interventions independently, research shows that they are more effective with consistent support. As such, spending one session, or providing them with a single visual about sleep hygiene, will not be sufficient. 

In order for our interventions to be most efficacious, we must address the topic of sleep over the course of multiple sessions. OTs should encourage the caregiver to record the results of their efforts and initiate discussions addressing any concerns that arise as well as develop solutions accordingly.

Patient-Centered is Best

Lastly, in order to effectively address sleep disturbances for patients with dementia, interventions must be patient-centered. While modifying the sleep environment by limiting background noise and cutting down on naps sounds like a good idea for some patients, it probably isn’t suitable for all. Some patients may even require sounds like white noise or soft music in order to fall asleep depending on their preferences. 

Although there is no definitive fix for insomnia and other sleep disturbances in dementia patients, sleep hygiene is an excellent place to start. Occupational therapists are uniquely positioned with their expertise in both sleep hygiene and caregiver education, to effectively improve sleep quality and overall quality of life for patients and caregivers alike.