Managing Sleep & Sundowning in Dementia Care

name is jamie if you're not aware i am the vice president of education here at the janesville west center in the james west center we are a long-term care community that serves purses and persons impacted by dementia and we do this in a variety of services one is our long-term care community we are able to serve 100 residents here in our building we have one building here located close to downtown fort worth so as we have those residents that live with us obviously we serve them and their families and friends that surround those loved ones we do have respite care that we can do a short term stay as well depending on availability and we also have a day program our day program has been around just as long as the west center has a little bit longer we're going to celebrate our 30th year next year our day program unfortunately did close because of covid but we are actively and working very hard to get that open again we're actually able to purchase a different building close to southwest fort worth to open that day program and really be able to serve more participants it's a larger building so we can serve more participants that come during the day if you want to learn more about the day program and kind of the progress we're at we can get you on an email list where we're sending updates on what the progress is applications all the details about around around the day program and i'm happy to share that information and make sure you get on that email list if you're interested just let us know because we want to make sure that you're getting all the resources that you need of course we also do our education that y'all are taking advantage of today we are proud to be celebrating our 10th year in education myself and holly glover you may know we are our education department here at the james l west center and we offer over a hundred different programs and support groups i would say we probably average about two to three programs and and support groups every week so we like to consider ourselves partners in care for families and professionals that are serving somebody impacted with dementia whether through its actual education and skill building but also the supportive services that we can offer and again you'll get more information on that i'm going to share my screen with everybody you'll get the slides this afternoon but i want to dive into this information about sleep disturbances and sun downing this is a topic that is it's needed because it's a um they're both i guess quote unquote behaviors that persons with dementia um commonly exhibit both of these really play into each other we're going to learn more about that um but in how really disruptive they can be so we are going to talk about identifying common symptoms what causes this what what does it look like when somebody has sundowning or any sleep disturbances but then really dive into how can i potentially prevent some of these behaviors um or how can i better manage them when they are presented and really on the person that living with dementia how can we better manage them and the symptoms and expressions they exhibit but also on the care partner side whether you're a professional or you are a family member how can i better manage myself to provide better care for that person living with dementia this is our course outline for the ce credits and the learning objectives i've just went over so knowing that sleep disturbances are very common um and it's it so the national library of medicine has suggested that about a quarter of persons living with dementia will experience a sleep disturbance at some point generally they happen in the mid stage of dementia and this is really any type of dementia so they're they're heavily present in persons that have alzheimer's disease type dementia lewy body type dementia which we'll kind of talk about separately parkinson's dementia vascular dementia frontotemporal we see these sleep disturbances in all of these and really for any in the mid stages of those is where we start to see them start to present or they're harder to manage or in the mid stages when somebody's having sleep disturbances however it also means that their primary care partner caregiver at the time is also probably having sleep disturbances as well um as their sleep is disrupted and they go hand in hand so sleep disturbances and sun down and go hand in hand because a sleep disturbance can be a cause of somebody potentially sun downing and sun downing can be a cause of somebody potentially having a sleep disturbance so that's why we put these two together and it's important to understand that as we're walking through this what's happening to the brain of somebody with dementia and why this might potentially be causing sleep disturbances and sun downing so we see here and those of you that have been on our programs before probably seen this illustration but you have the healthy brain our healthy brain is three pounds and somebody that's experiencing dementors in the later stages or as the brain the brain or the disease progresses the brain and the late stages or pass away from dementia will be one pound [Music] so we're going from three pounds to one pound and as that happens there's going to be a lot of changes that happen so there are permanent changes structural changes that happen and you can see the brain shrinks it becomes smaller um the ventricles enlarge the outside kind of the wrinkles you know the crevices in there they're going to enlarge as well and also as that happens chemical changes are going to happen too that gray matter and white matter another chemical how the brain wires and fires together it's going to change as all of these other changes happen and it is as the brain is losing or there's a degradation of or a loss of those neuronal pathways how those neurons talk to each other um like the brain controls everything so those neuronal pathways that are there that are being lost or starting to lose they really help maintain our sleep they can maintain our sleep wake cycle so that circadian rhythm or i've heard it called the pacemaker rhythm of our body that can change sleep changes can help us go to sleep what helps us go to sleep what helps us stay asleep is all going to change and be impacted as the changes of the brain are also occurring and again all these sleep disturbances are observed in persons with dementia so when we're talking about sleep disturbances really we're talking about sleep deprivation for the most part because if we have any type of disturbance there's going to be a deprivation in the sleep the amount of sleep that we get and it can be quality sleep and quantity the quantity of sleep as well when that happens there are a lot of safety concerns that can happen for both the person living with dementia and the person with um a person taking care of them right you're going to see more confusion and really if you think about this if you think about you've ever been sleep deprived or not had some good sleep i yeah i can think about a time where i've been sleep deprived didn't have more confusion um i'm not as able to control my emotions and this is the same for somebody with dementia so you will see more agitation and more irritability maybe more um quick to anger right not able to think as well reason things out concentrate on activities or tasks that you're doing just doing things and more errors in judgment as well this comes into it's harder for us to make good choices and a lot of this has to do with the hormonal balances when we're sleep deprived or not and what hormones get turned on or turned off or they aren't working as well so it is hard for us to make good choices and um have that motivation to go exercise or to get up and go walk we're tempted more to eat food that's not so good for us i'm tempted more to eat more for one thing we don't have that feeling of fullness or hunger that's um being satisfied feeling there's also the craving for sugar that happens or salt you know those cravings that aren't quite as good for us will happen more often as we're sleep deprived [Music] our bodies when we have sleep depression are not able to fight off illnesses as well it really does cut the immune system in half really any type of sleep loss of sleep that we get so we can't fend off illnesses as well whether it's the cold or the flu or an infection of some sort and it can take us longer to get to recover from those illnesses too and then there's increases in depression and anxiety that come along with sleep deprivation our body can be inflamed all over depending on that and then what we really see of course with persons with dementia is there is an increase in severity or worsening of the dementia that they already have so typical disturbances you may see so what a sleep disturbances can look like is they may sleep too much and this can be up to 16 hours a day and again this is when there's a sleep disturbance this really it's a disturbance in the early stages and middle stages persons with dementia in the later stages of the disease will sleep more often and that's a natural progression of the disease and not necessarily something to be concerned about we have to think about where their brain is and all the changes that have happened to them in those late stages of dementia the brain needs more rest it can only handle so much so this is really more if you're sleeping too much in those early stages or middle stages of the disease or it can be the opposite and they're not sleeping enough at all maybe two to four hours a night and they're up the rest of the time they can have their days and nights reversed so they're sleeping during the day but awake at night they might wander during the night so they get up and they're wandering and they're hard to redirect to go back to bed or they're not aware that it's time it's still nighttime and they need to go back to bed it can't be because they get up to go to use the restroom but it's more than normal you know it's a different than their baseline or what they have been doing they may not want to go to bed or understand what time it is and that it is time to go to the bed the body is not giving them those cues and maybe their environment is not giving them those cues as well they may not want to put on their pajamas to go to sleep they may not want to go to the bed to go to sleep but they'll sleep somewhere else another thing you can see is experiencing nightmares or they have vivid dreaming that they may act out which would be different from some from something in their past or they can confuse any dreams that they may have with what's happening in reality or when they're awake and if they're diagnosed with a lewy body dementia those individuals with that particular diagnosis do have more sleep disturbances that we see early on which we'll talk more about here in a second so other causes that we can see and you know we saw the picture there's brain changes that are happening in somebody with dementia they can be again disoriented at the time and not aware how much time is passed during the day that it's evening time night time morning time that awareness of time and where we are in the day changes for somebody with dementia pretty early on again their days and nights can be confused if they're in the later stages as of the disease another cause of sleep disturbance is another illness that they may have and it can be a short-term illness or a chronic illness that they might have if it's rls or restless leg syndrome and that feels like there's like a crawling on their leg or there's bugs there's kind of a just a general restlessness or anxiety-ish in your legs and you can't stop that feeling that they have sleep apnea so they have the irregular breathing when they're asleep to where it's they may even completely stop breathing for a period of time while they're sleeping there can be a uti as well or any other acute illness that's causing them to have some sleep disturbances i want to talk about anxiety depression and stress i think we can all probably think about a time in our lives where we've had height higher than normal stress or anxiety or depression that really did disturb our ability to sleep whether it was to go to sleep stay asleep um or get good quality sleep right there's a difference between the quantity which is important but it's that quality of sleep that we need and sometimes that's just that stress and anxiety can prevent us from getting that good quality sleep persons with dementia are going to experience that as well pain any type of pain or just being uncomfortable will really disrupt sleep and again those changes that are happening those chemical imbalances that are happening inside the brain that really can um mess up that pacemaker within our sticky that circadian rhythm that body clock that we have and then of course medication side effects are a huge a huge factor into sleep disturbances as well and medication side effects we'll talk more in depth about those but it could if they're causing drowsiness or they can cause us to not sleep well it can cause me more restlessness so i'm not able to get that sleep that i need and then as our lifestyle changes where persons with dementia's lifestyle changes and how they're interpreting the world and what they're able to do so are they getting as much exercise as they used to um what about how much is their diet changed or or hasn't changed are they too bored this is a big cause of sleep disturbances particularly in the elderly is that they're just not enough activity or stimulation throughout the day and that can be physical activity but it can also be mental cognition activity it can be emotional activity or even just that i giving a sense of purpose i'm able to contribute to my community or my family and if i don't have that that can cause me some boredom or cause me restlessness or it can cause more depression and then i'm having some sleep disturbances because of that too much napping now we'll talk you know there's a fine line between napping and what that looks like and how much um but sometimes we can nap too much to where we're just not tired at night right or any change in the routine um which we'll talk about and then a sleep hygiene and i'm going to give all of you guys great ways to have a good sleep hygiene um whether it is for your loved one with dementia your client with dementia or it's yourself to help with those and then the environment how is the environment changed has the person with dementia are they in a new environment um did they just move to a community or did they move houses or somebody moved into their home and it's changed the environment a little bit or maybe they're just not familiar with where they're at at that time does the atmosphere not promote good sleep have we you know i think about a person that i helped take care of and he was on hospice for a period of time but we had people coming in just helping him out before he was on hospice and he was in his home in his room but we changed the atmosphere of his room so much first of all there was a lot of people in and out that can really be confusing and destructive through all hours of the day and night but then just the equipment that was brought into the room there was the oxygen machine that was in there we brought in extra heaters to keep him warm right that were in there there was also a fan that had to be brought in for the care partners that were staying to watch them there was just all this extra equipment you know storage over here in the corner i can remember for um for medic medical equipment or you'd like bandages and his modification were over here but that was all in that room and it just changed his room like his space a lot and i really think that disrupted um his confusion and his environment and disrupted his sleep patterns in his sleep um and may i gave him sleep disturbances too much stimulation again is there too much going on in the room or is there too much going on throughout the day have you ever experienced where i've had such a busy day and so much going on that i've become restless or it's hard for me to come off of that high energy this or that rate that i'm going every day so it's hard for me to come down off of that of course the comfortableness is in a new environment how much noise is going on is it too loud is there too much light or is there not enough light where you'll see a theme here about some light throughout this presentation but if they had limited exposure to whether it's bright light um or sunlight that light really tells our brain and kind of helps set a rhythm for us it tells us brain our brain when it's time to be awake and it tells our brain when it time to wind down and that we need to be asleep so light plays an important factor into sleep disturbances and sun downing with lowy body dementia i mentioned so if somebody has a louis body dementia diagnosis this is a common factor or common hallmark symptom of this particular type dementia can be sleep disturbances so with the lewy body dimension in the earlier stages it may not be that we see somebody has a lot of short-term memory loss like you might see with an alzheimer's type dementia a symptom you might see is somebody with sleep disturbances so and what it typically looks like is they have very vivid dreams or they act out their dreams and again this would be different than their normal their previous or their normal behavior but they may yell or scream out during their dreams they may actually move like hit or kick or you know they're defending themselves or they are acting out whatever they're dreaming in there so you might see some periodic limbic moves or limb movements um so they're jerking or whatever it may be inside those streams and again they can have a hard time whatever they dreamt they may have a hard time separating that from that was just a dream that i had from this really happened to me and of course that can be scary and confusing they can also are more prone to having restless leg syndrome but then you can also see they're just more excessively drowsy during the day so these are and this is because this particular type of dementia is affecting different areas of the brain earlier on so you will see some more sleep disturbances because it's messing with those areas of the brain earlier on in this dementia whereas with an alzheimer's disease or even a vascular dementia you can see sleep disturbances again mid-stages more in the middle stages of the disease so we first want to rule out or treat any of those automatic things that we can treat or rule out so whether that is an illness do they have a uti particularly if you've noticed a sleep disturbance has come on suddenly or it's an acute change in them now sleep disturbance it may be caused because of the changes happening in the brain but we do want to make sure and roll out it's not an acute illness a uti an infection they've got acid reflux that they're not able to tell you about or gerd or something so that's hard to get them to go to sleep or when they lay down flat that really really bothers them well those we can fix pretty quickly um other pain that they may be having if their arthritis is acting up or you know even the changes in the weather right now we're here where we're at in texas there's a lot of changes going on in the weather the bariatric pressure can cause um some changes in how persons respond to fatigue or restlessness or whatever it is and but we have medications or other things that can help manage that and it says your pain of course physical pain but emotional pain as well we briefly talked about depression and anxiety and stress well how can i meet the needs of that particular pain or those particular needs that need to be met and help them through those things so they can get better sleep so do they need to talk about it do we need to do some like meditation therapy with them or pet therapy or maybe it's reminiscence therapy and we do that with them so that she may have a um they're able to work through some of those emotions or feel like they are able to contribute back to their community and so it lessens some of those feelings of depression um and they can help with their sleep disturbances medication side effects um if we can talk to a doctor about what the possible side effects are are of medications whether it's prescribed by a doctor it's over the counter we can talk to a pharmacist about that and maybe either change the medication or change the time of the day that we take it if it does cause drowsiness can i take it at night or if it causes me to have a little bit of restlessness or anxiety should i take that in the morning when just talking to that doctor and really brainstorming out um the medication is important but i want to make sure it doesn't with these side effects i don't want the side effects to interfere with other things that can cause more upsetting behaviors but also looking into their sleep history and habits what um what has been their sleep history have they always been a night owl so they always stayed up really late at night and that was just kind of how they were and maybe they slept in a little bit more in the morning or maybe they stayed up late at night and they did nap throughout the day but that's a history of theirs and it's a habit for them well we need to to look at that because that might be how we incorporate this into their daily lives now other habits and then looking at rituals too what do we do right before we go to bed how do we start to wind down and get our bodies and minds ready for bed and what did they used to do in the past is it um reading a book was it drinking a warm cup of tea was it going around and checking all the doors to make sure they were locked a couple of times like the house is secure now i can really get ready for bed you know is it little things like that that we can incorporate into their day or enter their sleep hygiene their sleep routine and the depression and anxiety and stress um making that environment stress-free especially doing some calming activities a few hours before bedtime and be aware of what they're watching is it the news is it um something a little bit more upsetting or that could be misinterpreted because what we watch this is the same for you and i but same for persons with dementia what we watch is going to interfere or influence on what we think about and that's important particularly when we go to bed what is on my mind as i'm going to bed or what did i just see as i'm going to bed because that can influence how fast we go to sleep or what we dream about or how long we stay asleep we'll talk about compassionate touch and how just soothing touch and reassurance can help with sleep and sun downing as well again have they snapped too much throughout the day and they're just not tired anymore or have they not gotten enough stimulation whether that's exercise just movement throughout the day we don't have to go you know walk every day but just moving getting up out of that chair and moving through the house every day and cognitive and emotional stimulation to you with exercise and movement the body does have to be able to burn off that energy that it has the metabolism they're still there they need to burn off some of that metabolism and if we don't burn off enough it can keep them awake because we have that energy there also exercise and movement has shown over and over again to reduce depression um so with this movement and exercise it can really work two different if not three can help reduce stress as well and anxiety help from three different areas for that so it is planning it's just making part of your daily routine whether it's getting up and going for a walk or we're doing stretching in the chair we are doing some gardening it also provides the opportunities for us to get outside and get that light that i mentioned earlier so that's the skin um soaks up the sunlight and that helps really the brain reset and say okay this is the time i need to be awake and it's part of setting that circadian rhythm or that pacemaker that's inside of our bodies that's controlled by our brain in a diet so our food what we eat when we eat how much we eat will play into our sleep um so eating a well-balanced diet that is healthy and makes us feel good if i'm eating too much of one thing whether it's sugar or salt or fat that can influence how my body feels and if my body feels uncomfortable again that can play into my sleep patterns cutting out caffeine um i would say if you can cut out caffeine altogether go to you know half caffeine or decaf over time or at least cut it off by noon at the latest because as our body gets older it takes us longer to metabolize things out of our system and that's cat that includes medications and it includes caffeine so it's just going to take it longer for us to get that caffeine out of our system um if we're still if it's still part of our daily habits i'm stopping liquids after dinner and this kind this will help play into how many how much time they get up or how many times they get up during the night to go use the restroom and i don't i want to be leery on saying we don't want to stop liquids off together or stop them in the middle a day because we don't want them to become dehydrated but it might be after dinner you know we've had our liquids and then that's about it for a night for now and then they do use the restroom right before they go to bed and that can help minimize how many times they get up at night lemon alcohol and night caps i know there's a um a thought that that night cap can make us drowsy and it does for a lot of people it does make a strousy but what happens is alcohol prohibits the brain to shut down and go into the quality sleep that we need so the alcohol prevents us to going into those rem cycles and there's certain we have to go through certain rinse cycles in many times over the night to get that quality sleep and alcohol is the prohibitant to getting into those rent cycles so being aware of that whether it's for your loved one your client or yourself and really being aware of what the environment is and what it's what it's communicating persons with image are very sensitive to visual cues but to their environment around them what's going on and also as the disease changes um they're how they interpret their environment is going to change as well so there are some basic things like is it too hot or too cold um colder temperatures for all of us do promote better sleep i still i will say people with dementia our bodies temperatures change a little bit too so they tend to operate at a lower their body temperatures already kind of lower so being aware if they're too cold it may be too hard to go to sleep so you might think gosh they don't need those three blankets because it's august and it's 100 degrees outside but to them it might be just right um what you know is there is the mattress uncomfortable is there you know the sensation of the fabric on the skin can change as well so what's the fabric and how soft is it using weighted blankets can also be a comfort to people with dementia again this is individualized but it can be very comforting to have a light weighted blanket on them because it can help soothe and comfort physically but also emotionally there's a secure feeling about that weighted blanket and they can really help promote sleep and help us stay asleep longer and maybe help them want to go to bed because they have that feeling of oh i really like how it feels when that when i have that blanket on me whether they're able to say that or connect what's happening with that feeling of security and comforts there and making the room familiar friendly and functional so it's a room they can get around in on their own it's friendly it's a place they want to be and it's familiar it's their space they know the people that are on the pictures on the wall they know that blanket that they've had since they were a little kid or that chair in the corner that they that they're grew up in their their previous home i've always had that so it's a familiar place and there can be too much light or too much noise um a white noise machine can help it's particularly um in a crowded home or in a community or something if i turn on that white noise machine it can drown out other background noise and then using night lights to help them find their way but being aware is the nightlife helpful or is it not so helpful and this is just an individual setting again talked about that exposure to light during the day um in in the light whether it's a bright light or it's sunlight really is a cue to our brain that it's this is wakefulness i mean again again it helps that brain kind of reset that circadian rhythm as it needs to keep those lifelong rituals and routines and then incorporating some more calming things whether it's a slow stroke back rub or it's a hand massage or a foot rub because that really helps people relax it helps decrease the stress hormone in the body and it helps increase an oxytocin hormone and the oxytoc oxycosin hormone is a care and connect hormone so it promotes feelings of safety and security while we're decreasing that stress hormone and this is through skin to skin contact palm to palm whether it's palm to the back palm to the feet a hand rub it's been shown over and over again that that body goes through the physiological response when we do that and we call this compassionate touch there's no you don't have to be a skilled massage therapist or know anything it's just knowing that my palm to their skin and being slow i'm rubbing their hands i'm rubbing their feet their back really does promote these responses in the body which helps promote calmness it helps promote or decrease depression decrease anxiety and again will help with those sleep disturbances turn off the um all the electronics about one to two hours before you go to bed so this is turning off the tv those the bright lights on from the tv that different kind of light that it sets off turn off the computer turn the phone off turn off if you're reading a kindle maybe you put it on the reading the reading light for that how on the radio so there's not a light coming out but it's really setting the environment for calm for calm and reassurance if they get up in the middle of the night gently remind them that it's nighttime redirect them back to their bed so it's again it's a visual cue hey it's still nighttime i need to see the bed maybe you show them outside that it's still dark outside i've had to do this and just show like open the curtains and say yeah there's just a few more hours it's still nighttime let's get those few hours of extra rest it's going to be great and i had to show them what time of the day it was because they were so disoriented and again confusing nights and days but that helped cue them in in their brain because they visually saw it as opposed to my words of just saying well it's still night time we still have several hours of night to go so why don't get back to bed it's that showing them that it's cueing that visual cues to them where where they need to be and for caregivers um particularly if you're there a family caregiver or they're at home still um and it's 24 7. um finding different times for you to get rest you know sleep when your loved one is sleeping if um if if we're still working on getting into a routine or if they are napping then maybe you can nap too um i would kind of skip ahead sleep in a different room if you need to or if you can using a room monitor i know a lot of families that use room monitors or noise monitors because i'm in a different room because it's i'm not as restless and neither are they but i can hear them in case they get up or i can see them in case they get up and i can judge from there whether i need to get up or not make sure that the house is safe and locked up so if they are prone to getting up in the middle of the night it can be okay it's kind of choosing our battles here it's okay that they get up if they're able to if as long as they're safe and they're not going to walk out that front door or get into the garage and start up the car or something right just make sure the house is safe and locked up it's okay if they wander around a little bit if you can't redirect them back and choosing those battles so if they're going to sleep in the chair then let them sleep in the chair right if they don't want to take their clothes off or it starts to become a fight or it starts to become a battle then let's not have that battle let's just say you know what you're right i'm going to let you sleep in those clothes it was the same clothes they've been wearing for the past seven days that's okay let's just you know next time they're in the shower let's swap those out or make sure they get cleaned right um but that's okay it's kind of if they're gonna go to sleep here in this chair in their jeans and they're going to sleep then that's that i'm going to let them sleep because that right now is the most important goal to get them to sleep so the sleep hygiene again this is for everyone this is for our clients our loved ones but it's also for you and knowing that good sleep hygiene is a day-long process so it is we want to wake up around the same time and go to bed around the same time you know you don't have to be militant about the time but it is you know within an hour of each other i'm waking up in this hour every day and i'm going to bed with this and with this hour every day and you can train your brain to do that um getting sunlight early early in the day so again that's that light that exposure tells me oh this is the wakefulness hours and of course exercise it improves our quality of sleep and it can help us to help us feel drowsy you know i say in this particularly for everyone the best time to exercise is the time that you're going to go exercise but with persons with dementia it really because it can excite you and keep you awake for a longer so make sure it's at least two to three hours before you go to bed if you're actually doing a physical exercise where you're sweating and getting working your heart rate up in the evening it is watching what those stimulants are and that stimulate can be food it can be alcohol it can be what's on tv i'm just watching the stimulus and really avoiding them all together if not let me eliminate and limiting them and use the bed for sleep if some of you use the bed for work or you use the bed for watching tv our brain will associate the bed with those certain activities and not necessarily sleep so really just hone in i'm in that bed i'm there to sleep and do your other activity watch the tv somewhere else and do your work somewhere else because the brain will associate what it needs to do when it's in that environment and go to bed when you're ready to sleep if you need to do certain exercises to calm yourself down whether it's reading a book for some people i know some people play games on their phone um to help them kind of calm down a little bit that deuce that somewhere else and when you're tired enough then you go to your bed and sleep um but give yourself time to ease into that sleep because sometimes i know um particularly caregivers we're going and going and going and going all day every day all day every day and then it's you know it's 10 o'clock oh man i need to be asleep by 10 30. so we expect everything just to stop and our bodies to calm down and our brains to calm down within 30 minutes so we should be asleep it doesn't typically happen that way for a lot of us or at least it doesn't for me it can take a lot longer i'm so backing into that time and saying okay i need to calm down earlier than 30 minutes before i really want to be asleep and what can i do how can i ease into that i need to turn off the phone i need to turn off the tv maybe i just turn down the lights in the house a little bit if that's helpful and create those relaxing rituals for me is it drinking that cup of tea or a warm cup of milk is it going around and shutting down the house and making sure we're all locked up everything's good i have lunch packed for tomorrow so i'm setting those routines that help me get ready for bed and set my mind ready for bed if you can't fall asleep within 30 minutes of getting into bed um then we want skins bed is for sleep so get out of bed and go do some calming activity whatever that is for you do that in a in another room or do that in the chair in the corner of your bedroom do that for 10 10 20 minutes until you start to get tired again and then go to sleep if you still can't sleep after that there are a few other approaches we'll talk about so non-drug approaches and there are some relaxation t techniques that have shown to help us go to sleep there's a progressive muscle relaxation and i will send you all an extra form on exactly what this looks like and how to do that but it's the tensing and relaxing of muscle groups throughout your body of course meditation and that's our mind focusing on nothing or focusing on a particular word like peace or sleep um or love or stress or no stress in our mind just focusing on that for a while and then guided image a guided imagery imagery and this is a form of medication but it's our mind going into another place using our mind's eye to visit a calming place right um to help us be more relaxed and this physiologically shuts and helps our body go into a relaxed state all three of these are shown to help us promote good sleep habits if all else fails um i'm going to talk a little bit about medications and i'm going to preface this this is just for educational purposes only i am not a doctor i'm not a sleep expert and with any medication you must consult a doctor first consult with your pharmacist as well but also know persons with dementia are more sensitive to sleep medications so is just the older adult in general so we always want to start low with any type of medication and go slow if you need to increase the dosage you go very very slow and really what know what the side effects are and weight them against what the benefits are so what are the pros and cons or the risks and benefits of this medication because we know medication side effects can increase falls and fractures in just the elderly population but particularly those with dementia because when you wake up you might have slept well but you wake up and you're still really drowsy and it's kind of like they call it the hangover effect and that hangover does promote more falls and fractures more confusion as well it's harder for us to come off that medication and then there can be a decline in cognition and the ability to care for oneself so from the alzheimer's association if sleep medications are used an attempt should be made to discontinue them after a regular sleep pattern is established so these medications really only need to be used for a short period of time to when you have that sleep pattern established and then you come off of them with the doctor slowly and that you to keep that sleep pattern established so the type of medication prescribed by doctors is often influenced by the behaviors that accompany these sleep changes so it's really saying here's the behaviors i'm seeing here's the medication the doctors wants to prescribe me so i'm talking with my doctor about this the behaviors i want to diminish how will help the sleep changes and really be in converse constant conversation with the doctor so we can can diminish those behaviors get those sleep changes fixed or managed better and then start to come off potential medications that are prescribed so the fda and this came from alz.org the fda has approved a medication for insomnia for people with dementia in the mild to moderate stages of course it lists here possible side effects are limited to but this is not an exhaustive list there can be an impaired alertness motor coordination complexity or worsening depression and suicidal thoughts and then complex sleep behaviors so they might do some sleepwalking or sleep driving and then comprised compromised respiratory function so there are some side effects but this medication has been approved to maybe help with that insomnia too and really when you're prescribed or your loved one or client is prescribed any type of new medication you always want to ask your healthcare team so this is the doctor the pharmacist your care partner who what are the benefits of the medication what's the risks of the medications are there other treatment options available or really a question that should be added is what's my goal what is the treatment goal where am i trying to get and how will this medication help with that so and then over the counter sleep aids very quickly and i hesitate to put this in here again i'm not a doctor i'm not a sleep expert but i put it in here because i know people take over the counter medications for sleep um that's just kind of what it is unfortunately so there are the medications the unisom and the z-coil that help and they're they're really older they're antihistamines that have been used and kind of repurposed that will make you feel drowsy and will make you fall asleep easy there's the unisom sleep tabs um there are newer medications that kind of have that antihistamine drowsy effect as well and they have fewer side effects so those two first bullet points they still have side effects um both of them this has the increase for falls it's that that hangover effect that will still be there they can have that complex sleep pattern so they might be sleepwalking you can see that or sleep driving you can see that in these these are some um side effects that have come on come have been shown with these drowsiness throughout the day but another thing is with these you want to if you're using these for a long term they're not really necessarily habit forming so they say but if you're using them for a long term there is a link to increased risk of dementia okay so so keep that in mind just really weighing the benefits of those benefits and risks of that of those medications melatonin and valerian those are melatonin is a natural hormone that our body produces that we stop producing as we get older or produce less of it but melatonin just promotes sleep and helps us go to sleep longer you can't buy this over the counter it's a hormone hormone replacement or supplement and just talking to your doctor about adding that in the pharmacy how much what because you can talk about the dosage how much you want to do because that has been shown to help promote good sleep and valerian is the same it's a plant-based supplement it's a little bit newer so we're just the side effects or the benefits of it just not really validated quite yet so sundowning so we talked about sleep disturbances and sun downing and sun downing is really it's a time of the day that refers to an increase of agitation or confusion in persons with dementia and they call it sundowning because typically this increase in confusion and agitation really tends to happen for most people in the late afternoon early evening so as the sun goes down we start to see these behaviors present in people with dementia so they call it sundowning or sun downer syndrome and it's very common in persons with late middle stage dementia really any type of dementia it's just they become restless they may want to go home they may just seem more confused i'm not able to communicate like they were earlier today they're more agitated right they might wander around more and this happens about the same time every day most people again it's early afternoon late evening early after late afternoon early evening but it can happen any time of the day so i've known people that have the these symptoms the sun downing symptoms early in the morning but typically it's in that late afternoon early evening they may see people or hear things that are not there so you're just kind of having that increase of dementia symptoms during that period of the day so a lot of suggestions is why does this happen and it can't happen because the sleep pattern changes in the body um people that are not have are having disruptive sleep that we may or may not be aware of they may be tired um they're not getting that quality sleep throughout the night so it makes them more tired as the day goes on and as they're more tired they're less able to manage their environment but also their response or their how they're behaving in their environment or how they understand the environment too they can just be reacting to the end of the day um you know depending on their environment the end of the day most people whether you're at home with a care partner or you're in a community around um a bunch of care partners we're all getting tired at the end of the day right um so it's been a long day we've had a lot of stuff going on and i'm also tired so me as the care partner might be exhibiting some um some tiredness or exhaustion or fatigue so i might not be able to control my patients as much um or my uh you know the vibe that i give off of tiredness is coming out more in the later afternoon so they can be turning or seeing that and just mimicking that behavior so this can look like it what contributes to sundown ages exhaustion they may be having a hard time understanding and hearing what's going on um what are they actually seeing so another theory is this as the sun goes down it plays it changes the environment so there's different shadows inside the um inside the house as the sun goes down the lights playing um or making more shadows or the light can play tricks on somebody in somebody's mind or the outside environment is changing and that can be confusing to somebody with dementia and that can cause fear if i don't understand why the environment's changing that can be scary um if there's a routine change um in the environment just a change in the routine or changing the environment at all again there's more people in it could be a shift change and so we have more people in and out more people might come visited the community at a certain time some more people are visiting during dinner time so you're having more people in and out of your environment uh or you're having more family and friends come over and help with that or you're just getting home from work or the kids are coming home from work so there's just changes in the environment too much noise too much activity or there can be two not enough not enough um and they haven't had enough activity throughout the day we've talked about that boredom and that loneliness and eventually that boredom and loneliness can make me seek out something to make me not bored or seek out not to be lonely i need a connection i need something so the brain will seek out something to do and that may be a safety concern or it may look like somebody's wandering around or they're more restless or they're agitated and they can't tell you verbally why and they may not understand why either but it's that innate feeling that we have as human beings they can be meeting formal obligations again that time of the day is just busy for most people most of our lives whether we're getting off of work and we're going home we got to pick up the kids to go take them to soccer practice and then i got to get home make sure dinner is started or i need to run to the grocery store real quick so really that's just naturally a busy time of the day so they might be regressing back into or remembering hey i should be doing something right now i'm an important person people are relying on me i need to i gotta i gotta be doing stuff i gotta get somewhere they might actually even say i gotta go get my kids i need to get home i need to go to work or they might just be starting to move and be more restless again they're not probably going to be able to tell you what's up um you can tell they can't if they are saying i'm trying to get home or i gotta go pick up the kids people are working you know i gotta get out of here then you might be able to say okay they're probably trying to meet some former obligations right um if they're just feeling restless or they're pacing or they're wandering around there's something they need to have either they're too overstimulated or not stimulated enough and they need something to do and they can just get be confused about what's going on and they may be looking for something that's comforting so if they are looking to go home or they are trying to find mom or dad or where is my sister they're looking for you know home mom dad sister or friend a pet um that is a form of comfort so they might also be seeking out right now i'm confused and more unfamiliar with what's going on so i'm seeking out something that's comforting to me and that might be home and that might be mom so the words that they're using are important we want to hear that but what's behind that are they seeking out comfort too and how can we fill that in that comfort and that support and knowing that with sun downing we may not be able to stop just like with sleep disturbance movement i'll be able to stop them completely or fix them completely but we can maybe manage the symptoms better or alleviate the severity of it so establishing a routine and this is staying on that routine helps with the sleep disturbances too right so this is getting up around the same time any appointment or activity that might be complex um for them or we need to leave to go to an appointment or we're going to go do don't go do this or we're going to exercise it is best to do that in the morning the morning time where they're more able to do that so they just came you know hopefully got a good night's sleep um and they're able to manage that better as the day goes on they might be less able to manage those appointments and really understand and getting out from that and if we can keep those in the morning and then you know we come back here's lunch we do a a familiar activity after lunch we get some rest and we do you know our morning or our routine throughout the day is the same but making sure those more complex things happen in the morning can be very helpful if we have to change it up for the afternoon sometimes you will probably notice a change in agitation or confusion later on in that day i had a lady i was working with she was a teacher during the year so her mom came to our day program and she so the mom was in day programs daughter caregiver was teaching and then summer came and the daughter didn't need to be teaching so she stopped bringing her mom to the day program because she honestly felt guilty about taking her mom to the day program while she wasn't at work but she called one day she said mom has just changed she's been acting out in the late afternoon and i don't know how to make she's more agitated she starts yelling at me she's wandering around the house and i don't understand what's going on um so we talked through it and we said well you've changed your mom's routine she was used to coming to the day program every day and that changed she's just kind of stopped um so why don't you try bringing her back you don't have to do it every day but at least a couple of days out of the week and see if that behavior that sun downing that agitation and late afternoon changes and goes back well sure enough it did her mom's routine had changed and that comfort that familiarity and she's getting social activities as well changed but it's that i got to get back into that routine that's so important to me and we all do better on a routine because there is familiarity there is comfort around that routine whether somebody with dementia knows exactly what's going to happen next in the day but they know this is familiar this is comfort this is supposed to happen and i understand this and then calming activities in the later afternoon you know and it might be that you go out for a walk or you might go take a drive in the car or give them activities that they would be used to doing so it might be helping starting dinner so they can stir some sauce or they can fold some clothes or they can sort through some bills right or they can pull weaves whatever it may be it can look through photos that are familiar to them to snuggle with a pet if you have that there are robotic pets that might be um therapeutic for certain individuals too that can help with the the symptoms of sun downing if you are to prevent overstimulation or tiredness um take an early afternoon nap again there's a fine line we don't want too much napping but a nap may help it can help that over tiredness in the late afternoon so it can help the brain kind of rest and reset itself and that way they can manage the later afternoon a little bit better and help them be more in control of their emotions activity throughout the day and i would say when you're looking at a routine i would incorporate equal parts activity and this is physical mental emotional social spiritual all of those activities that are important to a human being but also incorporate equal times rest to rest in restoration i need i'm not not rest necessarily a nap but just rest of who i'm going to sit down and just look at the birds right now and take in this fresh air it's because it's restorative and all human beings need that as well um persons in dementia can lose track of where they are again lose track of the day right but just where they are even if um they're in the house they've always grown up in um there are times where they can be unfamiliar to them um if they get up to go use the restroom and they may not know where the restroom is and that can be scary and confusing and make them feel nervous so that can contribute to symptoms of of sun so maybe we start to label the house and help them orient themselves to where they're at and that might be a picture of the toilet on the bathroom wall or it might be i'm leaving um lights on in the house so they can see where they're going right so we're not having these shadows potentially created and shadow can be interpreted as something more ominous and they might not be seeing a shadow it's well there's a dark hole or a dark um corner over here in the in the room and i don't like that it's a little bit scary so it's what they're seeing uh and how they're interpreting it's going to change so making sure the environment is calm and it's organized and it's familiar and it's functional i said that early it's functional they know what to do and they go into their bedroom um they know what to do and they go into the kitchen it's a functional thing there's not too many things out it's easy to manage and it's familiar and it's friendly it's a place they want to be i would say um for the environment if they are wonders or they like to pace that's not a bad thing we just want to make sure it's safe and make sure that they're okay they're not trying to meet obligations or they're trying to look for the restroom or something but it might help them to get up and expend some energy and be walking around so make sure it's safe and that can be anywhere from removing area rugs so they don't trip over them to making sure the doors are secure right um that the rooms are well lit and they can have sometimes have a hard time distinguishing between objects whether it's and it's similar colors are hard to distinguish between so it might be if i don't want them to go out a certain door like a door to the garage i might color that door the same or paint that door the same color as the wall because it's hard to distinguish between that or put something over the doorknob so they're not prone to going out there or drawn to going out there so little things like that and what are they hearing um you know are they hearing something on the tv that can be upsetting or they're seeing something on tv that can be upsetting what about conversations that are going on in the house or the community are those upsetting um or are they confusing right so keeping the environment simple and quiet they're less able to filter out background noise um so the quietness of the environment is important because there might be in particular in a community setting you know you got the kitchen noise from the kitchen you got the tv on over here you've got conversations going on over here people in and out the surface hallway over here it can be very loud and over stimulating so being aware of what the noise level is on that house or in that community or in that room whether it's a family home or family room and i would say set aside a space for just them um it's a it could be their bedroom right but it's a space that's safe it's familiar it's theirs and they can go and calm themselves down or they can just go and kind of exit and be away from a lot of stuff too to help with those sundowning syndromes there's sundowning symptoms avoid restraints you know this is chemical and physical restraints and we want to be reassuring and how we say stuff so it's firm but it's calm and it's reassuring and it's and it might you know they can't remember that they can't remember that they can't remember and they can't remember a reassurance reassurances either so we want to reassure keep saying those reassurances that you're safe you're where you're supposed to be you're we're here together i'm making sure that that's in a calm voice we don't want to argue with them or tell them that they're wrong or that if they're looking for their mom that mom has passed away and you're here now you know using those therapeutic stories as needed you know i haven't seen mom today or mom's working late she's going to come home later i can really use your help over here can you do this with me i can i need your help so making them being a part of that community or part of the family giving back to them or for them to give back to us and physical touch again going back to that maybe i hold their hand and rub it or put my arm around them and do a small back rub to help calm and suit again that puts our body into that physiological response exercise dinner or the food the diet that we have and having that safe space for them the caregivers have to care for yourself too and i'm gonna and with that it's sun downing is exhausting for both parties and it can be scary for both parties too for the person with dementia and yourself so it's important that you take care of yourself so you can best manage when some of those sundowning symptoms happen and you can better care for your loved one or your client or resident and that is eating you know it's exercise eating well-balanced science getting goods quality sleep everything we've recommended for persons with dementia and then seek out professional support as you need it and that could be what do i need to incorporate a day program do i need to get somebody else in here to help me manage during a certain time of day you know getting a companion in here do i need to have somebody during the day to help take them to the gym you know it's these things to help for that professional support and talk to a doctor it could be a medication that's causing this um causing more confusion or causing that drowsiness and they don't know what to do with that or just the side effects of a medication at all um or if it comes down to talking to a doctor is there a short-term medication that can help me because i've tried all these non-um non-medical approaches and you know i'm doing compassionate touch or it's a calm environment we're doing aromatherapy we've got pets you know pet we're snuggling up with our pets we're doing all these things is there something else that could help them um if they're still if it's to a point where they're very confused or very agitated or very scared and talking to them about help calming them during those times for a short period until they're established or the sundowning phase has passed right and making sure they're not sick or they're not in pain there's not a uti or an infection or anything like that constipation you name it and if it is the sleep they're not getting enough sleep during the day that can be causing these symptoms and of course if they suddenly become worse again it's that acute change when it's an acute change or a sudden change in our loved ones they're suddenly more confused or they're suddenly more agitated or restless then generally there's an underlying physical problem for that and we can get immediate help so here are some references um and articles that are referred to and our information here at the west center and i'm a few minutes over but are there any questions um if you want to unmute or put those in the chat am happy to question oh there are some questions in here apologies for not knowing the concept of sundowning i hope i cleared up what the concept of sundowning is and if i haven't please let me know but but are there other questions or comments that anybody has all right well i appreciate it thank you um i will send out the email this afternoon with a copy of the slides a copy of the recording our upcoming programs and we hope to see y'all on another oh in the evaluation for the ce credits um please do that and we hope to see you on a future program thank you so much

Channel: James L. West Center for Dementia Care

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Id: NWkaz8b4byg

Length: 63min 46sec (3826 seconds)

Published: Wed May 11 2022