Question:
My brother is 60 years old with late stage Alzheimer’s Disease. He has begun experiencing the occasional sleepless night (once a week). His doctor suggested Tylenol before bed so we started giving him a Tylenol P.M. I recently learned there’s Benadryl in that which can increase confusion in an Alzheimer’s patient. Ativan has also been suggested, again, that can add to his confusion, but so can not sleeping. I think this is a common symptom of late stage AD, do you have any suggestions on how we can best manage his sleep? We try to keep a regular sleep schedule.
Answer:
Thank you for your question. I am sorry to hear about your brother’s challenges.
You are correct, sleep disturbance is common in people with Down syndrome (DS) and Alzheimer’s disease (AD).
You mentioned having a regular schedule. That is part of “sleep hygiene”- various ways to improve sleep without medications. We have information on sleep hygiene in the Sleep section of our online resource library.:
A method that has been studied in people without DS who have AD is increasing sun exposure during the day. This may include going outside or sitting near a window. Even just being exposed to natural daylight without being in direct sunlight is likely helpful.
It is important to look at what medication the person is taking that might contribute to poor sleep.
It is also important to look at underlying health conditions that can contribute to poor sleep such as:
- Sleep apnea
- Gastroesophageal reflux disease
- Pain – a trial of acetaminophen (Tylenol) can be helpful in some individuals (see below for information on why we don’t recommend Benadryl)
- Hyperthyroidism (overactive thyroid)
- Depression
If the non-medicinal approaches don’t adequately improve sleep, our next step is usually to discuss possible natural products. Melatonin, magnesium, tryptophan, or valerian are some products our patients find helpful. Alteril is a product that combines melatonin, tryptophan, and valerian, and some individuals we treat have found it to be beneficial.
If the above do not adequately address the sleep problems, we consider medications. Chapter 26 of our Mental Wellness book is a chapter on Alzheimer’s disease and includes some information on sleep. You will note in this chapter that we don’t use diphenhydramine (Benadryl) due to concerns re: increased confusion, daytime sleepiness, unsteady gait, constipation, inability to urinate, and more. Similarly, we limit use of lorazepam (Ativan) and other benzodiazepines due to increased confusion, unsteady gait, and daytime sleepiness.
One medication we have found beneficial is trazodone. Trazodone is an anti-depressant that we don’t typically find beneficial as a treatment for depression but do find it can work as a sleep aid. We find that low doses (e.g., 25 mg) work well for some. Others may need a higher dose, but we raise the dose slowly and cautiously to monitor for increased confusion, unsteady gait, and daytime sleepiness. In our experience, these side effects are less common with trazodone than diphenhydramine or lorazepam, especially if starting with a low dose and raising cautiously.