Spotlight on Care: Alzheimer's Caregiving
Welcome to Spotlight on Care, the podcast where we share stories, experiences, tips and advice on caring for loved ones affected by Alzheimer’s and other dementias. Spotlight on Care is produced by the University of California, Irvine Institute for Memory Impairments and Neurological Disorders, UCI MIND. Please subscribe to the Spotlight on Care podcast wherever you listen. For more information, visit mind.uci.edu. What would like to hear about next? Email us at mwitbrac@uci.edu.
Spotlight on Care: Alzheimer's Caregiving
Importance of Sleep with Dr. Bryce Mander
In today’s episode of Spotlight on Care, co-hosts Steve and Virginia welcome Dr. Bryce Mander for an in-depth conversation on the critical role of sleep in healthy aging and dementia prevention. Drawing on his expertise in sleep science, Dr. Mander explains how and why sleep changes as we age, the impact these changes can have on memory and overall brain health, and why caregivers are particularly vulnerable to sleep-related challenges. The discussion also explores ways to recognize when sleep issues may need medical attention and how addressing them can benefit both those living with dementia and their care partners.
From the University of California Irvine, this is UCI MIND's Spotlight on Care, the podcast where we share stories, experiences, tips, and advice on caring for loved ones affected by Alzheimer's and other dementias. Welcome to Spotlight on Care. We have a really exciting episode today about sleep. We're going to talk about the importance of sleep treatment and how it affects the prevention of Alzheimer's. Our guest today is Dr. Mander. He is the Associate Professor of Psychiatry and Human Behavior at UCI. He's also got a PhD from Northwestern–Go Wildcats–and his research concern with characterizing the role of sleep in cognitive function and overall brain health across the human lifespan in both healthy populations and populations at risk for neurodegenerative disease. Basically, we call him Dr. Sleep. So we're going to attempt to make sure that we keep the language as fundamental as possible. So Virginia, is there anything you'd like to add to this topic about your experience with your mom and sleep?
Virginia:Well, you know, you hear a lot about the topic of sleep when it comes to dementias. And I always think,"Gosh, that was one problem my mother did not have." She passed away after eight years of dementia, Alzheimer's, and she slept like a baby at night. And I'm kind of the same way on that, but I know that that's a little bit unusual. So this is going to be interesting for me. I'm going to like this.
Steve:That's a great segue, because we're not only going to talk about early stages of dementia and how sleep affects it, but we're also going to talk a little bit about what it's like for the caregiver and how important sleep is for them. So let's jump right into this Dr. Mander. Broadly speaking, how important is sleep to our general health? If you can kind of give us an overview.
Dr. Mander:Of course, first, thank you, Steve, thank you, Virginia, for having me on this is going to be such a pleasure and so much fun. Really glad to hear that you sleep well. Not everybody is blessed with that.
Virginia:I know that.
Dr. Mander:I know many parents of young kids will envy you. Yeah. So sleep is important for a lot of reasons, and some people describe it as a pillar of health, like, if you think of health as supported by healthy diet, healthy lifestyle activities, a lot of people in our field think of sleep as one of those key factors supporting health across the entire lifespan. There's a lot of people that talk about it like it's important for supporting cognitive functioning and development, as well as maintaining cognitive health throughout the lifespan, but it's also useful for maintaining the health of any of the organs in our body. One of the things that I've always been fascinated by about sleep is that if you take an individual and you sleep deprive them, and you measure the different aspects of the biology of their organism, there isn't a single organ system in their body that isn't adversely affected by sleep deprivation. Now the good thing is, if you two acutely lose a night of sleep, you get sleep the next night, you can recover it from that. And that's totally fine. It's more than if you chronically don't sleep well that it becomes a problem.
Steve:Oh, good overview. Thank you. We've spoken about this whole idea of sleep aging. What is that? How do we age in our sleep?
Dr. Mander:Yeah.
Steve:However we describe that.
Dr. Mander:Yeah. So before I get into the details about that, I just want to preface it with this one important thing, which is that not everybody ages the same way. We see this in how different people have more or fewer problems with remembering things or thinking about things. The same is true for sleep. Not everybody ages the same in sleep. So if you think of sleep disturbance as people get older, it's not an inevitable destiny of aging. It's just something that we see commonly happen. But the typical pattern -now I'm going to start and focus on the adult lifespan, there's a lot of big changes in sleep that happen from being a newborn to being a young adult- but what we're thinking about, I think, in this podcast, is, how do you sleep when you're a young adult, versus how do you sleep when you are later on in life? And there are some clear signature changes you see in aging. One is you see that your sleep becomes more fragmented. You wake up a lot, right? You have a harder time sleeping all the way through the night, typically. That's a very common change with aging. Another is the depth of your sleep, how deeply you sleep, especially for that non rapid eye movement deep sleep, that becomes less prevalent and it becomes shorter in duration as you get older. In addition to that, there's a variety of different forms of sleep disturbance, or sleep disorders that can be more prevalent as you get older. For example, one of the more common sleep disorders in the population overall is insomnia, which is a difficulty in falling asleep, staying asleep, or you wake up before you want to wake up, or you find your sleep nonrestorative, and have daytime dysfunction. That is a very common problem that happens in the population, and the prevalence of that goes up as you get older. Another sleep disorder -particularly in men, that's very common- is something that so many of the listeners may have heard of, it's called sleep apnea. So this is a problem where you have pauses in your breathing at night because of changes in your airway and your ability for your muscles to stay open and keep your throat open, or you have your tongue collapse your airway. This leads to kind of repeated periods of use, pausing your breathing, which leads to repeated periods of your brain saying, "Wake up! I want to breathe." And you have your sleep becomes more fragmented, and in addition to that, you basically intermittently starve your body of oxygen. So this becomes more prevalent as you get older, as well. There's a number of other sleep disturbances that can become more prevalent. One is called restless leg syndrome, where you feel a creepy crawly feeling in your legs, and you have to kind of settle yourself, or rub your legs, where you can lie down. Another one, which is more rare, but it can be a sign of a risk of certain types of dementias or certain types of degenerative diseases is called REM sleep behavior disorder, which is when you act out your dreams while you're asleep, and that's an early sign of something that's coming. So those can increase in prevalence with age, though some are more specifically tied to disease than others. The good news for many of these is they're modifiable, and that's kind of really the hopeful part of that.
Steve:What about gender differences?
Dr. Mander:Yeah.
Steve:You mentioned men are women just naturally better sleepers than- I've always thought so. But ...
Dr. Mander:In some cases yes, some cases no. So unfortunately, both men and women sleep gets worse with age. They just seem to do so in different ways. So women are more likely to have insomnia complaints as they get older. Men are more likely to have sleep apnea complaints as they get older. However, when women experience sleep apnea, it's not the same way that men do, and the normal predictors, like weight gain or signs or risk factors that you would see that would predict sleep apnea in men as they get older is not as predictive in women. And women tend to experience sleep apnea in a different way. They are more likely to have pauses in breathing during their REM sleep than their non REM sleep, and because we spend most of our sleep in non REM sleep, it can look like they don't have a lot of events. And one of the things we're finding in our recent studies, and a bunch of other labs around the world are finding, is that when your events happen in REM they might be more likely to cause problems in your brain and problems with remembrance. And so we think women are being overlooked, and that we need to make sure that they get supported in better screening for sleep apnea.
Steve:Great.
Dr. Mander:sex differences. Women keep their deep sleep longer than men do throughout their lifespan. That's something that's been known, which is very nice. I wish I could do that.
Steve:So why is sleep so crucial for older adults who are at risk for Alzheimer's?
Dr. Mander:That's a great question. So there's a number of reasons, but I think the biggest reason is that there's a lot of evidence now to suggest that multiple different forms of disturbed sleep, including the presence of sleep disorders like insomnia or sleep apnea or disruptions in deep sleep, tend to be predictors of increased risk for developing dementia later on in your life. And in fact, there is one sort of real, important landmark study that was done out of NYU that showed that if people were diagnosed with sleep disordered breathing, they could end up with dementia 10 years earlier than if they weren't. But the good news in that study was that if they were treated for it, they weren't getting it early. This shows that there could be a big effect of sleep disorders on dementia risk, but that if you treat the sleep disorder, you can reduce that risk, and that is a really important part of that. Now we need larger scale studies to truly prove that, but that was a really nice piece of evidence that sort of blended the idea to this could be a modifiable effect.
Steve:Okay.
Dr. Mander:In addition to that, there's also evidence that if you sleep well, if you have other risk factors, like genetic risk factors for dementia, but if you can still sleep well, those genetic effects are minimized. And so it could be thought of as sleep could be sort of a factor that can kind of make you resilient against the oncoming risk for dementia. So those are two different reasons why I think it's important. There's other research that suggests that certain biological properties of sleep may actually help your brain clean itself and get rid of dementia proteins and pathologies. And that story is evolving, and it's very complicated, but the bottom line is that there's evidence that this sort of like biological process, where you kind of clear out toxins and waste from your brain, is maximally operating during sleep, especially deep sleep.
Virginia:Are you okay with medicines, sleeping pills? Are
Dr. Mander:That's a great question. It's also become a you okay with those? complicated question. So many of the sleep aids that are approved for things like treating insomnia symptoms or treating sleep problems are sedatives, and they change the way your brain expresses sleep. And there's some evidence that some of them might actually interfere with how sleep supports the functions of sleep, for example, that brainwashing sort of cleaning waste. There's recent evidence actually just published this year that suggests that one of the more common sleep aids that is used, Ambien, might actually disrupt the brain's ability to clear waste from itself. On the other hand, there are different kinds of medications that target different receptors in your brain that have been showed to actually reduced Alzheimer's pathology, at least in animal studies. Now we need to see what this looks like in humans, but it might be the answer to your question is it might depend on the person, it might depend on the specific medication, and that is really for someone who's thinking about taking sleep medications, that's really a conversation between them and their doctors to make the best decision for them, because I think sometimes these really important sleep aids are really good for a lot of other reasons. But depending on the context, are they high risk for dementia? Do they have other comorbidities
Virginia:So there's studies right now on new drugs? that has to come into the discussion?
Dr. Mander:Yes, right now, there's multiple different classes of new drugs, but one of the newer ones is this thing called a Dora drug, and it's basically, I'll explain what it means. It's kind of technical, but basically it targets receptors in your brain that are sensitive to a neuromodulator or chemical, a neurochemical called orexin, or another name for it is hypocretin. When this becomes elevated, you have more insomnia-like symptoms and the brain regions that express this, what they do is they determine whether your brain goes into sleep or stays awake, and they sort of support sustained wakefulness. So when they're over activated, they can make you more awake. And so these drugs are different from things like Ambien, because those target receptors that are actively involved in the expression of brain waves during sleep, so it sort of like hijacks your brain and forces it to express those brain waves. And that's sort of what a sedative state looks like, whereas in this it's sort of like acting on the switch between sleep and wake and saying, let's keep you asleep instead of going to wake. And so drugs that target that have been exciting to a lot of sleep clinicians, because it's an alternative pathway to target where you might not be altering the way the brain expresses sleep. Might just be determining the propensity to sleep or not. These drugs have been studied in the context of Alzheimer's, and there's been some promising results on it.
Virginia:So interesting.
Steve:Dr. Mander, I think what you're saying here is there's a lot going on, and before you do anything, it's important, probably to talk to your physician and possibly get a sleep study done. I just had one done. So after we're done, we're going to talk about it. But anyway, is that what you're saying? I mean, because they shouldn't be diagnosing themselves.
Dr. Mander:That is absolutely correct. Steve, yeah. So these always have to be conversations between the individual patient and their doctors, because the context really matters. And sometimes certain medications may be better to use than others, and in some contexts, maybe even not using drugs, but using another approach might be better. For example, if you have sleep apnea, giving a drug isn't the best approach. Giving sort of a pap mask or something else might be better. The context of insomnia, their behavioral interventions, the first line treatment, cognitive behavioral therapy for insomnia, is the first line treatment. So that should be discussed, probably first, but that, again, depends on the patient and the doctor and they really that's where the conversation needs to happen.
Steve:You're talking about kind of REM sleep. I think that's the phrase I've always heard being a non expert on sleep, especially a lot of sleep, and I've always heard that it was most important. But in our conversation, you really talked about some other forms of sleep that are as beneficial, if not more beneficial. So could you talk a little bit about the different kinds of sleep?
Dr. Mander:Yeah. So there are two different types of sleep your brain has. There's non rapid eye movement sleep, and there's rapid eye movement sleep, or non REM and REM sleep. Now when people think of REM sleep, that's where you think of as the state where you have your dreams, right? Well, it turns out you can actually dream in any of your stages of sleep, but the dreams that involve, sort of the emotional narrative, that involve you being the center of the story, that involves sort of bizarre logic, that's sort of like a REM. Non REM dreams, which can happen in the lightest stages all the way to the deepest stages, are more like you're passively viewing something. So the physiology of these two states of being, of non REM sleep and REM sleep are fundamentally different. And what I mentioned a couple of times, it's possible. I talked about deep sleep. I was actually not talking about REM sleep. I was talking about the deepest form of non REM sleep. This is called slow wave sleep. This is the form of sleep where that brain wave clearance system is most active. It's not most active in REM sleep it's most active in non REM sleep. And some of the evidence is suggesting that if you have decreasing amounts of that deep, slow wave sleep that specifically might increase your risk for dementia later on, and that is specifically a state where the brain is consolidating memories as well. So the other aspect of this is that it's not just a singular stage that matters. It's how your brain expresses sleep overall that matters. And going between non REM and REM sleep in cycles is actually fundamentally important. And part of the biology of how sleep should happen, and some of the disturbances you see with aging is that that cycling gets disrupted a little bit, and those cycles aren't as expressed as well. That's another part of that's important too. It's not just that this stage is better than that stage. They're all important for their own things. Now, REM sleep does disappear pretty dramatically in the context of neurodegenerative diseases, and that's a big warning sign in some cases, but it also supports a lot of important bodily functions, emotional regulation, also helps support memory as well, and they both kind of support body function, hormone regulation. So they're all important, but deep, slow wave sleep, that deep, non REM sleep is really important as well.
Steve:Well done, Doctor of Sleep.
Dr. Mander:Thanks. I'll create a badge for myself.
Steve:You know, now we're caregivers. Let's move to the caregiving function, and one of our loved ones isn't getting enough sleep. It's obvious. What are tips as something that they could be doing that they should be conscious of? I've heard dark rooms and things like that, but maybe you could go through some tips. I think is a good way for the caregiver to help somebody who's not getting sleep.
Dr. Mander:Yeah, sure. So there's a phrase that I'm going to use to start it off. It's a something that's called sleep hygiene, which is a phrase that describes basically, behaviors you can engage in to kind of maximally support better sleep. Now, some people with sleep disturbances still do all of these kinds of things I'm about to recommend, but still have sleep problems, and I think when you're at that stage, then I think that's when you really need to talk to your doctor, or you're caregiving with someone and they're having sleep problems despite doing these types of behaviors, that is really when the conversation needs to happen with the doctor, because there may need to be a disorder, may need to be diagnosed and treated, or there may be another approach needs to be taken. But in terms of sleep hygiene, some of the big recommendations are definitely have sort of like you said, a cool, dark environment you sleep in, not cold, not freezing, but cool, right? Because part of what your body does is it reduces its temperature at night while you're sleeping, if it's a warm environment, it's harder to sleep. You want it to be quiet. You want it to be dark. You want it cool. Before you go to bed, you want to engage in relaxing behaviors, especially if they're routines you can engage in every night to kind of build up this routine of this is my night time ritual, and that shouldn't include listening to an angry political pundit right before bed. That will activate you and make your sleep much worse and there's a tendency for that to happen. The other thing that really can be helpful is, you know, when you get up and try to get up at the same time every day, if you can, or at least within sort of an hour period of that don't wildly change your wake up times, and try not to widely change your bedtimes too. But really wake up times are really important, and when you get up in the morning, one of the best things you can do for yourself is just go outside and just enjoy and soak up that sun. There is no better way to align your sleep patterns with the environment, than to use the sunlight, which is the most powerful cue in the environment that you can have to tell your body this is what time it is. This is when I should be awake. And then you get two benefits from that. One benefit you get is aligning your body clock with the environment. The other is just bright light improves your mood. It makes you more alert. It's a good way to kind of start the day. So those are some other tips. Try not to have caffeine late at night. Usually we recommend avoiding caffeine before three or before noon, because caffeine has a long half life. I know there's a lot of promotion for caffeine being good for your brain and memory and the Alzheimer's sphere, but when you have that caffeine really matters, and so having it late at night can make it hard to fall asleep and disrupt your sleep at night. Also, don't take alcohol at night caps. I know that seems like, oh, it knocks me out, makes me fall asleep. That actually disrupts your sleep, because if you have that alcohol, it may help you sedate you put your brain into a sedation state, which is less like true kind of restorative sleep, and then it clears out your body in the middle of the night, totally fragments and disrupts your REM sleep, which is more prevalent at the second half of. So those are things to avoid there. When you eat, it's better to front load rather than end load your calories for sleep and health in general. So have a bigger lunch than dinner, for example. Eat a healthy diet that can help with your sleep, be active and exercise during the day, when you can just not right before bed. You can exercise for much of the day, and it can help improve your sleep. So there's a lot of these kinds of tips that you can do. Another one that I like suggesting is in the middle of the night, a lot of people, as they get older, have to get up and go to the bathroom, and that's okay. Three times, four times and the problem is not
Steve:No. That doesn't happen. that you get up to go to the bathroom. The problem more becomes if you have trouble falling asleep again. So if you're somebody who wakes up four times a night and goes the bathroom, don't worry about dementia. That's not going to cause dementia. But one of the things that I think is really helpful in the sort of that tip environment is have a warmer colored night light don't have a white night light. Don't have a blue night light or a green night light. Try to do something yellow, orange or red, because your body clock is very sensitive to green, blue light. And if you have light in the middle of the night, you can completely shift your body clock, but it's blind to red light. It's blind to warmer colors in general. So I would sort of ease towards that color to kind of avoid the green light. The other thing is, there's a lot of apps on phones now, and some where you can actually add a blue green filter so you don't expose yourself late at night to bright light before you go to bed. That's another good tip. Really try to limit that light. Are you suggesting like turning on your computer and sitting there and watching or reading or whatever else with your laptop or your iPad is not a good idea in bed.
Dr. Mander:That's absolutely true. That's exactly what I'm suggesting.
Steve:Okay.
Dr. Mander:It'll keep you up more. I also think watching Netflix until five in the morning is probably not best.
Steve:The obvious, yes, okay. Okay, so let's shift from talking about the patient or the loved one, let's talk about the caregiver. What kind of recommendations to getting in terms of the proper kind of sleep or caregiver?
Dr. Mander:That's a great question. Yeah, sleep is important for everybody, and that includes the caregiver. Now caregivers are faced with so much physical, emotional strain and stress, constantly trying to manage all the different things need to be done to take care of somebody, and often there's a lot of pressure to not focus on the health of the caregiver themselves because they're too busy caregiving somebody else, but the ability to kind of last as a caregiver, the ability to have a healthy life, the ability to just be able to cope and maintain your sense of sanity. Taking care of yourself and getting good quality sleep is an important part of that. If you have too little sleep or disrupted sleep, that can disrupt your ability to cope with the stresses, cope with the physical strains, and you'll be less able to carry on the different burdens that you have as a caregiver. So it's fundamentally important for any caregiver to prioritize getting their own sleep. And there's actually even evidence that one of the biggest predictors of people having patients with dementia being institutionalized was nighttime, this activity of that patient disrupting the sleep and the welfare and the quality of life of the caregiver, because it's already so hard to take care of people during the day, if you can't sleep at night, that's just beyond human capacity.
Virginia:My friend and neighbor is going through that now because she's caring for her husband, and she wakes up at night and he's pacing. He's all mixed up between days and nights. I'm worried for her.
Dr. Mander:Yeah, no, it's really tough.
Steve:Yeah. I think that leads us into just the whole concept of getting help, talking about help here in terms of how you do better sleep. But when you get to these stages as a caregiver, this is when you need outside help, whether it's somebody who's coming into your home that takes the night and you take the day, or whether it's a community situation which you find yourself needing to use, whatever it may be, but you've got to take care of yourself, as you said, because you can't care for somebody, if you can't care for yourself.
Dr. Mander:That's right. Can I just say... Just want to make a supportive plug that it is wonderful to seek out respite care help when you can. If you qualify for that, you're not failing, you're not being weak. You're just doing what you need to do to better support yourself and the person you're taking care of. That's why those services exist, and I cannot endorse them enough.
Virginia:Very important.
Steve:So if you had to sum up a big topic into a couple of key thoughts for caregivers and their loved ones. What would it be?
Dr. Mander:I would say, don't ignore sleep and sleep disturbances that you have. If you're having trouble sleeping, if it's affecting your ability to stay awake during the day, if you find yourself falling asleep all the time, or if you find yourself feeling like you have a fog during the day, there may be an underlying sleep disturbance, and it's worth talking with your doctor about it, because sleep disturbances can contribute to the problems that you're going through as a caregiver and as a patient. It's easy to think of it as, "Oh, I have this sleep problem. Oh, my God, I'm going to get dementia right and be scared." That creates a form of insomnia, which has led many people to seek care for insomnia. It's more that there's help out there, and whatever you can do to kind of be healthier, to be more relaxed, to be feel more supported, to feel like you have the energy to participate in life, the better for you. And one of those things is to kind of if you have a sleep disturbance, have it treated, because it's modifiable and the benefits are real, and so it's worth having that conversation. I know the masks are really uncomfortable for those people who have sleep apnea and don't want to go see a doctor for it, but the risks are really real too, and other alternatives might work for you, other than the mask. So this is why it's important to talk to your doctors about it, see what your options are.
Steve:That's terrific. I just like to thank you for an awesome discussion Dr. Sleep.
Dr. Mander:Dr. Sleep. I love it. I love it.
Steve:Well, you did a great job of keeping this on a plane that I think the rest of us non PhDs can understand and appreciate, and I think you touched on some wonderful things.
Dr. Mander:Thank you.
Virginia:Thank you for joining us today.
Dr. Mander:It was an honor. And you guys are wonderful. What you're doing is so important. And I just wanted to thank you for having me on to be part of that mission of just sort of educating people about how to manage such an important issue. It's the challenge of the century, I think the public health challenge of the century. And you know, anything we can do to help people, it's so important, communication and education is a pillar of that.
Steve:Spotlight on Care is produced by the University of California Irvine, Institute on Memory Impairments and Neurological Disorders (UCI MIND). Interviews focus on personal caregiving journeys, and may not represent the views of UCI MIND. Individuals concerned about cognitive disorders, prevention, or treatment should seek expert diagnosis and care. Please subscribe to the Spotlight on Care podcast. Wherever you listen for more information, visit mind.uci.edu.
