Difficulty Sleeping in Dementia

Difficulty sleeping is common in people living with dementia. A person may have trouble falling asleep, wake frequently during the night, wake too early, sleep during the day and stay awake at night, or become restless or confused after going to bed.

Poor sleep can also make confusion, anxiety, irritability, hallucinations, and other behavioral symptoms worse.

The first step is to look for what may be interfering with sleep rather than assuming the person simply needs a sleeping medication.

First, look for common causes

Ask whether anything has changed recently:

• Is the person sleeping or napping for long periods during the day?
• Is there too little physical activity during the day?
• Is the person getting outside and exposed to natural daylight?
• Is caffeine, nicotine, or chocolate being used later in the day?
• Is the person drinking a lot of fluids in the evening and waking to urinate?
• Could pain, constipation, urinary infection, hunger, reflux, itching, or shortness of breath be interfering with sleep?
• Is the bedroom too hot, cold, bright, or noisy?
• Is the person anxious about being alone at night?
• Has there been a recent medication change?
• Could a medication be causing alertness or disturbing sleep?
• Does the person snore loudly, stop breathing, gasp, or choke during sleep?
• Does the person have an urge to move the legs or uncomfortable sensations in the legs at night?

A medication review can be particularly helpful because some medications can cause either insomnia or excessive daytime sleepiness.

Strategies that can improve sleep

Keep a regular daily schedule

Try to keep approximately the same times for:

• Getting up
• Meals
• Activities
• Exercise
• Going to bed

A predictable routine can help the body recognize when it is time to be awake and when it is time to sleep.

Encourage activity during the day

Regular daytime activity can help promote nighttime sleep. Walking, exercise, household activities, hobbies, social activities, and time outdoors can all be helpful.

Try to avoid spending most of the day in bed or in a chair sleeping.

Limit daytime naps

Long or frequent naps can make it much harder to sleep at night. If a nap is needed, try keeping it relatively short and earlier in the afternoon.

Get daylight during the day

Exposure to natural daylight, particularly earlier in the day, can help reinforce the body's sleep-wake rhythm.

Even sitting outside or near a bright window can provide useful daytime light.

Create a calming bedtime routine

About 30–60 minutes before bedtime, begin slowing things down.

Consider:

• Lowering the lights
• Turning off the television
• Playing quiet music
• Taking a warm bath or shower
• Reading something calming
• Having a familiar bedtime snack or drink, if appropriate
• Using the bathroom before bed

Try to make the routine the same each night.

Make the bedroom comfortable and safe

Keep the bedroom:

• Quiet
• Comfortable in temperature
• Dark enough for sleep but safe for nighttime movement
• Free of unnecessary clutter

A night-light may be helpful if the person becomes frightened or confused in the dark. If the person gets up during the night, make sure pathways to the bathroom are clear and well lit.

Avoid things that interfere with sleep

When possible, avoid:

• Caffeine later in the day
• Nicotine close to bedtime
• Alcohol as a sleep aid
• Large amounts of fluid immediately before bed
• Television or stimulating activities immediately before bedtime

If the person wakes during the night

Try not to turn nighttime waking into a prolonged period of activity.

Use a calm voice and briefly reassure the person. If they need the bathroom, help them and then return to the normal bedtime routine.

Avoid arguing about what time it is or repeatedly telling the person, “You need to go back to sleep.” This can increase frustration.

If the person is awake because they are frightened or confused, focus first on making them feel safe.

Should a medication be taken for sleep?

Generally we try to avoid this whenever possible. Many medications for sleep, even over-the-counter ones, can be sedating and contribute to fall risk. This is why any medication for sleep should always be discussed with their provider first prior to taking. Medication options for sleep are quite varied and usually tailored to the person's unique situation; they each have their own risk and benefit profile that should be discussed with the provider. We generally do not like benzodiazepines and “Z-drugs” in dementia.

Special Situations: When Hallucinations Interfere With Sleep

Hallucinations can become more noticeable or frightening at night, particularly when the environment is dark, quiet, or unfamiliar. If hallucinations are keeping the person awake, the goal is to reduce fear and distress rather than trying to convince the person that what they are experiencing is not real.

What to do

• Stay calm and reassuring. Speak slowly and use a calm tone. Let the person know they are safe and that you are there to help.
• Don't argue or try to prove the hallucination isn't real. Saying “There's nobody there” or “You're imagining things” can increase anxiety and make it harder to settle down.
• Acknowledge the person's feelings. You don't have to agree that the hallucination is real. For example: “That sounds frightening. You're safe, and I'm here with you.”
• Try redirecting attention. Once the person feels reassured, shift attention toward something familiar and calming, such as quiet music, a favorite television program, looking at photographs, or another soothing bedtime activity.
• Improve the environment. Shadows, reflections, and low lighting can sometimes make visual hallucinations worse. A soft night-light, reducing shadows, closing curtains, or removing reflective objects may help.
• Check whether something in the environment is triggering the hallucination. For example, a coat hanging on a door may be mistaken for a person, or reflections in a window or mirror may appear to be someone in the room.
• Don't force the person to stay in bed if they are frightened. If necessary, move to a familiar, comfortable area and allow the person to calm down before trying bedtime again.
• Use familiar routines. Following the same calming sequence every night can provide reassurance and reduce anxiety around bedtime.
• Consider whether the person is becoming more distressed when alone. If so, having a caregiver remain nearby for a short period while the person settles may be helpful.

If the hallucination is particularly frightening

If the person believes someone is in the room, trying to harm them, or otherwise feels unsafe, focus on reassurance and safety rather than correcting the belief.

For example:

Instead of: “Nobody is in the room. You know that isn't real.”

Try: “I understand you're worried. You're safe here. Let's sit together for a little while.”

If hallucinations are regularly preventing sleep, causing significant distress, leading to nighttime wandering or unsafe behavior, or have recently become much worse, discuss this with the person's healthcare professional. The clinician can look for factors that may be worsening hallucinations and determine whether treatment needs to be adjusted.

Special Situations: Questions to ask about REM sleep behavior disorder

Some people with dementia, particularly those with Lewy body dementia or Parkinson's disease dementia, have a sleep disorder called REM sleep behavior disorder (RBD).

Normally, the body is largely still during REM sleep even though the person may be having vivid dreams. With RBD, the person may physically act out those dreams.

Ask the person who sleeps nearby:

• Does the person talk, shout, scream, or laugh during sleep?
• Does the person appear to be acting out a dream?
• Do they punch, kick, grab, or swing their arms during sleep?
• Have they fallen out of bed?
• Have they accidentally hit or injured their bed partner?
• Does the person describe unusually vivid or frightening dreams?
• Do the movements seem to occur while the person is dreaming?
• Does the person suddenly sit up or jump out of bed while apparently still asleep?
• Has this happened repeatedly?

If the answer to several of these questions is yes, tell the person's healthcare professional. A formal sleep study (polysomnography) can confirm RBD. RBD is an important symptom to recognize because it is strongly associated with Lewy body disorders and may occur before other symptoms become obvious.

Safety if the person acts out dreams

If RBD is suspected:

• Remove sharp or dangerous objects from around the bed.
• Move furniture away from the bedside.
• Consider placing the mattress lower or using a padded area beside the bed if falls are occurring.
• Protect the bed partner from injury; in some situations, separate sleeping arrangements may be safest.
• Tell the healthcare professional about any injuries or dangerous nighttime behaviors.

Treatment may be available. Medication decisions should be individualized because sedating medications can increase problems such as confusion, dizziness, and falls in older adults.