The Link Between Sleep and Dementia

Getting a good night’s sleep can become more difficult for people living with dementia. Changes to the brain can affect a person’s normal sleep pattern, while confusion, anxiety and physical health problems can also make it harder to settle at night.

An individual may begin waking frequently in the night, sleeping for longer during the day or becoming increasingly restless in the evening. These changes can be difficult for the person experiencing them and exhausting for family members who are providing care.

Although sleep problems are common in dementia, they should not simply be accepted as something that cannot be helped. Understanding what may be affecting someone’s sleep and making a few changes to their routine can sometimes make nights more comfortable.

How Does Dementia Affect Sleep?

Dementia can affect the body’s internal clock and disrupt the normal sleep-wake cycle. As a result, someone may find it harder to distinguish between daytime and nighttime, alongside:

• Have difficulty falling asleep.
• Wake frequently during the night.
• Wake very early in the morning.
• Sleep for long periods during the day. This is particularly common with dementia with Lewy bodies (DLB), Parkinson’s disease dementia, and late-stage Alzheimer’s disease.
• Become more active at night.
• Confuse night and day.
• Become restless or anxious in the evening.

Some people also experience sundowning, a pattern where confusion, anxiety, or agitation becomes more noticeable later in the afternoon or evening.

Sleep problems can be particularly difficult when someone becomes awake and confused during the night. They may not understand why everyone else is asleep or may believe that they need to get up and continue with their normal daytime routine.

What Sleep Problems Can Be Caused by Dementia?

Insomnia

Insomnia refers to a range of issues with falling and staying asleep, all of which result in poor-quality sleep. This is common for people with dementia as they usually suffer from pain or discomfort, anxiety or depression, other health (heart or lung) conditions that affect their sleep separately, and take medications that can cause insomnia. Many medications prescribed to improve other dementia symptoms, such as donepezil, rivastigmine, or galantamine, have insomnia listed as a potential side effect.

While insomnia can be treated through medications that promote easier sleep, they often increase the risk of dizziness and falls, which is unsuitable for many older people.

Sleep Apnoea

Sleep apnoea is the most common sleep-disordered breathing condition, which affects someone’s ability to breathe normally while sleeping. Over time, this can cause drowsiness, low mood, headaches and progression of other dementia symptoms. This is more likely for those with Alzheimer’s disease and vascular dementia.

Sleep-disordered breathing can be treated using a Continuous Positive Airway Pressure (CPAP) mask; however, those with advanced dementia may not be able to tolerate wearing this throughout the night.

Restless Legs Syndrome

Restless legs syndrome causes pain or discomfort and a strong urge to move their limbs randomly. This can occur during the day but is more common at night, especially for those with DLB or Parkinson’s disease dementia. The risk of having restless legs syndrome may be increased by health conditions such as arthritis, diabetes, thyroid disorders, kidney problems and iron deficiency, alongside taking anxiety and depression medication.

However, there are a range of treatments and lifestyle changes that can reduce the symptoms of restless legs syndrome, such as exercising during the day, using heat pads on your legs at night, acupuncture and avoiding caffeine, alcohol, smoking and eating a big meal late in the day. There are also available medications, such as pramipexole, ropinirole and rotigotine. However, these drugs may make hallucinations or delusions worse in people who have existing psychotic symptoms.

Periodic Limb Movement Disorder

Often occurring alongside restless legs syndrome, periodic limb movement disorder causes unconscious and repetitive limb movements during sleep. This movement wakes the individual, leading to poor-quality sleep. It can be caused by antidepressants, allergy medications, anti-sickness drugs, and antipsychotics.

Medication is not usually used to treat this condition unless it is very severe, in which case the treatment is similar to restless leg syndrome.

Rapid Eye Movement (REM) Behavioural Sleep Disorder (RBD)

Usually, our muscles are paralysed during sleep. Those with REM Behavioural Sleep Disorder, however, physically act out their dreams during REM sleep. This may entail moving their limbs, falling out of bed, or waking up suddenly. This will lead to the person feeling exhausted during the day without memory of the dream or what they were doing. It often begins developing years before a dementia diagnosis.

RBD can be treated using melatonin and clonazepam, but clonazepam may worsen other dementia symptoms alongside causing drowsiness during the day.

Why Is Good Sleep Important?

Getting enough sleep is important for physical and emotional wellbeing. Poor sleep can leave someone feeling tired, irritable, and less able to concentrate during the day. For someone living with dementia, tiredness can also make existing confusion or changes in behaviour more noticeable. This can create a difficult cycle where someone sleeps during the day because they are tired, but then struggles to sleep again at night.

This does not mean that poor sleep causes dementia; however, it can worsen symptoms and conditions related to dementia progression.

Tips for Better Sleep With Dementia

There is no single routine that will work for everyone. However, there are a range of lifestyle and routine changes that you can make to support better sleep for those with dementia.

Keep a Consistent Routine

Try to keep waking, mealtimes, activities, and bedtime around similar times each day. A familiar routine can provide reassurance and make it easier for someone with dementia to understand what is happening throughout the day. This doesn’t mean every day needs to run to the same schedule, but aim for enough consistency that your loved one knows what to expect.

Encourage Natural Daylight

Spending time in natural daylight can help reinforce the difference between daytime and nighttime. Where possible, encourage your loved one to spend some time outdoors or in a bright area during the day. This will encourage them to feel tired during the evening.

Encourage Gentle Activity During the Day

Gentle physical activity and social interaction can help someone stay engaged during the day and may reduce the amount of time they spend sleeping. This could include walking, gardening, gentle exercise, hobbies or taking part in social activities. If your loved one needs to nap, shorter or earlier naps may be less likely to interfere with nighttime sleep.

Create a Relaxing Bedtime Routine

A familiar routine before bed can help signal that the day is coming to an end. This could be as simple as reading, having a warm drink, and watching a familiar TV show. Avoid making bedtime feel like a strict rule. If your loved one is not tired at the usual time, forcing them to go to bed may create unnecessary frustration. A calm and familiar routine is more important than following an exact time.

Make Their Bedroom Comfortable

Small changes to the bedroom may make it easier for your loved one to settle and move around safely at night. Check that the bedroom is a comfortable temperature and that bedding is suitable. Reduce unnecessary noise and make sure there is enough low-level lighting for your loved one to see where they are going if they wake during the night. Nightlights or other appropriate low-level lighting may also make it easier for someone to find their way to the bathroom without becoming disoriented.

Keep Evenings Calm

A busy environment can be particularly tiring or overwhelming towards the end of the day, when someone with dementia may already be feeling tired or confused. Reducing background noise, turning down the television and avoiding too many activities at once can create a calmer environment.

If your loved one becomes particularly unsettled in the evening, think about what tends to happen around this time of day. A change in routine, hunger, tiredness or an overly busy environment could be contributing to their distress.

Avoid Caffeine, Alcohol and Smoking

Alcohol may make it easier to initially fall asleep, but it will reduce the quality of sleep throughout the night. Caffeine is a stimulant that reduces tiredness and, alongside alcohol, increases the number of times a person will wake up to use the toilet. Nicotine also reduces feelings of tiredness and can also increase heart rate, which will make falling asleep much more difficult.

For more information, Dementia UK published a great resource for those struggling with sleep and dementia.

What If Someone Wakes During the Night?

Waking during the night can be particularly confusing for someone with dementia. If your loved one gets up and seems unsure about what is happening, try to remain calm. Rather than immediately telling them that they should be asleep, reassure them and find out whether they need anything. They may need to:

• Use the toilet.
• Have a drink.
• Have something to eat.
• Adjust their bedding.
• Be reassured that they are safe.
• Have some help getting comfortable again.

For example, your loved one may wake at 2 am convinced that they need to get ready for work. Repeatedly telling them that they no longer work may only make them more confused or upset. Instead, calmly reassure them and gently redirect their attention towards something relaxing.

If this happens regularly, keep a note of when they wake and what happens beforehand. You may begin to notice a pattern that can help you understand what is disturbing their sleep.

When Should You Speak to a Healthcare Professional?

A change in sleep behaviour should not automatically be assumed to be part of dementia. A sudden change can sometimes be linked to another problem, such as pain, an infection, dehydration, anxiety or a medication side effect.

Speak to a GP or healthcare professional if your loved one’s sleep changes significantly or you are concerned about their health. It is particularly important to seek advice if they are experiencing frequent nighttime falls, significant daytime sleepiness, new or worsening confusion, breathing difficulties during sleep or behaviour that has become difficult to manage safely.

Finding the underlying cause may help improve their sleep rather than simply trying to manage the symptoms.

How Can a Care Home Support Better Sleep?

Moving into a care home will not necessarily solve someone’s sleep problems overnight. However, having staff available throughout the day and night means that changes in sleep can be monitored and supported.

A personalised care plan can record a resident’s usual bedtime, sleeping habits and preferences, as well as anything that tends to disturb their sleep. Staff can then use this information to create a routine that feels familiar.

Staff can monitor nighttime waking and look for patterns. If someone regularly becomes unsettled at a particular time, understanding what happens beforehand may help identify potential triggers.

Family members can contribute too. Information about a loved one’s previous routines, favourite music, usual bedtime and anything that makes them feel comfortable can help staff create a more familiar evening routine.

Supporting Better Sleep

Sleep problems can be one of the more difficult parts of caring for someone with dementia, particularly when they regularly wake during the night or become unsettled in the evening.

A regular daytime routine, natural daylight, gentle activity and a calm bedtime can all help, but what works for one person may not work for another. Pay attention to your loved one’s habits and look for anything that seems to make their sleep better or worse.

Try to remember that nighttime restlessness is not deliberate. If someone is confused or repeatedly getting out of bed, they may be frightened, uncomfortable, or simply unsure of what is happening.

If their sleep becomes increasingly difficult to manage, don’t be afraid to ask for help. A GP or other healthcare professional can help identify possible causes, while additional care and support may make nights safer and less exhausting.