Sleep problems in dementia

Many people living with dementia sleep poorly. They may wake again and again at night, get up and wander, or doze most of the day and stay awake all night. This is hard on the person and on the family member who is up with them.

Sleep problems are part of how dementia affects the brain, but some causes can be treated and steady daily habits often help. This page explains what to try first, what to know about light and medicines, and how to protect your own sleep.

What sleep problems look like

Sleep changes in dementia can take many forms. The person may:^2,3

• Take a long time to fall asleep, or wake many times during the night
• Wake very early and think it is time to start the day
• Get out of bed, pace, or try to leave the house at night
• Feel sleepy and nap a lot during the day
• Become more confused, restless or upset in the late afternoon and evening. This is called sundowning.

Mayo Clinic estimates that sleep problems affect up to 1 in 4 people with mild to moderate Alzheimer's disease, and about half of those with moderate to severe disease.³ The Alzheimer's Association notes that in the late stage, a person may spend about 40% of the night lying awake in bed.²

Day-night reversal

Some people end up with their days and nights fully flipped. They sleep through much of the day, then are wide awake and active at night.² Sleep doctors call a broken-up pattern like this an irregular sleep-wake rhythm. Sleep comes in short pieces spread across the 24 hours, instead of one long block at night.⁷

Why it happens

No one fully understands why dementia disturbs sleep. Experts think the brain changes of dementia upset the body clock.^1,2 The body clock (also called the circadian rhythm) is the inner timer that makes us sleepy at night and alert in the day. When it falters, the person may feel tired during the day and wide awake at night.¹

Other things often add to the problem:^1,2,3

• Normal aging. Many older adults sleep less deeply and need a little less sleep. See sleep in later life.
• Too little daylight and activity. Long days indoors with little to do give the body clock few clues about the time.
• Tiredness and overload at the end of a busy day.
• Dim light and shadows, which can be confusing or frightening.
• Body needs such as pain, hunger, thirst, constipation, or a full bladder. See bladder and bowel problems.
• Other sleep disorders, such as sleep apnea (breathing that stops and starts during sleep) and restless legs. Sleep apnea is more common in Alzheimer's disease.³
• Depression, which often disturbs sleep. See apathy and depression in dementia.
• Medicines. Some antidepressants can keep people awake. Memory medicines called cholinesterase inhibitors, such as donepezil, can cause trouble sleeping, especially if taken near bedtime.^2,3
• Caffeine, alcohol and nicotine.

Lewy body dementia: acting out dreams

In Lewy body dementia and Parkinson's disease, a problem called REM sleep behavior disorder is common. Normally, the body is briefly paralyzed while we dream. In this disorder, that does not happen, so the person acts out dreams. They may shout, punch, kick or jump out of bed, and can hurt themselves or a bed partner.^10,11

Safety steps help. Move sharp furniture and objects away from the bed, pad the floor beside it, and consider sleeping in separate beds until it is treated.^10,11 People with Lewy body dementia can react badly to some sleep and behavior medicines, so choices should be made with a doctor who knows this condition.¹¹

First, check for causes you can fix

Talk with the person's doctor about any new or worse sleep problem. A good checkup looks for treatable causes before anything else.^2,3 Bring notes on when the person sleeps, wakes and naps for one or two weeks. A behavior diary works well for this.

Questions to raise with the doctor:

• Could pain, an infection, constipation or a bladder problem be waking them?
• Could they have sleep apnea or restless legs? Loud snoring, gasping, or kicking legs are clues.
• Could any medicine be keeping them awake? Is the timing of each medicine right?
• Could an over-the-counter sleep aid be making confusion worse? Many contain antihistamines like diphenhydramine. See medicines that can worsen memory.

Do not change the time or amount of any medicine on your own. Talk with the doctor or pharmacist before changing anything.

What helps: building a steady day and a calm night

Non-drug steps are the first choice for sleep problems in dementia.^1,2 Research on them is still limited. A 2023 Cochrane review (a careful summary of many studies) found that physical activity, social activity and programs that combine several steps may slightly improve night-time sleep. The evidence was low certainty, mostly from nursing homes.⁵

In the evening

• Serve the bigger meal at lunch and a lighter meal in the evening.¹
• Plan baths, outings and appointments for the morning or early afternoon, when the person is more alert.¹
• Keep the evening quiet. Turn down the TV and loud music, and try soft music, looking at photos, or reading aloud.^1,3
• Keep the home well lit until bedtime to reduce shadows.¹
• Ask the doctor or pharmacist about the best time of day for each medicine.^1,2

In the bedroom

• Keep the room at a comfortable temperature and keep screens out of it.^2,3
• Use night lights so the person can see where they are and find the bathroom.^2,3
• A favorite blanket or object may bring comfort.²
• If the person cannot sleep, do not keep them lying awake in bed. Use the bed mainly for sleep.²

These ideas overlap with the healthy sleep habits that help everyone.

When the person wakes at night

1. Stay calm and speak softly. Do not argue, even if you are worn out.^1,3
2. Check for a need. Are they in pain, too hot or cold, hungry, thirsty, or needing the toilet?³
3. Gently say it is night. For example: "It's still nighttime. Everyone is asleep. Let's rest."^1,3
4. If they want to walk, let them pace safely. Stay nearby. Never tie or hold the person down in bed.^1,4

Make the home safe for nights when someone may be up and about. Use night lights along the path to the bathroom, clear trip hazards and clutter, and keep windows locked.¹¹ If the person may go out, think about door locks or alarms. See making the home safer, preventing falls and wandering and getting lost. If the person leaves home and you cannot find them, call 911 right away.

Light therapy: what we know

Bright light therapy means sitting near a special light box, usually in the morning, to help reset the body clock.

The evidence in dementia is weak. A 2014 Cochrane review found light therapy did not improve sleep.⁶ The 2023 Cochrane review said its effect on sleep is still uncertain.⁵ The American Academy of Sleep Medicine gives light therapy a weak "suggest trying" rating for older adults with dementia and a broken sleep-wake pattern, based on very low-quality evidence.⁷ Limited research

If you want to try a light box, talk with the doctor first and follow their directions.³ Ask whether it is safe for the person, especially if they have eye problems. Read more on our bright light therapy page. Plain daylight outdoors is free and safe for most people, and a good place to start.^2,3

What about sleep medicines and melatonin?

Most experts advise trying non-drug steps first.^1,2 Sleeping pills carry serious risks for people with dementia. They can raise the risk of falls and broken bones, add to confusion, and make daily tasks harder.² The American Academy of Sleep Medicine strongly advises against sleep-promoting medicines for older adults with dementia and a broken sleep-wake pattern.⁷

• Melatonin. A 2020 Cochrane review found melatonin had little or no effect on sleep in Alzheimer's disease.⁸ The AASM suggests not using it by itself for this problem.⁷ It may still have a role in REM sleep behavior disorder.¹⁰ Limited research
• Suvorexant (Belsomra). This prescription sleep medicine blocks orexin, a brain chemical that keeps us awake. In a four-week study in people with mild to moderate Alzheimer's disease, it helped them sleep somewhat longer than a placebo (look-alike pill). In 2020 the FDA added those results to its label.⁹ Across studies, medicines of this type added about half an hour of sleep a night.⁸ Moderate evidence
• Other medicines such as trazodone have only small studies behind them.⁸ Antipsychotics carry an FDA boxed warning for a higher risk of stroke and death in older adults with dementia.²

If a medicine is used, the doctor usually starts low and goes slow, and plans to try stopping it once sleep settles.^2,3 Our page on sleep medicines in dementia covers each option in detail. Never give a sleep aid, even one sold over the counter, without asking the doctor or pharmacist first.⁴

Protecting your own sleep as a caregiver

Caring for someone who is up at night wears you down fast. Across several studies, about 7 in 10 caregivers of people with dementia report sleep problems, and about 6 in 10 sleep less than 7 hours a night.¹² In one large survey of California caregivers, about 4 in 10 said the person they care for wakes them at night. Those caregivers also had more signs of depression.¹²

Sundowning and night-time problems are also among the most common reasons families move a loved one into a care home.¹² Getting help is part of good care, not a failure.

For more support, see caregiver stress and burnout and caregiver training and support programs. Programs that teach caregivers new skills may also help the person living with dementia sleep a bit longer.⁵

When to get help

Call the doctor soon if:

• Sleep problems are new, getting worse, or wearing you down
• The person snores loudly, gasps or stops breathing in sleep
• You think a medicine may be affecting sleep or behavior⁴
• The person acts out dreams or has hurt themselves or someone else in bed¹⁰
• You think the person may not be safe at home at night⁴

Call the doctor the same day if confusion or sleepiness changes suddenly over hours or days.

Call 911 if the person is missing, has a serious fall, or if anyone is in danger.⁴

If you are a caregiver in crisis, and feel you might hurt yourself or the person you care for, call or text 988 to reach the Suicide and Crisis Lifeline any time, day or night. More options are on our get help now page.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.