Improving Sleep in Dementia

By Deborah Bier

For many people living with dementia, a good night’s sleep is difficult to achieve. There are many reasons why poor sleep and dementia go hand-in-hand, such as brain changes due to dementia, disordered breathing and environmental factors.

One common factor that disturbs sleep is the need to use the toilet during the night and being unable to get back to dreamland. This can result in far too little sleep night after night. It often affects the sleep of family members who live with the person with dementia as well.

Toileting at night disturb sleep in various ways, including:

  • Inability to find the bathroom
  • Inability to find the toilet in the bathroom
  • Inability to find the way back to bed
  • Using the wrong type of light (blue-white instead of amber-white)[1]
  • Insufficient lighting
  • Something upsetting happens during the trip to/from the bathroom
  • Sundowning that continues through the night, exacerbating all the above

Effective environmental and behavioral interventions can address – and even prevent – some of the problems above. These require a good understanding of how the person with dementia perceives their world. Here are two solutions to use in any household or facility.

First, let me introduce you to Esther and her daughter, Andrea. Esther lives with her daughter. Esther has dementia that has progressed to mid-stage or beyond. Every night when Andrea goes to bed, she wakes Esther to toilet after about two hours of sleep. Esther can still toilet herself, and Andrea is wise enough to allow her the dignity to do so on her own.

However, some nights, Esther would scream in distress and run out of the bathroom, saying someone was looking at her through the window. Andrea would check the window but could find nothing. Not surprisingly, it was difficult for them both to calm down enough to get a good night’s sleep, and they ended up awake until dawn.

What Andrea found out is people with dementia might not recognize themselves in a mirror. They forget how old they are. Since their memories of their youth are clear while later ones are not, they may think of themselves as still young.

Esther was catching sight of herself in the bathroom mirror. She thought the elderly woman was someone else and the mirror was a window through which she was being watched. Understandably, this upset her greatly.

Once Andrea understood her mother’s mistaken perception, she saw how Esther’s conclusions were entirely logical. From then on, Andrea covered the mirror on the medicine cabinet with a beautiful, calming landscape painting. It looked as if it were a view from a window. As a result, the nighttime bathroom terror episodes immediately stopped and never returned.

Unfortunately, many family and professional caregivers do not recognize this source of such nighttime frights. In another setting, Esther might have been diagnosed as hallucinating. She might have received antipsychotic medication for hallucinations that did not exist. Considering the “black box warning” on these drugs states they cause an increased mortality risk for elderly people with dementia-related psychosis, it is worthwhile to avoid such medications whenever possible.[2]

The second intervention requires another story. Harry still lived at home on his own, despite his dementia. At night, Harry would wake up to toilet and would get lost in the house looking for the bathroom. Some mornings, his son, Samuel, would visit and find Harry had urinated into a large potted plant kept near a window in the bedroom hallway. Harry would have no recollection of doing this.

One night, Samuel stayed over and awoke to the sound of his father stumbling through the house in the dark. “Dad, turn on some lights,” he suggested. However, in his sleepy confusion, Harry couldn’t find any light switches. The delay in finding the bathroom resulted in a loss of bladder control. Harry was terribly embarrassed at wetting himself in front of his son and couldn’t get back to sleep for a long time.

In the morning, Samuel went to the hardware store and bought some LED rope lights and some motion-activated light switches. He set these up in the hallway between Harry’s bedroom and the bathroom to automatically switch on as Harry came by.

Samuel purchased two to three times the number of lights he would need himself. The reason for this is people with dementia need light two to three times brighter than normal household lighting to function at their best.[3] Samuel also made sure to select amber-toned white light, and not blue-white light, because blue-white light disrupts sleep and should not be used in late evening or at night.

Samuel also moved the potted plant downstairs, so it would never be confused with a toilet again. Harry could now easily find the bathroom at night, he could get back to sleep without incident and the potted plant thrived.

By understanding how their parents perceived their world, Andrea and Samuel put changes in place that allowed their loved ones to function better. Many such simple interventions to help sleep and reduce nighttime disturbances will be reviewed in the MHAN presentation at AiA18 about “Dementia and Sleep.”

Learn more at AiA18 at the ASA Mental Health and Aging Network (MHAN) session,“Dementia and Sleep,” scheduled for Tuesday, March 27 from 3 to 4 p.m.

Deborah Bier, PhD, is director of special populations at ComForcare/At Your Side Home Care. She has been a psychotherapist and home care agency director of care for over 25 years. She holds a doctorate in therapeutic counseling, a certificate in gerontology, and is a Certified Alzheimer’s Educator, Dementia Practitioner and Dementia Care Partner.

[1] Hatori, M., Gronfier, C., Gelder, R. N., Bernstein, P. S., Carreras, J., Panda, S.,…& Tsubota, K. (2017). Global rise of potential health hazards caused by blue light-induced circadian disruption in modern aging societies. Npj Aging and Mechanisms of Disease, 3(1).

[2] Yan, J. (July 18, 2008). FDA extends black-box warning to all antipsychotics. Psychiatric News. Retrieved February 19, 2018 from

[3] Raia, P. (Fall, 2011). Habilitation therapy in dementia care. Age in Action, (25)4.