Chapter 10: Sleep, Rest and the Shape of the Day

A Common Situation

A man in his sixties has been looking after his mother for several months. During the day she dozes in her armchair after breakfast, again before lunch and for a long time in the afternoon. In the evening she becomes restless, walks from room to room and asks more than once when they are going home, although she is at home. At night she wakes two or three times, calls out and sometimes tries to get dressed in the dark. Her son lies awake listening for her footsteps. By the end of the week both of them are tired in a way that one good night cannot fix, and the son begins to wonder whether something is wrong with his mother or with the way he is caring for her.

Nothing in this situation is anyone's fault. Sleep often changes in later life, and the shape of the day has a great effect on the shape of the night. In this chapter I explain the usual changes in sleep that care textbooks describe, and how a gentle daily rhythm can help both the body and the mind know when it is time to be awake and when it is time to rest. We will look at evenings and nights, at safety when the person wakes in the dark, and at the activities that make a day feel worth living. At the end we will come back to the carer, because the carer's sleep matters just as much as the sleep of the person being cared for.

How Sleep Changes in Later Life

Sleep is not one smooth state from evening to morning. It moves in cycles through lighter and deeper stages, with short moments close to waking in between. Care textbooks explain that with age the deep stages often become shorter and the light stages longer. This means that an older person may wake more easily, from a noise, from a full bladder or from a small discomfort, and may wake several times in one night. Many older people also feel sleepy earlier in the evening and wake earlier in the morning than they did when they were younger. These changes are common and are part of usual aging. An older person still needs real rest, but the rest may come in a different pattern from before.

Several everyday things can make sleep lighter still. The need to pass urine at night becomes more common with age, and getting up in the dark breaks the night into pieces. Aches in the joints, a cough, feeling too hot or too cold, or a bed that is hard to turn over in can all wake a person. Worry plays its part too: a person who is lying awake thinking about money, health or a loss may find that sleep does not come back easily. Drinks with caffeine late in the day, such as coffee and some teas, keep many people awake. A good first step is simply to notice which of these things seem to touch the person you care for, without trying to solve everything at once. Writing down for a week when the person went to bed, when the person woke and what seemed to cause the waking often shows a pattern that was hard to see from day to day.

Daytime naps are a natural part of life for many older people, and a short rest after lunch can be refreshing. The textbook advice is about balance. A short nap, taken in the early afternoon, usually does little harm to the night. Long naps, or naps late in the afternoon or early evening, can take away the sleepiness that the person needs at bedtime. A common moment is when a person dozes in front of the television for most of the afternoon simply because there is nothing else to do. In that case the answer is often not to forbid the nap, but to offer something more interesting to do, a short walk, a visitor or a task to share, so that rest becomes a choice rather than the only thing left.

Some changes in sleep are worth telling a doctor or nurse about. If the person you care for snores very loudly and seems to stop breathing for a moment during sleep, if the person is very sleepy during the day even after a full night, if pain or breathing trouble keeps the person awake, or if the pattern of sleep changes suddenly over a few days, it is worth mentioning at the next appointment, or sooner if you are worried. A sudden change in sleep together with sudden confusion needs a prompt call to the doctor or nurse. Questions about medicines and sleep belong with the doctor and the pharmacist, who know the person's whole situation and can explain what is safe.

It also helps to remember that a person who wakes at night is not necessarily suffering. Some older people are content to lie quietly, think, listen to the radio softly, and fall asleep again later. Many carers say that they used to worry each time they heard movement, until they learned that their father or their wife was simply awake and calm. The goal is not a perfect night by a younger person's standard. The goal is enough rest for the person to feel comfortable during the day, and enough safety at night for everyone to sleep with a quieter mind.

A Gentle Rhythm for the Day

The body has an inner clock that follows the cycle of day and night. Light, activity, meals and company all help to set that clock. When the days are all the same, with dim rooms, no fixed times and long hours in one chair, the inner clock loses its markers, and sleep can drift across the whole day and night. Care textbooks therefore suggest a gentle daily rhythm: getting up at about the same time each morning, eating meals at regular times, being active in the day and winding down in the evening. This is not a strict timetable. It is more like a familiar path through the day that the person can follow without thinking too hard about it.

Morning light is one of the strongest signals for the inner clock. Opening the curtains soon after waking, having breakfast near a bright window or sitting outside for a while in the morning can help the body understand that the day has begun. Many older people spend most of their time indoors, where the light is much weaker than outside even on a cloudy day. If the person can go out safely, a short walk, a few minutes on a balcony or a cup of tea on a bench by the door can all make a difference. If going outside is hard, a chair placed by the brightest window is a simple start.

Activity during the day helps the night as well. This does not need to be exercise in a formal sense. Walking to the kitchen to help make lunch, watering plants, folding laundry, standing up and sitting down a few times during the morning, or moving the arms and legs gently while seated all count. The amount should suit the person's strength, and the ways of moving safely are described in Chapter 6. What matters here is that the body has done something during the day, so that by evening it is ready to rest.

Meals at regular times give the day its shape, too. Breakfast says that the morning has begun, lunch marks the middle of the day, and an evening meal that is not too late and not too heavy prepares the body for night. A large meal just before bed can make sleep uncomfortable for some people. Drinking enough during the day is important for health, and many families find it helpful to offer most drinks in the morning and afternoon, with a smaller drink in the evening, so that the need to pass urine at night is reduced without the person going thirsty. Drinks with caffeine are best kept to the earlier part of the day.

The evening is the bridge between the day and the night, and a calm routine helps the person cross it. The same small steps each evening, such as closing the curtains, changing into night clothes, washing the face, a warm drink without caffeine, a little quiet music or a short conversation about the day, tell the mind that bedtime is near. Bright screens and loud, exciting programmes late in the evening can keep a person alert. The bedroom itself should feel safe and pleasant: not too hot, not too cold, with a comfortable bed, a familiar blanket and enough darkness for sleep, but with a soft light available for the moment the person needs to get up.

A rhythm works best when it is built around the person's own habits rather than around a rule from a book. Someone who has always been an early riser may be happiest up at dawn, while someone who has always gone to bed late may feel pushed if bedtime is suddenly brought forward. Ask the person, or family members who know, how the days used to look: when the person liked to wake, what the first drink of the day was, whether there was a walk after dinner or a favourite evening programme. Keeping these familiar pieces gives comfort, especially to a person whose memory is changing. On days when the rhythm breaks, after a hospital visit, a family celebration or a bad night, there is no need to worry. Simply return to the usual pattern the next day, gently and without fuss.

Evenings, Nights and Safety

Many families notice that the late afternoon and evening are the hardest part of the day. As the light fades, some older people, and especially people living with dementia, become more confused, anxious or restless. They may walk about, look for someone, want to leave the house or insist that they must go home, as the mother in our opening situation did. Care textbooks describe this as a common pattern. Tiredness at the end of the day, fading light that makes shadows confusing, a noisy household as everyone comes home, hunger or the need to use the toilet can all add to it. Seeing it as a pattern, rather than as the person being difficult, helps the carer stay calm.

There are gentle ways to soften the evening. Turning on the lights before it gets dark, closing the curtains so that the dark windows do not reflect strange shapes, and keeping the house quiet at this time can all help. A simple, familiar activity in the late afternoon, such as sorting a drawer together, looking at photographs or listening to well-loved music, gives the restlessness somewhere to go. When the person says "I want to go home", it often means "I want to feel safe and comfortable". Answering the feeling, with a calm voice, a hand to hold and words such as "You are safe here, I am with you", usually works better than arguing about where home is. Correcting the person again and again tends to raise the worry rather than calm it.

Waking at night is common, and the main concern is safety. The path from the bed to the toilet should be clear, with no loose rugs, cables or shoes on the floor. A night light in the bedroom, the hallway and the bathroom lets the person see the way without being dazzled by a bright ceiling light. The bed should be at a height that lets the person sit with feet flat on the floor before standing. Some families keep a commode, the toilet chair described in Chapter 9, near the bed for the night, so that the walk is shorter. The ways to make the whole home safer are explained in Chapter 5. If you are thinking of adding anything to the bed itself, such as side rails, ask a nurse or therapist first, because what helps one person can be risky for another.

When the person wakes confused in the night, a calm and gentle response is the first step. Turn on a soft light, use the person's name, say who you are and where the person is, and speak slowly. A short trip to the toilet, a sip of water, straightening the blankets or sitting together for a few minutes is often enough for the person to settle again. If the person wants to get dressed or start the day, it can help to say kindly that it is still night and that you will have breakfast together when it is light. A clock that clearly shows whether it is day or night can be useful for some people. Try to keep your own voice low and slow, even when you have just been woken yourself, because the person often takes the mood from you.

Some people living with dementia get up at night and try to go out of the house, and this is a real worry for families. Simple steps help: keeping the outside doors locked in a way the household has agreed on, while making sure that everyone in the home can still get out quickly in a fire, keeping keys out of the person's sight, and making sure the person carries something with a contact address when going out during the day. Some families use a soft chime on the bedroom or front door so that they hear when the door opens. Talk about these questions with the person's doctor or nurse, who can help you think about what is right for your home. If the person has left the house and cannot be found, call the emergency number without delay.

Days That Feel Worth Living

A good night often begins with a day that had some meaning in it. Care textbooks speak of meaningful activity: things that the person enjoys, that fit who the person has been and that give a sense of being useful, connected or simply happy. For one person this may be cooking, for another gardening, mending, reading the newspaper aloud, singing, praying, drawing or caring for a pet. The question is not "What will keep the person busy?" but "What has this person always cared about, and how can a small part of it still be part of the day?" Asking the person, and listening to the stories of earlier life, is the best way to find out.

Old skills are often kept long after other abilities change. A woman who cooked for a large family may no longer manage a whole meal, but she may peel vegetables, stir a pot or tell you exactly how much salt to add. If the whole task has become too much, break it into small parts and offer one part at a time. A man who worked with his hands may enjoy sanding a piece of wood, sorting screws or tightening a loose handle. Small tasks around the home, such as folding towels, laying the table, matching socks or watering plants, give a sense of contribution. It does not matter if the task is done perfectly. What matters is that the person is doing it with you, and that you thank the person for the help.

Music has a special place in many homes. Songs from a person's youth are often remembered clearly, and listening to them, humming along or tapping a rhythm can lift the mood and bring back memories that can be shared. Time outdoors is valuable too: the feeling of air and sun, the sound of birds, the sight of neighbours passing by. A short trip to a park, a market or a place of worship, if the person enjoys it and it can be done safely, can give the whole day a brighter colour. Activities should be offered as choices, never forced, and it is fine to try something else when one idea does not work.

Boredom and loneliness are among the quiet difficulties of later life. When friends have died or moved away, when hearing or sight make conversation tiring, and when going out has become hard, the days can feel empty. A person who is lonely may sleep more in the day, eat less or seem low in spirits. Regular contact makes a real difference: a phone call from a grandchild at the same time each week, a neighbour who drops in for tea, a visit from an old friend, or time at a day centre if the person would like it. The kinds of outside help that can bring company into the day are described in Chapter 14. Even a few minutes of real attention, sitting down together and listening without hurry, can matter more than a long visit spent in another room. If low mood lasts for weeks, it is worth telling the doctor.

Finally, the carer's own sleep. Many carers sleep lightly, always half listening, and some are woken several times every night. Over weeks and months this kind of broken sleep wears down patience, health and good judgement. It is not selfish to protect your own rest; it is part of caring well. Small steps help: going to bed early on some nights, a short rest of your own while the person naps, asking another family member to take one night a week, or using a simple sound monitor so you can sleep in another room and still hear if you are needed. If your own sleep has become very poor, tell your own doctor. Chapter 12 comes back to this.

A Question to Think About

When you picture a good day for the person you care for, from waking up to going to sleep, what small moment in it would that person most enjoy? You might ask the person directly, or think about it quietly and then try adding that one moment to the day this week.