Why they are awake: find the cause, then the fix
The short answer
- For one week, write down the clock time of every waking. (Each cause has its own hour.) The log.
- Check for pain at bedtime with a 5-point face-and-body check. (They may have no words for pain.) Pain.
- Ask about every pill: "Could this be keeping them up?" (Often the fix is a different time of day.) Medicines.
- Sudden change, fever or new confusion? Call the doctor today, before any of this. The signs.
Time of waking: what it points to
| When they wake | What it points to | First check |
|---|---|---|
| Can't settle in the first hour | Restless legs, pain lying still, a late steroid or decongestant, worry, cold feet, hunger | Legs, pain, pill times, feet |
| 2 to 4 hours after bed, with a big pee | Fluid from swollen legs, an evening water pill, or apnea | Ankles, water pill, snoring |
| 4 to 6 hours after a bedtime painkiller | The dose wearing off | A longer-lasting form |
| Sweaty, shaky or confused, on insulin or a diabetes pill | Low blood sugar | Night lows |
| Every 15 to 30 minutes, all night | Sleep apnea | A sleep study |
| Acting out dreams, mostly late in the night | A dream disorder, or a medicine | Safety tonight, the pill list |
| Up for good at 4 or 5, low all day | Low mood, an early chill, or too early a bedtime | Mood, warmth, bedtime |
Pain they cannot put into words
- Score pain at bedtime for 3 nights. Watch 5 minutes; score each 0 to 2: breathing, moaning or calling out, frowning, a tense body or clenched fists, whether you can comfort them. (The PAINAD scale: 1 to 3 is mild, 4 to 6 moderate, 7 to 10 moderate to severe.)
- A still, quiet person can still be in pain. (In nursing homes, residents with pain slept more, not less.)
- Ask about regular pain relief, not "only if needed". (Regular treatment, mostly acetaminophen, cut agitation by 17% in a 352-person trial.)
- Waking 4 to 6 hours after the bedtime dose? Ask about a longer-lasting form. (Swallow the 8-hour form whole. No more than 4,000 mg a day from everything, "PM" and cold products included.)
- No bowel movement in 3 days? Call the nurse. Daily: a toilet sit after breakfast, a low stool under their feet. (A blocked bowel may show only as confusion.)
Up at night to pee: which cause
| Sign | Likely cause | Fix |
|---|---|---|
| Swollen ankles by supper | Leg fluid turns into urine once they lie flat | Feet up an hour mid-afternoon. Ask a nurse about daytime compression stockings. |
| A water pill taken in the evening | The water pill | Take it in the morning |
| Snores, and pees at night | Apnea makes the body pass more water | A sleep study before any bladder pill. CPAP cuts night trips. |
| Leaking started after the memory pill | Donepezil can cause frequent peeing | Tell the doctor before any bladder pill |
| Fever, new pain on peeing, or new confusion | A real infection | Call the doctor today. After 65, do not trust a urine dipstick alone. |
Why we say this: a bladder pill like oxybutynin works against donepezil and can add confusion and falls.
- Stockings are not for poor circulation, numb feet, or someone who cannot say "too tight". (In a 34-person pilot, night trips fell and unbroken sleep rose by about 48 minutes.)
- On a prostate pill? Sit on the bed edge before standing. (It can drop blood pressure.)
- Don't wake them to change a pad. An overnight brief and barrier cream at bedtime; change only for skin risk or a soaked bed. (In nursing homes, 87% of pad changes were linked to waking.)
Restless legs: it can look like sundowning
- Watch their legs for 20 minutes before bed: rubbing a leg or the feet together, kicking, a "gas pedal" foot, crossing and uncrossing, fidgeting, up soon after lying down.
- Ask for a morning iron test, and ask about the number 75. (Sleep doctors: iron if ferritin is 75 or less. A "normal" result can still mean treat. Don't start iron alone.)
- Check the pill list for triggers: antihistamines and "PM" pills, many antidepressants, mirtazapine, anti-nausea pills like metoclopramide, antipsychotics.
- At home: a warm bath or heat pad, a walk, rubbing the legs.
- Medicine needed? Ask about the 2025 trial. (Gabapentin enacarbil added about 48 minutes of sleep; falls may rise. Sleep doctors now advise against routine ropinirole or pramipexole.)
Sleep apnea: snoring, gasps, pauses
- Snoring, gasps or pauses? Ask for a home sleep study. (Night peeing, morning headaches and dry mouth are signs too. People with Alzheimer's had 5 times the odds of apnea.)
- CPAP can work in dementia. Practice with the mask by day, and treat low mood alongside. (People with Alzheimer's used it 4.8 hours a night on average. Daytime practice: our reasoning.)
- New opioid, Valium-type pill or gabapentin? Listen for new snoring or pauses.
- CPAP a no? Ask about a dentist-fitted mouthpiece, and try side sleeping.
Acting out dreams
- Punching, kicking or shouting in sleep, eyes closed, easy to wake? (REM sleep behavior disorder, tied to Lewy body dementia and Parkinson's. Eyes open and walking point to confusion instead.)
- Tonight: pad the nightstand, clear what could be thrown, a soft mat by the bed. Call their name from across the room; don't grab. (Severe? Sleep apart.)
- Ask if an antidepressant could be causing it, then tell the doctor. (SSRIs are most often named. Melatonin or clonazepam have a conditional role; clonazepam can cause unsteadiness.)
Bed temperature
- Feel their feet and neck, not the thermostat. (Cold feet keep them up; a damp neck means too warm.)
- Warm footbath 1 to 2 hours before bed, 10 minutes or more, no hotter than 104°F (40°C) by thermometer.
- Loose bed socks, and a light layer that stays on through the early hours. (In a lab study, gently warming older sleepers' skin cut the chance of early-morning waking from 58% to 4%.)
Hunger and low blood sugar at night
- On insulin, glipizide, glyburide or glimepiride? Ask about night lows, looser targets and a glucose sensor. (In older adults, 56% of lows came at night and only 9% were noticed.)
- Early supper, up for the kitchen at night? A small bedtime snack. (Coughing soon after lying down may be reflux instead: then no food 3 to 4 hours before bed.)
Medicines and their timing
Ask the doctor or pharmacist before changing any time. (Memory pills raise the odds of insomnia by about half, donepezil more than galantamine.)
| Medicine | Ask about |
|---|---|
| Donepezil, with bad dreams or poor sleep | A morning dose. The NHS allows it; the US label says evening. |
| Galantamine, long-acting form | It is a morning pill |
| Steroids such as prednisone | With breakfast |
| Bupropion | Not near bedtime |
| Sertraline | Morning is an option |
| Decongestant cold pills | Last dose several hours before bed, or skip them |
| Beta blocker, with nightmares or poor sleep | The timing or the drug; some lower the night sleep hormone |
| Levodopa, with new nightmares or hallucinations | Tell the neurologist. The label says a lower dose may help. |
Why we say this: in a small trial of beta-blocker users, melatonin added 36 minutes of sleep.
New problem after a new pill? Ask, "Could the last pill have caused this?"
Worry and low mood
- Clinging and restless at night? Treat the worry: your calm voice, a familiar object, the same ritual. (In 153 people with Alzheimer's, worry, not sadness, predicted waking the carer.)
- Plan one small pleasure every day. (It probably eases low mood in dementia. Two common antidepressants did no better than dummy pills in a 326-person trial.)
Hearing and seeing at night
Glasses and hearing aids in one spot by the bed. Put them on when they wake scared.
Vitamin D, B vitamins and the gut
Blood tests to ask for, Dr Stasha Gominak's approach, ReCODE's targets and the safety limits are on their own page: Vitamins and sleep.
The one-week waking log
Log 7 nights, then test one fix at a time for 3 to 5 nights.
Each night: one line per waking
- Time
- The clock time
- Doing
- "Rubbing legs", "needed toilet", "looking for Mom"
- Pee
- Yes or no; big or small
- Settled
- Toilet, water, snack, painkiller, blanket, your voice
- Body
- Cold feet? Damp neck?
- Breathing
- Record 10 minutes on a phone at midnight and 3am
Each day: once
- Legs
- 20 minutes watching before bed
- Pain
- The 5-point score at bedtime
- Bowels
- Yes or no
- Ankles
- Swollen at supper?
- Pills
- Every dose and its clock time
- Meals
- Supper and last drink times
- Mood
- Low, clingy, worried?
- Day
- Naps, time outdoors, sugar readings
What to say to the doctor
Bring the log and every pill bottle. Over 7 nights they woke [number] times, mostly around [time]. Each time they [needed to pee / rubbed their legs / acted out a dream]. Pain score at bedtime: [score]. Here is every medicine and when they take it. What could be causing this, and what one thing should we try first? Then ask for the blood tests.