The sentence worth listening to carefully
"She's not sleeping, so we've started her on something to help her settle." It sounds like care, and often it is. But before accepting it, ask the question almost nobody asks: why is she not sleeping?
Because in the great majority of cases, an older woman who does not sleep in aged care does not have a sleep disorder. She has a daily routine that makes sleeping at night close to impossible.
What her night actually looks like
Ask for the night notes for the past week. Not somebody's impression — the notes. Then check four things, which usually explain the whole thing.
What time she is put to bed and what time she is woken. In many homes residents are settled at half past seven and woken at six, not because they want to be but because it fits the shift change. Ten and a half hours in bed is too many for anyone: sleep fragments, and at three in the morning she is awake. That is not insomnia. That is arithmetic.
How often her door opens. Night checks are necessary, but a torch in the face every two hours wakes anybody. Ask whether her checks can be spaced differently, or done without the overhead light.
How much she sleeps during the day. If she spends the afternoon dozing in a chair in front of the television, the night is lost before it starts. Daytime inactivity and lack of daylight are the commonest cause and the least treated — half an hour outside in the morning does more than any tablet, and in most of this country there is no season in which that is impossible.
Noise. Trolleys at six, call bells, a television at the nurses' station, doors. Visit once at six in the morning: twenty minutes there teaches you more than three meetings.
The fifteen-hour fast
This is the calculation almost nobody does, and it often explains everything on its own. If tea is at half past five and breakfast is at half past eight, that is fifteen hours without food. An older person wakes in the small hours hungry, with a dry mouth, and — if she is diabetic — sometimes with a low blood sugar.
The answer is not a sleeping tablet. It is a supper before bed and something reachable overnight. Food, drink and the dining experience now sit within the strengthened quality standards as an area providers answer for in their own right, which gives you standing to raise it as more than a preference. While you are there, ask what time her diuretic is given: moving it to the morning removes half the night-time trips to the bathroom.
What should be ruled out first
- Pain. The commonest cause and the most missed, especially in someone who can no longer say so. Ask which observational pain tool is used, what she gets and when.
- Needing the toilet. Afternoon diuretics, urinary infection, prostate — all treatable.
- Breathlessness lying flat, which points to heart failure rather than insomnia.
- Restless legs, common in older people and rarely diagnosed.
- Depression. Early-morning waking is a classic feature and is treated differently.
- Her current medicines. Several disturb sleep, and a pharmacist medication review is the place to raise it.
The number you can look up
Here is something specific to this country. Residential aged care providers report a set of mandatory quality indicators, and use of psychotropic medications is one of them. That means the rate at which a home medicates residents is measured, reported and compared — it is not a matter of impressions.
So two questions become answerable: what proportion of residents here are on a psychotropic, and how does that compare? A home that knows its own number and can talk about it is in a different position from one that has never looked.
On the pharmacology: in older adults benzodiazepines and Z-drugs consistently increase the risk of falls, hip fracture and next-day confusion. The rule is constant — non-drug measures first, then the lowest dose for the shortest time, with a review date rather than a permanent line on the chart.
Three questions if it has already started:
- What exactly is she on, at what dose, and since when?
- Who prescribed it, and when is the review? Without a date, a "short-term" prescription lasts years.
- Has gradual withdrawal been considered? It is possible, it is slow, and it is never something a family should attempt alone.
One clarification: medication given to sedate rather than to treat is a restrictive practice with its own authorisation and reporting requirements — a separate and more serious subject. If that is what has happened rather than a sleep aid, treat it as a different conversation.
Six questions to ask
- What time is she put to bed and woken, and who decided that?
- How many hours between tea and breakfast, and is supper offered?
- How often does her door open at night?
- Has her pain been assessed, and when does she get analgesia?
- What time is her diuretic given?
- What is this home's psychotropic use indicator, and what is she on?
If you get nowhere
Put it in writing to the facility manager, asking that bedtime, waking time, supper and the timing of the diuretic go into her care plan. None of it costs money, and in the plan it becomes checkable. If the concern is the prescribing, the GP is the person to ask, directly rather than through the home.
If that does not resolve it, the Aged Care Quality and Safety Commission takes complaints from family members, including anonymously, and clinical care and dignity are squarely within what it assesses. Free independent advocacy is available through the national aged care advocacy network.
Where to start
Do one thing this week: ask what time she is put to bed. If the answer is "about half seven", you already have the explanation for why she is awake at three — and a change to ask for that needs no prescription at all.
If you would rather not run it alone, we can. For A$109 we take down your mother's situation, look for the homes in your area that answer these questions properly, and report back what they told us, with names and dates. Start here
This article is for information and does not replace the advice of the clinicians caring for your mother. No medicine should be stopped or changed without the prescriber: withdrawal of a sleep medicine is done gradually and with supervision. Reporting requirements and indicators change over time: check the current position with the provider. Curalune does not allocate beds and does not guarantee availability.