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 a care home 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 records for the past week. Not somebody's impression — the records. 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 people are settled at half past seven in the evening and woken at half past six, not because they want to be but because it fits the shift pattern. Eleven 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 main 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.
Noise. Trolleys at six, buzzers, 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 hypnotic. It is a supper before bed and something reachable overnight. It is a concrete request, it costs almost nothing, and it can be written into her care plan. While you are there, ask what time her diuretic is given: moving it to the morning rather than the afternoon removes half the night-time trips to the toilet.
What should be ruled out first
- Pain. The commonest cause and the most missed, especially in someone who can no longer say so. Ask whether pain has been assessed with an observational tool, and 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 it is treated differently.
- Her existing medicines. Several disturb sleep. A structured medication review is part of the answer, and in a care home you can ask for one by name.
If a tablet is still on the table
There are situations where treatment is reasonable, and this is not an argument against it in principle. It is about knowing what you are agreeing to.
In older people, benzodiazepines and Z-drugs consistently increase the risk of falls, hip fracture and next-day confusion. That is why guidance is consistent: non-drug measures first, then the lowest dose for the shortest time, with a review date — not a permanent line on the medication chart, which is what usually happens.
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 review date, a "short-term" prescription lasts years.
- Has gradual withdrawal been considered? It is possible, it is done slowly, and it is never something a family should attempt alone.
One thing this article is not about: antipsychotics prescribed for distress in dementia are a separate and more serious question, with their own rules and their own risks. If that is what has been started rather than a sleeping tablet, 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 are there 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?
- If she is on something for sleep: what, since when, and when is it reviewed?
If you get nowhere
Put it in writing to the manager, asking that bedtime and waking time, a supper, and the timing of the diuretic be recorded in her care plan. That is where these things become checkable, and none of them costs money. If the concern is the prescribing, the GP practice covering the home is the route, and asking for a structured medication review is a reasonable, specific request. If the home cannot explain why an eighty-eight-year-old is in bed for eleven hours, that is a dignity and quality-of-life issue for the Care Quality Commission, and it is worth raising at the residents and relatives meeting, because it is never only her.
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 do it alone, we can. For £69 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 hypnotic is done gradually and with supervision. Curalune does not allocate beds and does not guarantee availability.
