Improving sleep quality in people over 65 comes down to a handful of evidence-based strategies: establishing consistent sleep and wake times, reducing exposure to blue light in the evening, limiting naps to 20-30 minutes before 3 p.m., managing medications that disrupt sleep, and addressing underlying conditions like sleep apnea or restless leg syndrome. A 72-year-old with mild cognitive impairment, for example, who begins going to bed and waking at the same time every day — even on weekends — often sees measurable improvements in sleep continuity within two to three weeks, without any medication changes.
These adjustments matter especially for brain health, because disrupted sleep accelerates amyloid beta accumulation, a hallmark of Alzheimer’s disease. This article covers why sleep changes with age, which behavioral and environmental strategies work best, how medications interact with sleep in older adults, the specific risks of sleep deprivation for dementia and cognitive decline, and when to seek professional evaluation for a sleep disorder. It also addresses common misconceptions — including the mistaken belief that needing less sleep is a normal part of aging.
Table of Contents
- Why Does Sleep Quality Decline After Age 65?
- What Sleep Hygiene Strategies Actually Work for Older Adults?
- How Does Sleep Deprivation Affect the Aging Brain?
- Medications, Supplements, and When They Help or Harm
- Identifying and Treating Sleep Disorders Common in Older Adults
- Environmental and Lifestyle Factors That Support Better Sleep in Older Adults
- Looking Ahead — Sleep as Preventive Medicine for Brain Health
- Conclusion
- Frequently Asked Questions
Why Does Sleep Quality Decline After Age 65?
Sleep architecture shifts significantly as people age. Older adults spend less time in slow-wave sleep (the deep, restorative stage) and more time in lighter sleep stages, meaning they wake more easily from noise, discomfort, or even a shift in room temperature. The circadian rhythm — the internal clock governing sleep-wake cycles — also advances with age, which is why many older adults feel sleepy earlier in the evening and wake earlier in the morning than they did at 40 or 50. This is not the same as needing less sleep; most adults over 65 still need seven to eight hours per night. Melatonin production also declines with age. The pineal gland produces less melatonin, and its release is blunted, meaning the body’s signal to wind down for sleep is weaker. Compare a healthy 30-year-old to a 70-year-old: the younger person typically experiences a sharp melatonin spike around 9-10 p.m.
that drives strong sleep onset, while the older person may see a flatter, earlier, and shorter curve. This makes the bedroom environment — darkness, temperature, quiet — more important with age, not less, because the hormonal signal alone is insufficient. Chronic conditions common in older adults compound the problem. Arthritis pain wakes people at night. Nocturia (waking to urinate) fragments sleep multiple times. heart failure and COPD cause breathing discomfort when lying flat. These are not inevitable facts of aging but treatable contributors that, when addressed, often restore much better sleep.
What Sleep Hygiene Strategies Actually Work for Older Adults?
The most effective behavioral intervention for chronic insomnia in older adults is Cognitive Behavioral Therapy for Insomnia, known as CBT-I. It outperforms sleep medications in head-to-head studies and produces durable results — meaning the improvements last after treatment ends, unlike with sedatives. CBT-I includes sleep restriction therapy (temporarily limiting time in bed to consolidate sleep), stimulus control (using the bed only for sleep and sex), relaxation techniques, and cognitive restructuring around unhelpful beliefs like “I’ll never sleep well again.” A meta-analysis published in Sleep Medicine Reviews found CBT-I produced significantly better outcomes than pharmacotherapy in adults over 60 across measures of sleep onset, total sleep time, and waking after sleep onset. However, sleep restriction therapy — a core component of CBT-I — is not appropriate for everyone. In people with bipolar disorder, sleep restriction can trigger manic episodes.
In those with severe sleep apnea, artificially restricting time in bed can increase the concentration of apnea events per hour. Anyone with these conditions should work with a clinician trained in CBT-I rather than attempting the protocol from a book or app alone. That caveat aside, for the majority of older adults with primary insomnia, CBT-I is the gold standard first-line treatment. Beyond CBT-I, basic sleep hygiene measures have meaningful but more modest effects. Keeping the bedroom cool (around 65-68°F), using blackout curtains, avoiding caffeine after 1 p.m., and limiting alcohol are all sensible and low-risk. Alcohol deserves special mention: many older adults use it as a sleep aid because it helps with initial sleep onset, but it fragments sleep in the second half of the night and suppresses REM sleep, resulting in worse overall sleep quality even if total hours appear adequate.
How Does Sleep Deprivation Affect the Aging Brain?
Sleep is when the brain clears metabolic waste through the glymphatic system — a network of channels that expands during sleep and flushes out proteins including amyloid beta and tau. Both are associated with Alzheimer’s disease pathology. Studies using cerebrospinal fluid analysis have found that even a single night of sleep deprivation raises amyloid beta levels in the brain measurably. Over months and years, chronic poor sleep appears to accelerate the accumulation of these proteins in ways that may hasten cognitive decline. A long-term study from the University College London, drawing on data from nearly 8,000 participants tracked over 25 years, found that people who consistently slept six hours or less per night at age 50, 60, and 70 had a 30% higher risk of developing dementia than those who slept seven hours.
This held true even after controlling for depression, physical health, and other confounders. The relationship is not simply that early dementia disrupts sleep — the data suggest poor sleep itself contributes to disease onset. For caregivers of people already living with dementia, sleep disruption creates a feedback loop. A person with dementia who sleeps poorly becomes more confused, agitated, and behaviorally difficult during the day. This is a common reason families report caregiver burnout. Addressing the sleep problem — through bright light therapy, structured activity schedules, and treating sleep-disordered breathing — can meaningfully reduce daytime behavioral symptoms, sometimes more effectively than medication adjustments.
Medications, Supplements, and When They Help or Harm
Prescription sleep medications require particular caution in adults over 65. Benzodiazepines (like temazepam and lorazepam) and Z-drugs (like zolpidem, sold as Ambien) are on the Beers Criteria — a list maintained by the American Geriatrics Society of medications considered potentially inappropriate for older adults. They increase fall risk, impair memory consolidation, and are associated with next-day cognitive impairment. Despite this, they remain widely prescribed because they work quickly and patients often request them. The tradeoff is real: short-term sleep improvement versus elevated risk of hip fracture, car accidents, and worsening memory. Low-dose melatonin (0.5 to 1 mg taken 60-90 minutes before the desired sleep time) is a safer option for older adults and is particularly useful for circadian rhythm disruption — the phase advance described earlier.
Higher doses, commonly sold as 5 mg or 10 mg, are not more effective and may cause morning grogginess. Most people take far more melatonin than needed. The goal is to supplement a depleted signal, not flood the system. Doxepin at very low doses (3-6 mg, brand name Silenor) is FDA-approved for sleep maintenance insomnia and works through a different mechanism than benzodiazepines — it blocks histamine receptors rather than GABA channels, and at these low doses does not carry the same anticholinergic burden as higher-dose tricyclics. It is a reasonable pharmacological option when CBT-I has been tried and has not fully resolved the problem, or when a patient is not a candidate for behavioral therapy due to cognitive limitations. Suvorexant (Belsomra), an orexin receptor antagonist, is another option with a more favorable side effect profile for older adults than benzodiazepines, though it remains expensive and less commonly prescribed.
Identifying and Treating Sleep Disorders Common in Older Adults
Obstructive sleep apnea is dramatically underdiagnosed in adults over 65, in part because the classic profile — a middle-aged overweight man who snores — does not describe many older women or thinner older men who also have the condition. In older adults, sleep apnea may present as insomnia, frequent nighttime awakening, morning headaches, or excessive daytime sleepiness rather than obvious snoring. A bed partner’s observation is helpful but not always available. Any older adult with unexplained cognitive decline, poor sleep despite good sleep hygiene, or persistent daytime fatigue should be evaluated with a sleep study. Untreated sleep apnea in older adults has serious consequences: it elevates blood pressure, increases atrial fibrillation risk, worsens glucose regulation in diabetics, and — critically for this population — is independently associated with faster cognitive decline and greater dementia risk. CPAP therapy, when tolerated, has been shown in studies to slow cognitive decline in patients with mild cognitive impairment and sleep apnea.
The limitation is adherence: many older adults find the mask uncomfortable or wake up having removed it in the night. Heated tubing, mask fitting by a respiratory therapist, and the newer APAP (auto-titrating) devices have improved adherence substantially. Restless leg syndrome (RLS) and periodic limb movement disorder (PLMD) also increase with age and are frequently missed. RLS causes an irresistible urge to move the legs, typically in the evening when sitting or lying down, temporarily relieved by movement. A person who reports that they “just can’t get comfortable” at bedtime and paces the hall before sleep may have undiagnosed RLS. Low iron stores are a reversible contributor — serum ferritin below 75 ng/mL in an RLS patient warrants supplementation before trying medication. Dopamine agonists are effective but carry a risk of augmentation (worsening of symptoms over time) with long-term use, a warning often not communicated to patients at the outset.
Environmental and Lifestyle Factors That Support Better Sleep in Older Adults
Light exposure is one of the most powerful and underused tools for improving sleep in older adults. Morning bright light — ideally 2,500 to 10,000 lux for 30 minutes shortly after waking — anchors the circadian rhythm and helps delay the phase advance that causes early-evening sleepiness and early-morning waking. In residential care settings, where older adults may spend most of the day in low-light interiors, this is a particular problem. A study conducted in Dutch nursing homes found that installing high-intensity lighting throughout common areas reduced agitation and improved nighttime sleep in residents with dementia after several weeks of exposure.
For older adults living at home, a light therapy lamp used during breakfast is a practical and inexpensive option. The same principle applies in reverse: reducing bright and blue-wavelength light in the two hours before bed helps support melatonin onset. Physical activity also improves sleep quality in older adults, with the strongest evidence for aerobic exercise performed regularly. A consistent finding is that both sleep onset latency and time awake after sleep onset decrease in older adults who exercise compared to sedentary controls. The timing matters less than many people believe — exercise in the late afternoon or early evening does not disrupt sleep for most people over 65 and may actually be preferable because it counters the post-lunch energy dip and provides a physiological drive toward sleep later that night.
Looking Ahead — Sleep as Preventive Medicine for Brain Health
The framing around sleep in older adults is gradually shifting from management of a symptom to preventive medicine for cognitive health. Research groups are actively investigating whether improving sleep quality in middle age and early older adulthood can meaningfully delay dementia onset or reduce its severity. Trials examining CPAP treatment in people with mild cognitive impairment and apnea, and trials of CBT-I in populations at elevated dementia risk, are underway. The hypothesis is that reducing chronic sleep disruption may slow amyloid accumulation enough to have clinically meaningful effects over a decade or more.
This has practical implications for healthcare conversations today. Sleep quality should be a routine part of cognitive health assessments in primary care, not an afterthought. Older adults who report difficulty sleeping should not simply be told it is a normal part of aging. A thorough evaluation — looking at sleep hygiene, medication side effects, mental health, pain, sleep-disordered breathing, and circadian factors — is an investment in long-term brain health, not just nighttime comfort.
Conclusion
Improving sleep quality in adults over 65 requires understanding that aging changes but does not eliminate the need for good sleep. The most effective approach layers behavioral strategies — particularly CBT-I — with careful medication review, treatment of underlying sleep disorders like apnea and restless leg syndrome, and environmental adjustments including consistent light exposure and a cool, dark bedroom. Low-dose melatonin has a role for circadian rhythm problems; sedative-hypnotics carry real risks and should be avoided or used only briefly and with clear informed consent about those risks.
The brain health stakes are high enough that this deserves serious attention. Poor sleep in older adults is not a minor quality-of-life complaint — it is a modifiable risk factor for cognitive decline and dementia. Families and clinicians who treat it accordingly, with the same seriousness as blood pressure or cholesterol management, are likely giving older adults one of the more meaningful protective interventions available.
Frequently Asked Questions
How many hours of sleep do people over 65 actually need?
Most adults over 65 need seven to eight hours per night. The common belief that older adults naturally need less sleep is incorrect. What changes is sleep structure and the ability to stay asleep, not the underlying requirement.
Is it safe to take melatonin every night?
Low-dose melatonin (0.5–1 mg) taken nightly appears safe for older adults in available research, though long-term safety data beyond several months is limited. It works best for circadian rhythm disruption rather than all types of insomnia. Higher doses sold over the counter are not more effective and may cause morning grogginess.
Can poor sleep cause dementia, or does early dementia just cause poor sleep?
Both are true. Early dementia disrupts sleep, but evidence from longitudinal studies also supports that chronic poor sleep — particularly short sleep duration — independently increases dementia risk. The relationship runs in both directions, which makes early intervention in sleep problems particularly worthwhile.
What should I do if my elderly parent refuses to see a doctor about sleep problems?
Start with non-medical changes: consistent sleep and wake times, morning light exposure, reducing afternoon naps, and limiting alcohol and caffeine. If these help only partially or not at all, frame the medical evaluation around a specific concern — daytime fatigue, memory issues, or fall risk — rather than sleep alone, which may be more motivating.
Are there risks to napping for older adults?
Short naps (20-30 minutes) before 3 p.m. are generally beneficial and do not impair nighttime sleep for most older adults. Long or late-afternoon naps can reduce sleep drive enough to significantly delay nighttime sleep onset or cause middle-of-the-night waking. People being treated with sleep restriction therapy as part of CBT-I are typically asked to avoid napping entirely during the initial phase.
When is a sleep study necessary?
A sleep study (polysomnography or a home sleep apnea test) is warranted when there is suspicion of obstructive sleep apnea — including unexplained daytime sleepiness, cognitive decline, witnessed apneas, morning headaches, or frequent nighttime waking — or when restless leg symptoms suggest periodic limb movement disorder. It is also indicated when standard behavioral treatments for insomnia have failed and the underlying cause remains unclear.
