Reconstructing Sleep and Stress Management Programs for People with Dementia

1. Introduction

Sleep disturbances in people with dementia—such as difficulty initiating sleep, nocturnal awakenings, and day–night reversal—and disruptions of circadian rhythms frequently lead to nighttime wandering, falls, and caregiver exhaustion. Through delirium and BPSD (including irritability, agitation, depression, and apathy), these disturbances readily precipitate acute exacerbations and hospitalization. These relationships can be conceptualized as a cascade (Figure 1), in which sleep and circadian disruption function as upstream destabilizing factors that, through nighttime confusion and stress-related BPSD, propagate sequentially to falls, delirium, emergency visits, hospitalization, and functional decline. The relationship between sleep and neurodegeneration is bidirectional, and disruption of sleep and circadian rhythms has been suggested to trigger symptom worsening (Musiek & Holtzman, 2016; Wang & Holtzman, 2020).

Similarly, the emergence and exacerbation of stress responses and BPSD accelerate cognitive and ADL decline, increase emergency visits and hospitalization, and lead to the addition or escalation of psychotropic medications—thereby elevating fall and delirium risk—and represent one of the most powerful drivers of increased medical and long-term care costs. Rather than being a direct expression of neurodegeneration per se, BPSD often emerge and worsen as reactions to physical discomfort, environmental changes, and interpersonal stressors, as summarized in multiple reviews and guidelines (Livingston et al., 2017; Kales et al., 2015). This framing aligns with the structure depicted in Figure 1, which conceptualizes sleep disturbance, physical discomfort, environmental factors, and inconsistent caregiving responses as interacting elements that amplify adverse outcomes including BPSD.

Accordingly, international guidelines position non-pharmacological interventions as the first-line approach for BPSD, with a focus on identifying causes and modifying environments and interactions (Livingston et al., 2017; Kales et al., 2015).

However, sleep hygiene and stress coping strategies often implicitly assume that individuals can understand instructions, monitor themselves, and flexibly adjust behavior. In dementia, impairments in attention, working memory, and executive function undermine these assumptions even at mild-to-moderate stages. As a result, theoretically sound interventions may fail to achieve sufficient adherence and dosage, producing an “implementation gap.” This pattern mirrors findings from the PrAISED trial in the exercise intervention field, where theoretically intensive interventions did not necessarily improve primary outcomes (Booth et al., 2018; Harwood et al., 2023).

Rather than interpreting this as evidence that sleep and stress interventions are ineffective, this paper reframes the problem as one of design mismatch and proposes a framework for reconstructing sleep and stress/BPSD management in a form that can function under the cognitive constraints of dementia.

2. Evidence Base for Sleep and Stress Management

2.1. Sleep and Neurodegeneration: Controlling “Conditions for Worsening,” Not Treatment

Sleep and neurodegeneration are bidirectionally linked: circadian and sleep-structure disruption are associated with neurodegenerative processes, while pathological progression further destabilizes sleep (Musiek & Holtzman, 2016; Wang & Holtzman, 2020). However, large-scale randomized controlled trials demonstrating that sleep interventions definitively slow disease progression after dementia diagnosis are not yet established. Clarifying this boundary is essential to avoid unrealistic therapeutic expectations.

Accordingly, the most defensible goal of sleep interventions is not halting pathology, but controlling “conditions for worsening” that precipitate nighttime agitation, delirium, falls, and hospitalization, thereby containing costs and preventing caregiving breakdown.

2.2. Stress, Emotion, and BPSD Management: Non-Pharmacological Interventions as First Line

BPSD readily emerge and worsen in response to physical discomfort (pain, constipation, dehydration, infection), sleep deprivation, environmental changes, and communication mismatches. Thus, management centers on iterative cycles of “cause exploration → non-pharmacological modification → evaluation” (Kales et al., 2015).

Prior research repeatedly emphasizes core elements of BPSD management: (1) systematic identification of physical and environmental triggers; (2) proactive removal of discomfort; (3) reassurance-oriented communication that avoids negation or correction; and (4) shared and standardized response strategies within care teams. Kales et al. conceptualize BPSD not as “symptoms” but as “meaningful behavioral responses,” and propose the Describe–Investigate–Create–Evaluate (DICE) framework as a first-line non-pharmacological approach (Kales et al., 2015).

3. Why Standard Sleep Hygiene and Stress Coping Often Fail in Dementia

3.1. Cognitive and Executive Constraints

Sleep diaries, stimulus control, staged behavior change, and selection of stress coping strategies all require self-monitoring, self-regulation, and planning. In dementia, these cognitive resources are constrained, rendering even “correct” interventions ineffective through reduced adherence.

3.2. Nighttime Problems as Environmental Design Issues, Not Patient Effort

Nighttime awakenings and agitation are difficult to control by patient intention alone. Inconsistent caregiver responses increase unpredictability, amplifying emotional load and BPSD. Evidence suggests that the meaning attributed to stimuli and interactions strongly shapes behavioral responses, and that standardized responses can improve emotional stability and engagement (Cohen-Mansfield et al., 2010).

3.3. More Is Not Always Better: The Implementation Gap Highlighted by PrAISED

As shown in exercise interventions, intensity and complexity can backfire in dementia by reducing adherence and increasing fatigue or refusal (Harwood et al., 2023). The same principle applies to sleep and stress interventions: designs that “work with minimal components” are central.

3.4. Redefining Design Assumptions for Sleep and Stress Interventions

Although many theoretically sound non-pharmacological interventions for sleep disturbance and stress/BPSD exist, they often fail in dementia care settings. This gap reflects not flawed content, but mismatched design assumptions.

Standard sleep hygiene and stress coping strategies implicitly presuppose: (1) introspective awareness of one’s state; (2) selection among multiple behavioral options; and (3) adaptive adjustment and maintenance of behavior. These abilities depend heavily on attention, working memory, and executive function, which deteriorate early in dementia.

Consequently, interventions that are “correct but complex”—such as sleep diaries, stimulus control, staged behavior change, and coping-skill selection—lose effectiveness through reduced adherence. This mirrors the structural pattern observed in the PrAISED trial. Therefore, in dementia-targeted sleep and stress interventions, the core challenge is not enabling patients to choose correct behaviors, but designing environments that minimize choice and judgment. This shift is not an indictment of patient effort, but a design transformation that maximizes feasibility under cognitive decline. The conceptual contrast is illustrated in Figure 2.

4. Dementia-Adapted Sleep & Stress Management Framework (D-SSM)

This section presents a reproducible intervention protocol that retains the active ingredients of sleep and stress/BPSD management while suppressing assumptions—self-judgment and complex behavior change—that are fragile in dementia. Based on the design philosophy in Figure 2, D-SSM reframes sleep and stress management as a caregiving environment design problem rather than a patient self-regulation task.

4.1. Design Principles

The framework is built on four principles:

Principle 1: No requirement for patient judgment or choice

Decisions regarding implementation, order, and timing are fixed and not delegated to the patient. This is not a convenience measure but a prerequisite for adherence under executive dysfunction.

Principle 2: Prioritize upstream rhythm anchors

Intervention centers on fixed wake time and morning light exposure rather than optimization of bedtime behaviors.

Principle 3: Treat BPSD as reactions, not outcomes

Behavioral issues are addressed as responses to physical discomfort or environmental stressors, with standardized proactive trigger removal.

Principle 4: Embed caregiver support as a condition of intervention

Monitoring, verbal reassurance, environmental adjustment, and shared response strategies are integral components of the intervention itself.

5. D-SSM Intervention Protocol (for Implementation)

5.1. Overall Structure

• Duration: Continuous (minimum 12 weeks)
• Frequency: Daily (each item requires only a few minutes)
• Recording: Simple caregiver checklist
• Setting: Home or institutional care

5.2. Sleep and Daily Rhythm Module (Three Mandatory Items)

(S1) Fixed wake time (±30 minutes)

Purpose: Establish a circadian anchor.

Implementation: Wake at the same time daily.

(S2) Light exposure within one hour of waking

Purpose: Circadian entrainment and daytime alertness.

(S3) Nap management (≤30 minutes, before 3 p.m.)

Purpose: Maintain nighttime sleep pressure.

5.3. Stress, Emotion, and BPSD Module (Three Mandatory Items + DICE)

(E1) Systematic check for BPSD triggers

Rationale: BPSD are reactions to modifiable factors (Kales et al., 2015).

(E2) Proactive removal of discomfort

Rationale: Addressing physical discomfort is foundational (Livingston et al., 2017).

(E3) Reassurance-oriented communication

Rationale: Meaning attribution influences behavior (Cohen-Mansfield et al., 2010).

(E4) DICE framework as needed

Rationale: Kales et al. (2015).

5.4. Weekly Standardization Meeting

Once weekly, family or staff briefly share effective responses and standardize communication and environmental adjustments (Cohen-Mansfield et al., 2010; Kales et al., 2015).

5.5. Progression Rule

Avoid adding or complicating items; when symptoms worsen, return to the basic set.

5.6. Key Performance Indicators (Cost-Linked)

Nighttime caregiving frequency, BPSD frequency, psychotropic medication use, emergency visits, and hospitalization.

6. Implications for Research, Practice, and Policy

Focusing exclusively on cognitive outcomes risks underestimating intervention value. Adherence and exposure should be treated as central mechanistic indicators.

7. Conclusion

Sleep disturbances and stress responses/BPSD in dementia are major accelerators of healthcare costs and caregiving breakdown. By redefining these issues as conditions for worsening rather than treatment targets, this paper proposes a minimal, dementia-adapted program (D-SSM) designed for real-world implementation. Future work should prioritize implementation-focused evaluation.