What can cause waking up at night and how can it be treated?

Waking Up at Night: Causes and Treatment

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment for chronic nighttime awakenings, specifically emphasizing sleep restriction therapy and stimulus control, which directly target sleep maintenance problems. 1

Common Causes of Nighttime Awakenings

Nighttime awakenings can result from multiple factors that require systematic evaluation:

Medical and Substance-Related Causes:

• Medications, caffeine, alcohol, nicotine, or environmental toxins can directly disrupt sleep continuity 2
• Underlying medical conditions causing physiological disturbances 2
• Caffeine intake (particularly at night) significantly increases risk of sleep disturbance (OR = 2.22) 3
• Alcohol causes sympathetic activation leading to nighttime awakening even after initial sedation 4

Behavioral and Environmental Factors:

• Using electronic displays in bed triples the risk of sleep disturbance (OR = 3.01) 3
• Irregular sleep scheduling and poor sleep hygiene practices 2
• Environmental temperature outside the thermoneutral zone (16-19°C with bedding) reduces total sleep time 4
• Noise levels above 50dB shorten total sleep duration 4
• Bright room lighting at night disrupts circadian rhythms 3, 5

Circadian Rhythm Disorders:

• Irregular Sleep-Wake Disorder (ISWD) causes multiple sleep bouts throughout 24 hours, most common in dementia patients 2
• Circadian misalignment from light exposure patterns or schedule irregularities 2, 5

Treatment Algorithm

Step 1: Implement CBT-I Components (First 4-6 Weeks)

Sleep Restriction Therapy (most effective for sleep maintenance):

• Limit time in bed to match actual sleep duration based on sleep logs 1
• This enhances sleep drive and consolidates sleep 1
• Gradually increase time in bed as sleep efficiency improves 2

Stimulus Control Instructions:

• Go to bed only when sleepy 1
• Get out of bed if unable to sleep within 20 minutes 1
• Use bed only for sleep and sex 1
• Maintain consistent wake time regardless of sleep quality 2

Sleep Hygiene Modifications:

• Eliminate electronic display use within 2 hours of bedtime and especially in bed 3
• Avoid caffeine after early afternoon 3, 4
• Avoid alcohol near bedtime despite its sedative effects 4
• Maintain bedroom temperature at 16-19°C with appropriate bedding 4
• Keep bedroom dark, quiet (below 50dB), and comfortable 2, 4
• Establish regular meal times, particularly dinner 3

Additional Behavioral Interventions:

• Add relaxation techniques or biofeedback if insufficient improvement after 4 weeks 1
• Consider afternoon physical exercise (improves sleep quality) 2, 4

Step 2: Address Circadian Factors (If Applicable)

For patients with circadian rhythm involvement:

Light Exposure Management:

• Increase bright light exposure (3,000-5,000 lux) for 2 hours in the morning 2
• Avoid bright light in evening hours 2
• Maximize daytime sunlight exposure 2, 3
• Use amber glasses blocking wavelengths ≤530nm from sundown until bedtime if evening light exposure is unavoidable 2

Structured Activity:

• Increase daytime physical and social activities to provide temporal cues 2
• Avoid daytime napping which fragments nighttime sleep 2

Step 3: Pharmacological Options (Only After 6-8 Weeks of Behavioral Therapy Failure)

Use shared decision-making to discuss benefits, harms, and costs before initiating medication. 2

FDA-Approved Options for Sleep Maintenance:

• Eszopiclone and temazepam are specifically indicated 1
• Low-dose doxepin (sedating antidepressant) 1
• Consider short-term use only 2, 1

Melatonin Considerations:

• May help if circadian rhythm disorder is suspected 2
• Evidence is inconsistent for general insomnia 2
• Typically taken 30-60 minutes before desired sleep time 6, 7

Critical Warnings:

• Avoid long-term benzodiazepine use due to dependence, tolerance, and cognitive impairment risk 1
• Monitor for residual daytime sedation and complex sleep behaviors 1
• Reassess regularly and attempt to discontinue when possible 1

Important Clinical Pitfalls

Sleep maintenance difficulties are more common than sleep-onset problems, especially in older adults 1, yet many clinicians focus treatment on sleep initiation rather than maintenance.

Avoid these common errors:

• Prescribing medications before attempting behavioral interventions 2, 1
• Ignoring medication timing for other conditions that may disrupt sleep 7
• Failing to address electronic device use in bed (strongest behavioral risk factor) 3
• Overlooking caffeine consumption patterns throughout the day 3, 4
• Not maintaining sleep logs to guide sleep restriction therapy 1

Document sleep patterns using sleep logs or actigraphy to objectively assess treatment response 1, as subjective reports often underestimate actual sleep time.

For patients with dementia or neurodegenerative disease showing irregular sleep-wake patterns, a multicomponent approach combining increased daytime light exposure, structured activities, reduced daytime bed rest, and nighttime environmental optimization is most effective 2.