At 2am in a residential aged care facility, the building is rarely quiet. Lights flick on for cares. Footsteps move down corridors. A resident calls out. Another has been awake since midnight, lying in the dark, waiting for a morning that is still hours away. For many aged care residents, poor sleep is not an occasional inconvenience. It is a nightly reality, one that compounds almost every other health challenge they face. Yet sleep disorders remain one of the most consistently underassessed and undertreated conditions in Australian aged care.

The numbers alone are striking. A 2025 systematic review and meta-analysis examining sleep disturbances among institutionalised older adults found that poor sleep quality affects 65% of residents, obstructive sleep apnoea is present in 67%, insomnia affects 43%, and circadian rhythm disruption affects around 30%. These are not background statistics. They describe the nightly experience of the majority of people living in residential aged care facilities across Australia and internationally.

What makes this particularly significant is that poor sleep in this population is not simply a comfort issue, it is a clinical one. Research consistently links poor sleep in older adults to accelerated cognitive decline, increased falls, greater frailty and higher mortality. A 2025 meta-analysis published in GeroScience found that sleep disorders, particularly insomnia and obstructive sleep apnoea, are significantly associated with increased risk of dementia, with emerging evidence suggesting that disrupted sleep may even serve as an early marker of neurodegeneration. For residents already living with dementia, cardiovascular disease, chronic pain and complex medication regimens, this creates a troubling cycle: the disease disrupts sleep, and disrupted sleep worsens the disease.

Despite this, sleep is rarely treated as a clinical priority in aged care. A 2025 Australian study published in the Western Journal of Nursing Research, which conducted a secondary qualitative analysis of evidence submitted to the Royal Commission into Aged Care Quality and Safety, found that sleep-related concerns emerged repeatedly across resident, family and staff submissions, yet sleep was not a specific focus of the Commission's recommendations. The study identified key themes around overnight care timing, environmental disruption and a lack of person-centred approaches to supporting sleep. Residents were being woken for scheduled cares at times that suited rosters rather than residents. In some cases, physical restraint was documented as a response to nocturnal restlessness rather than any attempt to understand or address the underlying sleep disruption.

This reflects a broader pattern. Sleep disruption in aged care is frequently attributed to dementia or old age and accepted as inevitable, when in reality it is often multifactorial and at least partially modifiable. Environmental factors including noise, light exposure, temperature and the movements of staff and other residents all play a role. Reduced physical activity during the day limits sleep drive. Excessive daytime napping further fragments the nocturnal sleep cycle. Circadian rhythm disruption, the gradual misalignment of the internal body clock, is common in institutionalised older adults and can manifest as early waking, nocturnal confusion and what families sometimes describe as their relative "being up all night and asleep all day."

Pain is another major and underappreciated contributor. Uncontrolled or undertreated pain is a significant driver of sleep fragmentation in aged care residents, and the interplay between pain, sleep and mood creates a cycle that is difficult to interrupt when any one element is ignored.

The clinical consequences extend well beyond tiredness. Chronic sleep deprivation in older adults is associated with increased agitation and behavioural disturbance, the very symptoms that most commonly lead to prescriptions for antipsychotics and sedatives in aged care settings. In other words, a significant proportion of the psychotropic medication burden discussed elsewhere in this issue may have its roots, at least in part, in unrecognised and unmanaged sleep disorders. This is not a speculative connection. It is a logical and evidence-consistent one that should prompt aged care clinicians to ask, before reaching for a prescription: what is driving this behaviour at night, and have we looked carefully at sleep?

The management of sleep disorders in aged care should follow the same principle that increasingly governs the sector's approach to other clinical problems: non-pharmacological approaches first. The evidence base for sleep hygiene interventions in this population includes consistent natural light exposure during the day, structured physical activity, reduction of daytime napping, attention to noise and light levels overnight, and, where possible, alignment of overnight care routines to individual sleep patterns rather than institutional convenience. Bright light therapy in the morning has shown generally positive, though variable, effects on circadian rhythm disruption and sleep quality in older adults in long-term care. These are not complex or expensive interventions. What they require is awareness and intentionality.

Where pharmacological treatment is genuinely indicated, the choice of agent matters enormously in this population. Benzodiazepines and benzodiazepine-related drugs such as zopiclone and zolpidem carry significant risks in older adults, including falls, cognitive impairment and dependence. Non-pharmacological approaches are preferred as first-line treatment, with Cognitive Behavioural Therapy for Insomnia (CBT-I) recommended by the Australasian Sleep Association as the treatment of choice, and where pharmacological treatment is necessary, short-term use at the lowest effective dose is the guiding principle.
For nurses and personal care workers, the opportunity to improve sleep outcomes begins with observation. Residents who are routinely drowsy during the day, who report difficulty sleeping, who are found wandering at night or who display nocturnal agitation are giving clinical signals that deserve a considered response. Documenting sleep patterns, flagging concerns to GPs and nurse practitioners, and advocating for care routines that protect overnight sleep are all within the scope of aged care nursing practice, and all have the potential to make a material difference to resident wellbeing.

Sleep is not a luxury in aged care. It is a clinical priority that has been quietly overlooked for too long. Treating sleep seriously, assessing it routinely, managing it thoughtfully, and designing care environments that support rather than undermine it, these are not just good practice. In a sector now governed by strengthened quality standards that demand person-centred care and the active management of residents' physical and psychological wellbeing, they are fast becoming an obligation.