Sleep after stroke

“I toss and turn for hours on end. No matter what I do, I just can’t seem to get off to sleep”.

“I’m very restless through the night, often waking and not able to get back to sleep”.

“I wake up two or three hours before I need to get up and just lie there trying to drop back off to sleep”.

“I never feel like I’ve had a proper night’s sleep. I sleep very lightly and seem to drift in and out of sleep”.

“I have no trouble sleeping. In fact I sleep way too much but I still feel really tired”.

Sleep problems are very common and are often referred to as insomnia. One study in America found that only 5% of adults reported never having trouble sleeping.

Another recent study found that as many as 30% of the adult population are affected by sleep problems. Sleep difficulties are particularly common in women, children and those over 65. In fact, roughly half of the elderly population complains of insomnia. Therefore to have trouble sleeping at some point in your life is quite normal.

A recent study found that around half of people who have had a stroke have some difficulties with their sleep, which is higher than the general population. Most often, these difficulties take the form of having trouble falling or staying asleep (sometimes called maintenance insomnia), as well as changes to breathing during sleep, which is called sleep apnoea.

A note on apnoea
Sleep apnoea is a condition where a person’s breathing is interrupted and stops and starts during sleep. It is sometimes called Sleep Disordered Breathing (SDB). Studies have found higher rates of sleep apnoea in people who have had a stroke compared to the general population. It may either have been present before the stroke or caused by the stroke.

The following are signs you might have sleep apnoea:

• If you have non –refreshing sleep (e.g. waking up feeling tired), even when you have had plenty of time asleep
• If someone else has heard you stop breathing, appearing to choke or gasp when asleep
• If you are a loud snorer
• If you wake with headaches in the morning
• If you are excessively sleepy during the day (e.g. falling asleep uncontrollably)

If you think that you might have sleep apnoea, it is important that you seek help via your GP who can you refer you on for a specialist assessment, as treatment is available.

Other changes to sleep:
As well as daytime sleepiness, there are other sleep problems that can be experienced by people who have had a stroke:

• Feeling restless, or finding it hard to keep your legs still (also called Restless Leg Syndrome)
• Unusual behaviour while you are asleep (also called parasomnias), such as sleepwalking or acting out dreams.
• Changes to the times when you feel awake or sleepy (Sleep Rhythm disorders)
• Sleeping more than usual (also called Hypersomnia)

There are lots of reasons why someone might have changes to their sleep following a stroke. Some of the following may apply to you:

• The part of your brain affected. You may have heard of the phrase ‘Circadian rhythms’. This is the regular pattern of changes that occur in your body over a 24 hour period including your brain activity, hormones, digestion and other functions. For example, most people tend to feel sleepy in the afternoon, after lunch. Specific areas of the brain organize these rhythms and depending on the part of the brain that was affected as part of your stroke, there may have been disruption or damage to these systems that are involved in sleep and circadian rhythms.
• Changes to routine. You may find that following your stroke your average week looks very different, and your bedtimes/ time of getting up have changed.
• Recovery. You may find that in the early stages of your recovery, you need to sleep e as part of the healing process.
• Pain. Pain can make it difficult to feel comfortable and to relax. People who are in pain may tend to wake up more during the night too.
• Toileting. Some people may find that they need to use the toilet more frequently, or differently, following a stroke. This can make it harder to get uninterrupted sleep.
• Changes to activity levels. Daytime activity is important for sleep and after a stroke, you may find that you have reduced mobility, or perhaps there are other reasons why it is harder for you to exercise. If your activity level during the day has dropped compared to how it used to be, it might be affecting your sleep.
• Changes to mood. It is not uncommon for people who have had a stroke to struggle with their mood. This may take the form of worrying more (anxiety), or feeling low, or even depressed. Problems with mood and worrying can both interfere with our sleep. Sometimes, nightmares can interrupt sleep too.
• Medication. Some medications can impact on your sleep in different ways, for example making it harder to fall asleep, or making you feel drowsy even when you are well rested.

Summary of sleep problems
Sleep problems are very common in the general population and more so in people who have had a stroke. This is because the stroke can cause physical, psychological and social changes for the person, all of which can make it more difficult to get a good night’s sleep.

Why is sleep important?
There are plenty of reasons why you should focus on your sleep as part of your rehabilitation and general wellbeing. Here are a few reasons for you to think about:

• We all know what it is like to feel sleep deprived. It is not pleasant and can affect your quality of life. For some people, they may feel irritable or more short-tempered. For others, it may have a greater impact on their mood and they may feel low, or worry more.
• Many people find that they have some changes to their thinking skills following a stroke. The most common of these are difficulties with attention and memory. Poor sleep will likely make these difficulties worse and make it harder for you to concentrate and remember things.
• Fatigue is a very common difficulty following a stroke. Reduced energy levels following poor sleep may make it harder for you to manage your fatigue.
• Some people find that other symptoms from their stroke can be made worse by poor sleep – such as dizziness or pain.
• Poor sleep is also associated with a number of chronic health conditions, such as obesity, diabetes, heart disease and high blood pressure. Looking after your sleep can help reduce your risk of developing these conditions and can help maintain a strong immune system.

How much sleep do we need?
You may have heard that we all need between 7 and 8 hours of sleep every night. This is not necessarily true, as everyone is different and people can vary greatly in their need for sleep. Some people may feel fully refreshed after as a little as 6 hours sleep, whereas others might prefer to have closer to 10 hours per night. The amount of sleep a person needs varies throughout their life. For example, a newborn baby spends 14 to 17 hours sleeping per day. As children grow older they require less sleep, possibly 11-14 hours as a toddler, and maybe 8 to 10 hours as a teenager. Older adults, aged 65 and over, may get slightly less sleep, however sleep requirements do not change into older age.

Not only does the need for sleep vary from person to person, and with age, it also varies depending on level of activity. For example, if someone is no longer at work or has experienced a reduction in their level of activity, they may be less active and therefore require less sleep. On the other hand, if they have a busy lifestyle and are constantly on the go, then they may require a bit more sleep. It is important to work out what is the right amount of sleep for you.

What are the signs that I might not be getting enough sleep?
You may already know what the right amount of sleep is for you. However, there are some signs that you might not be having enough sleep, such as:

• Falling asleep when you didn’t mean to
• Struggling to get things done
• Feeling exhausted through the day
• Waking up not feeling refreshed

If you are experiencing the above, it may indicate that it might be time to start making some changes.

There are also signs that you might be aiming for more sleep than you need. These can include:

• Taking a long time to fall asleep
• Waking through the night and struggling to get back to sleep
• Waking earlier than planned (before your alarm goes off)

Have a think about your current activity levels, pre-stroke sleep requirements and consider whether going to bed later or getting up earlier might be useful for you.

Sometimes, following a stroke, some people find that they sleep too much. Signs to look for might be:

• An inability to stay awake even when you are interested
• Feeling lethargic, or slowed down
• Sleeping for much longer in a 24 hour period than pre-stroke.

The rest of this resource is not aimed at people who sleep too much, so if you think the above describes your current sleeping pattern, we recommend that you speak to your GP who may wish to refer on to a specialist such as a neurologist.

Are there different sorts of sleep?
Sleep is not like a light bulb which is either on or off, but has different stages, varying from light to deep sleep. At least four different stages of sleep have been identified. Broadly, sleep is divided into what is called Rapid Eye Movement (REM) and non-REM (NREM) sleep. REM sleep occurs several times during the night and is where most dreaming is thought to take place. Non-REM sleep is divided into three stages, each stage being a bit deeper, almost like a staircase of sleep.

Rem sleep:

Stage 1: light sleep

Stage 2 : Deeper sleep

Stage 3: Deepest sleep

During the night whilst asleep, people go up and down this staircase many times and in fact, most of us wake up several times.

On a typical night an adult who sleeps well will spend about 25% in REM sleep, 5% in Stage 1, 45% in Stage 2, and 25% in stage 3.

As with the amount of sleep we need, the sort of sleep we have changes as we get older. Sleep in older people tends to be lighter and more broken, with more frequent waking.

For a typical person aged 70, deep sleep takes up less than 10% of the night’s sleep. Therefore, an older person may report waking more times throughout the night.

In summary, sleep in older people does tend to be shorter, more restless and more easily disturbed, but it should still be refreshing.

Summary of important information about sleep
Sleep is vital to many aspects of our functioning. It is therefore important to pay attention to our sleep because of the consequences of not getting enough sleep, which can impact our physical and mental wellbeing. The amount of sleep needed per person varies, and your requirements may have changed following your stroke.

Good sleep habits
Building healthy sleep habits is key to improving, and maintain good sleep. The following are always useful to consider when you are not sleeping well:

• Routine. A consistent routine is the cornerstone to good sleep. Try to get a consistent timetable so that your brain and body knows what is coming. Going to bed and getting up at roughly the same time every day is much better than trying to catch up on lost sleep, or going to bed early or napping at odd times during the day. In particular, getting up at the same time in the morning is helpful. This should be maintained even at weekends.
• Pre-sleep routine. Try to use the hour and a half before going to bed to unwind and prepare for sleep. Dim the lights, listen to some calming music and minimise screen use. Again, it is helpful to get into a pattern so that your body and brain know what to expect.
• Think carefully about naps:
  – Sometimes, naps have been specifically recommended as part of your rehabilitation or fatigue management programme. They can also help with brain recovery in the early stages after your stroke. Aim to nap in bed, after lunch, for around one hour. You may find it useful to set an alarm if you find you are oversleeping.
  – However, if you find that you are struggling to fall asleep at night, it may be worth thinking more carefully about cutting back on naps. Although naps can be a good way to catch up on sleep, it will mean that you are less likely to sleep well on the evening. Sleep is a biological need that builds over time, just like hunger- so having a nap is the equivalent of having a snack before your main meal. As an alternative, you may find it useful to have an allotted time every day where you are physically resting and having a break from concentrating.
• Bed is for sleep
  – Bed (and bedroom) is for sleep – make sure your bed is associated with sleep. For example, don’t watch TV, eat, play on your phone, answer emails or work in bed. The only exception to this is sex which can help with sleep.
  – Only go to bed when you are feeling tired (yawning is a good sign).
  – Spending time in bed feeling tense, clock watching or attempting to force yourself to fall asleep is unlikely to be helpful. Instead, if you find that you have not fallen asleep within 20-30 minutes, get up and go to another room. Listen to relaxing music, read a calming book or sit quietly until you feel sleepy again. It is important to avoid the use of electronic screens (iPad, mobile phone, television) when doing this. When you feel sleepy (again, look for yawning), return to bed.
  – The same is true if you wake during the night and are unable to fall asleep within 20-30 minutes – get up, doing something quiet and relaxing and then return to bed when feeling sleepy.
• Exercise. When your body is tired, your mind will follow. Explore opportunities to gradually increase your daytime activity and exercise. For best impact on sleep, exercise outdoors and in the mornings. Avoid exercising close to bedtime as the increase heart rate can make it harder for your body to relax and fall asleep. You may want to consider going for walks, accessing a gym or joining a local exercise group to motivate you. Speak to your team to find out if there are any groups in your area that specifically for people who have had a stroke.
• Electronic devices. Blue light emitting from these screens (TVs, gaming machines, tablets and smartphones) stimulates the brain and interrupts melatonin release – the hormone you need to sleep. Therefore it is best to avoid using electronic devices in the hour before bedtime. Some devices have settings that reduce the blue light, which can help- although the gaming, reading emails, texting etc are all stimulating activities which will make it harder to fall asleep. For best results, you could try turning off your devices in the early evening.
• Time spent outside. Daylight promotes the production of melatonin, the hormone we need for sleep. Try to spend some time outdoors every day, preferably in the morning.

It’s important to think about your mind as well as your body when working on your sleep. Some of your thinking habits may also be impacting on your chances of a good night’s sleep.

• Try not to worry too much about your sleep. Although sleep is important, fixating on the number of hours, or how tired you feel can be counterproductive. The more stressed you are about sleep, the less likely you are to fall asleep. Try to remember that the amount of sleep we get is an individual thing and can change throughout our life.
• Switching off. Some people can find it hard to ‘switch off’ and that when they go to bed, they find it hard to relax as they are bothered by thoughts which can make it hard to fall asleep. The following can be useful for busy minds:
• Mindfulness meditation is a way of distancing yourself from your thoughts and engaging with the present. You can learn to practise mindfulness through books, apps or even classes.
• Guided imagery can be useful as a means of relaxing. It involves imagining a calming scene, and making it as vivid as possible. Popular images include beach or forest scenes. Guidance on can be found online to help you develop this skill. Generally, imagining anything pleasant, allowing your brain to be creative and adding lots of details helps your mind relax. What would you do if you won the lottery? What would your ideal holiday be?
• Progressive muscle relaxation is a great way to relax and helps the body unwind. Instructions can also be found online.
• If you find that your mind goes over things you need to remember the next day, keep a notepad and pen by your bed. That way you can quickly write down what you need to remember- leaving your mind free to relax!
• You can find audio recordings of some of the above relaxation strategies here: www.cntw.nhs.uk/relaxation
• Mental health. It is normal to experience changes to your mood when a significant life event happens. Having a stroke can sometimes cause people to experience increased worry (anxiety) or lower mood (depression). If you feel that you are experiencing worry or low mood that interferes with your daily functioning, consider speaking to your GP or healthcare professional about treatment options that are available to you. Successful treatment of either of these conditions will likely result in improvements to your sleep.

Your environment can affect how well you sleep and if you find yourself waking through the night, consider what you might be able to change to improve your odds of having a good night’s sleep:

• Noise. Soft, silicone earplugs may help block out noise. Some people find a small amount of white noise or the sound of a fan helps too. Some phone apps can generate background noise to help you sleep.
• Light. An eye-mask or blackout blinds may help, especially in summer when sunset is later and sunrise is earlier.
• Electronics. Electronic devices such as laptops, mobile phones and tablets can disturb our sleep in a number of ways. They can emit light which interrupts one of the hormones we need to sleep (melatonin). They are also stimulating and distracting which can stop us fully relaxing. Consider moving them to a different room if possible, or deactivating them at night.
• Mattress and pillows. It may be time for a new mattress and pillows if you cannot get comfy with your current ones. Try several out if possible. Choose ones that are best for your back and neck.
• Temperature. Bedrooms should ideally be a few degrees cooler than the rest of the house to encourage good sleep. Consider changing your bedding with the seasons (consider the ‘tog’ of your duvet) to avoid feeling too hot or cold. Wearing socks, electric blankets, hot water bottles can all be used if you are too cold.
• Your partner. Your partner may have sleep habits of their own that impact on your sleep, such as being restless or snoring. Consider using earplugs or using a spare bedroom.

Good sleep depends on many factors, including what we eat and drink as they can all affect the balance of systems in our body. Consider making changes to some of the following areas:

Caffeine
Caffeine is a stimulant which promotes alertness and helps people feel more awake. It also reduces the quality of sleep and makes it more difficult to fall asleep. It should therefore be avoided in the evenings and if you are having trouble with your sleep then it is probably best to consider avoiding caffeinated drinks after lunchtime.

Caffeine is found in lots of drinks, including coffee, tea, energy drinks, hot chocolate and cola. Caffeine-free versions of tea and coffee are available in most supermarkets. Chocolate also contains caffeine.

Caffeine affects everyone differently and some people are more tolerant to the stimulating effects of caffeine than others. You may find that as you get older, you feel the effects more. You may find that it affects you more following your stroke.

The amount of caffeine in your body halves every four hours. So, if you have a coffee at 6pm, there will still be half as much caffeine in your system at 10pm, when you might be going to bed!

Cigarettes
Smoking last thing at night can keep you awake as nicotine is also a stimulant.  If you do smoke, try to have your last cigarette at least four hours before bedtime.  Nicotine patches or chewing gum can also affect sleep. Quitting smoking and nicotine withdrawal can make sleep difficult in the short term, but in the longer term your sleep will improve.

Medicines and other drugs
Symptoms, such as fatigue or low motivation (e.g. Amantadine). Some of these drugs can affect sleep because they are stimulants. Other medications can affect how deeply you sleep, such as certain drugs for asthma and for migraine. You may find it useful to speak to your GP to see if any of your new medications are known to affect sleep, and if you can adjust the timing of your medications to reduce the impact on your sleep. Following your stroke, you may have been prescribed medications for some of the

Sleeping tablets
These include benzodiazepines (such as diazepam and lorazepam, also known as Valium and Ativan) as well as the ‘Z’ drugs (Zopiclone, Zolpidem). Whilst they can help in the short term, they often cause sleep problems in the longer term as they interfere with the quality of sleep and can alter sleep patterns.  Sleeping tablets should only be taken for very short periods as they can be addictive and habit-forming. Sometimes people are also prescribed anti-histamines (Nytol, Sominex) for help with sleep, however these have various side effects and people who take them can still feel drowsy in the morning. They also have been found to be less effective within a few days of taking them. You can discuss medications for sleep with your GP.

Alcohol
Although alcohol may make you feel sleepy and help you fall asleep initially, you will be more likely to wake during the night and the quality of your sleep will be affected.  It is best to avoid drinking alcohol close to bedtime if you are having sleep problems. Alcohol-free versions of wine, beer and cider are available in most supermarkets. There are also other reasons you may wish to avoid alcohol post-stroke, for example the risk of falls and impact on your thinking skills.

Fatigue medication
You may also be prescribed medication for fatigue, which can sometimes impact on your sleep as well. If you feel that a medication you are prescribed for fatigue is interfering with your sleep, discuss this with your prescribing clinician to see if the timing or dose can be adjusted to minimise the impact on your sleep.

Other things to remember
These simple guidelines really can improve your sleep but they take time, especially if you are re-building a regular routine.   Please be patient, your hard work will pay off although it can take many weeks to develop new sleep habits. It may be useful to keep a sleep diary to measure changes as these may occur slowly.

Before your stroke, you may have never thought about your sleep much, or perhaps you have had sleep problems before. Either way, these recommendations are useful for everyone, if they have had a stroke or not.

Your sleep will never be perfect. No-one sleeps exactly the right amount every night and awakes feeling 100% refreshed every day. There will always be some factors outside your control which may interrupt your sleep from time to time. This could be changes to your mood, physical health, stress, etc. Although your sleep will likely change at these times, applying the above recommendations will help prevent you falling into bad habits.

Although sleep is important, and no-one likes feeling tired, try not to worry too much about your sleep. Obsessively monitoring your sleep is unlikely to help you relax at night and may even be counter-productive. Your body is good at recovering from poor sleep and you will sleep deeper after a period of disturbed sleep.

These techniques have been proven to help many people but take time and hard work. If you feel you are making little progress or the problem is getting worse then speak to your GP.

Summary of improving sleep
Our sleep is affected by lots of different factors. When trying for better sleep it is best to aim for a regular routine, an appropriate sleeping environment, a calm mind as well as avoiding medications or substances that impact on your sleep. You may need to make changes to some or all of these areas to maximise your sleep.

Good luck and sleep well.

British Association for Behavioural and Cognitive Psychotherapies
Email: [email protected]
www.babcp.com
Information and advice for people about behavioural and cognitive psychotherapy (CBT).

The Sleep Charity – The National Sleep Helpline
Tel: 03303 530 541 (Monday, Tuesday, Thursday evening 7-9pm, Monday and Wednesday morning 9-11am (excluding bank holidays).
https://thesleepcharity.org.uk/national-sleep-helpline/
The helpline is run by a team of specialist trained sleep advisors. Although we cannot give medical advice, we can talk through your issues, offer you some practical strategies and recommend services that could help.

Healthwatch
www.healthwatch.co.uk
If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, we want to hear about your experiences. As an independent statutory body, we have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care.

Mental Health Matters
Tel: 0191 516 3500
Email: [email protected]
www.mhm.org.uk
A national organisation which provides support and information on employment, housing, community support and psychological services.

Mind Infoline
Tel: 0300 123 3393
Email: [email protected]
www.mind.org.uk
Provides information on a range of topics including types of mental distress, where to get help, drug and alternative treatments and advocacy. Also provides details of help and support for people in their own area.
Helpline available Mon – Fri, 9am – 6pm.

NHS Talking Therapies
www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/
Provides details on how to access local talking therapies services.

The Sleep Book: How to Sleep Well Every Night
Guy Meadows
Orion 2014
A five-week plan based on principles of mindfulness and Acceptance and Commitment Therapy (ACT)

Overcoming Insomnia and Sleep Problems
Colin A. Espie
Robinson London 2006
A self help guide using cognitive behavioural techniques.

Why We Sleep: Unlocking the Power of Sleep and Dreams
Matthew Walker
Penguin 2018
An in-depth look at the past twenty years of research to find out why sleep matters (Note: this is not a self-help book)

A full list of references are available on request email [email protected]

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Published by the Patient Information Centre
2025 Copyright: Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

Ref: PIC/639/0125 November 2025 V1

Website: www.cntw.nhs.uk

Telephone: 0191 246 7288

Review date 2028