Sleep After Loss: What Helps and When to See a Clinician

The National Heart, Lung, and Blood Institute (NHLBI) lists the death of a loved one among the stresses that raise the risk of insomnia, and adds that worrying about whether you will get enough sleep, and watching the clock, can raise that risk or make insomnia worse. You may already know this at three in the morning, when the house is quiet and the mind begins its second shift.

A season of broken nights is not in itself a disorder. The useful question is what kind of problem you have. Some sleeplessness yields to a steadier routine. Some is chronic insomnia, for which federal health agencies point first to a structured therapy rather than a pill. And some signals something else, such as sleep apnea or a medicine that disagrees with you. This guide will help you judge which you face and what to ask a clinician.

How grief and age change the shape of the night

Grief usually arrives with a changed household. If you were a caregiver, your nights may still be arranged around someone who no longer needs you. The National Institute on Aging (NIA) notes that short-term insomnia can be caused by stress or changes to routine; bereavement tends to bring both.

Age compounds the effect. NIA says older adults need about the same seven to nine hours of sleep as other adults, but that sleep becomes shorter and lighter with age. It calls insomnia the most common sleep problem in adults 60 and older, and NHLBI adds that insomnia is more common in women than in men.

Duration is the clinical dividing line. NIA describes insomnia as trouble falling or staying asleep at least three nights a week, and treats it as chronic when it lasts more than three months and cannot be fully explained by another medical cause. You need not wait that long to ask for help.

Restore the frame: schedule, light, and the room itself

Start with structure. NIA’s guidance for older adults: go to bed and get up at the same time each day, including weekends and travel; keep a relaxing bedtime routine and a room neither too hot nor too cold; and avoid late-afternoon or evening naps, caffeine late in the day (tea, chocolate, and soda included), and large meals within two to three hours of bedtime. Exercise, but not late: NIA says not within three hours of bedtime, NHLBI at least five to six hours before.

Light is part of the signal. NIA explains that the body releases melatonin, which makes you sleepy, when it gets dark, and NHLBI warns that light from screens can disrupt the sleep-wake cycle. Keep evenings dim and screens out of the bedroom. To set and keep a steady sleep-wake cycle, a clinician may suggest light therapy: NHLBI describes daily time in front of a light box that produces bright light similar to sunlight.

If you now live alone, make the room safe for waking hours too: NIA suggests a lamp within easy reach, a nightlight in the hallway or bathroom, and a telephone with emergency numbers by the bed. Living Alone: The Practical Adjustments Nobody Lists covers the rest of the house.

Why therapy comes before a prescription

When poor sleep persists, NHLBI says cognitive behavioral therapy for insomnia, or CBT-I, is usually recommended as the first treatment option for long-term insomnia and can be very effective. It is a 6- to 8-week plan delivered by a doctor, nurse, or therapist, in person, by telephone, or online.

NHLBI describes five parts: cognitive therapy to ease anxiety about not sleeping; relaxation or meditation; sleep education; sleep restriction, which sets a fixed window in bed and lengthens it as sleep improves; and stimulus control, which means going to bed only when sleepy, getting up if you cannot sleep, and keeping the bed for sleep and sex. Sleep restriction can feel severe at first, one reason to do it with a trained clinician.

CBT-I treats the habits that sustain insomnia; grief counseling addresses the loss. Many people need both, and When Grief Is Not Easing explains when the second is warranted.

A bad night is information; a bad season is a reason to call someone.

Sleep medicines: a short-term tool with real costs

NIA is direct: sleep medicines may help in the short term, but they carry risks and should not be used long term. It cites dependence, next-day fogginess, and pills that lose their effect so that more is needed. NHLBI adds that benzodiazepines can cause dizziness, confusion, and muscle weakness, can interact dangerously with other medicines, are habit-forming, and should be taken for only a few weeks.

Over the counter, NHLBI says antihistamine sleep aids can be unsafe for some people and should be discussed with a doctor first. It states that research has not proven melatonin supplements effective for insomnia, lists side effects including daytime sleepiness and worsening depression, and notes that the FDA does not review supplements for safety and effectiveness before they are marketed.

A medicine can still be the right choice, but with a prescriber who knows everything you take and a plan for how long. Apart from the FDA’s stop-and-call instruction described below, do not stop or change a prescribed medicine without speaking to your prescriber.

The FDA boxed warning on three insomnia drugs

On April 30, 2019, the FDA announced a new Boxed Warning for three prescription insomnia medicines: eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, and Zolpimist). It cited rare but serious injuries, and some deaths, from complex sleep behaviors: sleepwalking, sleep driving, and other activities while not fully awake.

Clinicians should not prescribe these drugs to anyone who has had a complex sleep behavior after taking one of them, and a patient who experiences one should stop the medicine and contact a health care professional right away. NHLBI lists similar rare behaviors among the possible side effects of other insomnia medicines, including ramelteon and suvorexant.

Living alone, you may have no witness. Treat any sign that you acted at night without memory, such as food prepared or messages sent that you cannot recall, as a reason to call at once.

Alcohol: the nightcap that costs the second half of the night

A nightcap can seem like the gentlest sleep aid, and it works against you. NHLBI explains that it can make falling asleep easier but tends to produce lighter sleep and more waking during the night. NIA’s advice for older adults is to avoid alcohol, even in small amounts.

Consider a hypothetical case: suppose you fall asleep easily but have woken at three most nights for six weeks, and two glasses of wine at dinner have become routine, already more than the one drink a day NIA sets as the limit for women. Setting the wine aside for two weeks, and recording the result, is a sensible first experiment. If you have been drinking heavily for a long time, speak to a clinician before you stop: the National Institute on Alcohol Abuse and Alcoholism warns that stopping suddenly after prolonged heavy drinking can bring on painful, even life-threatening, withdrawal.

NIA also cautions that the death of a spouse can lead some people into harmful reliance on alcohol, that older women are more sensitive than men to its effects, and that alcohol with some sleeping pills, pain pills, or anxiety or antidepressant medicines can be deadly. Its standard drink of wine is a 5-ounce glass; a larger pour is a stronger drink.

Sleep apnea often looks different in women

Sleep apnea causes repeated pauses in breathing during sleep. NIA notes that snoring can be a sign but not everyone who snores has it, and that untreated apnea can lead to serious problems, including heart attack. The person most likely to have noticed your snoring, or a silence in your breathing, may no longer be there.

NHLBI says women’s risk rises during and after menopause, in part because of hormone changes, and notes that women may also gain weight around the neck during menopause. It adds that women more often have anxiety, daytime sleepiness, depression, morning headaches, insomnia, tiredness, and frequent waking, and may not snore at all. Because these overlap with grief and menopause, apnea can hide in plain sight. If routine changes have not helped, or you wake unrefreshed after a full night, ask whether an overnight sleep study is warranted.

When to see a clinician, and what cannot wait

Make an appointment if poor sleep is affecting your days, if you are always sleepy, or if trouble sleeping has settled into three or more nights a week. NIA suggests a sleep diary for a couple of weeks beforehand: bedtime, night waking, rising time, caffeine, alcohol, and exercise. A Health Checkup Plan for the Year After Your Spouse Dies sets sleep within a wider health review.

Some signs should not wait: a complex sleep behavior after a sleep medicine, gasping or breathing pauses that someone observes, and drowsiness while driving. If you have thoughts of harming yourself, call or text 988, the 988 Suicide & Crisis Lifeline, or call 911.

Questions to bring to the appointment

1. Here is my two-week sleep diary. Is this short-term insomnia, chronic insomnia, or something else?
2. Could anything I take, including cold and allergy medicines or melatonin, be disrupting my sleep?
3. Is CBT-I available to me, and who would deliver it?
4. Given my age, menopause history, and symptoms, should I be screened for sleep apnea?
5. If you recommend a medicine, does it carry the 2019 boxed warning, and what should I do if I notice a complex sleep behavior?
6. How long should I take it, and how might it affect me the next morning?
7. How does alcohol interact with everything I take?
8. Could depression, anxiety, or unresolved grief be part of this?

This article provides general U.S. educational information and is not medical or pharmaceutical advice. Discuss your symptoms and medicines with a clinician who knows your history.