The clinical and cost-effectiveness of improving sleep via carer delivered strategies in people with dementia: the DREAMS START parallel multi-centre RCT.
Rapaport P, Amador S, et al. • Health technology assessment (Winchester, England) • 2026
DREAMS START plus treatment as usual is clinically effective in reducing sleep disturbance in people living at home with dementia at 8 months, demonstrating sustained effectiveness beyond intervention delivery, and is likely to be cost-effective when delivered by non-clinically trained graduates.
Key Findings
Results
DREAMS START significantly reduced sleep disturbance in people with dementia at 8 months compared to treatment as usual.
Mean Sleep Disorders Inventory score at 8 months was lower in the intervention arm [15.16 (SD 12.77), n=159] versus treatment-as-usual arm [20.34 (SD 16.67), n=163].
Adjusted difference in means was -4.70 (95% CI -7.65 to -1.74; p=0.002).
The trial was a two-arm, multicentre, parallel-arm, superiority RCT with masked outcome assessment and intention-to-treat analyses.
377 dyads were randomly assigned (1:1 ratio): 189 to treatment as usual and 188 to DREAMS START plus treatment as usual.
Effectiveness was sustained beyond the period of intervention delivery, assessed at 8 months.
Results
DREAMS START was associated with a mean incremental reduction in health and care costs compared to treatment as usual.
The mean incremental difference in health and care costs incorporating wider costs was £116 less per dyad (95% CI -£5769 to £5536) for DREAMS START compared to treatment as usual.
There was a 78% probability that DREAMS START is cost-effective compared to treatment as usual at a £20,000 decision threshold.
There was no significant difference in quality of life between the two arms.
Cost savings were estimated incorporating both health and care service use across both people with dementia and their family carers.
Results
Mortality during the trial was equal between intervention and control arms and unrelated to the intervention.
Seventeen (9%) people with dementia in the intervention arm and 17 (9%) in the control arm died during the trial.
Deaths were described as unrelated to the intervention.
This finding supports the safety profile of the DREAMS START intervention.
Methods
DREAMS START is a six-session multicomponent manualised intervention delivered by non-clinically trained graduates to family carers of people with dementia.
The intervention was delivered face to face or remotely, weekly or fortnightly.
Components included information about sleep and dementia, promotion of de-arousal at night, adaptive stimulus control (e.g. bedtime routine maintenance), daytime behavioural activation, increasing access to light, improving carer sleep, and making a tailored action plan.
Delivery by non-clinically trained graduates was noted to increase potential for NHS implementation at scale.
The intervention was implemented by carers who applied strategies directly to their relatives with dementia.
Methods
The study recruited people with dementia experiencing sleep disturbance and their family carers from 12 NHS trusts and the Join Dementia Research service in England.
Recruitment took place between February 2021 and March 2023.
A total of 377 dyads (person with dementia and family carer pairs) were enrolled.
Mean age of participants with dementia was 79.4 years (SD 9.0), and 206 (55%) were women.
Participants were required to be living at home.
Results
Family carers who received DREAMS START reported better sleep and less anxiety than those who did not.
Carer sleep and anxiety outcomes were assessed at baseline, 4 months, and 8 months.
Carer benefits were noted alongside the primary outcome of improved sleep in people with dementia.
This finding suggests the intervention has benefits beyond the primary patient recipient.
Outcomes were based on family carers' proxy and self-reported measures, which the authors note may increase risk of bias as intervention participants could be more invested and optimistic.
Methods
The trial included a mixed-method process evaluation and additional substudies examining specific populations and comorbidities.
The process evaluation explored how the intervention works.
One substudy explored how UK-based South Asians experience sleep disturbance and dementia.
A second substudy explored the interaction of sleep, dementia, and long-term conditions.
A 2-year follow-up study of participants is ongoing to explore longer-term effects.
Discussion
The authors acknowledged key limitations including reliance on proxy and self-reported outcomes and the absence of actigraphy or other direct measures of sleep and activity.
Reliance on family carers' proxy and self-reported outcomes was identified as a potential source of bias, as intervention participants may be more invested and optimistic.
Based on findings from a prior feasibility RCT, actigraphy or another direct measure of sleep and activity was not included.
Authors called for future implementation studies to consider delivery and scaling up of DREAMS START in real-world healthcare settings.
What This Means
This research suggests that a structured, non-drug program called DREAMS START can meaningfully improve sleep in people with dementia who live at home. The program involves six sessions delivered by people without clinical training (such as university graduates) directly to family carers, who then use strategies like establishing bedtime routines, increasing daytime activity, improving light exposure, and promoting relaxation to help their relative with dementia sleep better. In a large clinical trial across 12 NHS sites in England involving 377 pairs of people with dementia and their family carers, those who received DREAMS START alongside usual NHS care had notably lower sleep disturbance scores after 8 months compared to those who received only usual care — and these benefits persisted even after the sessions had ended.
Beyond improving sleep in people with dementia, this research suggests that family carers who participated in DREAMS START also reported sleeping better and feeling less anxious than carers in the usual care group. From a cost perspective, health and care services used by those receiving DREAMS START cost an estimated £116 less per pair than those receiving usual care alone, and there was a 78% probability the program would be considered cost-effective at standard NHS thresholds. The fact that the program can be delivered by non-clinically trained staff makes it potentially scalable within the NHS.
This research matters because sleep disturbances affect many people with dementia and are distressing for both patients and their families, yet until now there have been no proven safe and effective non-drug treatments. Medications for sleep in dementia often carry harmful side effects and limited effectiveness. DREAMS START offers a practical, carer-delivered alternative with demonstrated benefits at 8 months, though the authors note that longer-term follow-up is still underway and future work is needed to understand how best to implement the program widely in real-world NHS settings.
Rapaport P, Amador S, Adeleke M, Barber J, Banerjee S, Bhojwani A, et al.. (2026). The clinical and cost-effectiveness of improving sleep via carer delivered strategies in people with dementia: the DREAMS START parallel multi-centre RCT.. Health technology assessment (Winchester, England). https://doi.org/10.3310/GJPR2620