Sleep medications and the elderly — the risks of pharmaceutical sleep

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

Your parent used to sleep through the night without thinking about it. Now they're waking at 3 a.m. and can't fall back asleep, or they're lying awake for an hour before bed, or they're waking up multiple times a night. The tiredness during the day is real. They're frustrated and exhausted, and they want a solution. When the doctor offers a sleep medication, it sounds like salvation. Finally, a fix. What nobody explains clearly is that pharmaceutical sleep isn't the same as real sleep, and in older adults, the risks can outweigh the benefits.

I remember my mother asking for sleep medication because she thought it would solve everything. She'd read that she should get eight hours and wasn't, and it felt like a failure. What she didn't understand, and what the doctor didn't emphasize enough, is that sleep naturally changes with age. Older adults need less sleep. They sleep lighter. They wake more during the night. This is normal. Taking a medication to force yourself to sleep through eight hours when your body only needs six is like fighting your own biology.

The medications that doctors used to prescribe for sleep in older adults, the ones that put people into a dead sleep, cause falls. They cause fractures. They cause cognitive problems. Some of them cause confusion and behavior changes that look like dementia but go away when you stop the medication. The medications on the Beers Criteria for medications to avoid in older adults include many sleep aids. These are evidence-based lists created by geriatricians because these medications hurt older people. Yet they're still prescribed commonly because the demand for sleep is high and the desire for a quick fix is stronger than the desire to do what's actually safe.

Why Sleep Changes With Age

Sleep becomes fragmented as people age. The deep, restorative sleep that you get in your 30s doesn't happen as much anymore. Your parent might wake up to use the bathroom. They might wake up because of pain or discomfort. They might wake up from noise that would never have woken them when they were younger. Some of this is normal. Some of it is fixable.

Medical conditions cause sleep disruption. If your parent has sleep apnea, where they stop breathing repeatedly during sleep, they're waking constantly because their body is panicking about oxygen. They might not remember these micro-awakenings, but they're not getting good sleep. Sleep apnea needs treatment with a CPAP machine or similar device, not a sleeping pill. Giving someone with sleep apnea a sedating medication is dangerous because it can cause their breathing to stop.

Nocturia, waking up multiple times to urinate, is a common sleep disrupter. This might be because of a urinary tract infection, an enlarged prostate, diabetes, heart failure, or just how the kidneys function with age. If your parent is waking up four times a night to urinate, no sleeping pill will help if they still need to go to the bathroom. Addressing the underlying cause matters more than the medication.

Pain causes sleep disruption. If your parent is lying down and their arthritis or back pain gets worse, they can't sleep. Acid reflux can also worsen when lying down. Anxiety about sleep itself becomes a problem. Your parent lies in bed worrying about whether they'll sleep, and the anxiety keeps them awake. All of these need different solutions than medication.

Medications your parent is already taking can disrupt sleep. Some blood pressure medications cause insomnia. Stimulating medications taken in the evening can keep them awake. Sometimes adjusting the timing of other medications helps more than adding sleep medication.

The Medication Risks

Benzodiazepines like temazepam, triazolam, and others work by sedating the brain. They shut down the nervous system and force sleep. The problem is that they also increase fall risk significantly. In older adults, they impair balance and coordination. A fall for someone with osteoporosis can mean a hip fracture, surgery, and rapid decline. They also cause cognitive impairment, especially with regular use. Your parent might become more confused, forgetful, or emotionally labile. These changes are dose-related and reversible if you stop the medication, but while taking it, their brain doesn't work as well.

Benzodiazepines are also addictive. Your parent might start taking them for a week and find they can't sleep without them. The brain adapts to the medication, and discontinuing it causes rebound insomnia that's worse than the original problem. Getting off benzodiazepines requires slowly reducing the dose over weeks or months, not just stopping. This dependency is real even though many people don't realize they're developing it.

Newer sleep medications like zolpidem, zaleplon, and eszopiclone don't have benzodiazepine in their name, but they work similarly and have similar risks. They're marketed as safer, but in older adults, they still increase fall risk and cognitive problems. They're on the Beers Criteria list specifically because of dangers in older people.

Mirtazapine and trazodone are antidepressants used off-label for sleep. They have less addiction potential than benzodiazepines, but they still increase fall risk and can cause cognitive changes. Trazodone can cause priapism, a dangerous condition, though this is rare. Both can cause significant sedation, and your parent might have a hard time waking in the morning.

Any medication that sedates the brain increases fall risk in older adults. The elderly are already at higher risk for falling because of balance problems, vision changes, and muscle weakness. Add a sedating medication, and you've increased the chance of a serious fall exponentially. This isn't a rare side effect. This is the main mechanism of how these medications work, and older bodies are more sensitive to them.

The cognitive changes are another serious concern. Your parent might become confused or forgetful, or seem like they're developing dementia. When you stop the medication, the confusion often clears. But while they're taking it, they're struggling cognitively, sometimes in ways that are scary and that you might attribute to progression of another condition.

Better Approaches

Sleep hygiene means creating conditions that support sleep. A dark, cool, quiet bedroom helps. If your parent's bedroom is bright from outside lights, blackout curtains might help. If it's noisy, white noise machines can mask disruptive sounds. A comfortable mattress and pillows matter. Some people sleep better with a weighted blanket or with extra blankets.

Timing matters. Going to bed and waking up at the same time every day helps establish circadian rhythm. This is true even on weekends, even when your parent is retired. Avoiding caffeine after early afternoon helps. Avoiding large meals close to bedtime helps. Limiting fluids in the evening might reduce nocturia.

Exercise helps sleep quality, but timing matters. Your parent shouldn't exercise close to bedtime because it's stimulating. But exercising earlier in the day, even a half-hour walk, can improve sleep at night. Exercise also helps with pain and mood, which are probably disrupting sleep anyway.

Relaxation techniques work for some people. Progressive muscle relaxation, where your parent tenses and releases different muscle groups, can help calm the nervous system. Deep breathing or meditation might help. Some people find a warm bath before bed helps them relax.

Addressing underlying causes is important. If your parent has sleep apnea, getting tested and treated with CPAP or another device will improve sleep more than medication ever will. If pain is disrupting sleep, managing pain during the day and getting pain medication right before bed might help. If nocturia is the problem, treating urinary tract infection or adjusting fluid timing might fix it.

Cognitive behavioral therapy for insomnia, or CBT-I, is evidence-based and doesn't have side effects. Your parent meets with a therapist who helps them identify thoughts and behaviors that disrupt sleep, and teaches techniques to improve it. This actually fixes the problem rather than just forcing sedation. Many sleep specialists offer this, though your parent might have to seek it out because it requires more effort than writing a prescription.

Sometimes sleep medication is still the answer, but only after other things have been tried. If your parent has severe insomnia that's affecting quality of life, has tried behavioral approaches, and has medical conditions ruled out, a low dose of medication might help. But it should be the lowest dose that helps, with a time limit. It shouldn't be a forever medication. Regularly reassess whether it's still needed.

Your parent might sleep less than they did at 30 and that's okay. Six good hours of sleep is better than eight hours of light, fragmented sleep interrupted by medication side effects. Five hours of actual sleep is better than the daytime confusion and falls that come with medication. Your job is to help your parent understand that pharmaceutical sleep comes with real costs, and that there are usually better ways to address whatever is disrupting their sleep.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.