One of the more challenging issues in working with an aging private practice is how to manage insomnia safely and effectively. By age 50-55, our livers and kidneys begin slowing down which means we are not breaking down medications as quickly and ending up with higher levels of medication and side effects; many times, these issues can be mitigated by lowering doses but as we age other factors come into play. One challenge is the aging brain itself associated with a weakening of the body’s circadian rhythms, significantly less melatonin (the sleep hormone) production, a sharp decline in slow-wave sleep (deep) sleep and REM sleep, and a higher likelihood of chronic health problems that directly sabotage a good night’s rest. Studies show that 43% of the general population of adults 65 and older report difficulty with sleep onset or maintenance. Many of the patients I have worked with have struggled with sleep for almost their entire lives so once we find something that works, it’s not that simple to consider other options. And, yet, what was helping for much of their lives can be “potentially inappropriate” according to the American Geriatrics Society (AGS). The 2023 AGS Beers Criteria (often referred to as the Beers List) is the definitive prescribing guideline for older adults that lists medications to avoid severe side effects and minimize adverse reactions in older adults. Dr. Mark H. Beers was a specialist in healthcare for older adults who created the criteria in 1991 to identify potentially inappropriate medications for older adults, starting with nursing home residents; today the AGS manages and updates the list every three years. In this article, I will list the major culprits in prescribing sleep medications to an older population, and then discuss safer sleep options.
What are the medications used for sleep on the Beers List?
First-generation antihistamines such as Benadryl (diphenhydramine), Unisom, ZzzQuil, Advil PM, and Tylenol PM.
Benzodiazepines such as Valium (diazepam), Ativan (lorazepam), Klonopin (clonazepam), Xanax (alprazolam) and Restoril (temazepam)
Tricyclic antidepressants such as Elavil (amitriptyline), Tofranil (imipramine) and Pamelor (nortriptyline)
Trazodone and clonidine are also on the Beers List
Z-drugs such as Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon)
Antipsychotics such as Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine)
What are the potential risks of these medications for older adults?
Sedating anti-histamines like Benadryl have significant anticholinergic effects. Anticholinergic drugs block acetylcholine—a neurotransmitter critical to memory, attention, and muscle control—and that blocking effect is amplified in older adults and associated with risk of falls, delirium, and cognitive decline. As we age, it’s harder for our bodies to properly get rid of these antihistamines that can greatly raise your risk of side-effects, including confusion, falls, constipation and dry mouth.
Benzodiazepines are on the list because they increase the risk of cognitive problems, delirium, falls (20-50% increase), accidents (double motor vehicle accident risk), and hip fractures (50-110% increase). Many papers suggest increased Alzheimer’s risk with long-term benzodiazepine use. However, a 200,000+ subject study found this may not be true. Notably, benzos don’t cause typical anticholinergic side effects. The question remains unsettled.
Researchers have also found benzodiazepines plus Z-drugs—people who use them have significantly higher rates of new-onset atrial fibrillation, and the risks climbs with dose and duration. Zolpidem in particular now has evidence that it can trigger abnormal heart rhythms at usual doses, especially in people who already have heart disease, low potassium or magnesium, or taking other QT-prolonging medications. The other Z-drugs—eszopliclone and zaleplon—do not yet have the same amount of data, but that should not be read as a clean bill of health as they work on the same receptor system (GABA-A). This matters because these medicines are most often given to older adults who already have cardiovascular diseases, diabetes, or sleep apnea—the very people least able to tolerate extra strain on the heart. For them, a pill offered as a sleep aid can quietly raise the odds of the arrhythmias that lead to stroke, heart failure, or sudden death. That trade-off is rarely discussed when a prescription is written, but it deserves to be part of any informed decision about starting a benzodiazepine or Z-drug (ie. benzodiazepine receptor agonist).
Trazodone, tricyclic antidepressants and clonidine are useful for people with difficulty falling asleep but are problematic in older adults due to dizziness, and orthostatic hypotension. In addition, tricyclic antidepressants at higher doses are associated with anticholinergic effects such as urinary retention, constipation, dry mouth, blurred vision, and confusion.
Antipsychotic medications are associated with dizziness, hypotension and motor tremors but are still appropriate to use in older adults if the patient has Schizophrenia or Bipolar Disorder. There is a “black box” warning to not use in Dementia patients with behavioral problems (such as agitation or aggression) due to increased risk of stroke and accelerated cognitive decline.
Since cannabis is not on the Beers list, is that a better sleep aid option?
Technically, cannabis is not on the Beers list because it’s not considered a standard pharmaceutical but it carries similar burdens to the medications on the Beers List: increased daytime sleepiness, grogginess, brain fog, impaired driving, dizziness, confusion, sudden drops in blood pressure, blurred coordination with increased fall and fracture risks—which is exactly what the Beers Criteria tries to prevent.
Frequent THC use significantly impacts cognitive function by binding areas responsible for memory, learning, and executive functioning. THC also has an impact on higher cardiovascular risks with increased heart rate, blood pressure fluctuations, and elevates the risk of heart attacks, strokes, and heart rhythm disorders regardless of whether one smokes, vapes or consumes edibles.
What are safer sleep options not on the Beers List?
While the Beers List ruled out some of the most common sleep medications, there are still some good options that include:
Low dose Doxepin is a bit of a surprise since Doxepin is a tricyclic antidepressant. Studies have shown that if the dose is less than 10 mg, there is a benefit in older populations for sleep maintenance and duration but not for sleep initiation. Higher doses should be avoided in older adults because of anticholinergic effects that may cause cognitive difficulties.
Mirtazapine (Remeron) is an antidepressant, with few drug interactions, and has appetite-stimulating properties that may lead to some weight gain. I find it helpful in older adults who are not eating or sleeping well.
Dual orexin receptor antagonists first came out in 2015 and are a newer class of medications for insomnia that target the orexin system. Orexin is thought to be part of the neuronal system that promotes wakefulness, and thus blocking orexin 1 and 2 is believed to inhibit the wake drive. Three dual orexin receptor antagonists are approved by the US Food and Drug Administration: suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq). The most common side effects were daytime somnolence, fatigue and dry mouth. Despite no physical dependence or withdrawal and rarely being misused, these medications are technically a controlled substance due to “drug-liking” scores in clinical abuse potential studies.
Melatonin and ramelteon (aka Rozerem and is prescription version melatonin agonist) may be an alternative treatment option for older adults, given their good tolerability and at least some efficacy.
Low dose gabapentin (Neurontin) and pregabalin (Lyrica) can be useful in helping a person gradually wean off a benzodiazepine and can be helpful for sleep maintenance. However, anticonvulsants are also on the Beers List and are recommended against unless the person has a seizure disorder or Bipolar Disorder. I will consider a smaller dose of gabapentin (100 MG 2-3X/day) or pregabalin (25 MG 2X/day) in an older person if they struggle with severe anxiety or insomnia and are not on other medications that may amplify side effects (like a benzodiazepine or opioid).
CBT-I or Cognitive Behavioral Therapy-Insomnia is recognized as the gold standard and first-line treatment for insomnia in young and aging patients. A course of CBT-I involves seeing a therapist for 6-10 sessions delivered weekly or biweekly to address maladaptive behaviors and cognitions that perpetuate insomnia. It incorporates psychoeducation, sleep hygiene, stimulus control, sleep restriction, relaxation training and cognitive therapy techniques. I believe this is valuable to try especially if patient motivation is high.
Supplements to consider would be magnesium glycinate, L-theanine, glycine and niacinamide.
Final Thoughts
If you are currently taking a medication on the Beers List and are over 65 years old, that doesn’t mean you or your prescriber did anything wrong and this article is not meant to alarm you. For some people in specific circumstances, they remain appropriate. But accumulating evidence on cognitive, physical, and functional risks—especially long-term—requires thoughtful decision making. My intention is to help inform decisions going forward—continuing, adjusting, tapering, or exploring alternatives—honoring both immediate needs and long-term health. You deserve collaborative, informed, responsive care. Ask questions, seek second opinions, and advocate for what feels right.
